23 December 2005. It is understandable that psychosis and negative symptoms are in the foreground in any discussion of schizophrenia, but an important, and much-neglected effect of the disease is the toll on the cardiovascular system, according to Charles Hennekens and his colleagues. Given the already difficult task patients face in trying to live the heart-healthy lifestyle, the famed epidemiologist calls for psychiatry to focus on prescribing regimens that do not add one more burden on the heart. Wading into the already contentious discussion of which antipsychotic drugs are preferable (see, e.g., SRF news item on CATIE study), he suggests preference be given to drugs that do not increase obesity, diabetes, or cholesterol problems.
If you're taking one of those tiny aspirins each day for cardiovascular health reasons, you largely have Hennekens and his colleagues to thank for it. Through his distinguished career at Brigham and Women's Hospital in Boston, he directed many large-scale studies (the Physicians Study, the Nurses Study, the Women's Health Study, among others) that explored risk factors for cardiovascular disease, as well as other disorders. Now at Florida Atlantic University in Boca Raton, Hennekens has recently published a review with colleagues at several other institutions on the increased risk of cardiovascular disease for people with schizophrenia (Hennekens et al., 2005).
Hennekens and colleagues point out that people in the US with schizophrenia have a life expectancy 15 years lower, on average, than does the population as a whole. While it is true that the rate of suicide is higher among people with schizophrenia, more than two thirds die of coronary heart disease (CHD). The well-known major risk factors for CHD are cigarette smoking, poor cholesterol profiles, hypertension, obesity, and diabetes, and they all influence one another in ways that bode ill for cardiovascular health.
It is certainly no secret that people with schizophrenia are overly burdened by these risk factors, but Hennekens and colleagues put them into context. They note that the incidence of smoking among people with schizophrenia is 75 percent, compared to 25 percent for the general population; high cholesterol is both more prevalent and less often treated; and hypertension is more common in the disease. Obesity is also increased in schizophrenia. As if that weren't enough, diabetes is 1.5- to 2-fold higher among people with schizophrenia than in the general population.
What can be done, then? "The treatment and prevention strategies should include encouraging healthy lifestyles, smoking cessation, appropriate diets and levels of activity, and integrating medical services, as well as screening and treatment," write Hennekens and colleagues. But it is hard enough to lower cholesterol and reduce smoking in the general population, argue the authors, much less people with schizophrenia. "These considerations emphasize the importance of choosing antipsychotic drug regimens that do not adversely affect cardiovascular risk," they write.
The second-generation antipsychotic drugs such as clozapine, and popular later arrivals like olanzapine, have a variety of negative metabolic effects (see, e.g., Newcomer, 2004). Hennekens singles out ziprasidone as being preferable to other second-generation antipsychotics in terms of metabolic effects (see also Masand et al., 2005), something that will surely spur further skirmishes in the public relations wars among the manufacturers of the major antipsychotic drugs, with major battles already being fought over the relative merits of the drugs in terms of efficacy and side effects (see Newcomer, 2005).—Hakon Heimer.
Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J. 2005 Dec ;150(6):1115-21. Abstract