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A Burden on the Heart—Schizophrenia and Coronary Heart Disease

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.

Reference:
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

 
Comments on News and Primary Papers
Primary Papers: Schizophrenia and increased risks of cardiovascular disease.

Comment by:  William Carpenter, SRF Advisor (Disclosure)
Submitted 19 December 2005 Posted 19 December 2005
  I recommend this paper

Schizophrenia may be bad for your metabolic health, and the associated behaviors such as diet, exercise, and smoking create very substantial risk. Proper medical care and prevention is generally not provided. Added to this burden is the fact that antipsychotic drugs may substantially increase risk for the metabolic syndrome. Not all antipsychotic drugs are similar in this regard, and prescribing patterns need to be extensively influenced by knowledge of differential adverse effects between drugs. It is not sufficent to monitor an obesity index since this is often neglected; hyperlipidemia may occur without weight gain, and reversing adverse effects is challenging.

View all comments by William Carpenter


Comment by:  Kiumars Lalezarzadeh
Submitted 27 December 2005 Posted 28 December 2005
  I recommend the Primary Papers

The relation between fatty acid and dopamine needs basic consideration. Two-week-old pups of mother rats fed n-3 polyunsaturated fatty acid-deficient diets (3 weeks before and 2 weeks after birth) showed an increase of D2 (and D1) receptors in the mesolimbic-mesocortical pathways of mothers and many brain areas of the pups (Kuperstein et al., 2005). The depressing effects of increased cholesterol level may be seen in reverse.

The effects of different antipsychotics on the immune system and fungal pathogens need consideration also. Antipsychotics reduce calcineurin protein levels and elevate phosphatase activity of calcineurin in striatum and prefrontal cortex (Rushlow et al., 2005). Calcineurin increases fungal pathogens and its inhibition is related to immune suppression (Cruz et al., 2001). Antipsychotics need further study in relation to...  Read more


View all comments by Kiumars Lalezarzadeh

Comment by:  Robert Peers
Submitted 30 December 2005 Posted 31 December 2005

In what may be a landmark study of lifestyle intervention in schizophrenia, Australian dietitian Sherryn Evans was highly successful in limiting weight gain in newly diagnosed schizophrenia patients treated with olanzapine (Evans et al., 2005). Nutritionally educated patients were only 2 kg heavier after 3 months and 6 months, and were happier; controls were 6 kg and 9.9 kg heavier at the same time points.

The key to nutritional success is close supervision, best provided in community centers accessible to schizophrenia patients. A gym would help. F. M. Baker once ran a program in a poor area of Baltimore, in which the patients were collected daily and brought in, to cook their own (healthy) meals and take part in psychosocial therapy; medication compliance improved, and readmission rates fell dramatically.

The adverse metabolic effects of most newer antipsychotic drugs have stimulated a renaissance of interest in nutritional factors and physical health in schizophrenia that will hopefully...  Read more


View all comments by Robert Peers

Comment by:  Patricia Estani
Submitted 3 January 2006 Posted 4 January 2006
  I recommend the Primary Papers

More studies must be designed to research variables that affect heart disease in schizophrenia. I think that integrating medical services, for example, adding nutritional treatment or dietary services to psychiatric support is essential to prevent the metabolic syndrome commonly observed in schizophrenic patients.

View all comments by Patricia Estani


Comment by:  SuSanne Henriksen
Submitted 10 January 2006 Posted 10 January 2006
  I recommend the Primary Papers

Is there any evidence of an increased incidence of arrhythmias, especially tachycardia, in schizophrenia?

View all comments by SuSanne Henriksen

Comments on Related Papers
Related Paper: Metabolic risk during antipsychotic treatment.

Comment by:  James Manning IV
Submitted 25 November 2005 Posted 25 November 2005
  I recommend this paper

This paper provides good insight into the limitations of trials secondary to confounding design variables.

View all comments by James Manning IV

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