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Medical Comorbidity in Schizophrenia

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Medical Comorbidity in Schizophrenia VOL 22, NO. 3, 1996 Medical Comorbidity in 413 Schizophrenia by Dilip V. Jeste, Abstract Mens sana in corpore sano. Downloaded from https://academic.oup.com/schizophreniabulletin/article/22/3/413/1829806 by guest on 24 September 2021 Julie Aklko Gladsjo, (Sound mind in a sound body.) Laurie A. Undamer, and The extent and consequences of [Juvenal, 2nd Century A.D.; cited Jonathan P. Lacro medical comorbidity in patients in New Encyclopedia Britannica, with schizophrenia are generally 1993, p. 667] underrecognized. Patients with comorbid conditions are usually excluded from research studies, although they probably represent The comorbidity of physical and the majority of individuals with mental illnesses has implications for the treatment, health care utilization schizophrenia. Elderly patients are and cost, quality of life, and under- especially likely to have comorbid standing of the pathophysiology of disorders. In this article, we review those disorders. A number of studies selected literature on medical have examined the relationship comorbidity in schizophrenia, between depression and physical ill- including physical illnesses, sub- nesses (see Schulberg et al. 1987). stance use, cognitive impairment, Medical comorbidity in schizophre- sensory deficits, and iatrogenic nia, however, has been studied to a comorbidity. Data from the Univer- much smaller extent. sity of California, San Diego Clini- cal Research Center on late-life psy- chosis are also presented. Older Anosognosia for Medical schizophrenia patients report fewer Comorbidity In Schizophrenia? comorbid physical illnesses than healthy comparison subjects, but Anosognosia is broadly defined as their illnesses tend to be more ignorance, real or feigned, of the severe. These results suggest that presence of disease (specifically of schizophrenia patients may receive paralysis) (Stedman 1990). We believe less than adequate health care. Sub- that, in a larger sense, there is an stance abuse is more common in insufficient awareness of (or patients with schizophrenia than in "anosognosia" for) medical comor- the general population and may bidity in schizophrenia on the part of exacerbate psychiatric symptoms in patients, caregivers, health care these patients. Although general- providers, and researchers. Medical ized cognitive impairment is associ- comorbidity has often been underrec- ated with schizophrenia, the main ognized and underdiagnosed in psy- contributors to dementia in older chiatric patients, especially among patients are more likely to be those with schizophrenia (Koranyi comorbid neurological and other 1979; Sheline 1990). Some data sug- physical disorders, substance abuse, gest that schizophrenia patients may and medication side effects. Iatro- have a greater pain tolerance than genic comorbidity results primarily healthy subjects (Dworkin 1994). This from the use of neuroleptic (e.g., tar- deficit in schizophrenia patients' sen- dive dyskinesia) and anticholinergic sitivity to physical pain, combined (e.g., confusion) medications. Clini- cal and research recommendations Reprint requests should besent to Dr. are made for management of comor- D.V. Jeste, Geriatric Psychiatry Clinical bidity in schizophrenia. Research Center (116A), Veterans Affairs Schizophrenia Bulletin, 22(3): Medical Center, 3350 La Jolla Village Dr., 413-430,1996. San Diego, CA 92161. 414 SCHIZOPHRENIA BULLETIN with poor insight, may result in a research that has sought to uncover found that 92 percent of the patients Downloaded from https://academic.oup.com/schizophreniabulletin/article/22/3/413/1829806 by guest on 24 September 2021 lower rate of schizophrenia patients associations between schizophrenia had at least one comorbid physical reporting physical problems to their and certain medical disorders, in disorder. Cardiovascular disease was physicians. Neuroleptics—the most order to identify risk factors or possi- most prevalent (34%), followed by commonly used treatment for psy- ble etiological mechanisms for either neurological (22%), genitourinary chosis—may reduce pain sensitivity disorder. Even studies examining (17%), respiratory (17%), and gas- (Part et aJ. 1994) and have indeed physical comorbidity in schizophre- trointestinal (17%) disorders. been used to treat pain due to cancer nia often have been narrowly focused Diagnosis of comorbid conditions and other chronic conditions. Thus, on a single medical condition, or they in schizophrenia patients has impor- many patients with chronic schizo- have been limited by methodological tant implications for their care and phrenia may not seek, and therefore problems that restrict the validity quality of life. Unrecognized physical may not receive, diagnosis and treat- and generalizability of the conclu- diseases may exacerbate the symp- ment of physical illness. By focusing sions (Harris 1988). One major limita- toms of psychiatric illness by affect- solely on the presenting psychiatric tion has been the diagnosis of schizo- ing brain function or by affecting symptoms or by viewing physical phrenia itself. Across studies, differ- other organ systems. complaints as "psychosomatic" ent diagnostic systems have been In this article, we will review the symptoms, health-care professionals employed to diagnose schizophrenia, literature on the prevalence and risk also may tend to overlook coexisting making it difficult to compare results. factors or associations of five main medical conditions in their mentally Neuroleptic medication has adverse categories of comorbidity in schizo- effects, such as glucose intolerance ill patients. Koranyi (1979) studied phrenia: (1) physical illnesses; (2) detection of physical illnesses by and tardive dyskinesia (TD) (dis- substance abuse and dependence, physicians referring patients to a psy- cussed later); researchers must con- including alcohol use, smoking, illicit chiatric clinic and found that nonpsy- trol the effects of neuroleptic medica- drug use, caffeine consumption, and chiatric physicians missed one-third tion when they are investigating polydipsia; (3) cognitive impairment; and psychiatrists missed one-half of medical illnesses in individuals with their patients' comorbid medical con- schizophrenia. In addition to the (4) sensory deficits; and (5) iatrogenic ditions. In a study examining the methodological problems, numerous disorders. In each of these categories, prevalence of physical disease in psy- other confounds, such as the effects we will briefly summarize selected chiatric patients in the California of aging, institutionalization, and literature and will refer the reader to public health system, Koran et al. other health-related behaviors (e.g., more comprehensive reviews of these (1989) reported that only 47 percent smoking, lack of exercise), may have areas. We will also present data on of the patients' physical illnesses an impact on comorbidity findings in comorbidity from our cohort of older were recognized by the mental health schizophrenia. Despite these limita- schizophrenia patients. Finally, we staff. Among the undiagnosed med- tions, it is important to investigate will offer clinical and research recom- ical conditions, 16 percent of the medical comorbidity in schizophrenia. mendations. physical illnesses were considered Relatively few studies have exam- "causative" (i.e., entirely responsible Physical Comorbidity for the presenting psychiatric symp- ined concurrent medical and psychi- toms), whereas 45 percent were atric disorders in elderly mentally ill believed to have exacerbated a pre- patients. The likelihood of someone Literature Review. A number of existing psychiatric disorder. having a medical problem increases research reports have suggested that with age (Kovar 1977). The projection schizophrenia patients have a lower The tendency for researchers to that 130 million people in the United prevalence of some physical illnesses exclude from their studies subjects States will be over the age of 45 by and a higher prevalence of other with comorbid medical conditions in 2050 suggests that there will be a physical illnesses than people in the order to eliminate the possible con- large number of middle-aged and general population and, often, pa- founding effects of physical illnesses elderly persons with coexisting psy- tients with other psychiatric condi- is another factor that may contribute chiatric diagnoses and medical prob- tions. to the lack of awareness of the impact lems. Sheline (1990) examined the Rheumatoid arthritis. Several of physical illnesses on schizophrenia prevalence of physical illnesses in studies have reported a negative patients. The exception has been geriatric psychiatric inpatients and association between rheumatoid VOL22.NO. 3, 1996 415 arthritis and schizophrenia. Rheuma- ship between rheumatoid arthritis cancer in schizophrenia are surpris- Downloaded from https://academic.oup.com/schizophreniabulletin/article/22/3/413/1829806 by guest on 24 September 2021 toid arthritis—a largely genetically and schizophrenia, but the reason for ing, given the high rates of smoking transmitted autoimmune disorder the decreased prevalence of rheuma- among schizophrenia patients (dis- that causes peripheral vascular and toid arthritis in schizophrenia is as cussed later). Some researchers have inflammatory changes in the joints— yet unknown (Vinogradov et al. hypothesized that neuroleptic med- affects approximately 1 to 3 percent 1991). ication may have an anticancer effect of the population (Sorensen 1990). Cancer. The relationship between (Mortensen
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