Physical Health in Schizophrenia and Role of Clinical Pharmacist: A Narrative Review

Schizophrenia (SCZ) is a Serious Mental Illness (SMI) marked by persistent mental disruptions affecting consciousness, language, awareness and sense of identity. Psychotic experiences such as hearing voices, delusions and cognitive and psychosocial impairment are common in SCZ.¹ Schizophrenia spectrum disorders have a significantly higher Cardiovascular Disease (CVD) related morbidity and premature mortality rate than other severe mental disorders. Several factors contribute to cardio-metabolic morbidity a few significant ones are a sedentary lifestyle, abnormal dietary habits and adverse effects from Antipsychotics (AP) due to long-term use.²

Developing countries experience the highest morbidity and mortality rate due to CVD, with an estimated prevalence of 54.4 million due to Physical Illnesses (PI). In addition to shorter life expectancy of 10 to 20 years, individuals with SMI including SCZ and bipolar disorder also represent a higher incidence of PI and a higher mortality rate.³ The patients with SMI require lifelong therapy with AP and the most common Adverse Drug Reaction (ADR) reported is metabolic syndrome, which increases the risk of chronic cardiovascular diseases such as diabetes mellitus, hypertension, dyslipidemia and metabolic issues such as weight gain and obesity.⁴ A significant portion of hospital readmissions in SCZ is due to ADR and is a major contributor to escalating health care costs.⁵

SCZ patients with reduced ability to access adequate healthcare due to low economic status are at an increased risk of PI.⁶ There are numerous guidelines around the world alerting the need to monitor this vulnerable group’s physical health. However, the screening strategies to identify at-risk patients are still inadequate worldwide. This might be due to barriers involved in the Patient and System domains (Figure 1). These barriers can be overcome by the collaboration of healthcare professionals as a whole.⁷ This review aims to explore factors related to physical health in schizophrenia and the pharmacist’s role in improving the outcomes.

Low educational level may influence schizophrenic’s knowledge of the PI. Patients are more concerned about treating psychotic symptoms than their general health. It is also less critical for them to worry about the likelihood of severe PI which makes it challenging to proper recognition of somatic symptoms.⁸

Living in disadvantaged economic circumstances, compounded by the stress and isolation associated with low income, poses formidable obstacles to timely and effective screening and treatment of the illness.⁹

Their solitary behaviour may be associated with cognitive prejudices that impact mental and physical health more than those in the healthy population. Furthermore, patients are more likely to agonize over challenging socio-environmental situations (e.g. poverty, low occupation rates, stumpy marriage) than the general population.¹⁰

There are specific reasons responsible for physical inactivity (Table 1). First, a reduction in physical activity and an increase in the time spent on sedentary behaviour may be related to unemployment and social isolation allied with low communal functioning in persons with SCZ. Second, these patients may experience a decline in physical fitness due to antipsychotic-induced extrapyramidal symptoms or weight gain, which may hamper their activity levels. Third, there is a higher level of psychopathology and a lower level of social engagement in those physically inactive than in those involved in physical activities.^11,12

Poor diets in patients are related to low socioeconomic status and reduced access to healthy foods. Several studies have been conducted and the results suggest that the diets of these patients tend to contain a lower intake of fresh fruits, vegetables and more saturated fats.¹³

Second-Generation Antipsychotics (SGA) are well known for increasing appetite, which can contribute to weight gain and obesity when lifelong drug therapy is recommended (Table 2).¹⁴ The initiation of AP therapy is accompanied by a marked acceleration in appetite and early triglyceride escalation, resulting in a new or deteriorated dyslipidaemia and glucose dysregulation. A premature weight gain may also occur during drug therapy and persist for months or years and may lead to treatment denial, reduced self-confidence, shame and deteriorating physical health.^15,16

In those suffering from psychiatric conditions like SCZ, alcohol use disorder is more prevalent making the condition worse and affecting their treatment outcomes. Excessive drinking has been related to various physical health conditions, such as CVD, liver disease and digestive problems.¹⁷

SCZ patients smoke at an average rate of two to four times greater than those without the condition. Consequently, tobacco smoke increases the risk of natural cause mortality by a factor of more than two. In addition, there is an additive effect on cardiovascular and respiratory health. Furthermore, research has found that in the majority of cases of SCZ, there is a high risk for CVD as a result of lifestyle influences like smoking, even before the onset of psychosis.¹⁸

Research has shown that those SCZ patients who slept poorly had higher levels of depression, anxiety and more likelihood of ADR than those who slept well.¹⁹ It is generally accepted that patients with concurrent sleep disorders have a poorer Quality of Life (QoL).²⁰

Most physicians involved in treating SCZ acknowledge that primary care has a significant role to play in physical health. Unfortunately, in practice, they may fail to address and treat metabolic challenges in this population. Receiving treatment advice in a busy medical clinic can be challenging. Further worsening of the situation may arise when there is no adequate number of professional rehabilitators with expertise and functional abilities to treat SCZ patients with complex behaviours and substance abuse.²¹

The main reasons for the poor screening in SCZ are the lengthy screening process and the extra paperwork required in addition to the admission assessment. In some situations, a physical examination may be postponed due to the patient’s uncooperative or hostile nature. Finally, the question of responsibility for physical screening remained unclear: should it be the psychiatrist or the hospitalist? If no screening occurs, an ideal chance to lower health risks and death rates among these vulnerable individuals will be missed.²²

Figure 1:
Depicts the typical representation of factors affecting physical health in schizophrenia. There are numerous patient and system-related factors that source for the deterioration of physical health and development of cardiometabolic complications in schizophrenia.

Most guidelines recommend physical examination for people with SMI like SCZ, without including specific standards for monitoring adverse cardiometabolic effects of AP. Moreover, these guidelines differ from one another when it comes to monitoring the nature, extent and range of physical health domains to be assessed. Some guidelines recommend ‘frequent’ surveillance when monitoring indications, primarily only when risk factors are present. However, only a few of them suggest frequent monitoring following the use of AP medication.^23–25

Literature indicates that current screening procedures using blood samples for assessment of physical health of SCZ in low and middle-income countries are relatively expensive.²⁶ This disparity is probably due to differences in economic status between the countries, availability of resources and mental health personnel and government funding allocation to mental health. Another main factor contributing to increased cost is that most large psychiatric facilities are situated in urban settings and charge a massive amount for screening cardiovascular complications that hinder patient access in the rural setting.²⁷

Figure 2:
An overview of the role of a pharmacist . A clinical pharmacist is capable of educating, spread awareness and promote the health of patients through interventions. But in many of the countries their services are unrecognised or underutilised.

An integrated and holistic approach to monitoring physical health can contribute to better patient outcomes in SCZ when guided by psychiatrists, nurses, pharmacists, dieticians and counsellors when working independently or in collaboration.²⁸ Preliminary evidence supports that pharmacist-managed cardiovascular risk reduction interventions in a population with SMI can improve clinical outcomes.²⁹ Clinical complications, such as diabetes and dyslipidemia, have been improved with patient interventions offered by pharmacists.³⁰

The psychiatrist relies on the caregivers to develop a patient-centred treatment plan since patients are mentally impaired. Caregivers will be better able to support SCZ only if they are educated on patient health. To effectively communicate information, it is essential to use various strategies, including caregiver workshops, psychoeducational therapy, media and educational materials like leaflets. A clinical pharmacist can educate caregivers on mental health diagnoses and manage physical health through these interventions.^29,31 Pharmacists can provide printed resources that contain information on disease, prescribed medications and lifestyle choices. The use of such written resources has been shown to improve patient outcomes despite their differing levels of health literacy. When patients ask face-to-face with their pharmacists or any healthcare provider, they better understand the disease which aids in recognizing the symptoms properly and knows what aggravates those symptoms in SCZ.^32,33 It is also possible for pharmacists to serve as guides and counsellors for individuals seeking treatment for substance abuse. Patients can be taught and warned about the consequences of substance abuse and it can be prevented. Patients can be encouraged to quit smoking by their pharmacists at the point of care. Using pharmaceutically based smoking cessation programs can result in improved health outcomes and lower healthcare costs.³⁴

A pharmacist can provide tailored education strategies to improve diet.³⁵ Dietary education should be focused on calorie restriction, healthy eating and discouraging maladaptive eating behaviours. A patient’s concerns can be minimized if they are thoroughly informed about psychiatric medications before receiving medication. Nicotine replacement therapy and obesity management interventions through exercise are a few examples of services that pharmacists can offer to patients using the requisite level of guidance or coaching.³⁶ In addition, a pharmacist can also take part in medication therapy management; help patients adhere to medication regimens; recognize, manage and mitigate drug-related problems; perform patient evaluations; recommend and modify treatment options, order and assess clinical parameters.^37,29 Delivering medication counselling to patients is not only the pharmacist’s single task in the health care system. They are also responsible for preventing weight gain and obesity in this vulnerable group by enhancing physical activity through interventions. Exercise interventions may aid functional recovery if implemented early in any illness. Thus, people with SCZ can improve their QoL, psychiatric symptoms, cardiovascular complications and daily functioning through exercise. A pharmacist can help people with SCZ engage in physical activity through personalized encouragement or feedback from each patient and by promoting group-based exercise sessions that may overcome several common obstacles such as lack of confidence in exercising, injury concerns and insufficient knowledge about exercise.³⁴

A supportive environment and open communication between patients and pharmacists in mental health settings improve social connectivity. Education combined with an appropriate conversation with patients is considered more effective than awareness-enhancing approaches alone in the case of socially deprived schizophrenics.³⁸ A pharmacist can provide awareness of the importance of sleep hygiene in SCZ patients. Since no single intervention was found to be ideal in treating sleep disorders concerning the patient’s perception, a pharmacist can non-pharmacologically intervene by advising schizophrenics about developing self-strategies such as keeping routine timing for bedtime to improve sleep. Using pharmacological strategies such as consuming medications that induce sleep may aggravate psychotic symptoms in schizophrenia.³⁹

In developing countries diabetes, hypertension and high cholesterol are increasingly prevalent in the adult and elderly, with a 24% mortality rate. It is challenging to screen for cardiovascular and metabolic risk factors in such a large population with conventional blood sampling techniques. High expenditure, increased analysis time and sensitive procedures may limit the patients to volunteer to evaluate clinical parameters. This issue can be minimised with the help of risk scores. The use of risk scores could prove to be extremely useful. It eliminates the need for biochemical assessments, reducing the time and cost associated with screening.²⁶ One example of such a tool is the World Health Organization (WHO)’s mhGAP Intervention Guide for Mental and Neurological Disorders. Guidelines for care of coexisting physical health conditions in SMI are included in the guide. Prioritization is evident at the policy level. Reducing excess mortality in persons with SMI should become part of the broader health agenda. To resolve complex, multifaceted issues, we must establish a standard for integrating various programs (e.g., physical exercise, nutrition and tobacco cessation).⁴⁰ Figure 2 outlines an overview of the role of pharmacists in improving physical health.

The physical health problems related to SMI, like SCZ, are a significant health burden worldwide. There is a need to bring the attention of healthcare, government and policymakers regarding the aspects of the importance of physical health in severe mental illnesses like schizophrenics to improve their QoL. Clinical pharmacists who are experienced in psychiatric pharmaceutical care are best suited to assist with the physical, mental and psychological needs of the schizophrenia communities they serve. However, their contribution and impact on mental healthcare remain rarely evaluated, investigated and reported in research papers due to a lack of funding and clarity about the effectiveness of the services pharmacists provide. There is a growing need to develop standardized, economically feasible interventions to prevent or reduce cardiometabolic complications.