Editorial

Abstract

An important paper (1) in this month's journal draws attention again to what the authors call ‘poor health behaviour’ in patients with all major psychiatric diagnoses, especially schizophrenia and depression. I prefer the terms ‘physical health’ and ‘lifestyle’, but no matter. The findings are not surprising, but are discouraging. Health behaviour of 363 psychiatric in-patients with various diagnoses, including schizophrenia, affective illness and neurotic disorders was compared with that of a sample of 7200 persons of the German general population. More patients smoked and abused drugs and alcohol. Their diet was unhealthy and BMI was increased in those with schizophrenia. An intriguing finding was that patients with depression were more physically active than members of the general population – I wish the authors had speculated a little bit more as to why this might be. These findings add to the already considerable literature on physical health and severe mental illness, although most of the work has focussed on schizophrenia. People with schizophrenia, both men and women, die on average 10 years earlier than members of the general population. Suicide is the most notable cause, but is now believed to account for only about 5% of deaths (2). Natural causes predominate, especially cardiovascular and respiratory disease. Other conditions more common in schizophrenia include eye cataracts, diabetes and possibly the metabolic syndrome; their dental health is poor (3). The main putative factors that contribute to the poor physical health of people with schizophrenia include the illness itself, lifestyle and medication. With regard to the illness, two recent studies from Dublin, Ireland found that first episode patients had greater visceral obesity (4) and impaired fasting glucose levels (5) than healthy volunteers. With regard to lifestyle, a previous study on diet (6) found that compared with the general population, fewer individuals with schizophrenia consumed acceptable levels of fruit, vegetables, milk, potatoes and pulses. The recommended daily intake of fruit and vegetables is five portions; people with schizophrenia were consuming only 16 portions per week (6). With regard to medication, antipsychotics are implicated in obesity and sexual dysfunction, especially erectile dysfunction which is common in people with schizophrenia (7). As the authors of the paper in this month's journal point out and discuss there are probably complex neurobiological, psychosocial and treatment related factors important in the relationship between severe mental illness and physical health. Whatever the reason, this and previous papers have shown that our patients with severe mental illness, especially schizophrenia, are amongst the most vulnerable and disadvantaged in our community. What to do about it is another matter. Interventions to help people with schizophrenia stop smoking have not produced impressive results (8). The first double-blind study of bupropion, a noradrenaline- and dopamine-reuptake inhibitor, for smoking cessation in people with schizophrenia found the drug to be modestly effective for smoking cessation, without worsening the symptoms of schizophrenia (9). The first randomized controlled trial of a dietary intervention in people with schizophrenia (10) found that, when given free fruit and vegetables for 6 months, patients consumed markedly more fruit and vegetables than control (treatment-as-usual) patients. However, 12 months after the intervention, consumption had fallen back to pretreatment levels. It can be hard to involve people with severe mental illness in programmes designed to improve their physical health. For example, although 179 men were approached to take part in the first double blind study of sildenafil in men with schizophrenia and erectile dysfunction, only 24 consented to enter the study (11). Who should be responsible for monitoring the physical health of people with severe mental illness? In the UK, an authoritative body, the National Institute for Health and Clinical Excellence, is in no doubt that ‘secondary services should undertake regular and full assessment on the mental and physical health’ of people with schizophrenia (12). This may be so, but tackling satisfactorily the causes of poor physical health in people with severe mental illness still appears to be a long way off. To finish on an historical note. Although I would certainly not advocate a return to the ‘good old (paternalistic) days’, things were very different 40 years ago, when I entered psychiatry. Most people with severe mental illness, especially schizophrenia, spent much of their adult lives in a psychiatric hospital. There, their access to cigarettes was controlled; there was little or no alcohol or drug misuse; hospital food, though ‘stodgy’, was more nutritious; there were many opportunities to work (industrial therapy, the farm, domestic and clerical work); and ample opportunity to meet people of the opposite sex. Nowadays people with severe mental illness have choices; their lifestyle is not imposed upon them. So the question today is: how far should ‘professionals’ impose their view of a satisfactory lifestyle on patients?