Increased Cardiometabolic Disease Risk in Schizophrenia or With Antipsychotic Use

When treating any condition, there is always a risk of unwanted side effects. But when it comes to treatments for schizophrenia and the use of antipsychotic medication, research is increasingly showing that treatment may elevate the risk of metabolic syndromes and heart disease. The National Institute of Mental Health1 cites a study2 showing that people taking atypical antipsychotic medications may gain large amounts of weight and experience metabolic changes.

Below, R. Scott Hamilton, MD, the medical director of McLean County Center for Human Services, in Bloomington, Ill., discusses these risks versus the importance of treatment. He also discusses the psychiatrist's role in helping to protect patient heart health.  

CARDIOMETABOLIC RISK IN SCHIZOPHRENIA

Studies have shown that treatment for schizophrenia or the use of antipsychotic medications may have implications for heart health. Researchers have found links between schizophrenia and a higher incidence of coronary events. It has also been shown that antipsychotic use may raise the risk of diabetes, which also has heart-health implications for patients. How do you think psychiatrists should view these findings?

I think we need to take these risks very seriously. It appears to me that it is very well established that some of these medications do indeed increase the risk of various cardiovascular problems, most notably metabolic syndrome. Antipsychotics appear to raise cholesterol and triglycerides in some patients. They may also increase the risk of diabetes, which in turn can raise cardiovascular risk. Antipsychotic drugs may also promote weight gain, which also contributes to cardiovascular risks.

Another issue to note is that these medications can also cause heart rhythm disturbances on the QTc interval of an electrocardiogram. While this has not turned out to be as big a concern as initially thought, it is still a cardiovascular issue nonetheless.

Are there specific factors that you believe contribute to potential cardiovascular and metabolic risks related to schizophrenia or antipsychotic use?

Many patients suffering from schizophrenia already have an elevated risk for heart problems. It is not unusual for these patients to have a sedentary lifestyle, and they tend to be more likely than the average person to smoke. Due to their illness, many patients with schizophrenia don't have the economic stability to afford healthful foods or have access to health care services. In addition, the illness may make these patients more apathetic about issues of health and weight.

While not definitively established, there are also indications that patients with schizophrenia may be more genetically predisposed to diabetes and metabolic syndrome.

INDIVIDUALIZING THERAPY: A BALANCING ACT

How should the potential for adverse cardiovascular events play into treatment decisions for these patients?

When prescribing medications for these patients, psychiatrists should look at the efficacy of the medications balanced against the cardiometabolic risks. This risk balancing act is common in all areas of medicine. Schizophrenia is a terrible illness, and people who suffer from the condition are dramatically affected as far as their functioning. When they are really sick, they can't function in society or care for themselves, so we really do need to treat the disease, and we really do need to get these people better. Like cancer, schizophrenia is a serious and horrible enough illness to justify medications that have a higher level of risk or toxicity.

Whenever possible, however, psychiatrists should opt for drug treatments with the lowest risk of side effects. For example, if a patient has really good symptom relief on a particular medication but experiences severe metabolic side effects, the psychiatrist may want to consider switching to a medication that controls the symptoms almost as well but has less significant side effects.

However, there are cases when patients only have adequate symptom relief with a drug that causes significant side effects. In those instances, psychiatrists may have limited choice. However, more drugs are in the pipeline that may provide better alternatives in the future.