The paradox of premature mortality in schizophrenia: new research questions.

The life expectancy of patients with schizophrenia is reduced by between 15 and 25 years. Those patients dying of natural causes die of the same diseases as in the general population. In 2009 the World Health Organization (WHO) identified underlying global risk factors for mortality in the general population. However, there is little evidence in the literature assessing their validity in those with schizophrenia. The WHO report on global health risks (2009) identifies hypertension, smoking, raised glucose, physical inactivity, overweight and obesity, and high cholesterol as the six leading global mortality risk factors. Currently, there are minimal data on the contribution to mortality that these risk factors make in schizophrenia, and their optimum management. Both short and long-term studies are needed to address these gaps. New research has raised important questions about risk balance with regards to ideal body mass, with some studies showing that being overweight is associated with lower all-cause mortality and lower suicide rates. Cardiorespiratory fitness is being recognized as a more powerful predictor of mortality than smoking, hypertension or diabetes in men. However, there are virtually no published data on assessment of fitness levels in schizophrenia. New studies have raised concerns about the quality of physical care for patients with schizophrenia, which is another important avenue of future research. A greater biological understanding of the relationship between these disorders and schizophrenia would inform clinical practice. Low birth weight has been associated with increased risk for schizophrenia, and it will be important to explore this risk factor for both physical and mental health outcomes.

Are there modifiable risk factors which will reduce the excess mortality in schizophrenia?

The 2009 World Health Organization report on global health risks identifies hypertension, smoking, raised glucose, physical inactivity, obesity and dyslipidaemia, in that order, as being the top six modifiable global mortality risk factors. Patients with schizophrenia have high levels of all these risk factors. There are a small number of studies showing that interventions can improve these, but prospective long-term studies are not available to show their impact on mortality. A number of studies are now supporting the view that patients with schizophrenia may be dying prematurely as they are not gaining access to or receiving the same medical care as the general population. The literature now suggests that low cardiorespiratory fitness and muscle strength are among the strongest predictors of all-cause mortality in the general population. Smoking is still one of the largest risk factors for premature all-cause mortality. The literature supports the thesis that lifestyle intervention programmes addressing exercise, smoking cessation and compliance with medication are likely to have significant impact on mortality in schizophrenia. It will be important to ensure that all patients with schizophrenia have advocates to ensure appropriate treatment and avoid prejudice, and to establish fitness standards in schizophrenia.

The evolution of hyperprolactinaemia as an entity in psychiatric patients.

This paper explores chronologically the evolution of raised prolactin levels as an entity in psychiatric patients. Menstrual problems were described in patients with schizophrenia prior to the introduction of antipsychotic medication, but galactorrhoea and gynaecomastia were not commonly seen until the advent of antipsychotics. Following the introduction of antipsychotic medication single case reports of patients with galactorrhoea and gynaecomastia appeared. These were followed by a collection of case reports and the process reached today's data of laboratory defined rates of prolactin and sexual side effects. The paper also reviews the emerging research linking hyperprolactinaemia with increased risk of osteoporosis and possibly breast cancer. An overarching thread which runs throughout these publications, is the paucity of clinical research, which has only recently begun to be addressed.