Do we truly appreciate how difficult it is for patients with schizophrenia to adapt a healthy lifestyle?

Vancampfort et al. (1) compared 60 Belgian patients with schizophrenia and 40 healthy volunteers according to the distance they walked in 6 min and explored the relationship between their performance on this task with their routine participation in physical activities and their physical self-perception. Selection dictated that patients were more likely to be obese and have preexisting painful musculoskeletal conditions. They were also more likely to smoke. As expected, patients with schizophrenia walked significantly shorter distances than controls and became short of breath easily. Their performance improved with decreasing adiposity but even normal weight patients walked about 95 fewer meters in 6 min than the controls. Patients participated less in leisure or sport-related physical activities (and likely had fewer resources and opportunities to do so) than the controls. Regarding self-perception, patients were significantly more likely than controls to rank themselves poorly on sports competence, physical self-worth, and body attractiveness. A healthier body mass index (BMI) projected into a more favorable self-perception.

A recent editorial in Acta Psychiatrica Scandinavica underlined many of the adverse consequences of schizophrenia (2). Compared with the general population, they commonly live below the poverty line, are three times as often smokers, and commonly suffer from substance abuse disorders. Half are obese, their risk of diabetes is doubled, they have increased medical morbidity, and they die over 20 years sooner than the general population – notably from cardiovascular diseases, cancer, and suicide. Despite knowledge of and efforts made to correct these risk factors, the mortality gap between patients with schizophrenia and the general population has not changed over the last two decades (2, 3). Adapting a healthful lifestyle is a process that involves appreciation of its importance, motivation to plan a change, and physical, psychological and material resources to adhere to the plan. Patients with schizophrenia are at a disadvantage at each step of this process.

Schizophrenia is an illness of cognition, perception, affect and volition. Despite best treatment, deficits in these mental faculties persist in most cases causing variable degree of impairment in ability to effectively plan and follow-through. Patients with severe, noticeable residual deficits may receive case management services but those with mild, subtle deficits usually do not. Their efforts to eat healthfully are undermined by the appetite stimulating effect of their medications. Besides, the atypical antipsychotic medications may also promote their responsiveness to external eating cues (4). For these patients quitting smoking is also harder than it is for individuals without schizophrenia. Nicotine provides greater stimulation and state-enhancement for them than it does for healthy individuals (5). They also have a poorer appreciation of the risks associated with smoking (5). Recurrent episodes of acute psychosis are frequent in patients with schizophrenia and disrupt any efforts they might make towards a healthful lifestyle.

The findings of Vancampfort et al. (1) are not unique to patients with schizophrenia. Decrease in functional exercise capacity with smoking and adiposity, development of painful musculoskeletal conditions with obesity, and diminishing physical self-worth with increasing adiposity and lack of participation in physical activities would be expected even in individuals without schizophrenia. What is unique to patients with schizophrenia is their greater difficulty in breaking the pattern of unhealthful lifestyle and preventing its consequences due to factors related to their illness and its treatment. Till the time our approach to the care of patients with schizophrenia takes this into account, both at policy-making and clinical levels, the outcome of patients with schizophrenia is unlikely to change.