General Physical Health

It is generally believed that schizophrenic persons have worse health than their age peers in the general population, and that their conditions often go undiagnosed and untreated (Dixon et al. 1999). For example, increased rates of comorbid physical illness in schizophrenic patients have been reported to occur primarily in the categories of non-insulin-dependent diabetes mellitus (NIDDM), cardiovascular disease, infectious diseases, respiratory disease, some forms of cancer, and a variety of other illnesses (Dixon et al. 1999). It has also been suggested that persons with schizophrenia may be subject to more severe forms of disorders (Jeste et al. 1996), which may be exacerbated by the side effects of antipsychotic medications (e.g., anticholinergic, cardiovascular, or metabolic effects) and by psychotic illness itself, with significant correlations found between positive symptoms and the number of medical conditions (Dixon et al. 1999; Jeste et al. 1996).

Because data suggest that the diagnosis of schizophrenia across all age ranges confers greater risk for physical illness, it might be assumed that older persons with schizophrenia are more medically ill than age-matched peers. Moreover, it is conceivable that age may interact with schizophrenia so that older schizophrenic persons might be disproportionately more ill relative to their age peers than younger schizophrenic persons.

Nevertheless, researchers in San Diego (Jeste et al. 1996; Lacro andJeste 1994) found that middle-aged and older schizophrenic persons had fewer medical illnesses (mean=1.0) than persons with Alzheimer's disease (mean= 1.4) and major depression (mean = 2.4), with a comparable severity index on the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) compared with an older normal comparison group. Similarly, a study in New York City of 117 schizophrenic persons age 55 and over, with a mean age of 63 years (C.I. Cohen, unpublished data), found that 33% of the schizophrenia sample and 48% of the community sample reported 2 or more physical disorders; the mean number of disorders was 1.35 and 1.66 for the schizophrenia and community groups, respectively. In the latter studies, the annual rate of hospitalization was comparable between the groups (21% community group, 22% schizophrenia group), although more than half the hospitalizations among the schizophrenia group had been for psychiatric reasons, whereas among the community sample only about 1 in 20 hospitalizations had been psychiatric in nature. However, a confounding factor in both of these investigations was that the normal comparison groups were older—12 years and 6 years in the San Diego and New York City studies, respectively. Interestingly, the San Diego study found a significant correlation between physical symptom severity and positive symptoms of schizophrenia, depression, and overall psychopathology, whereas the New York study did not find any significant correlations.

The studies in New York and San Diego do not suggest that older schizophrenic outpatients have more physical disorders or that their disorders are necessarily more severe than those of their age peers from comparable backgrounds, although results of the latter study were equivocal due to age differences between comparison groups. One possible explanation for these findings is that persons in the schizophrenia samples were all involved to some extent in clinical programs, most of which encouraged or provided physical examinations. Moreover, because aspects of psychopathology tend to diminish with age, older persons may be more apt to attend to medical problems and be better received by other health professionals. The San Diego researchers interpreted the significant correlation between positive symptoms and physical health as reflecting the fact that physical symptoms may seem less important or be overlooked in the presence of florid psychosis and, conversely, are more apt to be addressed when the patient is less symptomatic. A "survivor effect" may be another plausible explanation for the lack of differences between the older schizophrenic and community persons. That is, because the mortality rate for schizophrenic persons substantially exceeds that of the general population throughout their lifetime, those who are oldest are presumably the heartiest, both physically and emotionally.

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