Introduction

The focus of schizophrenia research and treatment has broadened in the past decade beyond the narrow emphasis on positive and negative symptoms, which characterized the earlier approach to this disorder (Tsuang and Faraone 1999). Schizophrenia is now fully recognized as a multidimensional illness, with a profound impact on behavior, perceptions, thinking, emotions, neurocognition, and psychosocial functioning, that may not be fully managed with pharmacotherapy (O'Leary et al. 2000). The advent of rehabilitative models and multidisciplinary teams composed of mental health practitioners other than medical professionals has become the standard of care in many communities. This approach to schizophrenia treatment is centered on the need to remediate all aspects of dysfunction to maximize quality of life. Nevertheless, despite these efforts to provide more comprehensive services for the chronically mentally ill, data continue to demonstrate the substantial burden of medical comorbidity and excess mortality exacted from patients with schizophrenia (Brown et al. 2000). To be afflicted with schizophrenia implies a life expectancy approximately 20% shorter than that of the general population (Newman and Bland 1991), with much of this excess mortality due to medical causes rather than accidents or suicide, both of which are also prevalent. Many patients with schizophrenia receive little or no routine or preventive medical care during their interactions with the health care system in the United States, resulting in greater severity of illness and a higher burden of untreated medical conditions (Druss et al. 2002; Jeste et al. 1996). Although the focal point of contact for those suffering from schizophrenia is the psychiatric office or clinic, data from the National Ambulatory Medical Care Survey amassed from 1992 to 1999 on 3,198 office visits found that psychiatrists provided clinical preventive medical services in any form (e.g., health behavior and lifestyle counseling, measurement of blood pressure) to patients with severe mental illness during only 11% of visits (Daumit et al. 2002).

For many reasons, including the unfortunate dissociation of psychiatric and medical care that is common in the United States, and inherent aspects of the disorder, such as self-neglect, the medical needs of patients with schizophrenia often go unattended during the lifetime course of their psychiatric care (Stroup and Morrissey 2001). It should therefore not be surprising that patients with schizophrenia present with more advanced medical illness than do sex- and age-matched peers (Muck-Jorgensen et al. 2000), and that natural causes account for approximately half of the excess deaths in this population (Osby et al. 2000). This neglect and "myopia" regarding medical illness in schizophrenia care is not confined to community mental health practitioners, but is also reflected in the messages received from academia. Most textbooks on schizophrenia treatment devote little or no space to medical issues in this population, and typically offer no discussion about important sources of increased morbidity, including infectious diseases such as human immunodeficiency virus and hepatitis C, and cardiovascular disease, a primary source of excess mortality for these patients. The net result is not only shortened survival and decreased quality of life for those with schizophrenia due to the burden of untreated medical conditions, but also functional impairment and a direct adverse impact on psychiatric symptoms.

Two recent studies underscore this interaction between medical comor-bidity and psychiatric status among patients with schizophrenia. That pa tient self-report about past medical service use is reliable in this population has been documented over the past decade, most recently in data demonstrating strong consistency among responses in a sample of 29 patients with schizophrenia who were interviewed two times, one week apart, regarding medical contacts over the past year (Goldberg et al. 2002). The survey interview method was employed by Dixon and colleagues to study a group of 719 patients with schizophrenia in various community settings as part of a Patient Outcomes Research Team (PORT) project examining the association between physical health, psychiatric symptoms, and quality of life (Dixon et al. 1999). After controlling for social and demographic factors, the authors concluded, "A greater number of current medical problems independently contributed to worse perceived physical health status, more severe psychosis and depression, and greater likelihood of a history of a suicide attempt (p. 496)."

Another study examined the association between physical health and psychiatric symptoms prospectively among 950 psychiatric admissions to the Johns Hopkins Hospital Phipps Psychiatric Service, of which 15.6% were diagnosed with schizophrenia. In those patients who received general medical health ratings, medical comorbidity was a focus of concern in 20% and represented a serious active problem in 15% at time of presentation; moreover, medical comorbidity was associated with a 10%—15% increase in psychiatric symptoms and functional impairment, controlling for clinical status at time of admission (Lyketsos et al. 2002).

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