Identifying and treating comorbidities in people with psychoses including schizophrenia

People with psychotic disorders tend to die earlier and have higher rates of comorbidities (especially cardiometabolic disease) than the general population because of:

lifestyle (eg smoking, poor diet, lack of exercise)
antipsychotic adverse effects
inadequate healthcare, often received late in the illness
socioeconomic disadvantage.

To reduce rates of early morbidity and mortality, identify and manage chronic conditions (eg cardiometabolic and respiratory diseases).

Preventing and treating common comorbidities in patients with psychotic disorders lists common comorbidities in patients with psychotic disorders, and strategies to prevent and treat them.

Table 1. Preventing and treating common comorbidities in patients with psychotic disorders
[NB1]
Comorbidity	Prevention strategies	Treatment strategies
cardiometabolic disease [NB1]	avoid using an antipsychotic with significant cardiometabolic adverse effects (see Approximate relative frequency of common adverse effects of antipsychotics) encourage the patient to stop smoking [NB2] support the patient to eat a healthy diet and undertake regular physical activity [NB3] [NB4] [NB5] reduce alcohol intake help the patient to maintain a healthy weight	preventive strategies are also treatments—also see Cardiometabolic adverse effects
osteoporosis and fractures	see Preventing a minimal-trauma fracture for advice	see Considerations before treating osteoporosis for advice
poor dental health	maintain good oral hygiene undergo annual dental assessments	see the Oral and Dental guidelines for treatment of oral and dental conditions
respiratory	encourage the patient to stop smoking [NB2] and avoid second-hand smoke exposure if the patient is exposed to smoke, monitor for wheeze, shortness of breath, cough, and chest discomfort or tightness	see the Respiratory guidelines for treatment of respiratory conditions
sleep disorders	assess the patient’s sleep (including for obstructive sleep apnoea) encourage the patient to practice good sleep hygiene	see treatment advice for insomnia, circadian rhythm disorders and parasomnias in the Psychotropic guidelines, and obstructive sleep apnoea here
depression and anxiety	use psychosocial interventions to decrease isolation support the patient to eat a healthy diet and undertake regular physical activity [NB3] [NB4] [NB5] monitor for substance use that can increase risk of depression	depression and anxiety may settle with acute psychosis treatment. If depression or anxiety persists, or develops after this period, see Assessing a person with depressive symptoms or Assessing a person with anxiety approximately 5% of patients with schizophrenia die by suicide. The risk is highest early in the course of disorder and in patients with comorbid depression—closely monitor and assess for thoughts of self-harm and suicide
problem use of alcohol, cannabis or other illicit substances	monitor for problem substance use inform the patient that problem substance use can lead to increased hospital admissions, drug interactions, reduced antipsychotic responsiveness, and increased risk of relapse, self-harm, arrest and accommodation problems	treat problem substance use and the psychotic disorder concurrently with an integrated treatment program; see Overview of interventions for disorders of substance abuse and addictive behaviours and Psychosocial interventions for psychoses including schizophrenia
Note: NB1: Monitor for antipsychotic adverse effects according to the schedule here. NB2: Stopping smoking can increase the concentration of some antipsychotics (eg clozapine, olanzapine); consult a drug information resource. If available, use therapeutic drug monitoring to guide the lowest effective dose. A list of Australian laboratory test databases is available at the Australasian Association for Clinical Biochemistry and Laboratory Medicine (AACB) ‘Testing for health’ website. For information on therapeutic reference ranges of psychotropics, see Hiemke C, Bergemann N, Clement HW, Conca A, Deckert J, Domschke K, et al. Consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology: update 2017. Pharmacopsychiatry 2018;51(1-02):9-62. [URL] NB3: For advice on a healthy diet, see Australian Dietary Guidelines. NB4: For advice on physical activity, see Australia’s Physical Activity and Sedentary Behaviour Guidelines and the Australian 24-Hour Movement Guidelines. NB5: Exercise interventions are most effective when provided by an expert (eg physiotherapist, exercise physiologist) and coupled with dietary interventions provided by a specialist dietician.