Vascular Disease in Schizophrenic Patients Bernard Sklar MD April 22, 2004

1. Vascular Disease in Schizophrenic PatientsBernard Sklar MD April 22, 2004 • Patients with schizophrenia have a much greater chance of developing vascular disease than the general population. • Patients with schizophrenia are at much higher risk from the complications of obesity, high cholesterol, diabetes, high blood pressure, and cigarette smoking.

2. Let’s talk about Arteries • Arteries are the blood vessels that carry blood and oxygen to all parts of the body • When arteries are functioning, oxygen gets to where it needs to go and you function well • Clogging of the large arteries is called “atherosclerosis” (or, commonly, “arteriosclerosis” or “hardening of the arteries”) • When arteries are clogged, parts of the body lose their oxygen and become sick or die • Three important body parts are the heart, the brain and the legs

4. Coronary Artery (Heart) Circulation

5. Neck Arteries

6. Leg Arteries

7. An Artery Getting Sick

8. Vascular Disease • When arteries are clogged or narrowed, blood and oxygen do not get through • If the arteries that feed the heart become clogged, you get “coronary artery disease” which can lead to heart attack or heart failure • If the arteries that feed the brain (carotid) become clogged (“cerebrovascular disease”) you can have strokes leading to paralysis or mental change • If the arteries to the legs become clogged (“peripheral vascular disease”), you may lose your legs.

9. Getting back to our Patients • Patients with schizophrenia have a much greater chance of developing vascular disease than the general population. • Patients with schizophrenia are at much higher risk from the complications of obesity, high cholesterol, diabetes, high blood pressure, and cigarette smoking.

10. Why does that happen? • There may be something about the disease of schizophrenia itself which causes an excess of these problems; or vascular disease may be a result of the poor health habits which seem to be common in our patients (too much eating, too little exercise, smoking, drinking, drug use, etc – more on this later)

11. Why does this happen? • The drugs (the so-called “atypical antipsychotics” cause or contribute to these problems. • Zyprexa • Clozaril • Risperdal • Geodon • Abilify • Seroquel

12. Why does this happen? • Other medications can also be at fault • Mood stabilizers (Depakote), Lithium • Antidepressants (especially tricyclics) • Benzodiazepines (Ativan) possibly

13. Let’s look at the conditions • Each of the conditions to be discussed causes harm by affecting the large arteries, especially those of the heart, brain and legs (as well as the small arteries, especially those of the kidneys and eyes, but we’ll discuss those another time)

14. How does that happen? • Any condition or behavior which causes buildup of fat (especially “bad” cholesterol) in the arteries, constriction of the arteries or increased pressure in the arteries will contribute to the process.

15. Obesity (Overweight) • When fat builds up in the body, it also settles in the arteries. People who are overweight have a much higher risk of vascular problems. • Unfortunately, most of our medicines cause patients to gain weight. • Diet and exercise will reduce weight, but it is difficult for many patients. • Weight loss medications can work, but they can be risky

16. High Cholesterol (Hyperlipidemia) • Most foods contain cholesterol • We all need cholesterol for our bodies to function, BUT… • Too much of the wrong kind of cholesterol can lead to clogged arteries

17. Types of Cholesterol • A “bad” cholesterol, called LDL, lays down fat deposits in the arteries. We want our patients to have a low LDL • A “good”cholesterol, called HDL, “cleans” fat deposits off the arteries. We want our patients to have a high HDL.

18. Lowering Cholesterol • Low fat diet, weight loss, exercise and medications will very reliably lower the “bad” (LDL) and raise the “good” (HDL) cholesterol. • The medications are generally very safe and effective

19. Diabetes - Cause • Type II diabetes occurs when too much fat “overwhelms” the cells of the pancreas which produce insulin. The level of the sugar in the blood rises. • We usually see diabetes in middle-aged overweight patients. Diabetes occurs twice as often in schizophrenic patients than in the general population and even more often in those taking the atypical antipsychotic medications. • Diabetes causes the process of “atherosclerosis” to go much more quickly, leading to heart attack, stroke, and poor circulation in the legs, also to blindness and kidney failure.

20. Diabetes - Treatment • Lowering the blood sugar and keeping it low will prevent much of the damage from diabetes • Weight loss, exercise and medications are all very effective treatments for diabetes

21. Hypertension (High Blood Pressure) • Hypertension exists when the pressure inside the arteries is too high • It is not caused by “nerves” or anxiety • Most of the time, patients with hypertension do not “feel” anything • Hypertension can only be diagnosed and monitored with a blood pressure cuff and stethescope

22. Hypertension Injures Arteries • Hypertension causes injury to the arteries by the constant excessive pounding against the walls of the arteries leading to bruising and tearing of the inside of the arteries • This gives a good place for the “bad” cholesterol to settle and cause blockage

23. Hypertension - Treatment • The blood pressure can be lowered by weight loss, exercise and medication • There is a huge number of blood pressure medications. Each has its advantages and side effects and some interact with the psychiatric medications.

24. Cigarette Smoking • Cigarette smoke contains nicotine and other substances that cause the arteries to “constrict’ (narrow); less blood gets through the arteries to the heart muscle, the brain, the kidneys and the muscles of the legs. • Cigarette smoking greatly increases the risk of all the vascular diseases.

25. Cigarette Smoking - Treatment • This is probably the toughest to treat of all the conditions discussed here. Nicotine is highly addictive and very difficult to give up, especially in our group of patients. • There are many stop-smoking techniques and treatments.

26. What can we do? • First Step: • Recognize the problem: Our patients are at much greater risk from dying of vascular disease than the general population.

27. What can we do? • Identify the particular patient by: • Asking often about cigarette smoking • Weighing the patient regularly • Checking the blood pressure periodically • Checking the blood sugar and cholesterol regularly

28. What can we do? • Be especially attentive to weight gain and elevated blood sugar in patients on • Zyprexa, Clozaril, and Seroquel. • Other medications such as Risperdal, Geodon, Abilify, Depakote, Lithium

29. What can we do? • Refer the patient early for treatment of these conditions • Ask the patient regularly about compliance with his/her medical physician • Consult frequently with the medical physician • Repeat weight, BP, and lab work often • Ask about smoking often

30. Questions/Comments? • Please contact me with questions, comments or suggestions at • 510-481-3712 or by email at Sklar@bhcs.mail.co.alameda.ca.us • Two good web sites for psychiatric education: • www.cmelist.com/psychiatry.htm (Sklar) • Medicom Worldwide http://medicaled.com/