What factors affect the lifestyle What factors affect the lifestyle choices of people with a choices of people with a

diagnosis of schizophrenia?diagnosis of schizophrenia?

Dr Hosam AbedDr Hosam Abed

IntroductionIntroduction

A great deal of research has been done on physical health in A great deal of research has been done on physical health in schizophrenia which has shown that sufferers have higher rates of schizophrenia which has shown that sufferers have higher rates of morbidity and mortality from cardiovascular and respiratory diseases, morbidity and mortality from cardiovascular and respiratory diseases, and a shorter life expectancy (Brown S and a shorter life expectancy (Brown S et al, et al, 1997; Brown S 1997; Brown S et al, et al, 2000). 2000).

People with schizophrenia tend to eat less fruit and vegetables, take People with schizophrenia tend to eat less fruit and vegetables, take less exercise, are more likely to smoke and have higher rates of less exercise, are more likely to smoke and have higher rates of obesity (Brown S obesity (Brown S et al, et al, 1999; McCreadie R 1999; McCreadie R et al, et al, 2003). 2003).

To make matters worse many of the drugs used to treat schizophrenia To make matters worse many of the drugs used to treat schizophrenia are associated with weight gain and have been linked to obesity and are associated with weight gain and have been linked to obesity and type II diabetes (Russel J type II diabetes (Russel J et al, et al, 2001; Newcomer J, 2005). 2001; Newcomer J, 2005).

When compared to people from low social class backgrounds in the When compared to people from low social class backgrounds in the general population, sufferers have been shown to have significantly general population, sufferers have been shown to have significantly less healthy lifestyles (Brown S less healthy lifestyles (Brown S et al, et al, 1999; McCreadie R 1999; McCreadie R et al, et al, 2003). 2003).

MethodMethod

This is a qualitative study in which 7 people with schizophrenia were This is a qualitative study in which 7 people with schizophrenia were interviewed using semi-structured interviews about their lifestyle, interviewed using semi-structured interviews about their lifestyle, including their diet and exercise and were encouraged to talk about the including their diet and exercise and were encouraged to talk about the various factors which might influence their decisions and behaviour with various factors which might influence their decisions and behaviour with respect to these. respect to these.

They were deemed to have had a stable mental state for at least the They were deemed to have had a stable mental state for at least the previous 1 month prior to interview and be living in the community. previous 1 month prior to interview and be living in the community.

The subjects were selected using criterion based purposeful sampling The subjects were selected using criterion based purposeful sampling (Patton, 2002). They were identified through discussion with their (Patton, 2002). They were identified through discussion with their consultant, care coordinator and family if possible, and review of their consultant, care coordinator and family if possible, and review of their medical notes. medical notes.

Those who also had a diagnosis of a comorbid affective illness, anxiety Those who also had a diagnosis of a comorbid affective illness, anxiety disorder, alcohol dependence or illicit drug dependence were excluded. disorder, alcohol dependence or illicit drug dependence were excluded.

Data was collected through semi-structured, audiotape recorded Data was collected through semi-structured, audiotape recorded interviews carried out by one interviewerin the subject’s home which interviews carried out by one interviewerin the subject’s home which lasted 1-2 hours.lasted 1-2 hours.

Typical Interview QuestionsTypical Interview Questions Could you describe your typical day?Could you describe your typical day? What kinds of things do you usually eat?What kinds of things do you usually eat? Could you give me some examples of things you can cook?Could you give me some examples of things you can cook? Could you give me an example of a healthy meal?Could you give me an example of a healthy meal? What difficulties might there be in making your diet more healthy?What difficulties might there be in making your diet more healthy? Tell me about any exercise that you doTell me about any exercise that you do Tell me about any difficulties you may have encountered in trying to do regular Tell me about any difficulties you may have encountered in trying to do regular

exercise?exercise? Why do you suppose people think it is important to do regular exercise?Why do you suppose people think it is important to do regular exercise? Have you ever tried to give up smoking and what difficulties did you encounter?Have you ever tried to give up smoking and what difficulties did you encounter? Why do you suppose people think it is important to eat healthily?Why do you suppose people think it is important to eat healthily? Can you tell me about any health problems related to smoking that you are Can you tell me about any health problems related to smoking that you are

aware of?aware of? Have you heard of cholesterol? Can you tell me what you know about it?Have you heard of cholesterol? Can you tell me what you know about it? Have you heard of diabetes? Can you tell me what you know about it?Have you heard of diabetes? Can you tell me what you know about it? What are your sources of income?What are your sources of income? Do you think you might eat different things if you had more money?Do you think you might eat different things if you had more money?

Method continuedMethod continued

Thematic analysis was used to analyse the data which was Thematic analysis was used to analyse the data which was coded into categories in order to identify common themes coded into categories in order to identify common themes (Merriam, 2009). (Merriam, 2009).

The analysis of transcribed interviews was carried out by 5 The analysis of transcribed interviews was carried out by 5 analysts made up of a GP, general nurse, psychiatric nurse, analysts made up of a GP, general nurse, psychiatric nurse, psychiatrist and a layperson with a legal background. psychiatrist and a layperson with a legal background.

All 5 analysts were asked to read through the 7 transcripts All 5 analysts were asked to read through the 7 transcripts in full, and were asked to pick out sentences they thought in full, and were asked to pick out sentences they thought gave valuable or relevant information giving the line gave valuable or relevant information giving the line reference from the appropriate text, and give a reason or reference from the appropriate text, and give a reason or comment on why they thought that particular segment of comment on why they thought that particular segment of text was significant. text was significant.

Method continuedMethod continued

The information provided by the analysts was sent as a The information provided by the analysts was sent as a feedback report to the primary investigator. The feedback feedback report to the primary investigator. The feedback reports from the analysts were then analysed in detail by reports from the analysts were then analysed in detail by the primary investigator with reference to the transcripts to the primary investigator with reference to the transcripts to identify common themes.identify common themes.

The themes identified by the analysts were assigned The themes identified by the analysts were assigned colours which were used to code the data by highlighting colours which were used to code the data by highlighting the lines in the feedback reports where any given theme the lines in the feedback reports where any given theme was found, and were then cross-referenced to identify was found, and were then cross-referenced to identify those which appeared to be the most frequent and those which appeared to be the most frequent and consistent across all subjects interviewed. ie common consistent across all subjects interviewed. ie common themesthemes

Results – Subjective Lack of MotivationResults – Subjective Lack of Motivation

Quote 1: Quote 1: “I just can’t get anything done. I can’t “I just can’t get anything done. I can’t get motivated to do anything like housework or get motivated to do anything like housework or even going walking outside, I don’t want to do even going walking outside, I don’t want to do it sometimes.”it sometimes.”

Quote 2: Quote 2: “The other thing that’s stopping me “The other thing that’s stopping me from buying more food is lack of motivation. It from buying more food is lack of motivation. It takes you about an hour to cook and eat a takes you about an hour to cook and eat a meal doesn’t it really. You know, something meal doesn’t it really. You know, something substantial like meat and 2 veg. It just gets too substantial like meat and 2 veg. It just gets too much. I like to just have things that are easy much. I like to just have things that are easy and simple even though it gets boring.”and simple even though it gets boring.”

Results – Psychotic symptomsResults – Psychotic symptoms

Quote 3: Quote 3: “I’ve ended up burning stuff and “I’ve ended up burning stuff and letting pans boil dry because I’ve got all this letting pans boil dry because I’ve got all this going on in my ears and I’m not paying going on in my ears and I’m not paying attention to what I’m doing. I can’t concentrate attention to what I’m doing. I can’t concentrate on the food when I’ve got these voices in my on the food when I’ve got these voices in my ears..” ears..”

Quote 4: Quote 4: “If I met somebody in a red coat I’d “If I met somebody in a red coat I’d feel they were saying “we don’t want to know feel they were saying “we don’t want to know you, you’re a dangerous person.” That’s what I you, you’re a dangerous person.” That’s what I think about the colour red, it symbolises that think about the colour red, it symbolises that I’m a dangerous person and people don’t want I’m a dangerous person and people don’t want to know me.”to know me.”

Results-Lack of knowledge of physical Results-Lack of knowledge of physical health-related issueshealth-related issues

Quote 5: Question: “Do you think people who can get Quote 5: Question: “Do you think people who can get diabetes partly as a result of being overweight?”diabetes partly as a result of being overweight?”

Answer: “My uncle`s got it, I`ve heard it mentioned on Answer: “My uncle`s got it, I`ve heard it mentioned on television as well. All that propaganda about living television as well. All that propaganda about living healthily. It`s good that we have it, I mean some healthily. It`s good that we have it, I mean some countries have propaganda about, I don`t know, Fidel countries have propaganda about, I don`t know, Fidel Castro don`t they?”Castro don`t they?”

Quote 6: Question: “Do you know of any relationship Quote 6: Question: “Do you know of any relationship between your illness or your medication and diabetes?between your illness or your medication and diabetes?

Answer: “No not at all.”Answer: “No not at all.”

Results-Medication side effectsResults-Medication side effects

Quote 7:Quote 7: “Well I can get myself motivated, I can “Well I can get myself motivated, I can gear myself up, but it’s like fighting a losing gear myself up, but it’s like fighting a losing battle with the medication. It just drains you, it battle with the medication. It just drains you, it tires you out.”tires you out.”

Quote 8: Quote 8: “The hunger is hard to describe. It’s “The hunger is hard to describe. It’s an overwhelming urge and you can’t get it out an overwhelming urge and you can’t get it out of your mind until you eat. In the past I’ve of your mind until you eat. In the past I’ve stopped taking my medication for 6 to 8 stopped taking my medication for 6 to 8 months and ended up in a psychiatric hospital. months and ended up in a psychiatric hospital. I’ve managed 6 to 8 months without medication I’ve managed 6 to 8 months without medication and I’ve gone down to my normal weight in that and I’ve gone down to my normal weight in that time.”time.”

DiscussionDiscussion

A meta-analysis of 11 RCTs found that adding SSRIs to antipsychotics A meta-analysis of 11 RCTs found that adding SSRIs to antipsychotics did not reduce negative symptoms in people with schizophrenia-did not reduce negative symptoms in people with schizophrenia-spectrum disorder (Sepehry AA spectrum disorder (Sepehry AA et al, et al, 2007). 2007).

The efficacy of glutamatergic agents for negative symptoms has also The efficacy of glutamatergic agents for negative symptoms has also been studied, and they have also generally been found to be been studied, and they have also generally been found to be ineffective (Buchanan R W ineffective (Buchanan R W et al, et al, 2007) 2007)

Research is ongoing in this area and psychosocial interventions may Research is ongoing in this area and psychosocial interventions may prove more useful than medication at tackling this syndrome of prove more useful than medication at tackling this syndrome of symptoms, for example some positive effects in reducing negative symptoms, for example some positive effects in reducing negative symptoms have been found with music therapy (Gold C symptoms have been found with music therapy (Gold C et al, et al, 2005). 2005).

A recent meta-analysis ofA recent meta-analysis of CBT for schizophrenia showed a significant CBT for schizophrenia showed a significant beneficial effect on positive symptoms but in the group of beneficial effect on positive symptoms but in the group of methodologically adequate studies the effects on negative symptoms methodologically adequate studies the effects on negative symptoms were not significant (Wykes T were not significant (Wykes T et al, et al, 2008). 2008).

Discussion continuedDiscussion continued

Other studies have also shown a relationship between Other studies have also shown a relationship between positive symptoms and impairment in quality of life (Mohamed positive symptoms and impairment in quality of life (Mohamed S S et al, et al, 20082008)). Recently more emphasis has been placed on . Recently more emphasis has been placed on the use of psychosocial interventions to help reduce these the use of psychosocial interventions to help reduce these symptoms, and there is a great deal of evidence that CBT symptoms, and there is a great deal of evidence that CBT especially is effective (Wykes T especially is effective (Wykes T et alet al, 2008)., 2008).

Studies have shown that interventions which have included Studies have shown that interventions which have included health promotion and education such as a nurse led well health promotion and education such as a nurse led well being programme (Ohlsen RI being programme (Ohlsen RI et alet al, 2005), 2005) and a GP led and a GP led inpatient service (Welthagen E inpatient service (Welthagen E et alet al , 2004) , 2004) can have can have significant beneficial effects in patients with a variety of significant beneficial effects in patients with a variety of mental disorders including schizophrenia.mental disorders including schizophrenia.

Discussion continuedDiscussion continued

The detrimental effect of weight gain (Allison DB The detrimental effect of weight gain (Allison DB et alet al, , 2003) and metabolic syndrome (Meyer JM 2003) and metabolic syndrome (Meyer JM et alet al, 2005) on , 2005) on quality of life has been found in other studies. quality of life has been found in other studies.

An RCT in of patients with first psychotic episode An RCT in of patients with first psychotic episode schizophrenia found that metformin and lifestyle changes schizophrenia found that metformin and lifestyle changes (psychoeducation, dietary changes and exercise) were (psychoeducation, dietary changes and exercise) were effective in reducing antipsychotic induced weight gain in effective in reducing antipsychotic induced weight gain in adults, especially when used together (Wu RR adults, especially when used together (Wu RR et al, et al, 2008).2008).

A meta-analysis of non-pharmacological interventions A meta-analysis of non-pharmacological interventions (CBT, nutritional counselling and exercise) found that they (CBT, nutritional counselling and exercise) found that they were effective in managing weight gain related to were effective in managing weight gain related to antipsychotic use in people with schizophrenia spectrum antipsychotic use in people with schizophrenia spectrum disordersdisorders (Alvarez-Jimenez M (Alvarez-Jimenez M et alet al, 2008). , 2008).

ImplicationsImplications

The aim of this study was to improve our understanding of The aim of this study was to improve our understanding of the possible causes of the unhealthy lifestyle choices of the possible causes of the unhealthy lifestyle choices of people with schizophrenia. These findings suggest that people with schizophrenia. These findings suggest that there are many factors at play which appear to make it there are many factors at play which appear to make it more likely for people with a diagnosis of schizophrenia to more likely for people with a diagnosis of schizophrenia to make unhealthy choices rather than healthy ones. This make unhealthy choices rather than healthy ones. This emphasises the complexity of this illness which has emphasises the complexity of this illness which has multiple syndromes and also the less than ideal treatments multiple syndromes and also the less than ideal treatments we currently have at our disposal. It suggests that we need we currently have at our disposal. It suggests that we need to take a holistic approach when considering the physical to take a holistic approach when considering the physical health of such patients and that health promotion and health of such patients and that health promotion and education must go hand in hand with rigorous physical education must go hand in hand with rigorous physical health monitoring and careful prescribing.health monitoring and careful prescribing.

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