Dr. Craig Chepke, Membro do Conselho de Administração da Fundação CURESZ, Psiquiatra de Prática Privada e Professor Assistente Adjunto de Psiquiatria, Escola de Medicina da Universidade da Carolina do Norte

Why try to improve someone’s life psychiatrically if we let them die from cardiovascular disease 10-20 years earlier than people without serious mental illness? My psychiatry training program maintained that one is “a physician first, and a psychiatrist second.” Therefore, I have increasingly asked myself this question over the past several years. In addition to being a severe brain disease, schizophrenia is also associated with a greater risk of many other physical disorders, referred to as comorbidities. Common comorbidities include obesity, cardiovascular and metabolic disease (e.g., diabetes or high cholesterol), respiratory illnesses, infectious diseases, and many others disorders.

As pessoas com esquizofrenia têm mais que o dobro da taxa de mortalidade e a expectativa de vida é reduzida em 10 a 25 anos em comparação com a população em geral (1). Embora parte dessa diferença possa ser devida ao risco muito maior de suicídio (12 a 170 vezes maior do que a população em geral), o número de mortes excessivas por doenças cardiovasculares supera as resultantes de suicídio para pessoas com esquizofrenia (2,3). Talvez seja hora de começar a pensar nas comorbidades como uma emergência da mesma forma que fazemos o suicídio!

Devemos também considerar que muitas pessoas com esquizofrenia são socioeconomicamente desfavorecidas. Isso aumenta a probabilidade de ter riscos de estilo de vida, como fumar, falta de exercício e dietas pouco saudáveis. Eles também podem não ter acesso a cuidados médicos preventivos regulares devido a um sistema médico sobrecarregado, problemas de seguro ou problemas de transporte.

This is a powder keg of risk factors and on top of that, most antipsychotic medications have some degree of weight gain or other metabolic problems as potential side effects.

“As pessoas que vivem com esquizofrenia merecem uma vida com ambos
estabilidade mental e boa saúde física”.

Psychiatrists have a significant challenge in figuring out how to proceed when these complications develop. A common strategy is to switch the person to an antipsychotic medication with a lower risk, such as ziprasidone, lurasidone, cariprazine, or lumateperone. However, the antipsychotic medications that carry the highest risk for these obstacles also have some of the best reputations for efficacy, including clozapine and olanzapine. Antipsychotic medications are usually not interchangeable when it comes to maintaining treatment response, which puts the person at risk of relapse.

Finding the balance between benefits and side effects can be like walking the razor’s edge at times. Both are important, but which one should we prioritize? The National Institute of Mental Health performed a large clinical trial to answer questions like this. The CATIE study took a more “real-world” approach by comparing the length of time people with schizophrenia continued to take the antipsychotic medications they were on. This approach is based on the theory that if someone keeps taking a medication over the long run, the benefits must exceed the drawbacks. People stayed on olanzapine longer than the other antipsychotic medications tested despite having the highest amount of weight and metabolic side effects, presumably because of its superior efficacy (4). CATIE also highlighted the unfortunate lack of medical care for people with schizophrenia. Participants in clinical trials generally get a higher level of care than in the general community, but in the CATIE study, 30% of participants with diabetes, 62% with high blood pressure, and 88% with high cholesterol were not receiving any treatment for these conditions (5).

The saying that “an ounce of prevention is worth a pound of cure” is common for a reason. It’s much harder to lose weight than it is to prevent weight gain from happening, so waiting to react until after weight gain occurs isn’t usually a good strategy. As such, it’s becoming increasingly common for psychiatrists to prescribe metformin (also used in type 2 diabetes) at the start of treatment with an antipsychotic to reduce the risk of weight gain proactively. Similarly, a medication was approved by the FDA in 2021 containing the highly effective antipsychotic olanzapine with a medication that reduces weight gain potential, samidorphan, in a single pill.

Pode não ser óbvio pensar na saúde física como parte do plano de tratamento psiquiátrico, mas é essencial fazê-lo. Começar pode parecer esmagador, então aqui estão alguns itens de ação para ajudar as pessoas com esquizofrenia a lutar contra o desgaste físico que isso pode causar em seu corpo:

1) Talk to your psychiatrist about your physical health and ways to help you support it.

2) Acompanhe as mudanças no peso e no tamanho das calças, pois o tamanho da cintura é um indicador útil da síndrome metabólica.

3) Certifique-se de fazer exames regulares com um prestador de cuidados primários.

People living with schizophrenia deserve a life with both mental stability and good physical health. Let’s make fighting for the best of both worlds your New Year’s Resolution!

Referências:

  1. Folha de informações sobre transtornos mentais da Organização Mundial da Saúde. https://www.who.int/mental_health/management/info_sheet.pdf
  2. Zaheer, Juveria, et al. “Preditores de suicídio no momento do diagnóstico no transtorno do espectro da esquizofrenia: um estudo populacional total de 20 anos em Ontário, Canadá.” Pesquisa sobre esquizofrenia (2020).
  3. Ösby, Urban, et al. “Mortalidade e causas de morte na esquizofrenia no condado de Estocolmo, Suécia.” Pesquisa de esquizofrenia 45.1-2 (2000): 21-28
  4. Lieberman, Jeffrey A., et al. "Eficácia de drogas antipsicóticas em pacientes com esquizofrenia crônica." Revista de medicina da Nova Inglaterra353.12 (2005): 1209-1223.
  5. Nasrallah, Henry A., e outros. “Baixas taxas de tratamento para hipertensão, dislipidemia e diabetes na esquizofrenia: dados da amostra do estudo de esquizofrenia CATIE na linha de base.” Pesquisa de esquizofrenia 86.1-3 (2006): 15-22.