Craig Chepke 博士，CURESZ 基金会董事会成员，私人执业精神科医生和北卡罗来纳大学医学院精神病学兼职助理教授

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.

与一般人群相比，精神分裂症患者的死亡率是其两倍多，寿命缩短 10-25 年 (1)。虽然这种差异的部分原因可能是自杀风险高得多（比一般人群高 12 到 170 倍），但仅心血管疾病导致的额外死亡人数就超过了精神分裂症患者自杀造成的死亡人数 (2,3).也许是时候开始将合并症视为一种紧急情况，就像我们自杀一样！

我们还应该考虑到许多精神分裂症患者在社会经济上处于不利地位。这增加了吸烟、缺乏运动和不健康饮食等生活方式风险的可能性。由于医疗系统不堪重负、保险问题或交通问题，他们也可能无法获得定期的预防性医疗服务。

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.

“患有精神分裂症的人应该同时拥有这两种生活
心理稳定，身体健康。”

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.

将身体健康视为精神病治疗计划的一部分可能并不明显，但这样做是必不可少的。 开始似乎势不可挡，所以这里有一些行动项目可以帮助精神分裂症患者抵抗它可能对他们身体造成的身体伤害：

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

2) 跟踪您的体重和裤子尺寸的变化，因为腰围尺寸是代谢综合征的有用预测指标。

3) 务必定期与初级保健提供者进行检查。

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!

参考：

  1. 世界卫生组织精神障碍信息表。 https://www.who.int/mental_health/management/info_sheet.pdf
  2. Zaheer、Juveria 等人。 “精神分裂症谱系障碍诊断时的自杀预测因素：加拿大安大略省一项为期 20 年的总人口研究。”精神分裂症研究 (2020)。
  3. 厄斯比、厄本等人。 “瑞典斯德哥尔摩县精神分裂症的死亡率和死因。”精神分裂症研究 45.1-2 (2000): 21-28
  4. 利伯曼、杰弗里 A. 等人。 “抗精神病药物对慢性精神分裂症患者的疗效。” 新英格兰医学杂志353.12 (2005): 1209-1223.
  5. Nasrallah, Henry A., 等人。 “精神分裂症中高血压、血脂异常和糖尿病的低治疗率：来自基线时 CATIE 精神分裂症试验样本的数据。”精神分裂症研究 86.1-3 (2006)：15-22。