When managing their patients with schizophrenia, psychiatrists are increasingly concerned about physical disorders, including weight gain, obesity, metabolic abnormalities (in particular, diabetes and the metabolic syndrome), prolactin increase, sexual dysfunction and cardiovascular disease. Other common health-related problems in these patients include recreational drug use, sedation/physical inactivity, adverse drug effects and poor self-care. Each of these can have an impact on patient well-being, adherence to therapy and life expectancy. Collectively they can pose substantial barriers to optimal outcomes. However, the widespread acknowledgement of the importance of the physical health of patients with schizophrenia does not always result in consistent monitoring and management of physical health risks in the clinic. Urgent action is needed to ensure that psychiatrists prioritise physical healthcare alongside mental healthcare as a way to improve the longterm outcomes of treatment in all patients with schizophrenia.

In the management of schizophrenia, mental health outcomes are the principal focus of treatment. The objective is to control the psychotic symptoms while minimising negative features of the illness, to achieve an overall improvement in the societal functioning of patients. Physical health is also important because if it is compromised, many of the benefits of improved mental health will be offset. Compared with the general population, schizophrenia patients are at increased risk of weight gain, abdominal obesity, diabetes, metabolic syndrome, and cardiovascular disease. These physical health problems can contribute to the decreased quality of life, lowered self-esteem and reduced life expectancy commonly reported in schizophrenia. For these reasons there is a pressing need to improve both the monitoring and the management of physical health in patients with schizophrenia as a part of their overall care. A consensus for metabolic monitoring of patients receiving treatment with antipsychotic drugs is available. However, the practicing clinician requires guidance about management of physical health in routine clinical practice. This should include recommendations for measurements that have strong predictive value about physical health risks yet are easy to make, and about the use of medications that have the least effect on physical health parameters. This article will review the gravity of the physical health risks facing schizophrenia patients.

Determinants of antipsychotic selection and response include parameters of the primary disorder, psychiatric and physical comorbidities, past treatment effects, patient preferences, availability and acceptability of different treatments and formulations, as well as expected efficacy and safety. In the absence of consistent and sufficiently large efficacy differences among antipsychotics (except for clozapine in refractory patients), and in view of a greater focus on physical health, functional outcomes and quality of life, relatively more predictable differences in adverse events have become an important management consideration. Treatments are often selected because of a relatively lower propensity for extrapyramidal and sexual side effects, sedation, and, especially, the reduced development of cardiometabolic risk states and disorders. In this context, differences in receptor binding affinity, intrinsic activity and in the half life of antipsychotics are crucial to adopt adequate dosing and switching strategies. Dopamine rebound phenomena can occur when the level of dopamine blockade is not kept relatively constant during the switch process. This can happen when the new antipsychotic is underdosed or not fully absorbed, the switch is too abrupt from an antipsychotic with a short half life to one with a much longer half life, or when a dopamine antagonist is switched too fast to an antipsychotic with markedly less dopamine affinity or to a partial dopamine agonist. Intra-switch destabilization can also occur when changing too quickly from antipsychotics with strong histaminergic and/or cholinergic blockade to ones with lower affinity to these receptors. Overlapping “plateau” switch strategies and transient co-treatment with calming medications, such as benzodiazepines, have emerged as potential solutions to these rebound phenomena that can complicate the early switch period. To optimize outcomes, antipsychotic treatment should be pharmacologically informed and measurement based, combining both acute and long-term management goals and balancing efficacy and adverse effect considerations.

Severe mental disorders have a chronic course associated with a high risk for co-morbid somatic illnesses and premature mortality, but despite this increased risk, general health care needs in this population are often neglected. Over recent years, several groups have developed screening and monitoring guidelines for metabolic and cardiovascular risk assessment in patients treated with antipsychotics. The psychiatrist needs to be aware of the potential metabolic side-effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness. Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population. In our University Centre, a structured and elaborate screening and monitoring protocol was introduced in late 2003. This paper describes the practical aspects of this monitoring protocol and the results obtained 4 years after its implementation.

Medical morbidity and mortality levels remain elevated in people with schizophrenia compared with the general population. Despite the increasing recognition of an excess of physical health problems in this population, health screening remains limited. Medical risk in this population can be related to a variety of sources. The disease process itself as well as poor diet and sedentary lifestyle contribute to the overall physical health problems. In addition antipsychotic medication can contribute to the risk of cardiovascular and metabolic problems. The Dundee Health Screening Clinic was developed to address the needs of this population by monitoring physical health and providing follow-up to ensure that patients received the necessary care. The Clinic demonstrates how a coordinated approach can be used to take simple steps to improve the overall well-being of these patients. It was set up by adapting the manpower resources and procedures of the community mental health team and local resource centre, without specific additional funding. Simple clinical measurements and tests were conducted in the Clinic and patients clearly demonstrated on a satisfaction questionnaire that they considered the health checks important. This Clinic is an example of how a holistic approach can impact on both the physical and mental well-being of patients and offer them improved care and therefore a better quality of life.

Physical health monitoring is crucial in the light of current knowledge about the risks associated with schizophrenia and its treatment. Cooperation between psychiatrists, patients and informal carers can significantly enhance patient wellbeing in this regard. Moreover, an advocacy approach elevates patients from being passive recipients of care to active participants in an integrated system that has outcome benefits for all stakeholders. Considerable progress is being made in this regard, although there is still a long way to go to maximise the benefits of carer involvement in the global management of schizophrenia.

This international meeting discussed the management of physical health in patients with schizophrenia in several countries including France, Spain, Germany, the UK and Italy. Physical health parameters, including weight, blood pressure, blood glucose, lipids and standard biochemical assessments are measured in many patients at the first hospital consultation. These reveal physical disorders such as obesity, hypertension, dyslipidaemia, the metabolic syndrome, substance abuse, cardiovascular disease, extrapyramidal symptoms, sexual dysfunction and diabetes in substantial proportions of patients. Psychiatrists consider switching antipsychotic therapy if excessive sedation, extrapyramidal symptoms, unacceptable weight gain, hyperglycaemia or dyslipidaemia occur. In general, switching is more likely to be considered for symptomatic adverse events than for laboratory abnormalities. Switching is discouraged by limited knowledge of protocols, the absence of guidelines and fears of relapse or reduced treatment adherence. The physical health of patients with schizophrenia receives much less attention in the community setting than in the hospital setting. Improved guidelines, protocols, resources and support are needed to improve the physical health of patients in the community.

Improved physical health care is a pressing need for patients with schizophrenia. It can be achieved by means of a multidisciplinary team led by the psychiatrist. Key priorities should include: selection of antipsychotic therapy with a low risk of weight gain and metabolic adverse effects; routine assessment, recording and longitudinal tracking of key physical health parameters, ideally by electronic spreadsheets; and intervention to control CVD risk following the same principles as for the general population. A few simple tools to assess and record key physical parameters, combined with lifestyle intervention and pharmacological treatment as indicated, could significantly improve physical outcomes. Effective implementation of strategies to optimise physical health parameters in patients with severe enduring mental illness requires engagement and communication between psychiatrists and primary care in most health settings.