Schizophrenia is a common psychiatric disorder affecting approximately 1% of the global population. In addition to psychosis, schizophrenia is characterized by a combination of positive, negative, and cognitive symptoms.  

Positive symptoms can include delusions and hallucinations, while negative symptoms can include things such as amotivation or social withdrawal. Cognitive symptoms vary, causing deficits in memory and function.1,2 These symptoms greatly impact patients with schizophrenia, with many struggling with day-to-day activities. Unemployment rates can be as high as 80% to 90%.3 Additionally, patients often have trouble with social interaction, leading to problems with family and friend relationships.4

The economic burden of schizophrenia is significant for everyone—patients, caregivers, and society. It has been estimated that annual costs associated with schizophrenia in the United States are greater than the annual costs of all cancers combined.5  

Patients with schizophrenia use healthcare at a high rate, with direct healthcare costs including inpatient, outpatient, emergency department, long-term care, pharmacy, and other care such as rehabilitation services.  

Direct non-healthcare costs can include costs associated with law enforcement, homeless shelters, and other social services. Lastly, indirect costs can be related to unemployment, caregiving, productivity loss, and premature mortality.

To put this into perspective, a recent study found the estimated economic burden of schizophrenia in 2019 to be $343 billion in indirect costs, $62 billion in direct healthcare costs, and $35 billion in non-healthcare costs. Indirect costs were predominantly related to caregiving, premature mortality, and unemployment.5

In addition, patients with schizophrenia are at a higher risk for several comorbidities. It has been estimated that 50% to 80% of individuals with a serious mental illness such as schizophrenia suffer from one or more comorbid conditions.6 Patients with schizophrenia find themselves at a higher risk for cardiovascular disease, stroke, and heart failure.7 Patients with schizophrenia are also more likely to develop metabolic syndrome, including obesity, hypertension, dyslipidemia, and diabetes.8 Other common comorbidities include respiratory and pulmonary conditions, genitourinary disease, and epilepsy.6

Many factors can contribute to comorbidities, including some medications.9 Antipsychotics may be associated with a wide range of side effects that can cause severe impairment and even death.10 Patients taking antipsychotic medication can experience additional neurological, behavioral, anticholinergic, cardiac, pulmonary, metabolic, skeletal, and sexual system side effects. Because these side effects can range from mild to severe, making the choice of which antipsychotic drug to use is an extremely important decision.10,11

Patients with schizophrenia are also much more likely to die prematurely, losing an estimated 15 to 20 years of their life.12 These patients are at a higher risk of death by suicide, unnatural causes, and death associated with cardiovascular or respiratory disease.13 There are many proposed factors leading to the premature mortality rate for schizophrenia patients. We’ve already talked about how, in addition to the many psychiatric symptoms that these patients have, they often also have multiple comorbidities. Studies have shown that people with schizophrenia may not receive the medical care and treatment that they need as compared to the general population, increasing their risk of premature mortality.13 Lifestyle factors and antipsychotic medication use or lack of use can also contribute to this increased mortality rate.12

A recent meta-analysis aimed to quantify the risk of premature death in schizophrenia by looking at 135 cohort studies comparing 4.5 million schizophrenia patients with 1.1 billion people in the general population. The study found a 2.9-fold increased risk for all-cause mortality in schizophrenia patients versus the general population. With physical disease-matched controls, the increased risk was 1.6-fold.12 The most common causes of premature mortality were found to be suicide; non-natural causes such as poisoning; pneumonia; infectious, endocrine, and respiratory diseases; injury or accidents; diabetes; alcohol use and gastrointestinal disease; urogenital disease; neurological disease; cardiovascular disease; liver disease; cerebrovascular disease; and cancer.12

The study found that relative to the same-aged general population, premature mortality was more common in patients with earlier-phase schizophrenia compared to later, chronic schizophrenia. All-cause and suicide-related mortalities were more likely to occur in patients younger than 40 years of age relative to their age-matched general population controls. As expected, substance use increased the risk of premature mortality while antipsychotic treatment decreased the risk.12

Results from this study emphasize the importance of early and accurate diagnosis followed by initiation of treatment. Despite the side effects associated with antipsychotics, antipsychotic use (particularly second-generation agents or long-acting injectables) was associated with a lower all-cause mortality rate. Class of antipsychotic matters, with first-generation antipsychotics being associated with an increased risk of suicide in patients with first-episode schizophrenia. Interestingly, another study using a within-subject design found that the use of antipsychotics was associated with a higher concurrent adherence rate to other medications—including statins, anti-diabetic agents, anti-hypertensives, and beta blockers, potentially explaining the mortality—reducing effects of antipsychotics despite often having cardiometabolic side effects.12

Monitoring patients is of the utmost importance. Suicide is one of the leading causes of premature mortality and can be prevented through screening efforts. Often, patients with more severe illness or illness with depressive symptoms are more likely to commit suicide, something providers can be aware of and devote extra time to optimize the treatment plan for this subset of patients.12

Monitoring patients regularly is essential due to the multitude of comorbidities possible and increased risk of premature mortality, particularly by suicide, but also by cardiometabolic disorders.    

References:

  1. Velligan DI, Rao S. The epidemiology and global burden of schizophrenia. J Clin Psychiatry. 2023;84(1):MS21078COM5. doi:10.4088/JCP.MS21078COM5
  2. McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia-an overview. JAMA Psychiatry. 2020;77(2):201-210. doi:10.1001/jamapsychiatry.2019.3360
  3. Wander C. Schizophrenia: opportunities to improve outcomes and reduce economic burden through managed care. Am J Manag Care. 2020;26(3 Suppl):S62-S68. doi:10.37765/ajmc.2020.43013
  4. Crespo-Facorro B, Such P, Nylander AG, et al. The burden of disease in early schizophrenia - a systematic literature review. Curr Med Res Opin. 2021;37(1):109-121. doi:10.1080/03007995.2020.1841618
  5. Kadakia A, Catillon M, Fan Q, et al. The economic burden of schizophrenia in the United States. J Clin Psychiatry. 2022;83(6):22m14458. doi:10.4088/JCP.22m14458
  6. Bahorik AL, Satre DD, Kline-Simon AH, Weisner CM, Campbell CI. Serious mental illness and medical comorbidities: findings from an integrated health care system. J Psychosom Res. 2017;100:35-45. doi:10.1016/j.jpsychores.2017.07.004
  7. Correll CU, Solmi M, Veronese N, et al. Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry. 2017;16(2):163-180. doi:10.1002/wps.20420
  8. Vancampfort D, Stubbs B, Mitchell AJ, et al. Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta-analysis. World Psychiatry. 2015;14(3):339-347. doi:10.1002/wps.20252
  9. Vancampfort D, Correll CU, Galling B, et al. Diabetes mellitus in people with schizophrenia, bipolar disorder and major depressive disorder: a systematic review and large scale meta-analysis. World Psychiatry. 2016;15(2):166-174. doi:10.1002/wps.20309
  10. Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry. 2018;17(3):341-356. doi:10.1002/wps.20567
  11. Solmi M, Murru A, Pacchiarotti I, et al. Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review. Ther Clin Risk Manag. 2017;13:757-777. doi:10.2147/TCRM.S117321
  12. Correll CU, Solmi M, Croatto G, et al. Mortality in people with schizophrenia: a systematic review and meta-analysis of relative risk and aggravating or attenuating factors. World Psychiatry. 2022;21(2):248-271. doi:10.1002/wps.20994
  13. Olfson M, Gerhard T, Huang C, Crystal S, Stroup TS. Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry. 2015;72(12):1172-1181. doi:10.1001/jamapsychiatry.2015.1737