Navigating the A to Z of Schizophrenia, Part 1: Prevalence and Persistence

Transcript:

Hi, I'm Andrew Penn. I'm a psychiatric nurse practitioner and a clinical professor at the University of California San Francisco School of Nursing. I also treat patients at the San Francisco VA.  

This video is going to discuss a high-level overview of the widespread impact of schizophrenia and also unmet needs, including comorbidities and contributions to disability.

Schizophrenia is a chronic and disabling mental illness that affects approximately 24 million people globally, around 0.3% of the total world’s population.

In the United States, estimating schizophrenia’s prevalence is difficult due to underreporting and underdiagnosing of the condition, which may be the result of ambiguity surrounding the diagnosis and stigma associated with seeking and receiving mental healthcare. 

Reviews of survey samples, including clinical diagnostic interviews and medical numbers, place the estimate closer to 0.25% to 0.64%.

Schizophrenia affects males and females roughly equally, but the onset tends to occur earlier in males, typically in their late teens. Females, by contrast, often experience onset of schizophrenia in their early twenties.

Females also show a secondary age of onset around 45 years of age; females make up 66% to 87% of patients who have a new onset after the age of 40 to 50 years.

Females tend to report a higher degree of positive symptoms, such as hallucinations or delusions, whereas males report more negative symptoms, like depression and social withdrawal. Males also tend to have more severe deficits in memory and more pronounced symptoms.

These differences may be due to dopamine receptor differences between males and females, although the data is inconclusive. Other factors, such as hormones and genetic components, are under ongoing investigation.

Schizophrenia is a progressive mental illness that develops over several distinct stages, each with specific symptoms and challenges.

The prodromal phase often begins in the late teens or early twenties and is marked by withdrawal from social activities, unusual or paranoid thoughts, and a noticeable decline in school or work performance. This phase is subtle and often goes unrecognized until the acute phase occurs, in which psychotic symptoms such as hallucinations, delusions, and disorganized thinking begin to emerge. These symptoms can be highly disruptive and typically lead to a diagnosis and sometimes require hospitalization to manage.

The chronic phase of the illness follows and is characterized by persistent cognitive impairments, such as memory problems, difficulty with attention, and reduced executive function, all of which worsen over time.

In the residual phase, while psychotic symptoms may diminish, individuals often experience ongoing cognitive and social challenges.

Throughout this whole progression, a gradual decline in daily functioning occurs, with increased difficulty in managing basic tasks and maintaining independence. Early intervention and consistent treatment are critical to improving outcomes, and long-term data show substantially increased response rates in patients who receive treatment, with up to 34% demonstrating a positive response.

Schizophrenia is also one of the leading causes of disability around the world, with an average of 28.5 years of potential life lost among people with schizophrenia in the United States. Roughly half of people with schizophrenia have comorbid behavioral health disorders.

Approximately 5% of people with schizophrenia die by suicide, and about 55% of people with schizophrenia have attempted or will attempt suicide. 

There is a noticeable decrease in the likelihood of suicidal behaviors after the age of 45 for both sexes, so some good news there.

Psychiatric comorbidities are common in schizophrenia. There is an increased prevalence of PTSD (posttraumatic stress disorder), OCD (obsessive-compulsive disorder), GAD (generalized anxiety disorder), and social anxiety disorder among patients with schizophrenia. Panic attacks and panic disorders are common in patients with schizophrenia, with studies showing that 28% to 63% of patients may experience panic attacks. PTSD was observed in 10% to 22% of patients with schizophrenia, and OCD in about a third.

Both depression and substance abuse are evident in around half of patients with schizophrenia.

Beyond psychiatric comorbidities, individuals with schizophrenia face heightened risks of physical health conditions, including cardiovascular disease, diabetes, and obesity.

These risks are due to medication side effects, but also lifestyle factors (such as smoking), and disparities in access to healthcare for people with serious mental illness. These comorbidities contribute greatly to early mortality experienced by people with schizophrenia.  

Direct medical costs associated with schizophrenia include hospitalization and medications, while indirect costs arise from things such as unemployment and the cost put upon caregivers for taking care of loved ones. Together, these costs contribute significantly to economic, societal strain. The financial burden of schizophrenia doubled from 2013 to 2019 and now costs around $343 billion annually.

Of the total economic burden for schizophrenia in the United States, only 18%, or $62 billion, is for direct healthcare costs. The largest and most overlooked aspects of this burden are the indirect costs of $252 billion, this caregiving cost that results in lost economic opportunities and comprises about one-half of the indirect costs of the illness. It’s estimated that the annual caregiving cost to care for a patient with schizophrenia is about $29,000. Underemployment and early mortality for patients with schizophrenia are another large portion of these indirect costs. Most research concludes that addressing these indirect costs is one of our greatest unmet needs.

Though prevalence estimates vary widely due to underreporting and diagnostic challenges, schizophrenia affects millions of people worldwide with an estimated point prevalence of close to one-third of one percent.

Many patients with schizophrenia have comorbid conditions, including physical health issues that can markedly shorten lifespan, and psychiatric comorbidities that impact quality of life. Societal stigma further complicates care, emphasizing the need for multifaceted interventions.

Please see our other presentations on the symptomatology and diagnosis of schizophrenia, as well as novel treatment mechanisms related to the condition. Thanks for watching.