Text adapted from "The patient with Psychosis" in Psychiatry in primary care by George Foussias and Z. Jeff Daskalakis (CAMH, 2019).
Schizophrenia and related psychotic disorders are chronic illnesses characterized by significant morbidity and mortality. These outcomes are a consequence of psychiatric symptoms and the physical illnesses that often accompany these disorders, particularly diabetes mellitus, obesity, metabolic syndrome, hypertension, and cardiovascular and pulmonary disease. Contributing to the risk of developing these physical illnesses are disease-related factors (e.g., the impact of symptoms on help-seeking behaviour), lifestyle factors (e.g., high rates of smoking, poor diet and inactivity), the effects of antipsychotic medication and reduced access to primary medical care.
This complex interplay between psychiatric symptoms and physical illness highlights the importance of ongoing collaborative multidisciplinary care in treating people with schizophrenia and related disorders.
What is reasonable to expect of a primary care practitioner?
- Diagnose and conduct initial screening for underlying medical illnesses.
- Assess suicide risk.
- Initiate treatment and monitor treatment response and symptom severity.
- Monitor extrapyramidal symptoms.
- Monitor metabolic and cardiovascular risk factors in all patients taking antipsychotic medication, particularly SGAs, regardless of which treatment provider is prescribing them.
- Manage comorbid physical illnesses.
- Refer when necessary.
When to refer to a specialist
- First presentation of psychotic symptoms
- Diagnostic clarification and treatment
- Severe presentation (safety risks to self or others, serious functional impairment, comorbid medical or substance use problems)
- Refractory to standard treatment (two or more medication trials)
- Acute decompensation
- When considering clozapine or ECT