Barriers to effective physical health care management of people with schizophrenia literature review

Barriers to effective physical health care management of people with schizophrenia literature review


Chapter 2: Critical Review of the Literature

Chapter 2.1: Causes of Physical Health Problems in Schizophrenia

Brown and Mitchel (2012) posited that people suffering from Schizophrenia have a significantly low life expectancy with reports of their mortality being 2-3 times that of the general population. In their article, Brown and Mitchel (2012) argue that the leading cause of mortality among these patients is natural causes with the largest percentage cause of death being cardiovascular disease. There argument is in tandem with the reports that physical illness is quite common among individuals suffering from severe schizophrenia. The two authors attribute the same to different factors such as the association between mental and physical illnesses and the complications resulting from the mental illness itself following persistent use of medication.

Schizophrenia patients and other mentally ill patients often suffer many physical health-related problems. Various studies on the interaction between physical health and mental health indicate psychiatric patients often endure physical health complications. In their article, Heggelund et al (2011) posited that most of the patients with Schizophrenia and major depression often suffer from cardiovascular and respiratory disease. The authours  attribute the occurrence of these diseases in these patients to higher rates of smoking. In addition, Harrison and Gill (2010) suggest that the people with Schizophrenia experience poor dietary habits, poor living conditions and cognitive impairment among others.


Heggelund et al. (2011) observed that patients suffering from Schizophrenia tended to gain weight and become obese. A research conducted by Brown and Mitchel (2012) showed that the incidence of obesity was high in Schizophrenia patients, accounting for up to 42% compared with 27% of the general population. The high percentage of Schizophrenia patients developing obese has thus been a key physical concern largely because it leads to the development of diabetes among other diseases.

The tendency by the Schizophrenia patients to become obese has been attributed to different factors. In their article, Connolly and Kelly (2005) suggested that one of such factors is because the patients, in many cases, consume poor diets that are rich in fat and low fibre content without any consideration of the health implication. The authors also argue that these patients tend to lead a sedentary life, and this often reflects symptoms such as apathy and somnolence. The accumulation of calories in their bodies coupled with poor diet and lack of regular exercise serve as the predisposing factors for these patients to become obese. Barriers to effective physical health care management of people with schizophrenia literature review.

Hagg, Lindblom, Mjorndal and Adolfsson (2006) observed that physical weight gain, as in the case of obesity, has serious health complications. They posit that obesity can lead to a condition known as metabolic syndrome that is commonly associated with Type II diabetes, dyslipidaemia and hypertension. In addition, studies show that obesity could lead to long-term physical consequences such as the development of uterus cancer, problems with prostate gland, the kidney and the gall bladder. Hagg et al. (2006) also argue that despite the huge physical implications linked with obesity in patients with schizophrenia; the disease has failed to attract the prerequisite attention largely because it is treatable.

In his article, Garden (2005) cites different studies indicating that a majority of the people with Schizophrenia tend to have smoking habits. Although there is no direct link between the disease and the initiation of smoking seen in the patients, Levander, Berhard and Lindstro (2007) posited that once the patient begins smoking, they tend to do so heavily more than the general population. In the process of smoking, the patients take in large proportions of nicotine, and this is what causes even greater addiction. Levander, Berhard and Lindstro (2007) attributed this effect to deeper inhalation by the Schizophrenic patients and also a genetic factor that links Schizophrenia with some of nicotine receptor (Levander, Berhard & Lindstro, 2007).

Studies also show that smoking may induce hepatic enzymes (Juhlin et al., 2009). As a result of the induction, the enzymes increase the rate at which they clear drugs from the bloodstream; consequently, this lowers the plasma levels of any antipsychotic drugs the patient may have taken. Accordingly, the high incidence of smoking in the Schizophrenia patients means these people are highly vulnerable to experience detrimental effects of the smoking, for instance, cardiovascular disease, morbidity and mortality. Juhlin, Bjartveit, Lindstrom and Jones (2009) also reported that smoking is a risk factor for metabolic syndrome in psychotic patients and may lead to weight increase in patients.

Although physical health problems in Schizophrenia are linked to alcohol, (Levander, Berhard & Lindstro, 2007) argued that the statistics detailing the percentage of Schizophrenia patients indulging in alcohol remains scanty. However, one study conducted in Scotland revealed that a large proportion of the patients indulged in substance abuse (Levander, Berhard & Lindstro, 2007). Although the study reported a harmful use of alcohol by the patients, the numbers of Schizophrenia patients who were involved was quite small as compared to the general population. Connolly and Kelly (2005) suggested that substance abuse may be the likely cause of increased severity in some Schizophrenia patients. Although this link is not fully established, Heald (2010) argue that it is likely that overindulges to substance abuse has a significant effect on the dopamine system.

Various studies also link physical health problems to diet. In their article, Sebastian and Beer (2006) observed that patients suffering from Schizophrenia tend to consume a poor diet that is mostly composed of high-fat content and low fibre content. Although there is no clear reason for this behaviour, Sebastian and Beer (2006) suggest that it could be related to factors including unemployment and smoking of which are associated to low dietary standards. Ascher-Svanum et al., 2006 also believe that the negative symptoms associated with the condition, for instance, apathy impacts immensely on dietary selection towards less healthy convenience foods. Poor diet is also cited as having detrimental consequences on physical health in the sense that it could lead to obesity. In addition, an imbalanced diet could also cause malnutrition and thus impact on the general physical health of the patient (Ascher-Svanum et al., 2006).

Lack of exercise is also linked to the health problems experienced by people suffering from Schizophrenia. It is often the case that patients with Schizophrenia tend to do less exercise compared to other patient groups. In their article Montejo (2010) argue that this could be as a result of the illness itself compounded with factors such as apathy and co-morbid disorders such as depression. The consequence of these factors is that they counter the patient’s drive towards any physical activity. In addition, people with psychotic disorders tend to have a reduced social interaction and, as a result, this limits their opportunity to exercise (Mcdevit & Wilbur, 2006). It is also widely reported that antipsychotic drugs especially those taken to control symptoms make the patient less physically active. Physical inactivity has potential problems especially in Schizophrenia patients as it could increase the individuals’ risk to conditions such as atherosclerosis, obesity and hypertension, and reduced glucose tolerance (Citrome & Yeomans, 2005).

In summary, people suffering from Schizophrenia are reported to have a low life expectancy and high mortality. Brown and Mitchel (2012) observed that most of their deaths occur as a result of natural causes with a high percentage being cardiovascular disease. Schizophrenia patients often experience physical health problems, and this are caused by various factors such as heavy smoking by the individual and poor diet taken by the patients. In addition, the physical problems are attributed to alcohol intake and the sedentary life led by the individuals while avoiding exercises.


Chapter 2.2: Importance of lifestyle interventions in schizophrenia

In their work, Attux et al. (2013) linked Schizophrenia with metabolic morbidity and conditions such as cardiovascular disease. In order to reduce the problem, the authors propose efforts aimed at reducing this metabolic burden including weight control. Their 6 months investigation into the effectiveness of lifestyle interventions showed a significant decrease of weight at the end of the six months. In their article, Attux  et al. (2013) claim that weight increase among Schizophrenia patients occurs due to less exercise, poor dietary choices and habits such as smoking. Consequently, the authors reported these people raised concerns and led to the commissioning of various programs aimed at improving lifestyle and managing weight. This is done in the hope of increasing their life expectancy; different forms of treatment and management behaviour have been developed. In the bid to improve the lifestyle of the patients of Schizophrenia, Chacón et al. (2011) observed that the interventions target not only reversing weight gain, but also other aspects of lifestyle. This is aimed to will lower the occurrence of cardiovascular disease. According to Bradshaw, Lovell and Harris, (2005), most of the lifestyle interventions are focused on group work. In addition, this is thought that in addition to assisting in improving lifestyle, other benefits such as self-esteem may be improved in the process. Barriers to effective physical health care management of people with schizophrenia literature review.

It is argued that lifestyle management interventions are developed on the basis that attaches significance even to the smallest weight losses.  This is justifiable because according to Aranceta et al., 2009, a weight loss of just 5% of body weight in people with obesity offers a significant reduction in both morbidity and mortality. In addition, Bellivier (2005) suggested that the reduction could be influential in controlling glucose in diabetic patients. A weight loss of just 1% of an obese person, for instance, leads to a reduction in blood pressure of up 1.9 mmHg (systolic) and 1.3mmHg (diastolic). It is also vital to note that since hypertension is part of the metabolic syndrome, any amount of weight loss could mean a reduction in blood pressure and this highly important (Gentile, 2009).

According to Bradshaw, Lovell and Campbell (2010), some of the most advocated lifestyle management interventions for weight-gain management incorporate standard check-ups, way of life and solution guiding, drug appraisals, behavioural control programs and pharmacological medication. From Bradshaw, Lovell and Campbell’s (2010) perspective, the interventions are categorised depending on whether their purpose it to achieve weight reversal or weight gain. In many of the listed interventions, prevention of weight gain is taken as a realistic target. Consequently, any amount of weight lost is usually perceived as a bonus.

In the last few years, Brown, Goetz and Van Sciver (2005) claim there has been an inflow of data indicating that weight management strategies among psychotics may be effective. More data is, however, required to substantiate the same as only a small number of controlled researches have been carried out. Luckoff et al. (2005) argued that most of the lifestyle interventions interrogated have used a combination of nutritional, exercise, and behavioural interventions. This combination has led to the creation of vast lifestyle management programmes. Barriers to effective physical health care management of people with schizophrenia literature review.

An analysis of available data shows lifestyle interventions for smoking cessation in Schizophrenia patients are vital in lowering smoking cases. According to Rigotti, Munafo and Stead (2008), these interventions are composed of lifestyle counselling together with pharmacotherapy. Although studies in this area have cited the significance of these interventions, Rigotti, Munafo and Stead’s (2008) view is that psychotics do not easily quit smoking.  As a consequence, the rates of smoking cessation among mentally ill patients are quite low compared to the general observation. Rigotti, Munafo and Stead (2008) observed that smoking cessation interventions become more effective when they are applied in combination with a pharmacological treatment that is adjuvant.

It is argued that lifestyle interventions are quite efficient in hypertension management. Bushe, Haddad, Peveler and Pendlebury (2005) reported that studies to establish the same (the Premier trial) in Schizophrenia patients indicated a 12-14% reduction compared to the general population. In the study, Bushe et al. (2005) claims the interventions contributed significantly towards weight loss and a consequent reduction in systolic blood pressure and diastolic pressure. Along the line of Bushe et al. (2005), a significant reduction in hypertension values has been reported in psychotic patients who abide by the lifestyle intervention largely based on diet and exercise. Kelly and McCreadie (2006) reported that lifestyle interventions including stopping smoking, reduction in the amount of salt intake and regular exercise have a significant effect on blood pressure reduction that impacts on hypertension.

Lifestyle interventions are also claimed to be critical in the management of diabetes mellitus in the psychotic patients. Attux et al. (2013) reports a study that was set to determine the impact of lifestyle intervention in diabetic psychotic patients. Results from the eating habit and activity based mediation demonstrated a standardized glucose resilience in more than 50% of the diabetic psychotic patients. The significant improvement in glucose tolerance was attributed to weight reduction and increase in fitness following regular exercising by the subject (Bellivier, 2005). In an investigation to determine the efficacy of lifestyle interventions in Schizophrenia patients based on psychoeducational, dietary, and exercise programs, for antipsychotic-induced abnormalities in insulin insensitivity. It showed that when metformin is used alone and in combination, significantly improved insulin sensitivity induced by antipsychotic medications. Leucht et al. (2007) reported that the combination of pharmacological treatment with lifestyle intervention in this instance proved quite effective in treating diabetes mellitus than when Metformin was used alone. Studies have also shown that lifestyle intervention can be more effective when used alone compared to the pharmacological treatment of Schizophrenia patients.

Since pharmaceutical treatment for diabetes mellitus presents a minimal effect on glycemic control.  In their article, Brown, Birtwistle, Roe and Thompson (2009) suggested the use of lifestyle interventions especially those tailored to regulate glucose increase in the blood system. Accordingly, it is essential that these interventions start with the symptoms of diabetes mellitus manifest and before the blood glucose level goes beyond the normal range. All the intervention groups i.e. psychoeducational program, dietary program, and exercise program were proved to play a critical role in regulating weight and insulin in Schizophrenia patients. Consequently, a combination of these lifestyle intervention groups with pharmacological treatment can be very vital in the management of diabetes mellitus variables (Luckoff et al., 2005).


Lifestyle intervention can be additionally effective in the management of dyslipidaemia and metabolic syndrome in Schizophrenia patients. This was shown in a study by Poulin et al. in which they applied lifestyle intervention to manage the dyslipidaemia and metabolic syndrome in Schizophrenia patients based in Canada. According to Hardy, Deane and Gray (2012), the results of the study following lifestyle management intervention revealed a significant reduction in the rates of metabolic syndrome and blood lipids in the patients.

In summary, there is clear case to justify the use of lifestyle interventions. Developing Attux et al. Work to its logical conclusion shows that lifestyle interventions can play a significant role in the management of cardiovascular disease factors in psychotic and schizophrenia patients. Since the cardiovascular disease factors show a close interrelationship, Roberts and Bailey (2011) observed that the application of lifestyle intervention can be very helpful in the minimization of the risk factors. Cases of obesity and smoking and exercise among others can be addressed through life intervention. Since obesity is the most common factor in many cardiovascular diseases, lifestyle interventions based on diet and exercise will especially be crucial in weight reduction and the consequent achievement of benefits in other physical parameters. Barriers to effective physical health care management of people with schizophrenia literature review

Chapter 2.3: The attitude of mental health professionals towards the physical health care of people with schizophrenia

Most people in the general population have a mixture of little and wrong information with regards to mental illness, and this has led to the wary and cautious attitude held towards these people. In their article, (Mittal et al., 2014), observe that such little and wrong information is one of the key factors that contribute to the inability quickly to recognize developing cases of mental health problems amongst people. In addition, it also contributes to the attitude people, both professionals and non-professionals have towards the mentally ill people.

According to (Mittal et al., 2014), attitudes towards people with Schizophrenia and other mentally ill patients impact largely on the quality of care they receive from physicians. Hugo (2007) claims that attitude also affects the doctors’ ability not only to identify, but also respond swiftly to their psychological needs. In their work, (Mittal et al., 2014), cited a survey carried out in South Australia which sort to compare the attitudes of over 250 mental health professionals and the general public with regards to the outcomes of patients with Schizophrenia. The results of the survey indicated that the health professionals were largely pessimistic as to whether the people would recover compared to the general public. In the study, the psychiatrists, who were directly involved in the treatment of these patients, were found to be even less optimistic than the nurses.  The argument advanced from the study was that a large portion of the wellbeing experts bases their state of mind upon their individual experience of treating mentally ill people (Mittal et al., 2014).

According to Broadhead, (2006), the bias shown by the physicians can be understood as being the direct consequence of drawing upon their personal clinical experience during the times when they offer advice to the people with Schizophrenia. It is often the case that in discharging their services at the health facilities, the doctors often discharge from care, the patients who recover quickly. Lauber, Nordt and Braunschweig (2006), claim that doctors acquire most of their negative attitude as a result of treating patients who do not recover. In addition, they get discouraged in cases where patients who recover and relapse after a short while. The tendency does not follow up on the patients who are treated and discharged is also cited as one of the contributing factors in the attitude shown by doctors (Broadhead, 2006).

It is argued that negative attitude is more pronounced in forensic psychiatrists whose working life revolves around assessing and offering treating the psychotic offenders, usually those involved in serious crimes. In their article, Connor et al., (2013) suggest that the frequent interaction with these offenders make the psychiatrists more cautious and pessimistic about their therapeutic outcomes compared to the general psychiatrists. In recent years, however, many studies on Schizophrenia have been carried out and the findings of the outlook for the condition published. These findings have helped to demystify some of the earlier perceptions of the conditions.

Analysis of various data on the attitude of the health professionals show a majority tend to be negative towards people with particular mental disorders, for instance, people who are diagnosed with a “personal disorder.” Studies carried on this person suggest that there are some cases of stigma posed by the health professional against people with a personality disorder. According to Chambers, Guise and Valimaki (2010), people with a personality disorder are perceived by the healthcare stuff to be difficult to handle and less deserving of care. In addition, they are seen by the health staff as being manipulative, attention-seekers and in many instances are largely in control of their suicidal urges. As a result of this view, Hert et al. (2011) some mental health professionals interpret their diagnosis as being pejorative and one that fails to persuade the staff to show them empathy.

Chambers, Guise and Valimaki (2010) claimed  that nurses too demonstrated to have an attitude towards people with Schizophrenia.  This was shown in a study to investigate the attitude of nursing staff working in somatic care centre. During the course of the study, that involved 100 participants, the nurses were required to give their views with regards to intimacy with mental illness and attitudes for different mental illnesses including Schizophrenia. In their article, Chambers, Guise and Valimaki (2010) reported that the results indicated that 73% of the  nursing staff had a significantly negative attitude towards the people with Schizophrenia than any other form of mental illness. The study demonstrated that the nurses felt that Schizophrenia patients were dangerous and unpredictable and, consequently, kept a considerable social distance from those patients. Following the study, Chambers, Guise and Valimaki (2010) concluded that attitudes among nursing staff towards Schizophrenia patients were, in many ways similar with that of the public opinion concerning the mentally ill persons.

Studies on medical students’ attitude towards mentally ill people also showed that they have certain preferences for some categories of psychotic patients. In particular, Mahto & Verma, (2009) reported that the students had little or sympathy upon patients they believed to be undeserving of treatment as they were largely responsible for their condition. This attitude drawn largely from inaccurate deductions, and negative views of mentally ill patients led to a few of them settling for psychiatry as a career. In fact, statistics indicates a dwindling number of medical students going into psychiatry especially in developed countries.

It is argued that the attitude of the medical professionals towards the people with Schizophrenia has a great impact on the quality of health care delivery given to this population. Mittal et al. (2014) reported that 63% of the doctors were of the view that Schizophrenia patients presented communication difficulties between doctors and patients. They also reported that 68% of the doctors felt that Schizophrenia was quite disruptive; a factor they felt made them to doing more work for practice. As a result, the doctors felt frustrated and disgusted with Schizophrenia patients; consequently, they withdrew from attending those patients. Such a behaviour is thought to impact significantly affect the quality of services given not only to people with Schizophrenia, but also people suffering from other forms of mental illness (Rao et al., 2009).

As a result of the negative attitude expressed by health professionals towards individuals with Schizophrenia, there are numerous reports of mentally ill people showing displeasure with the health services they are given. According to Rüsch, Angermeyer and Corrigan (2005), most of the patients indicated that they were not given enough opportunity to ask questions or seek explanations with regards to their health problems. The reason for their dissatisfaction was largely because of the feeling of being ignored and the care providers emphasizing on the symptoms of their mental illness. In addition, patients complained that the health care providers failed to refer them to specialists to address their concerns (Thornicroft, Rose & Kassam, 2007).

In summary, (Mittal et al., 2014) work on the attitudes of health professionals towards people with mental illness affects the quality of service the patients with schizophrenia are given. A number of studies demonstrate that a large portion of health care providers has a negative attitude towards people with Schizophrenia. Psychiatrists are working with mentally ill offenders, in particular, are depicted to have a very negative attitude towards these people. According to Cooper, Corrigan and Watson (2007), the health professionals claim that people with Schizophrenia tend to be unpredictable; they are difficult to handle, manipulative, attention-seekers and hence less deserving of care. There is a need, therefore, for the professionals to change their attitude in order to ensure quality health care delivery to this group of people. Barriers to effective physical health care management of people with schizophrenia literature review.

Chapter 3: Conclusions and Recommendations

This literature review critically examined the fundamental causes of the physical health problem in people with Schizophrenia. Moreover, it looks at the importance of lifestyle interventions in people with Schizophrenia and the attitude of mental health professionals towards the physical health care of people with schizophrenia. The development of this review involved the use of twelve primary articles from which the themes were derived. The findings in each of the three distinct themes were found to be highly significant and provided essential critical information to the study and understanding of Schizophrenia.

The literature review established that the people with Schizophrenia suffer many physical health problems, and these occur as a result of many factors. In particular, this study found obesity to be the greatest cause of the physical health challenges faced by Schizophrenia patients. Poor dietary habits by Schizophrenia patients were also identified as causing significant health problems to them. Other factors identified include the tendency to engage in heavy smoking and also to engage in drug and substance abuse including alcohol. The study also identified a lack of exercise among the people with Schizophrenia to be a critical factor in causing them physical health problems.

This literature review also sort to determine the attitude of the health professionals towards the physical health care of Schizophrenia patients. Contrary to the held belief that health professional have high regard towards psychotic patients, many studies indicated that a large proportion of them have a negative attitude towards this class of people. The study, however, determined most of the reasons for the negative attitude were unfounded and based on personal stereotyping of the people with Schizophrenia. On the significance of lifestyle interventions for people with Schizophrenia, it was established that lifestyle interventions played a significant role in the management of Schizophrenia. Studies done on the different cause of the physical health problems proved effective in the management of the condition.

Limitations and Recommendations

This research relied on written literature to draw conclusions on the subject matter that was being investigated. Obtaining some resources was also challenging as some required one to pay before accessing the content. The school provided a limited amount of resources, and as such, this research was limited to the materials provided by the school. This form of research required firsthand experience with the subject under investigation; unfortunately this was not possible. It is also worth mentioning that most of the literature also relied on  had their limitations; consequently, this could impact on the findings of this study.

This research was conducted in full knowledge of the critical importance Schizophrenia has to the wider society. In recognition of the findings of this literature review, the study recommends the following: There should be a proper sensitization about Schizophrenia to the general public. The public should be enlightened on how to identify the early signs of the condition in order that they seek medication early enough. This study also recommends the formulation of policies to serve as a guide to health professionals when handling people with Schizophrenia. It is important to note that the negative attitude shown by the health professionals creates a barrier to effective treatment of Schizophrenia. Lastly, treatment of Schizophrenia should be based on a holistic approach that includes a combination of different interventions. Since the study found lifestyle interventions to play an important role in managing the condition, it recommends to health care services to integrate lifestyle interventions with others such as pharmacological interventions. Barriers to effective physical health care management of people with schizophrenia literature review.












Aranceta J., Moreno B., Moya M., Anadón A., 2009.  Prevention of overweight and obesity from a public health perspective. Nutr Rev, 67(Suppl 1): S83-S8.

Ascher-Svanum H., Zhu B., Faries D., Lacro J.P., & Dolder C.R., 2006. A prospective study of risk factors for nonadherence with antipsychotic medication in the treatment of schizophrenia. Journal of  Clinical Psychiatry, 67:1114–1123.

Attux C., Martini C.L., Elkis. H., Tamai S., & Freirias A., 2013. A 6-month randomized controlled trial to test the efficacy of a lifestyle intervention for weight gain management in schizophrenia. BMC Psychiatry, 13(60), 2-9

Bellivier F., 2005.  Schizophrenia, antipsychotics and diabetes: genetic aspects. European Psychiatry, 20 (Suppl 4): S335-S339.

Bradshaw T., Lovell K., & Campbell M., 2010. The development and evaluation of a complex health education intervention for adults with a diagnosis of schizophrenia, Journal of Psychiatric and Mental Health Nursing, 17, 473–486

Bradshaw T., Lovell K., Harris N., 2005. Healthy living interventions and schizophrenia: a systematic review. Journal of Advanced Nursing, 49:634-654.

Broadhead, W. E., 2006. Misdiagnosis of depression. Physicians contribute to the stigmatization of mental illness. Archives of Family Medicine, 3, 319–320.

Brown C, Goetz J, Van Sciver A., 2005. A psychiatric rehabilitation approach to weight loss. Schizophr Bull 21: S520

Brown S, Birtwistle J., Roe L., & Thompson C., 2009. The unhealthy lifestyle of people with schizophrenia. Psychol Med 29: 697–701

Brown S., Mitchel C. 2012. Predictors of death from natural causes in schizophrenia:  10-year follow-up of a community cohort Soc Psychiatry Psychiatr Epidemiol 47:843–847

Bushe C., Haddad P., Peveler R., Pendlebury J., 2005. The role of lifestyle interventions and weight management in schizophrenia. Journal of  Psychopharmacol, 19(Suppl):28-35.

Chacón F., Fernando Mora F., Gervás-Ríos A., & Gilaberte I., 2011. Efficacy of lifestyle interventions in physical health management of patients with severe mental illness, Annals of General Psychiatry, 10(22): 2-10

Chambers M., Guise V., Valimaki M., 2010. Nurses’ attitudes to mental illness: a comparison of a sample of nurses from five European countries. Int J Nurs Stud 47:350–362

Citrome L., & Yeomans D., 2005. Do guidelines for severe mental illness promote physical health and well-being? Journal of  Psychopharmacol  19(Suppl. 6):102–109.

Connolly M., &  Kelly C., 2005. Lifestyle and physical health in schizophrenia. Adv Psychiatr Treat, 11:125–132.

Connor K.O., Brennan D., Loughlin K.O., Wilson L., Pillay D., Clarke M., Casey P., Malone K., & Lane A., 2013. Attitudes towards patients with mental illness in Irish medical students, Ir J Med Sci, 182:679–685

Cooper, A. E., Corrigan, P. W., & Watson, A. C., 2007. Mental illness stigma and care seeking. Journal of Nervous and Mental Disease, 191, 339–341.

Corrigan, P., 2005. How stigma interferes with mental health care. American Psychologist, 59, 614–625

Faulkner G., Cohn T., & Remington G., 2005. Validation of a physical activity assessment tool for individuals with schizophrenia. Schizophr Bull 21: S523

Fleming, J., & Szmukler, G. I., 2006.  Attitudes of medical professionals towards patients with eating disorders. Australian and New Zealand Journal of Psychiatry, 26, 436–443.

Garden, G., 2005. Physical examination in psychiatric practice, Advances in Psychiatric Treatment. 11: 142-149.

Gentile S., 2009. Contributing factors to weight gain during long-term treatment with second-generation antipsychotics. A systematic appraisal and clinical implications. Obes Rev, 10:527-542.

Glynn S., Reilly M., Avalos G., Mannion L., Carney P.A., 2006. Attitudinal change toward psychiatry during undergraduate medical training in Ireland. Ir J Psych Med 23:131–133

Hagg S., Lindblom Y., Mjorndal T., & Adolfsson R., 2006.  High prevalence of the metabolic syndrome among a Swedish cohort of patients with schizophrenia. Int Clin Psychopharmacol, 21:93–98.

Hardy S., Deane K., Gray. R., 2012. The Northampton Physical Health and Wellbeing Project: the views of patients with severe mental illness about their physical health check, Mental Health in Family Medicine, 9:233–40

Harrison J., & Gill A. 2010. The experience and consequences of people with mental health problems, the impact of stigma upon people with schizophrenia: a way forward, Journal of Psychiatric and Mental Health Nursing, 17, 242–250

Heald, A., 2010. Physical health in schizophrenia: a challenge for antipsychotic therapy, European Psychiatry 25 S6-S11

Heggelund J., Hoff J., Helgerud J., Nilsberg G.E & Morken G. 2011. Reduced peak oxygen uptake and implications for cardiovascular health and quality of life in patients with schizophrenia, BMC Psychiatry, 11:188, 1-8

Hert. M., Cohen.D, Bobes I., Cetkovich-Bakmas.M., Jeucht S., Ndetei D.M, Newcomer. J.W., Uwakwe R., Asai I., Moller H., Gautam S., Detraux. J., Correll. C.U., 2011. Physical Illness in Patients with Severe Mental Disorders. II. Barriers to care, Monitoring and Treatment Guidelines, Plus Recommendations at the System and Individual Level; World Psychiatry, 10(2): 138-151

Hugo, M., 2007. Mental health professionals’ attitudes towards people who have experienced a mental health disorder. Journal of Psychiatric Mental Health Nursing, 8, 419–425.

Johnstone R., Nicol K., Donaghy M., & Lawrie S. 2009. Barriers to uptake of physical activity in community-based patients with schizophrenia, Journal of Mental Health, 18(6): 523–532

Juhlin H.Y., Bjartveit M., Lindstrom E., & Jones P., 2009. Schizophrenia and physical health problems, Acta Psychiatr Scand, 119 (Suppl. 438): 15–21

Kelly C. & McCreadie R.G., 2006.  Smoking habits, current symptoms and premorbid characteristics of schizophrenic patients in Nithsdale, Scotland. American Journal of Psychiatry 156(11), 1751–1757.

Lauber C., Nordt C., & Braunschweig C., 2006. Do mental health professionals stigmatize their patients? Acta Psychiatr Scand Suppl 429:51–59

Lauber C., Nordt C., Braunschweig C., Rössler W., 2006. Do mental health professionals stigmatize their patients? Acta Psychiatrica Scand, 113(Suppl. 429): 51–59.

Leucht S., Burkard T., Henderson J., Maj M., & Sartorius N., 2007. Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand, 116:317-333

Levander S., Berhard J., & Lindstro  E., 2007. Nicotine dependence among psychotic patients, and its correlates. Acta Psychiatr Scand, 435:27–32.

Luckoff D., Wallace C., Liberman R.P., & Burke K., 2005. A holistic program for chronic schizophrenic patients. Schizophrenia Bulletin 12(2), 274–282.

Mahto R.K., Verma P.K., & Verma A.N., 2009. Students’ perception about mental illness. Ind Psychiatry J 18:92–96

McCann E., 2010. The sexual and relationship needs of people who experience psychosis: quantitative findings of a UK study.  Journal of Psychiatric and Mental Health Nursing, 17(4): 295-303.

McCreadie R. G., 2006. Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. Br J Psychiatry 183: 534–539

Mcdevitt J., & Wilbur J., 2006.  Exercise and people with serious, persistent mental illness. Am J Nurs, 106:50–54.

Mittal D., Sherman D.M., Han X., Reaves C., Morris S., Sullivan G., Mukherjee S., Chekuri L., & Corrigan P., 2014. Healthcare Providers’ Attitudes Toward Persons With Schizophrenia, Psychiatric Rehabilitation Journal 37 (4), 297–303

Montejo, A.L., 2010. The need for routine physical health care in schizophrenia, European Psychiatry 25(1), 3-5

Nordt C., Rossler W, Lauber C., 2008. Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophr Bull 32:709–714

Pelham T.W., & Campagna P.D., 2007.  Benefits of exercise rehabilitation of persons with schizophrenia. Canadian Journal of Rehabilitation 4(3), 159–168.

Rao H., Mahadevappa H., Pillay P., Sessay M., Abraham A. & Luty J.  A. 2009. A study of stigmatized attitudes towards people with mental health problems among health professionals, Journal of Psychiatric and Mental Health Nursing 16, 279–284

Rigotti N.A., Munafo M.R., Stead L.F., 2008. Smoking cessation interventions for hospitalized smokers: a systematic review. Arch Intern Med, 168:1950-1960.

Roberts H.S., & Bailey J.E.,  An ethnographic study of the incentives and barriers to lifestyle interventions for people with severe mental illness, Journal of Advanced Nursing, 69(11), 2514–252

Rüsch N., Angermeyer M.C., Corrigan P.W., 2005. The stigma of mental illness: concepts, forms, and consequences. Psychiatr Prax, 32(5): 221–232.

Sebastian C. & Beer. D.M,.2007.  Physical health problems in schizophrenia and other serious mental illnesses, Journal of Psychiatric Intensive Care, 3(2):101-111

Sebastian, C., &  Beer, M.D., 2006. Physical health of psychiatric patients admitted to a low secure challenging behaviour unit. Journal of Psychiatric Intensive Care, 1: 77- 83.

Thakore, J.H., 2005.  Physical health of patients with schizophrenia. Psychiatry. 4(11): 58-60.

Thornicroft G., Rose D., & Kassam A., 2007. Discrimination in health care against people with mental illness, International Review of Psychiatry, 19(2): 113–122

Wahl O, Aroesty-Cohen E., 2010.  Attitudes of mental health professionals about mental illness: a review of the recent literature. J Commun Psychol 38:49–62

Barriers to effective physical health care management of people with schizophrenia literature review