Cardiovascular disease in schizophrenia: the leading cause of premature death

The hardest number in schizophrenia care is the life-expectancy gap. People diagnosed with schizophrenia die, on average, 13 to 15 years earlier than people without the diagnosis. A 2017 Lancet Psychiatry meta-analysis by Hjorthøj and colleagues confirmed and quantified this across multiple high-quality cohort studies (Hjorthøj et al., 2017). Suicide accounts for some of the gap, but the largest single driver is cardiovascular disease.

The size of the problem

A widely cited Swedish national-registry study by Westman and colleagues found that people with schizophrenia had roughly two- to three-fold higher cardiovascular mortality than the general population (Westman et al., 2018, BJPsych). A 2015 meta-analysis by Correll and colleagues in World Psychiatry reviewed prevalence and mortality across cardiometabolic conditions in serious mental illness (Correll et al., 2015). The takeaway in both: the cardiovascular gap explains more of the early mortality than suicide.

Why the risk is so high

Smoking

Smoking rates in schizophrenia have historically been around 60–70% — three to four times the general-population rate. Smoking is the single largest modifiable contributor to cardiovascular and respiratory mortality (see our smoking and schizophrenia article). The CDC's summary of smoking-related disease outlines the cardiovascular toll in any population — multiplied here by higher prevalence and longer cumulative exposure.

Metabolic side effects of antipsychotics

Weight gain, dyslipidemia, insulin resistance, and frank diabetes occur at elevated rates on second-generation antipsychotics, particularly olanzapine, clozapine, and quetiapine. Each component independently raises cardiovascular risk; together they accelerate atherosclerosis. See metabolic syndrome on antipsychotics.

Illness-related risk

Even before medication, people with first-episode psychosis show increased markers of cardiometabolic vulnerability — possibly due to chronic inflammation, dysregulated stress hormones, and shared genetic risk between psychosis and metabolic disease (Pillinger et al., 2019).

Healthcare system failure

People with serious mental illness are less likely to receive guideline-concordant cardiovascular care. They are less likely to be prescribed statins when indicated, less likely to receive revascularisation after a heart attack, and less likely to have routine blood-pressure or lipid monitoring documented. The disparity has been demonstrated repeatedly in registry studies in Europe and North America.

What monitoring looks like

The 2004 ADA/APA consensus and updated 2020 European guidance both recommend assessment of:

• Smoking status — at every visit
• Blood pressure — at every visit
• Weight, BMI, waist circumference — at baseline, 4/8/12 weeks, then quarterly
• Fasting lipid profile — baseline and annually
• Fasting glucose or HbA1c — baseline and annually
• ECG when starting QT-prolonging agents (see QT prolongation)

Cardiovascular risk should be quantified using a validated calculator — for example the ASCVD risk estimator from the American College of Cardiology or the QRISK3 tool used in the UK NHS (qrisk.org). These calculators take blood pressure, lipids, age, sex, smoking status, diabetes, and other inputs and estimate 10-year risk of a cardiovascular event.

What reduces risk

Smoking cessation

The single highest-impact intervention. Pharmacologic options that work in this population include nicotine replacement, bupropion, and varenicline — all studied in people with schizophrenia and shown to be effective and safe (Anthenelli et al., 2016). See quit-smoking strategies.

Blood-pressure control

Standard hypertension treatment with thiazide diuretics, ACE inhibitors, ARBs, or calcium-channel blockers. Most have minimal interaction with antipsychotics; orthostatic hypotension is the main thing to watch for in combination.

Statin therapy

Statins reduce cardiovascular events even in people without elevated cholesterol if their overall risk is high. The major guidelines support starting a statin in adults with 10-year ASCVD risk ≥ 7.5–10%. People with schizophrenia are under-prescribed statins relative to risk; asking about statin eligibility at primary care is reasonable.

Glucose and weight management

Metformin, GLP-1 agonists, lifestyle programs, and switching to weight-neutral antipsychotics where possible all matter — see our diabetes and obesity articles for detail.

Exercise

Even modest amounts of aerobic exercise reduce cardiovascular risk and have additional mental-health benefits. See exercise and schizophrenia.

Closing the gap

The 13- to 15-year life-expectancy gap is not inevitable. A meaningful portion is preventable through smoking cessation, metabolic monitoring, lipid and blood-pressure control, and the same standards of cardiovascular care that the general population receives. The challenge is largely organisational: aligning psychiatry, primary care, pharmacy, and patient self-management around a problem that no single clinician owns. Patients and families who advocate for monitoring and treatment, and care systems that integrate physical and mental healthcare (the "behavioural health home" model promoted by SAMHSA), are slowly closing the gap.

This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.