On a Thursday in July, Rusty Potter took his girlfriend to his mother's house so the two could meet. Ruth Potter told the couple to take it slow. But she was pleased to see her son, a 40-year-old man with schizophrenia, looking so happy and talking about the future.

He lived at Baldwin House, a residence in downtown Hamilton run by the Canadian Mental Health Association. For the past few years, he'd been taking Clozaril, one of the newer medications for people with schizophrenia. He was doing better than he'd ever done in his life. He took his turn cooking and cleaning at Baldwin House and volunteered every Wednesday running the second-hand store for St. Joseph's Hospital. Then suddenly, five days after he stopped by to see his mother, Rusty died.

What killed Rusty Potter is now the subject of several investigations in Hamilton, including one by the coroner and another by St. Joseph's Hospital. He collapsed at St. Joe's after waiting more than an hour to see a doctor in the emergency ward. In addition to his schizophrenia, he had a history of asthma. And some of the drugs he was on are associated with serious side effects. But when he couldn't breathe, the nurses at St. Joe's didn't realize they had a medical emergency on their hands.

Without speculating further before the investigations are completed, there's one point that family members and friends of people with mental illness can learn from the tragedy of Rusty's death. People with chronic mental illness are at higher risk for medical illnesses than the general population. They need general medical care. Yet, they're less likely to be treated for medical problems than the next person. Mental illness leads to cognitive difficulties that can prevent a patient from seeking medical care. When they do get to a doctor's office or an emergency room, the staff may be uncomfortable treating them.

"When a person's had a psychiatric problem, it flags on their file," says Helen Ball, Rusty's sister. She's right. And when a nurse or doctor sees that flag, they tend to blame the patient's psychiatric disorder for the medical symptoms. Yet, general medical care for people with mental illness is vital. Their mental problems place them at risk, and their drugs, while effective, can cause medical problems. This is expecially true of the newest class of drugs for schizophrenia, the "atypical antipsychotics."

The "atypical" drugs, including Clozaril, Zyprexa, Risperdal, Seroquel and Geodon, have some advantages over older drugs for schizophrenia. They don't produce the disfiguring side effect known as tardive dyskinesia (TD) that's responsible for the abnormal movements of the mouth or hands sometimes seen in mentally ill persons. TD is caused by older drugs and it's incurable.

Atypical drugs also may work better to keep patients from having to go back in the hospital. But they're linked to diabetes, substantial weight gain and, in some cases, heart disease.

Recently, a study about the link between atypical antipsychotics and diabetes caught the eye of investors. After it came out in the journal Pharmacotherapy in July, shares of Eli Lilly, makers of Zyprexa, dropped nearly 6 per cent.

Medical experts say that patients taking any of the atypical antipsychotics should be on the lookout for diabetes. They recommend that patients have a fasting blood sugar check when starting on an atypical antipsychotic, and that they have their blood sugar levels checked every four months for the first year of therapy and every six to 12 months after that.

Most of the atypical drugs, including Clozaril, Zyprexa and Risperdal, also cause considerable weight gain. Doctors advise that people taking them have an exercise plan and stick to it.

Clozaril, the oldest of the new drugs for schizophrenia, is associated with a serious heart condition known as myocarditis, as well as heart failure and heart attacks. That doesn't mean that people on Clozaril should switch to another drug, but they have to see a medical doctor regularly and be alert for signs of heart disease, such as a rapid heart rate, shortness of breath or swollen ankles and feet.

Clozaril can also cause seizures and a potentially fatal blood condition that can be prevented with frequent blood tests. Patients don't receive their pills unless they've had the blood tests.

Individuals with serious mental illness often don't know that the drugs they take are linked to serious medical conditions. But they know when they need urgent medical care.
Miriam Shuchman, MD, teaches medical ethics at the State University of New York at Buffalo and the University of Toronto.
mshuchman@globeandmail.ca