Comorbidity is the presence of one or more additional conditions co-occurring with a primary condition. In this episode, host schizophrenic Rachel Star Withers with her cohost Gabe Howard will be discussing comorbidity with schizophrenia. Comorbidity is associated with worse health outcomes, more complex clinical management and increased health care costs.

Occupational therapist and host of the podcast Occupied, Brock Cook, will be joining us to discuss ways that he works with people with schizophrenia to manage multiple health issues. 

Highlights from “Comorbidity with Schizophrenia” Episode

[01:28] What is comorbidity

[03:37] Antipsychotic medication side effects leading to comorbidity

[05:00] Obesity with schizophrenia

[08:30] Medication side effect of weight gain

[11:08] Lifestyle factors of people with schizophrenia

[14:00] Obstacles to getting treatment

[16:19] How loved ones react

[19:00] Doctors not wanting to treat other comorbidities

[20:50] Tracking your symptoms

[25:00] Everyone needs to be on the same page

[27:00] Guest Interview with Occupational Therapist Brock Cook

[29:00] Smoking unhealthy/healthy?

[33:00] Learning new coping mechanisms

[36:00] Set small goals

[43:30] What is Rachel’s small goal?

About Our Guest

, Inside Schizophrenia: Comorbidity with Schizophrenia, Box Tree Clinic | Your Key to World Class Private TherapyBrock Cook is an Occupational Therapist in Australia and host of the podcast “Occupied”.

His podcast explores all things Occupation, Occupational Science, and Occupational Therapy.

Computer Generated Transcript of “Comorbidity with Schizophrenia” Episode

Announcer: Welcome to Inside Schizophrenia, a look in to better understanding and living well with schizophrenia. Hosted by renowned advocate and influencer Rachel Star Withers and featuring Gabe Howard.

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Rachel Star Withers: Welcome to Inside Schizophrenia, a Psych Central podcast. I’m Rachel Star Withers here with my co-host, Gabe Howard. In this episode, we will be exploring co-morbidity, having another health condition in addition to schizophrenia. Co-morbidity is associated with worse health outcomes, more complex clinical management and increased health care costs. Occupational therapist and host of the podcast Occupied, Brock Cook, will be joining us to discuss ways that he works with people with schizophrenia to manage multiple health issues.

Gabe Howard: Rachel, co-morbidity is one of those things that it happens in all illnesses. But specifically, we’re talking about how it relates to managing, living with, and acknowledging schizophrenia. Can you give us a little more background on co-morbidity?

Rachel Star Withers: Co-morbidity is the presence of one or more additional conditions co-occurring with a primary condition, and for our show, the primary condition we are focusing on is schizophrenia. How co-morbidity is classified in mental health, though, it’s like really confusing. So, if you have schizophrenia and depression, is that two different things? Or is that schizophrenia with a negative symptom of depression? Or is that schizoaffective disorder? That’s where things start to get like a little bit hairy as to what’s a whole separate disorder and then what’s a side effect? Others are like anxiety, panic disorder, post-traumatic stress disorder, obsessive compulsive. It’s estimated that depression occurs in 50 percent of patients with schizophrenia. I personally have the diagnosis of schizophrenia and depression.

Gabe Howard: It’s important to understand while we move through this episode that there is a difference between a symptom of an illness like, for example, you can have a cold and a symptom of having a cold is a runny nose. So, you don’t have the co-morbid disorder of a cold with a runny nose. And that’s a very bad example. And I know that every general practitioner who listens to our show is like, Gabe. No. Full disclosure, didn’t go to medical school, but we’re really trying to talk about the things that are vastly different from schizophrenia. We’re not even necessarily talking about schizophrenia and depression or schizophrenia and anxiety. We’re also talking about schizophrenia and physical health traits and trends that people with schizophrenia more often than not have higher rates than the general population.

Rachel Star Withers: Schizophrenia has been described as the life shortening disease. Physical co-morbidity accounts for 60 percent of premature deaths that are not related to suicide in people with schizophrenia. We have an increased rate of developing glucose regulation abnormalities, insulin resistance, and type 2 diabetes. And of course, now some of that’s going to be attributed to lifestyle factors, which we’ll come back to. But a big part is the side effects of antipsychotic medications. If you’ve ever been on different medications, you’ve definitely learned weight gain, even with diet and exercise, is really hard to avoid. My weight’s gone up and down throughout the years and I’ve always been active to some degree. Whether it was fighting, doing mud runs, or like I’ve always just been a very active person. And I mean, I weighed 70 pounds more than I do right now at one point.

Gabe Howard: And it’s important to point out that for your career as a stuntwoman, being physically in shape is a requirement. So, when you say that you have always been active, you have been active at a level different from the majority of the population. You’re not talking about a planet fitness membership here. This is part of your career to earn a living and to be paid to do the stunts that you have been so successful at doing.

Rachel Star Withers: And it’s not so much just even stunts, just being on camera for different things. Unfortunately, my looks kind of matter. And you set yourself up whenever you’re doing Internet things for horrible comments. And that’s been rough, just hearing the things people will send like, oh, this fat, you know, and on and on has been definitely really hard just dealing with other people’s responses.

Gabe Howard: And while we’re certainly not saying that it’s more reasonable to have your weight commented on if you, quote, deserve it, it’s important to point out that your lifestyle didn’t change. Your medication did. You were still eating the same, working out the same, exercising the same. You were still just as active. The only thing that changed is your medication, but your weight shot up. And again, I want to be very, very clear. It’s not OK to insult people’s looks or weight if they gained weight because they eat cake. But we do want to point it out. Right? Your level of activity did not change. You made no lifestyle changes. You made a medication change to manage schizophrenia and as you stated, gained 70 pounds, even though that’s the only change that you made.

Rachel Star Withers: Patients with schizophrenia are more likely to be obese than the normal population. And if you have long term schizophrenia, you are three times more likely to develop diabetes than the general population. That’s a lot. Three times more. I was like, oh, wow, when I read that. And it makes sense because like I said, there was so much of it was out of my control. Like I was doing everything I could and I was still packing on weight. And that did not help the depression part.

Gabe Howard: One of the things that I thought was interesting, Rachel, was you talked about whenever you were given a new medication, the very first thing that you Googled was the name of the drug and weight gain. That was your primary concern. Well, why is that? Why is that your primary concern? Because there seems to be a lot more important things to worry about.

Rachel Star Withers: Yeah, you would assume that I should care more about my mental state, but at the same time I felt, and I still feel, that I can only fight so many battles. You know, I’m trying to maintain a mental state of being able to go to work and live a life. At the same time, I don’t want to be like gaining and gaining and gaining weight because that affects those exact things. Me trying to live life. Me trying to, I don’t want to say make friends and date and things, but it does. It does. It changes different things. And it’s like I can only fight so many battles to the point that it just becomes overwhelming.

Gabe Howard: And of course, because your physical health is important, you gain the weight because of the psychiatric medications. Direct cause, it’s co morbid obesity, schizophrenia. You end up in a doctor’s office. And the first thing that a doctor tells you is, oh, you’re overweight, your morbidly obese, you have obesity issues, you need to lose weight, and you’re thinking to yourself, this isn’t my fault. And the doctor is just looking at the chart and saying, oh, you’re 5′ 7″, and you have this weight. You need to be at this weight. So, make better choices. Because they’re trying to avoid all of the things you mentioned earlier, diabetes and joint pain, etc. So, Rachel, you know that the weight gain is a side effect of your medication. It’s the side effect of your treatment of schizophrenia. But the doctor is treating you like, hey, you just need to join a gym. That’s got to hurt. That’s got to rub you the wrong way. That’s got to feel bad.

Rachel Star Withers: Yeah, it’s just beyond frustrating and it kind of makes you just be like, well, I don’t even want to try. I just, I don’t, I don’t even want to try. And for me, whenever I’ve had a doctor prescribe an antidepressant or antipsychotic, none – none – have ever warned me about weight gain. And I get it because their job is to help me mentally. And I guess maybe it’s deal with the mental; the physical stuff we can deal with later. But it’s so interconnected. I feel like they just play off of each other. And I will sometimes actually tell my psychiatrist, like, is there a better option? Because this says quite a few people online are complaining about weight gain. And they’ll be like, well, maybe you shouldn’t look at that. Nope. Nope, looking it up right now and just literally sitting there with my phone in my hand as we’re discussing options like, oh, okay. Okay. Hold on.

Gabe Howard: I think it’s important to sidebar here in point that this is a tough choice for people with schizophrenia. They’ve got to decide if they want to be mentally healthy, but have some physical consequences or be mentally unwell. It’s important to point out that while that is a difficult decision, it’s kind of not right. I mean, having full control of our faculties, of our brains, of our bodies, it is very, very important. But I do want to provide hope. There’s new research and there’s new medications and there’s new drug trials. And thankfully, the medical community is aware that people are struggling with this decision and in many cases not taking psychiatric medications because the side effects are just so difficult.

Rachel Star Withers: And it’s not just weight gain. It’s a lot of things like cholesterol levels. The insulin resistance. It’s not just, oh, well, I’m going to gain a lot of weight. There are like other health issues. One that I haven’t really ever talked about is my cholesterol. I have to follow a very strict, strict diet because my cholesterol is insane. And they’ve warned me about it so many times. They are like you can’t have fast food. And I’m like, I haven’t had fast food in like five years. And they’ll be like, you can’t eat red meat. I almost never eat red meat or anything like that. I’m on such a strict diet. But my cholesterol is still abnormally high and they think that it is due to some past medications that I’ve been on kind of changed some chemistry. So, it isn’t just for my people listening out there like, oh, you shouldn’t worry about weight gain. It’s a whole physical situation going on sometimes.

Gabe Howard: One of the things that you’re trying to point out, Rachel, is that people living with schizophrenia and managing their schizophrenia well are often seen to be lazy because of this excess weight or because of the physical health conditions that they’re having. It’s kind of like a combination punch. You know, first you have schizophrenia. And that’s difficult to manage. And then everybody is like, why are you overweight? You should go for a walk. And then on top of that, you have accelerated rates of osteoporosis. You have higher incidences of irritable bowel syndrome and you have so many stats to deliver. And people are just looking at you like, hey, why don’t you make better choices? And the reality is, is you are making excellent choices for your situation as a person who’s living with schizophrenia.

Rachel Star Withers: And we can’t blame everything on medication, though. Tobacco smoking rates in people with schizophrenia are actually twice that of the general population. That’s interesting. I’ve always found that people with mental disorders do tend to smoke a lot more. The times that I’ve been at different mental health facilities, it’ll be crazy how many people there smoke. It’s like everybody smokes. And I’m someone, I never grew up smoking. I just I really didn’t grow up around it. No one I knew smoked. My parents don’t smoke. But whenever I meet other schizophrenics, you know, nine times out of ten, most of them smoke.

Gabe Howard: Obviously, the individual reasons that people choose to smoke are just that, their individual reasons. But if when we’re looking at people with schizophrenia as a whole, it’s somewhat easy to understand why decisions are made, like smoking. Cigarettes are easy to get. They are somewhat of a social activity. They provide a bump. When you’re smoking, you are feeling better. None of these are good reasons to smoke, but they are understandable reasons. And later on in the show, when we hear from Mr. Cook, he’s going to explain why it is a coping mechanism. It’s not a good coping mechanism. But in that moment, people with schizophrenia are trying to make a decision that makes them feel better. In his job, he helps people make decisions that provide the same feel better without the negative consequences of smoking. And I hope that people with schizophrenia hear that because it like you said, it is a choice that they’re making, which gives them the power to make a different choice.

Rachel Star Withers: And we’re not putting down anybody who smokes. Please don’t be upset. Because I also think about other issues, like when you look at things like smoking, alcohol, weed in some areas, if it’s legal and you’re like, OK, I’m already dealing with this major mental disorder and now you’re telling me I can’t even have a legal vice? It’s not like I’m doing anything bad, Rachel. But unfortunately, yeah, there are some things that having schizophrenia, we’re setting ourselves up to fail in some ways by doing stuff, even if it is legal. It’s one reason I never, ever drink alcohol. It affects medications. And I can’t actively be saying, oh, I’m working really hard to maintain my mental state if I’m drinking because I know that messes with the medications and is just going to continue to make things worse. Am I legally totally fine? I’m far, far above age 21 to drink. Yes, but it is something that I have to, like, take into consideration. It’s like an extra thing that I have to do to manage my schizophrenia is to not drink.

Gabe Howard: We also have to consider that one of the reasons that people living with schizophrenia don’t get help for their physical co-morbidities is because of their circumstances, their living situations, homelessness, money situation. It’s expensive to go to the doctor. And if you don’t have a good payer source, if you don’t have good health care, if you’re on government assistance, if you don’t have a ride. If you live in an area that doesn’t have good public transportation, you may be thinking to yourself, look, it’s going to cost $20 to see the doctor. It’s going to take all day to go to the free clinic. I’m going to have to sit on the bus. I don’t have the time, resources, money, or even the psychological wherewithal to deal with this for the next nine hours. So, I’m gonna go ahead and let it pass. We have to remember that many people living with schizophrenia, they’re not living with the same resources as your average middle-class American. It’s just important to understand that this is a barrier to their treatment and it may well be a barrier to your treatment as well.

Rachel Star Withers: And people with schizophrenia, we are 63 percent more likely to suffer a serious infection. And I think so many times it’s probably a small infection, but someone’s like, oh, well, if I can decide between going to my psychiatrist this month or going to like a normal doctor over an infection like, come on, I’m sure my infection will be fine. And it does. It escalates from there. Or like you said, we’re looking at a homelessness situation or just generally not being able to afford to take care of ourselves that well, that small infection can escalate very, very quickly in people with schizophrenia.

Gabe Howard: And it’s that escalation that leads to the very serious co-morbidities, the co-morbidities that we’re talking about here. Obviously living with schizophrenia is tough enough and I don’t mean to harp on it, but so often we look at people who are managing schizophrenia, and in many cases very, very well, and then we start to pick on the physical issues that they’re having. Nobody is saying not to pay attention to your physical health. In fact, we very much encourage people to pay attention to their physical health. But I think a lot of times the advice that we give to our friends, to our loved ones is the same advice that we would give to our friends and loved ones who are not managing schizophrenia. And I think that we need to meet people where they’re at. And we just really, really, really want to get across that a lot of these issues that people with schizophrenia are going through are not their fault. They’re just their responsibility. Rachel, the specific question that I want to ask you as a person living with schizophrenia is how does it feel to know that you’re managing your schizophrenia very well, but when your friends or your loved ones approach you on the physical side, they don’t pay attention to that at all? They treat you as somebody that just has a physical condition. And they don’t acknowledge that you have managed your schizophrenia and they’re just like, hey, you need to do x y, z. How does that feel?

Rachel Star Withers: It just adds to, especially for me, the depression of it and the feeling of hopelessness that okay, even if I feel like man, I have done so good this past week. But no one else notices. What was the point? Or if someone is constantly like on me about my diet like, hey, Rachel, you know, you’re not supposed to have that. Rachel, you’re not supposed to do that. And then I’m like, OK, I’ve actually been really, really good. And I’m just like, come on. All of it, it’s very frustrating. And it makes me want to push back and be like, well, fine, I’m not even going to try.

Gabe Howard: Obviously, people want to get credit for what they’ve done. That’s not a schizophrenia thing, that’s not a mental health thing. That’s just a life thing. And when you’re trying to encourage somebody to get help for something and you don’t acknowledge the great strides that they’ve made. And I think that this is one of the reasons that separating out mental health and physical health is just so incredibly foolish. Right? Because you’re not acknowledging somebody’s mental health, because you’re worried about their physical health, or you’re worried about something with his physical health, and you’re not acknowledging your mental health. We have one body and we have one life. And that’s where comorbid disorders really come in. Right? Because all of these disorders, all of these issues are happening to one person.

Rachel Star Withers: And to my caretakers, my friends, my family out there who are like, okay, well, I’ll be more careful about saying things like that. But also notice when someone is doing good, even if it’s like a little bit of doing good, like, hey, you know what, you are looking so much more awake this week or you know what? You’ve been looking a lot happier since you started walking. You know, whatever the thing is. Don’t lie and be like you look like you’ve lost 30 pounds and you’re like, no, I haven’t. But just like little things go a long way. I’d just be like, you know, since you’ve switched over to such and such you it seems like you’re a lot more upbeat. Do notice, like, those little tiny achievements because they are a big deal.

Gabe Howard: Here, here, Rachel. Getting back to stats for a moment. I was really shocked to learn that in the United States, about 80 percent of Medicare spending is devoted to patients with four or more chronic conditions. So, co-morbidity is not something that only people with schizophrenia have to deal with and have to live with. It’s actually very common. And schizophrenia is a very serious illness. So, it’s not surprising that a very serious illness would have co-morbidities.

Rachel Star Withers: Yes. And I do believe that people with schizophrenia, when we’re having multiple issues, that doctors sometimes deal with it differently than they would someone who is just dealing with multiple physical issues. A lot of time doctors who are not psychiatrists, they don’t feel comfortable just treating someone with schizophrenia with their normal things, just kind of like, oh, I just I mean, you have schizophrenia and I’m like, right, but this is a cold. And he’s like, yeah, but you know, I don’t really know. You know, it’s like they’re afraid to treat you, that they might do something wrong. And then, of course, if I go to a psychiatrist about a cold, they’re like, OK, well, Rachel, you need to go to your general practitioner. That’s not what we do here. And it can be frustrating because I’m getting bounced around doctor to doctor. And then, of course, there’s the fear of me going to a normal doctor that they’ll think that it’s psychosomatic. Oh, well, you know, you think you’re in pain. It’s probably your schizophrenia. That’s frustrating alone, because if you have schizophrenia, not only can you have a difficulty in communicating what’s going on sometimes, trying to describe it, and then people aren’t believing you or just kind of brushing off what you say. That’s really great if you have the friends and family who can go with you to the doctor and almost kind of be your backup, you know, to make you, this is gonna sound bad, but not seem crazy. My mom, usually, it’s gotten to the point that she’ll go with me to most of my doctor’s appointments because she’ll be like, yes, she has been dealing with this specifically for two months.

Gabe Howard: Rachel, in your opinion, how do we fix this? Because we do have trouble in America looking at a whole person. They want to pay attention to your mental health or they want to pay attention to your physical health. But Rachel Star Withers, isn’t two people. Rachel Star Withers is one person. You’ve been managing schizophrenia for a long time and you’ve managed many comorbid disorders, again for a long time. How can you help people get to the other side?

Rachel Star Withers: With having schizophrenia, you do have to take a lot of the responsibility on yourself. Which is like, you’re like, well, Rachel, I mean, come on, I’m already having to deal with my mental state. Yeah. Every night I have a little app that I write down any physical issues I had during the day. That way it could kind of like be tracked over time. So, if something is coming up, hey, you could actually look through my little app and be like, oh, well, this started two months ago or this started back at the same time you went on this medication. It helps me to have that because, it almost kinda backs up what I’m saying, instead of me just going to the doctor and be like, oh, my gosh, I’ve gained 10 pounds. I can be like, look, when I started this, a week later, I had gained two pounds. And it does, it just backs up what you’re saying when you go to the doctor’s. But you kind of have to step up to the plate and be like, all right, if my psychiatrist isn’t requiring that I have physicals or checking that my physical health is OK, that might be something you need to do. Whether you’re doing them every few months, whether it’s once or twice a year, tracking weight changes, your blood pressure, your blood sugar. If you’re having sleeping problems, all those kinds of things. And yeah, a lot of it does fall on the patient’s responsibility.

Gabe Howard: And honestly, it’s not a bad thing that it falls on the patient because that’s very empowering, right? You can take control of your health care; you can take control of your health. And I’m fond of saying that it doesn’t matter if you have schizophrenia or not, the physical rules of the world still apply to you. And in fact, as we’ve learned throughout this episode, they really, really apply to you. You have to worry about managing schizophrenia. You have to worry about managing your physical health. And you have to worry about managing the co-morbidities between the two. While it is a tough road, it’s your road. And I think it’s very, very empowering to be able to walk that road with as much agency as humanly possible. But don’t be afraid to ask for help. Part of agency is asking for that help. As Rachel said, she utilizes her family. And I’ve never seen a better team. There are very, very good team. And I think that’s important to point out. Rachel, that’s what I’ve always been impressed with. It’s not your family taking care of you. It’s not you demanding things from your family. Your family has formed a team to manage your schizophrenia, your co-morbidities and your physical health together. I feel that’s a very good system because it gives you, as the person living with schizophrenia, a lot of agency. And I think that’s very, very powerful, because ultimately it is your life.

Rachel Star Withers: Gabe, I totally agree. My parents are awesome. And this is something that we’ve worked out over many years. It wasn’t just like they decided one day, okay, this is how we’re gonna work out with Rachel and everything’s gonna be great. It has definitely taken a while for us to kind of find a groove that worked. And I helped them with things, also. The really good thing about me having to be so strict on my diet is that it makes my dad also be kind of strict on his diet. Me having to exercise, I can have my mom exercise with me. I don’t want it to sound like, oh, everyone’s doing all this stuff for poor Rachel. I would like to think that it’s a whole team effort and everyone is benefiting. You know, we are helping each other in different areas, I think all of us across the board. Exercise is important, eating right is important. Whether you have a health issue or not, it’s just that’s good stuff to do.

Gabe: We’ll be right back after this message from our sponsor.

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Gabe: We’re back discussing co-morbidities and schizophrenia. 

Rachel: When it comes to going to your psychiatrist and your different doctors, one thing you need to make sure is that they are on the same page, that your general practitioner knows the medications that your psychiatrist has you on and vice versa. And any other doctors, do not assume that they are talking. Do not assume that they double checked that one medication doesn’t affect a different one. That’s something I’ve had to learn the hard way. I listed it on the paper, the medications I was on, but that doctor almost didn’t pay attention to it and the medication they were gonna prescribe for a completely different health issue, it raised blood pressure while the other one did the same thing. And it would potentially be very bad. And I literally was the one on my phone again. And I was like, well, it says on this little app here, and they don’t like when you do that, but it’s very important that you do that. Yeah, I’ve had quite a few run-ins where they’re like, oh, wow, yeah, no, we can’t have you on both of these because they didn’t realize my other treatment plans fully with other doctors. So do make sure you speak up when it comes to things like that. Family, friends, if you’re going to the doctor with them, my mom loves to make sure I have my whole little tote bag of medications. I’m like, Mom, I got them written down. I don’t need the actual bottles. She says, just to be safe. Okay, we’ll bring the bottles also. But they are on this piece of paper, which I’m sure they’d rather have the piece of paper that’s, you know, organized than a bag of bottles but whatever. Though, yeah, don’t just assume that doctors know 100 percent what’s going on in different areas of your health.

Gabe Howard: Rachel, you had the opportunity to interview a gentleman named Brock Cook. He’s an occupational therapist out of Australia and he works specifically to help people with schizophrenia manage their comorbid conditions and lead the best life possible. I’m excited to hear this interview. So, we’re gonna go ahead and roll it now.

Rachel Star Withers: We are here talking with Brock Cook, who is an occupational therapist out of Australia. And he’s also the host of the podcast Occupied. So welcome, Brock. Thank you so much for being on our show.

Brock Cook: Thank you very much for inviting me.

Rachel Star Withers: You get to work with a lot of different people and we know each other from me having schizophrenia and talking to you about it on your podcast. How would you describe what you do?

Brock Cook: I have worked pretty much my whole career in the mental health service here in my local state, and I’ve worked in all different areas of mental health, everything from acute inpatient to community rehab to intensive rehab to pretty much, you name it, I’ve worked there. In terms of what OT does with people with mental health conditions, an occupational therapist works with the things that people want and need to do. When we talk about occupation, we talk about the things that people occupy their time with. So for people with mental health conditions, it’s the things that they would normally do at a set age to occupy their time. So it might be anything from learning how to maintain a house to learning how to get a job, to supporting them in navigating relationship transitions like pretty much you name it, we have the skills and capacity to support people to lead a fuller life as they possibly can.

Rachel Star Withers: And when dealing with mental disorders, what have you seen to be the main physical co-morbidities affecting people with schizophrenia?

Brock Cook: A lot of people who have schizophrenia tend to end up with co-morbidities due to what health would deem as lifestyle disease. So things like smoking and drugs and that kind of stuff. We also would work with people a lot who have issues with weight. A lot of the people I work with had co-morbidities to do with different types of self-medicating, whether it was illicit substances, marijuana. I know it’s legal in some places in the states. It’s not legal here. But so illicit substances and marijuana. Alcohol is another one in particular. Cigarette smoking is really, really common with people who have a diagnosis of schizophrenia. I can’t remember the exact statistic, but the percentage of people who smoke co-morbidly with a diagnosis of schizophrenia is phenomenally larger than just the general population who smoke. It’s often used as a coping mechanism. It unfortunately does work quite well for some people, whether it’s just having some time out. Even the the act of, I guess, regulated breathing that happens when people smoke tends to work. There’s actually some documented benefits that people do get from it, which makes it really hard as a health therapists of any kind really to try because they’re actually getting some some benefit from what is often deemed as a very unhealthy behavior

Rachel Star Withers: When it comes to things like cigarettes, alcohol, that are legal and that people use as a coping mechanism, how do you address this with people’s schizophrenia?

Brock Cook: So that’s one of the things I think it is important that we do take note of, I guess, why people are using different measures. For instance, if we are going to use cigarette smoking, why are people using? What are they actually getting out of it? Is it that they’re just having some time out and it gives them time to think? Is it that the regulated breathing? Is it that they smoke with friends and it’s a bit more of a social outlet? We need to really understand why people are doing it. Because what we’re able to do then and this is something that I think OTs are good at, because this is pretty much what we do as a profession, is once we understand why, we understand what that need is that, say, cigarettes is filling, we’re able to then explore healthier options that can also fill that same need. Because what will generally happen to anyone trying to quit smoking who tries to do it cold turkey. I think the success rate of cold turkey quitting smoking is about 5 percent, meaning that 95 percent of people who try to quit smoking cold turkey don’t succeed. The reason for that is we kind of almost build up like a habit of these coping mechanisms.

Brock Cook: And what tends to happen is if we just take those coping mechanisms away, eventually the stress, the anxiety that comes along with that change gets a little bit too much. And your brain’s default mechanism is to just switch to what knows. And for most people, if you’re cold turkey and you’re really, really craving a cigarette, what it knows is I can get rid of this feeling by having a smoke. The same thing happens when we’re working with people with schizophrenia or any other mental illness. If we are looking at understanding why they’re smoking, then we can put in healthier mechanisms. Might be things like meditation. I’ve worked with people where their thing to relieve that craving was just to put their hand in a bucket of ice just for a couple of minutes, just almost like a tactile thing. I’ve worked with people where it was that social outing and that’s how they felt they could make that social link was by smoking cigarettes with the people in that building complex. So, we worked on some ways where they could still meet that social need, but without the cigarettes.

Rachel Star Withers: What about medication side effects that play a huge part in the development of physical co-morbidities like diabetes? When it comes to weight gain and stuff and that’s something that, you don’t have as much control over. If I have to take these antipsychotics and they are causing my metabolism to slow down or whatever to happen inside of me to make me gain weight, how do you address that?

Brock Cook: There’s a few ways, and I think it’s going to be dependent on the individual and their lifestyle in a lot of cases, but I think we treat it the same way we would treat it for anyone. If someone is worried about weight gain, then we can have a look at developing some healthy lifestyle type options. So might be getting into exercise or trying a different type of exercise, or if it is about diabetes and it might be learning about diabetes management, whether it’s insulin dependent or not, which again, a lot of the time comes down to diet as well as a big management thing for diabetes. It could be a matter of either supporting them themselves or linking them in with services that can already help them with those. And it might be through their GP, it might be through a specialist dietician. It might be, I know here I’m not sure over there, but here we have specific diabetes educators, which are quite often nurses by trade, but they’ve done a lot of training specific to diabetes management. So, we can link them in with services like that. There’s not a lot that we can do specifically for the medication. If we know that there are other options, we can advocate to the psychiatrist on the person’s behalf. Quite often if the advocacy for that is coming from a health professional for some reason, I hate that it happens that way, but it seems to almost carry more weight than when it comes from the person itself, which is ridiculous. But as a health professional, that’s part of what we sign up for. Like most people got into those sorts of professions because they want to help people and advocacy happens to be a big part of that. We can either try and develop some healthy habits around countering whatever the side effect is, as well as advocating for potential medication changes or at least review it with their doctors.

Rachel Star Withers: Dealing with schizophrenia, it’s definitely exhausting. Between, let’s say, me having a vice that causes something else or just me developing something else due to treating my schizophrenia. What advice do you have for people just to not be overwhelmed?

Brock Cook: One of the biggest things is to try and have a little bit of an understanding of how motivation works. But more importantly, how it doesn’t work, which is often how a lot of health professionals try and promote it. And what I mean by that is a lot of health professionals look at motivation like it’s a cup. You either have some, you have a little bit, you have a lot, you don’t have any, that kind of thing. Well, it doesn’t actually work like that. Everyone has motivation, you just have to find what they’re actually motivated by. So, for example, if someone is having issues with their weight, they want to exercise. I think most people can vouch that actually starting to get into exercise, that’s something that is really hard. It’s a difficult habit to form. What we need to do is not just go, okay, you’re having issues with weight. You should try walking every day. Because that person might not give two hoots about walking. But there might be a team sport. They might want to play tennis. They played tennis when they were kids. That’s something that they can do. They can engage in that. They’re going to get their exercise in. So, it’s a matter of not just sticking to one option is one thing. You try and find something that you’re motivated to do as opposed to trying to find the motivation to do something, kind of flip it on its head. Start with the obvious in terms of your goal setting. When you’re trying to start a new habit, start with the smallest thing you can 100 percent guarantee you can do.

Brock Cook: So if it’s I can do a five minute walk at some point during this week, if that’s all that you can 100 percent guarantee that you can do. Done. That’s it. Start with that. The next week you can go, well, I did five minutes once last week. I’m going to do it twice this week. Start with that. And I think that’s one of the big things. And that’s not just for people with schizophrenia. That’s a big thing for everyone when it comes to goal setting is they start with I’m going to lose 20 kilos, or 20 pounds depending on where you’re from. It’s almost too big and it becomes overwhelming and it feels like, how am I going to do this? And it’s been two weeks and I’ve only lost half a pound and that kind of thing. It sounds really hard. And a lot of people after a few weeks or even less than that, usually after a week, they lose motivation. They lose interest because they don’t see they’re making any progress. Whereas if you’re essentially setting yourself up for success because you’re hitting the tiniest little goal. It could literally, I’ve heard of a guy who his goal was to go to the gym. So, for two months, literally, all he did was get dressed, get in his car, walk into the gym, get back in his car, go home. That was it. But that was how he was. And then he started off like two days and three days a week, etc. It started off for the smallest possible thing that he could guarantee that he could do. And then built on that. And that’s how you start building a sustainable habit change.

Rachel Star Withers: I absolutely love that. Like the whole time you were talking, in my head, I was like, okay, let me read them and all of my goals, all of the ones I haven’t done. Let me let me rethink about some things.

Brock Cook: It works.

Rachel Star Withers: Yeah. I seriously I’m like, ready to just bust out my little goal sheet and scratch ’em all out and be like, let’s reexamine my situations. Family, friends, caretakers of people with schizophrenia, what kind of signs should they look for? That a physical co-morbidity might be on the horizon?

Brock Cook: The main things I guess that you’re going to notice are behavior changes. All of a sudden they’ve gone from smoking one or two cigarettes to smoking a pack a day. All of a sudden, you’ve noticed that clothes aren’t fitting properly or well or they don’t feel comfortable. A lot of the I guess, the negative symptoms, isolation and that kind of stuff, because people might not feel comfortable going out. They don’t feel like they’ve got anything to wear. They feel like they’re going to be judged for whatever it is, whether it’s weight or smoking or that kind of thing. It’ll be a behavior change of some variation. The biggest thing friends and family can do is to try and maintain open communication with their loved ones. The person themselves is going to know if anything’s happening before anyone else notices anything. And if you’ve got that open communication, you’ve got at least someone that you have that open communication with, then hopefully you’ve developed that enough where they can feel comfortable to tell you like, oh, you know, my pants aren’t fitting.

Brock Cook: I just feel really uncomfortable. Don’t really want to go to this this work do on Friday night. I just don’t feel like I’ve got nothing to wear. I’ve been struggling to get through a workday without itching for a cigarette like any of those kind of changes. It’s open communication with anything like that is probably the key thing. Try and take it at their speed. It sounds like a weird thing to say, but people will when they do express their concerns about it, you’ll be able to pick up how they express it, how urgent an issue it is to that person, and if it is something that they’re feeling is really urgent, then take urgent steps. And if it’s something they’re like kind of like, oh, don’t like, oh my God, we have to change everything because you just mentioned this tiny thing because you’re gonna scare ’em. You’ll scare people and they’re probably not going to open up to you anymore.

Rachel Star Withers: Thank you so much, Brock, for coming and talking with us about this. I absolutely loved especially the goals part. Our listeners can find you at and you are the host of Occupied. Tell us about your podcast.

Brock Cook: It’s a podcast generally for occupational therapists. And what I’m trying to do for therapists is just open their eyes up to one, the range of different things that OTs can do. But I’ve also done quite a series of podcasts now, one of which you yourself was on, where I get people with a lived experience of something in your instance, schizophrenia, and have a chat about your story and your experience with it. To one, educate OTs and other therapists that listen about people’s experience of some of the conditions that we generally would work with. But also, it’s a resource there for people who may have schizophrenia or I’ve done other ones on alcohol abuse, borderline personality disorder, those kinds of things. But it’s a resource for those people to, I guess, almost the other way to try to get an understanding of this is how specifically an occupational therapist might work with someone presenting with those sort of symptoms or with that diagnosis. So, or Occupied can be found pretty much anywhere you can find a podcast. So yeah, if anyone’s interested in checking it out, feel free.

Rachel Star Withers: Well, thank you so much, Brock.

Brock Cook: No, thank you. Absolute pleasure.

Gabe: Rachel, that was incredible. It was interesting for me because I always tend to think of occupational therapy in terms of you got in a car accident and you’re having trouble walking, I think of occupational therapy as arthritis or it never occurred to me that occupational therapy could exist in the mental health field. For example, he said that it’s easy to let schizophrenia overshadow other health issues and that that’s a very bad idea.

Rachel Star Withers: Oh, absolutely. And I loved how many like practical answers he had and he didn’t just kind of harp on, oh, you’re doing all these bad things, you’ve got to stop doing these bad things. It was, we need to learn how to control some of these bad habits. Not so much get rid of them all. We need to kind of learn to control to make it healthy across the board just for you to live life, to do the things that you want to do. And I don’t, I loved his approach with all that. It was very upbeat. And I didn’t feel like he was fussing at me or anyone else over like life decisions.

Gabe Howard: My biggest takeaway and the thing that is most important is he said these are coping mechanisms. They are bad habits. They aren’t in your best interest. They do have long term effects and they are impacting your physical health, but you’ve chosen them for a reason. So, he helps you figure out what that reason is and choose a better option. I think that that is a very, very valuable takeaway for two reasons. One, I think that people with schizophrenia are often beat up on for making bad decisions with no care given to why they made that decision. And two, I think that it is important to make better decisions. As we’ve learned throughout this episode with the stats of people dying younger simply because they have schizophrenia, simply for managing schizophrenia, simply for doing all of the right things. We want people to live longer. Rachel, I want you to live to be 85. And he understands that’s the goal. But he also understands that the goal is to manage your life in the here and now. That really spoke to me in a very big way.

Rachel Star Withers: I agree 100 percent with that. I said in the interview, one of my favorite things was when he was like, OK, what’s the baby goal you could absolutely do? What’s the tiniest thing that you can totally do? And I’ve been thinking about that. Something that I’ve been struggling with for a while is waking up. I have such a hard time getting out of bed for when I don’t sleep well. I usually have to be on like sleeping pills, so I might end up being in bed for twelve hours, but not ever actually going to like a really deep sleep. Just kind of coming in and out of this kind of confusion. So, I’m always exhausted and if I have work or something, I can make myself get out of bed. That’s not a problem. But most days I don’t. Oh, I only work twelve hours a week, so most days I do not have any real reason to get up. And so, I was thinking, yeah, over and over, I set the goal, oh, I’m gonna be up and out of bed by 8 a.m. 9:00 a.m. Today. It’s just crazy because I keep missing the goal and I get so frustrated and I beat myself up and I was thinking, OK, what was like the smallest thing? Because I know I can get up when I have to.

Rachel Star Withers: And I was like, I’m going to pick at least one day a week, where I do not have to be up for any reason, that I will force myself to get up and be up and moving around at least for two hours, I was like, oh, yeah, I can totally do that. So guess what, Gabe? Tomorrow morning my alarm’s already set. Tomorrow morning, I got it set for, I have like actually 10 alarms set for 8:00, but I have them all set to end at 8:00 hopefully. And that’s my goal is to wake up, at least be up moving around, doing things till 10:00. And then if I’m still exhausted, tired, and need to lay back down, then I will. I’m not going to beat myself up over that. But, you know, we’ll see what happens. Maybe I’ll be able to stay awake the whole time and be as refreshed as I normally am.

Gabe Howard: Well, Rachel, I hope so, too, because as you’ve said a million times, you need to be proactive with your health because you’re worth it and you need to speak up and make sure that you’re on the same page with your doctor. This is all good advice for everybody. Forget about managing or living with schizophrenia. This is just good advice, and the rules don’t change because you live with schizophrenia.

Rachel Star Withers: Yes, it is so easy to let schizophrenia overshadow everything else in your life. However, it is just a part of you and every other part is just as important, including your physical health. Be knowledgeable of the medications that you’re on and their side effects so you know what to expect. All right. So, you know, okay, this could happen. And when it does, what’s going to be my plan? Who am I going to let know? What lifestyle changes might I have to take? Speak up. Make sure that everybody is on the same page for your treatment because it is your treatment. Be proactive. Take care of yourself, because like Gabe and L’Oreal says, you’re worth it. Thank you so much for listening. Like, share, subscribe, to this podcast and share it widely with your friends and family. We’ll see you next month here on Inside Schizophrenia.

Announcer: Inside Schizophrenia is presented by, America’s largest and longest operating independent mental health website. Your host, Rachel Star Withers, can be found online at Co-host Gabe Howard can be found online at For questions, or to provide feedback, please e-mail The official website for Inside Schizophrenia is Thank you for listening, and please, share widely.

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