This study examined effects of cigarette smoking on mortality risk in 1213 persons aged 19-69 years with schizophrenia-related psychotic disorders admitted to State of Maryland Hospitals between 1994 and 2000. Inpatient medical records from 7 hospitals were reviewed to obtain demographic information, diagnosis, medication use, as well as smoking and other substance use. Social Security Death Index data were used to identify deaths in the study group between 1994 and 2004. Death records were reviewed to obtain manner of death and underlying disorders. Of the 1213, 55% were smokers and 71% abused substances. There was an age × smoking interaction (χ(2) = 14.6, df = 1, P = .0001) for mortality, with estimated hazard ratios (HRs) for smokers vs nonsmokers of 2.1 among 35- to 54-year olds and HR of 0.7 among those aged 55-69 years. Five- and 10-year mortality rates for smokers aged 35-54 years were 7.0% and 14.2%, compared with 3.3% and 10.0% for nonsmokers, respectively (χ(2) = 5.53, df = 1, P = .019). Cardiac causes were identified in 43% of deaths in smokers but only 19% of deaths in nonsmokers (P < .006). For those aged 35-54 years, the odds of cardiac related death was increased by 12 fold in smokers relative to nonsmokers (HR = 12.4, χ(2) = 12.0, df = 1, P = .0005). Among people aged 35-54 years, those smoking greater than one pack daily have a significantly increased total mortality risk (HR = 2.7) vs nonsmokers. Cigarette smoking, particularly in people aged 35-54 years, contributes to an increased risk of death. Greater smoking severity significantly increases this risk. Smoking cessation in people with schizophrenia deserves significant attention.

Olanzapine and chlorpromazine showed similar efficacy, and the total amount of improvement with either drug was modest. Olanzapine-treated patients had fewer side effects than chlorpromazine-treated patients.

Although clozapine has demonstrated unique efficacy for the treatment of seriously ill patients with refractory psychosis, its real-world use presents challenges to clinicians in a variety of settings, leading to its underutilization in the United States. The barriers include a lack of prescriber knowledge and confidence, negative prescriber attitudes, special monitoring requirements, administrative burden, unprepared health systems, and inadequate appreciation of clozapine's unique nature by policy makers and payers. In 2016, the National Association of State Mental Health Program Directors (NASMHPD) gathered a national team of expert clinicians and researchers to identify and address barriers to clozapine use. NASMHPD has since expanded the work group, which convenes monthly to continue addressing specific recommendations. This Open Forum describes the deliberations of the work group and urges practitioners, administrators, local and state governments, researchers, families, and patients to join similar efforts to promote better access to clozapine and improve the treatment management for patients receiving clozapine.