'Shocking' Stats for Diabetes Screening in Mentally Ill

Pauline Anderson

November 11, 2015

Despite long-standing recommendations that severely mentally ill patients who take antipsychotics undergo annual screening for diabetes and other indicators of metabolic change, only 30% receive such screening, new research shows.

"It's an outrage to me that this population and others like it don't get the care they deserve," said lead author Christina Mangurian, MD, associate professor of clinical psychology, University of California, San Francisco.

This lack of screening is due in part to the "total segregation between the mental health and primary care systems.

"These parallel systems of care are unintegrated, so people who are vulnerable, like those with severe mental illness, fit predominantly on the mental health side, not on the primary care side," Dr Mangurian added.

The study was published online November 9 in a research letter in JAMA Internal Medicine.

Need for Systemic Change

Patients taking antipsychotic medications, particularly second-generation agents, have twice the risk of developing diabetes compared with the general population.

In 2004, a consensus panel composed of psychiatrists and other experts determined that seriously mentally ill patients should be screened annually for diabetes as well as dyslipidemia and hypertension.

For the current study, researchers at the University of California, San Francisco, analyzed data from the California Medicaid and Client and Service Information systems for two study periods ― January 1, 2009, to December 31, 2009, and October 1, 2010, to September 30, 2011. They used data from the second period to characterize diabetes screening in the subgroup who did not have diabetes mellitus in the first period.

The study cohort included adults with a diagnosis of severe mental illness who received a prescription for an antipsychotic medication at least once during each of the study periods.

The main outcome was evidence of diabetes screening via a glucose-specific fasting serum test or glycated hemoglobin test.

Of 50,915 patients in the study, only 15,315 (30.1%) received diabetes-specific screening. A total of 15,832 (31.1%) received no form of glucose screening at all during the year-long period.

The rates for those who received no glucose screening were similar for younger and older patient groups (38.4% for patients aged 18 - 27 years; 31.9% for patients aged 28 - 47 years; 26.9% for those aged 48 - 67 years; and 40.9% for those aged 68 years and older).

Dr Mangurian said that this means young adults are not getting tested, and therefore prediabetes is not being caught.

With proper treatment, mentally ill patients "can be totally functional for the rest of their lives, but nobody is checking them for these medical problems, which is necessary to prevent long- term sequelae."

Contact with primary care improved diabetes screening rates, according to the study. Patients with severe mental illnesses who had at least one primary care visit in addition to receiving mental health services were more than twice as likely to be screened than those who did not have a primary care visit (35.6% vs 19.8%).

Psychiatrists are "trying their best" to get this vulnerable population screened, but they do not have access to the patients' electronic primary care medical records. In addition, many of these patients are so ill that preventive healthcare is low on the list of priorities.

"If a person is homeless or suicidal or abusing drugs, checking them for diabetes falls to the bottom of the list," said Dr Mangurian.

Another problem is that severely mentally ill patients are "quite disorganized," and even if a physician gives them a requisition for a laboratory test, they may never follow up on it, she said.

"Psychiatrists are out there trying to fight the good fight, but they have no access to electronic medical records, and they're dealing with very sick patients, so the system is more failing them than the other way around. I think it's a systemic issue; it's not the providers' fault."

A "gigantic first step" to solving this problem would be to integrate patient medical and psychiatric records, said Dr Mangurian. However, she acknowledged that this would be a major undertaking. Nevertheless, she said integration needs to happen.

Healthcare providers may want to consider diabetes tests that do not require fasting.

"Some providers can get caught up on older guidelines about fasting labs," which can be complicated for someone with a mental illness, said Dr Mangurian. "I don't think people need to have fasting labs anymore; they could just get a hemoglobin A1C to test for diabetes."

Shocking Stats

Commenting on the findings for Medscape Medical News, Thomas Wise, MD, associate chair of psychiatry, George Washington University School of Medicine and Health Sciences, Washington, DC, said he found some of the statistics in the study "really shocking."

"It reminds us that we have a long way to go" and should be "a wake-up call," because diabetes is related to other serious disorders.

"These are very vulnerable people due to their illness," said Dr Wise. "They're sedentary; they're poor; they eat badly; and a lot of them smoke. They have assorted other illnesses, including hypertension, cardiovascular disease, and obesity."

Physicians, he said, have "a short memory," because recommendations about annual diabetes screening for patients receiving antipsychotics were published in Diabetes Care and the American Journal of Psychiatry in 2004.

But although there is lots of blame to go around, Dr Wise agreed that the main culprit is "the system."

"This study demonstrates that if we really care about the health of our seriously mentally ill, we will have to use population health techniques."

Those techniques, he said, might involve use of case registries and case managers. And these dedicated experts may have to drive around to get homeless mentally ill people to take them to get screened for diabetes.

Such an approach may prove cost effective. Dr Wise described his own 1000-bed hospital in which treating patients with serious mental illness "costs a fortune." Changing the system so that more seriously mentally ill patients are screened for diabetes would likely save money over time. But more importantly, he added, it would improve the quality of life of these patients.

In an accompanying editorial, Mitchell H. Katz, MD, director of the Los Angeles County Department of Health Services, in California, said that to improve care for persons with serious mental illness, it will be necessary to "break down the silos that separate the mental health and physical healthcare systems.

"Integrated care (care provided by a team of physical and mental health clinicians) ― or at least collocated care (care provided by physical and mental health clinicians in the same place) ― offers the promise of improving the physical health of individuals with mental illness, as well as the mental health of those seeking physical health services," he writes.

Dr Mangurian, Dr Wise, and Dr Katz report no relevant financial relationships.

JAMA Intern Med. Published online November 9, 2015. Abstract, Editorial

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