Diabetes Screening, Risk Management and Disease Management in a High-Risk Mental Health Population Part II
Condition: Diabetes Mellitus; Schizophrenia; Psychotic Disorders
MeSH terms: Diabetes Mellitus; Schizophrenia; Psychotic Disorders
Study type: Observational

Summary: 
      The purpose of this study is to learn more about the relationship between serious mental
      illness and the detection and management of diabetes and pre-diabetic conditions. Patients
      who have been diagnosed with schizophrenia are at an increased risk for developing diabetes
      and pre-diabetic conditions such as impaired glucose tolerance and impaired fasting glucose.
      In addition, novel antipsychotics have also been linked to impaired glucose metabolism and
      increased incidence of diabetes. The medical management of these patients may be difficult ot
      achieve through standard family practice. The objectives of this project are to: screen a
      sample of this high-risk population using an Oral Glucose Tolerance Test (OGTT), and to
      provide multidisciplinary team support to those identified as having diabetes or a
      pre-diabetic condition.
    

Detailed description: 
      Many studies suggest that the extensive psychiatric needs of some patients could take
      attention away from management of other health problems and from the usual health promotion
      services physicians provide. Studies suggest that medical comorbidity has often been under
      recognized and under diagnosed in psychiatric patients, especially among those with
      schizophrenia. Unrecognized physical diseases are often associated with serious, potentially
      fatal illness, and may exacerbate the symptoms of psychiatric illness.

      The disorder of schizophrenia has been repeatedly associated with a higher than normal
      incidence of medical illnesses- specifically, diabetes mellitus (DM). The prevalence of DM in
      a retrospective study of 95 chronic schizophrenic patients was found to be 15.8% - 4 to 5
      times higher than that reported in epidemiological surveys in the general population. This
      increased risk has recently been formally recognized in the Canadian diabetes practice
      guidelines. In addition, the first line treatment of schizophrenia as per many published
      clinical practice algorithms, novel antipsychotics (NAP), has been associated independently
      with increased risk for diabetes. Novel antipsychotics such as clozapine, olanzapine,
      quetiapine, and risperidone have demonstrated efficacy in the treatment of schizophrenia with
      generally fewer extrapyramidal side effects than high dosed typical neuroleptics. However,
      there is accumulating data suggesting that treatment with at least some of the NAPs may be
      associated with the development of DM and associated risk factors. The use of olanzapine, for
      example, has been associated with weight gain, exacerbation of previously well-controlled
      diabetes, and onset of type 1 and type 2 diabetes. Clozapine has also been associated with
      weight gain in several reports, as well as increased risk of developing diabetes, and at
      least one report citing deaths from diabetic ketoacidosis after long-term use.

      High-risk groups need targeted diabetes strategies. The Canadian diabetes practice guidelines
      outline that the service model needed to achieve the benchmarks set for diabetes care will
      need to be designed to reflect the unique diabetes related challenges faced by various
      segments of the diabetes epidemic. Diabetes care should be organized around a
      multidisciplinary diabetes healthcare (DHC) team that can establish and sustain a
      communication network between the person with DM and the necessary healthcare and community
      systems. The high risk mental health communities in Ontario need a targeted primary health
      care service delivery model that attends to the unique set of diabetes related challenges
      they face, including: weight increase related to medication use, inadequate self-care
      resources and capacity related to poverty, social constraints and lack of supports,
      communication barriers and mental health symptomology impacting interactions with service
      providers.

      Current guidelines for diabetes management are clear regarding the monitoring and treatment
      of identified high-risk groups. Screening for DM should be performed every three years in
      individuals over 40 years of age. However, more frequent and/or earlier testing with a 75-g
      Oral Glucose Tolerance Test (OGTT) should be considered in people with identified risk
      factors such as schizophrenia and NAP use. Annual screening could detect individuals with
      undiagnosed DM as well as individuals with the pre-diabetic conditions of Impaired Fasting
      Glucose and Impaired Glucose Tolerance. Results of large, well-designed studies assessing
      early interventions in adults to prevent the progression from pre-diabetic conditions to DM
      have recently been published. These studies have demonstrated significant risk reduction with
      lifestyle management and appropriate pharmacologic interventions. It is also well documented
      that a comprehensive multidisciplinary Diabetes Healthcare team can help slow the progression
      of the disease and reduce the incidence of DM-related complications for those already
      diagnosed with DM.

      The London Intercommunity Health Centre (LIHC) has recently piloted a diabetes program
      addressing the needs of a high-risk mental health population within the recommended
      guidelines. The program was designed as a "one stop shop" for self-management teaching,
      medication and glucose monitoring, and referral to specialist providers as needed. The
      structure of the program followed the Canadian Diabetes Association Clinical Practice
      Guidelines. Although the program has yet to be implemented long enough to determine if the
      progression from pre-diabetes to diabetes was prevented, pre-diabetic patients involved in
      the program have demonstrate clinically significant improvement in lipid profiles and blood
      pressure measurements. Those patients diagnosed with DM, who participated in the program,
      were found to attend regularly, and demonstrated a clinically significant improvement in
      their metabolic control. Thus, initial results from the LIHC, and a recent extension of this
      model into a community population, indicate that this model of diabetes care for this
      high-risk mental health population is promising for diabetes risk and disease management.
    

Intervention name(s): Management; Screening
Intervention type(s): Procedure; Procedure
Time perspective: Other