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Managing diabetes
in people with
severe mental illness
ohn endlebury, ichard I olt
rticle points
1.
iabetes is two to three Diabetes and other metabolic abnormalities, as well as an unhealthy
times more common in lifestyle, are more prevalent in people with severe mental illness
people with severe mental (SMI), increasing their risk of cardiovascular disease (CD) he
illness (SMI) than in the most common cause of death in people with schiophrenia and
general population. bipolar illness is CD, accounting for up to of all deaths
. The reasons or this here are many different causes of diabetes in people with SMI,
are multi actorial and
include genetic and as in the general population arguably the most important are
environmental ris actors potentially modifiable lifestyle factors eople with SMI are
as well as disease and more likely to be unemployed, have low incomes, live in rented
treatment actors. accommodation, have a poor diet and be more physically inactive
. There is a need or Mental illness itself further contributes to the risk of developing
screening diabetes
prevention and strategies diabetes ntipsychotic medications have been implicated in the
to manage the diabetes aetiology of diabetes he increased prevalence of diabetes in people
i this occurs. with SMI has clinical implications for care, including screening,
. sychiatric and diabetes diabetes prevention and strategies to manage the diabetes if this
services need to wor occurs ealthcare professionals working in psychiatry and diabetes
together to improve
communication pathways care need to collaborate closely to provide the integrated care that
and collaboration to people with SMI need he DS
has a pivotal role in this
ensure that people with
SMI and diabetes enoy a
long and healthy li e. he connection between diabetes and with one another more often than can be
ey words the two main severe mental illnesses accounted for by accidental coincidence
T(SMIs) – schizophrenia and bipolar or sequence.”
ntipsychotics illness – was recognised more than a century
ipolar illness ago. In 1 Sir enry Maudsley in The The prevalence o diabetes in people with
Schizophrenia
Severe mental illness Pathology of Mind commented that schizophrenia or bipolar illness (1–1) is two
to three times that in the general population
“Diabetes is a disease which often shows (.–) (olt et al ).
iabetes and other
itself in families in which insanity metabolic ris actors may eplain to a large
prevails. Whether one disease predisposes etent the increased rates o cardiovascular
in any way to the other or not, or disease (
) in people with SMI.
is
whether they are independent outcomes the most common cause o death in people
uthors’ details can be ound of a common neurosis, they are certainly with SMI and is partially responsible or the
at the end o the article. found to run side by side, or alternately reduction in li e epectancy (by 1–1 years) in
ournal of Diabetes
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Managing diabetes in people with severe mental illness
able ositive and people with schizophrenia compared with the o
IC () Schiophrenia
negative symptoms general population (rown et al ). guideline recomendation
of schiophrenia Severe mental illness eople with schizophrenia at increased ris
ositive symptoms SMI here taen to mean the psychotic o developing cardiovascular disease and¥or
l
elusions. illnesses schizophrenia and bipolar illness diabetes (e.g. with elevated blood pressure
l allucinations. is associated with a lac o insight by the raised lipid levels smoers increased waist
l Thought disorder. su erer. Schizophrenia a ects around 1 measurement) should be identified at the
o the population and occurs eually in men earliest opportunity.
egative symptoms and women (ablensy oodwin et
l ¢ac o energy. al ). nset o psychosis be ore the age generation or “atypical” antipsychotics were
l Social withdrawal. o 1 years is rare but can occur at any time developed and introduced in the 1s with
l ¢ac o motivation. a ter this most o ten between 1 and years the prospect o more e ective treatment or
l £lattening o a ect. o age. Symptoms o schizophrenia are o ten SMI and ewer sidee ects (Table 2).
l nhedonia. described as positive or negative (Table 1) but
schizophrenia may also be associated with Metabolic abnormalities
mood disorders and cognitive impairment. ardiovascular ris actors other than
ipolar disorder previously nown as manic diabetes are also more common in people
depression involves cycles o mania and with SMI than in the general population and
depression but those a ected may also have so it is important that these are considered in
times when mood is normal. addition to diabetes (Box 1; Table 3) (
e ert
The lives o many people with SMI were et al ).
trans ormed in the 1s ollowing the
etailed guidelines about the management
development o antipsychotic medications o these ris actors may be ound in the oint
(Table 2). This maredly reduced the uropean sychiatric ssociation uropean
number o psychiatric inpatients in the ssociation or the Study o
iabetes and
rom approimately hal a million in uropean Society o ardiology position
the preantipsychotic era to the current statement (
e ert et al ).
figure o less than 1. This figure is
continuing to all with the introduction o etiology of diabetes in SMI
early intervention crisis resolution home nderstanding why diabetes and other
treatment and liaison services. metabolic comorbidities are more common in
lthough this meant that SMI could people with SMI is vital i we are to develop
be treated e ectively or the first time appropriate holistic strategies to meet the
conventional or “typical” antipsychotics were clinical challenges that this presents.
ound to have a number o stigmatising side There are multiple ris actors or diabetes
e ects such as etrapyramidal movement in the general population and similarly these
disorders including tardive dysinesia contribute to the increased ris o diabetes in
parinsonism dystonia and aathisia. Second people with SMI (olt and eveler ¡a
¡b). ¢i estyle actors are arguably the
able Currently available antipsychotic medication most important as these are potentially
modifiable. overty urbanisation poor diet
Conventional or Secondgeneration or and physical inactivity are all important
“typical” antipsychotics “atypical” antipsychotics ris actors or diabetes and occur more
hlorpromazine haloperidol misulpride aripiprazole reuently in people with SMI. eople with
thioridazine trifluoperazine clozapine olanzapine paliperidone schizophrenia tend to have diets that contain
flupentiol fluphenazine uetiapine risperidone higher amounts o at and refined sugar
pipotiazine zuclopenthiol. sertindole zotepine. but lower amounts o fibre mainly because
o inadeuate ruit and vegetable intae
ournal of Diabetes
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Managing diabetes in people with severe mental illness
able stimated prevalence of modifiable cardiovascular risk factors development o diabetes they may provide a
in people with schiophrenia and bipolar illness and relative risk lin between diabetes and SMI.
compared with the general population ntipsychotics have also been implicated
in the development o diabetes. The first
Schiophrenia ipolar illness reports appeared in the 1s ollowing the
Modifiable revalence elative revalence elative introduction o conventional antipsychotics
risk factor risk risk (iles 1¡) when the term “phenothiazine
Smoing – – –¡ – diabetes” appeared in the medical literature.
yslipidaemia –¡ ≤ – ≤ This sidee ect seems to have been first
iabetes 1–1 – –1 1.– ignored and then orgotten as there were no
ypertension 1– – –¡1 – alternatives to antipsychotic treatment. The
issue o treatmentemergent diabetes only
besity – 1.– 1– 1– returned a ter the introduction o the newer
Metabolic syndrome –¡ – – – secondgeneration antipsychotics (Ss).
dapted rom
e ert et al () There are many reported cases o people
developing diabetes a ter starting treatment
(Mcreadie et al 1 rown et al 1) with Ss some o which remit a ter
compared with the general population. cessation o treatment (in et al ).
enetic actors are also important as In these cases it seems liely that the
demonstrated by the high number o people antipsychotic played a maor role in the
with SMI (1–) who have a firstdegree development o diabetes but what is less clear
relative with type diabetes (ough and is how ar this can be etrapolated to the
’
onovan ). lso firstdegree relatives wider body o people receiving antipsychotics
have a high reuency o other glucose (olt and eveler ¡a).
abnormalities (Spelman et al ). bservational studies have suggested that
The mental illness is liely to contribute people receiving antipsychotics are more
urther to the ris o diabetes as illustrated by liely to develop diabetes than those who
studies o drugnaïve people during their first are not but these data may be biased by the
episode o psychosis. ne study o ¡ people con ounding e ect o the mental illness and
age points with “firstepisode” psychosis ound that its associated genetics and li estyle (olt and
1. Some recent studies but more than 1 had impaired asting glucose eveler ¡a).
not all have raised the levels compared with none o the healthy bservational studies have also suggested
possibility o biological controls (§yan et al ). Individuals with that treatment with Ss is associated
lins between diabetes and “firstepisode” psychosis also had three times with a small increase in the ris o diabetes
severe mental illness (SMI). as much intraabdominal at as controls compared with treatment with a first
. ne putative mechanism (Thaore et al ). generation antipsychotic (Smith et al ).
is the change in Some more recent studies (ohn et al Some studies have suggested a higher ris
neuroendocrine unction Saddichha et al ) but not all (rranz et o diabetes with clozapine and olanzapine
seen during acute episodes al raham et al ) have confirmed compared with other Ss but these reports
o psychosis where people
with SMI have higher these findings raising the possibility o are inconsistent (itrome et al ).
concentrations o cortisol biological lins between diabetes and SMI. round prospective studies have reported
and catecholamines. ne putative mechanism is the change in glucose abnormalities but none ound any
. s both these hormones neuroendocrine unction seen during acute significant di erences between di erent
are insulin antagonists episodes o psychosis people with SMI antipsychotics or indeed between antipsychotic
and elevations o these have higher concentrations o cortisol and and placebo. This suggests that the main
hormones have been catecholamines (§yan and Thaore actors responsible or the development o
associated with the
antzer et al ). s both these hormones diabetes are the illness and associated genetics
development o diabetes
they may provide a lin are insulin antagonists and elevations o these and environment as opposed to the medication
between diabetes and SMI. hormones have been associated with the (ushe and ¢eonard ) (Figure 1).
ournal of Diabetes
ursing ol
o
Managing diabetes in people with severe mental illness
Implications for the clinical Figure 1. chematic representation of the reasons why people with severe
care of people with SMI mental illness develop diabetes. ost of the ecess prevalence can be eplained
The higher prevalence o diabetes among people by an increase in traditional ris factors, while the illness itself conveys a
with SMI has a number o clinical implications further ris. ntipsychotic medication increases the ris, but this is small
or care or those woring in diabetes and compared with the overall ris. dapted from olt and eveler b.
psychiatry services. £irst we need to screen or
diabetes then we need to implement strategies typical vs atypical
to reduce the ris o diabetes and finally care typical vs typical
plans should be developed to manage those ny antipsychotic
individuals who develop diabetes. medication
Screening Severe
mental
The high rates o undiagnosed diabetes and illness
long duration between onset o diabetes and
development o symptoms support the need to Traditional
screen or diabetes in the general population. ris actors
This coupled with the higher prevalence o e.g. amily history low birth
both diagnosed and undiagnosed diabetes weight obesity diet eercise
in people with SMI provides a stronger
imperative or screening in this group.
s many as ¡– o all cases o
diabetes in those with SMI are undiagnosed
(Subramaniam et al Taylor et al In such circumstances a random blood glucose
oruganti et al ) not least because o level is a reasonable alternative (olt et al
possible diagnostic uncertainty as people with ). In due course it may also be reasonable
SMI may have negative symptoms and side to screen by b1c as at the time o writing age points
e ects that mimic the symptoms o diabetes. the ªorld ealth rganization is considering 1. s many as ¡–
£urthermore opportunities or screening may the use o b1c as a diagnostic test. o all cases o diabetes
be limited or those people with SMI who lthough much o this wor will be in people with severe
attend their surgery less reuently than undertaen by the psychiatry team or mental illness (SMI)
the general population. healthcare pro essionals in primary care are undiagnosed.
£or these reasons a number o national and
S¨s may be needed to provide advice about . ne reason or this is
international bodies including ¨I () screening and interpretation o blood test diagnostic uncertainty as
iabetes the oint uropean Societies results (Box 2). people with SMI may have
(
e ert et al ) the merican
iabetes negative symptoms and
ssociation anadian
iabetes ssociation revention of diabetes sidee ects that mimic the
symptoms o diabetes.
and ustralian
iabetes ssociation have There are studies rom hina £inland India
recommended screening or diabetes in people and the S demonstrating the e ectiveness . number o national
with SMI irrespective o their treatment o li estyle modification in preventing and international bodies
recommend screening or
(itrome and ©eomans ). diabetes in people with
It is recommended that symptoms o o
IC () Schiophrenia SMI irrespective o their
diabetes and blood glucose concentration guideline recommendation treatment.
should be assessed at baseline – months . It is recommended that
a ter initiation o or changes in antipsychotic ealthcare pro essionals in secondary care diabetes symptoms and
medication and annually therea ter. should ensure as part o the are rogramme blood glucose levels be
ªhile a asting blood glucose concentration pproach that people with schizophrenia assessed at baseline –
is probably the ideal screening test a pragmatic receive physical healthcare rom primary months a ter initiation
care as described in recommendations o or changes in
view is needed because people with SMI may 1..1.1.–1..1.. antipsychotic medication
find it di ficult to attend asted or a blood test. and annually therea ter.
ournal of Diabetes
ursing ol
o
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