Barriers and enablers of type 2 diabetes self-management in people with severe mental illness

The Determinants of Mental Illness Self-Management for Patients With Schizophrenia and Type 2 Diabetes: A Self-Determination Theory Approach

AIM

This study based on self-determination theory aimed to assess the relationship between motivation, competence in diabetes management and perceived autonomy support respectively and mental illness self-management; furthermore, the authors intended to explore the determinants of mental illness self-management for patients with schizophrenia and diabetes.

DESIGN

This was a cross-sectional study.

METHODS

One hundred ten participants were recruited at the psychiatric hospital and assessed with the Illness Management and Recovery Scale, the Treatment Self-Regulation Questionnaire, the Perceived Competence Scale for Diabetes and the Health-Care Climate Questionnaire.

RESULTS

Patients with lower educational levels, who were admitted to the chronic ward, were unemployed, had lower motivation in illness management, lower competence in diabetes management and perceived lower autonomy support all had lower mental illness self-management. Competence in diabetes management, employment status, autonomy support, educational levels and living alone were the determinants of mental illness self-management.

CONCLUSION

Recovery from schizophrenia and comorbid diabetes is an enduring and complicated process requiring support from healthcare providers. Health professionals should assess the levels of illness self-management and provide integrated care interventions for patients with schizophrenia and diabetes, helping them manage both conditions.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The illness management programme could apply to patients with schizophrenia and diabetes and address patients' characteristics such as low levels of education, living alone and being unemployed while additionally promoting motivation and competence, and providing supporting autonomy.

REPORTING METHOD

The STROBE checklist was followed.

PATIENT OR PUBLIC CONTRIBUTION

Patients with schizophrenia and diabetes were recruited for this study and voluntarily completed the questionnaire.

Living with schizophrenia and type 2 diabetes and the implication for diabetes self-care: A qualitative study

AIM

To achieve an in-depth understanding of the challenges associated with diabetes management when having both schizophrenia and type 2 diabetes, while also identifying the needs for improved diabetes self-care.

DESIGN

The study employed a qualitative explorative design utilizing a phenomenological-hermeneutic inspired approach, involving field observations and individual semistructured interviews.

METHODS

Data were collected during 2020-2021 through 17 field observations of outpatient consultations and 13 individual semistructured interviews. Data, including field notes and verbatim transcribed interviews, underwent analysis following Ricoeur's interpretive philosophy, encompassing three levels: naïve reading, structural analysis and critical interpretation and discussion. This study adheres to the COREQ guidelines for qualitative research.

RESULTS

Three key themes emerged: 'Diabetes when life is noisy', 'Sacrifices and compromises in life' and 'The double silence'. Everyday life is significantly affected when having both schizophrenia and T2D. The mental health state dominates in relation to diabetes self-care and individuals experience challenges balancing between the two conditions. However, there exists a general acknowledgement for diabetes and its long-term complications as a serious medical condition demanding careful attention and treatment.

CONCLUSION

Self-managing two such complex conditions can be overwhelming and make it difficult for the individual to differentiate symptoms and prioritize diabetes care. Moreover, the existing fragmentation within healthcare systems poses communication challenges, resulting in disjointed patient pathways.

IMPLICATIONS FOR PATIENT CARE

The study emphasizes the need for a holistic re that addresses the physical, emotional and social challenges. There is also a need for increased awareness and education among informal caregivers and healthcare professionals to foster better understanding and support.

Nationwide Evaluation of Quality of Care Indicators for Individuals with Severe Mental Illness and Diabetes Mellitus, Following Israel's Mental Health Reform

Diabetes Mellitus (DM) is more common among individuals with severe mental illness (SMI). We aimed to assess quality-of-care-indicators in individuals with SMI following the 2015 Israel's Mental-Health-reform. We analyzed yearly changes in 2015-2019 of quality-of-care-measures and intermediate-DM-outcomes, with adjustment for gender, age-group, and socioeconomic status (SES) and compared individuals with SMI to the general adult population. Adults with SMI had higher prevalences of DM (odds ratio (OR) = 1.64; 95% confidence intervals (CI): 1.61-1.67) and obesity (OR = 2.11; 95% CI: 2.08-2.13), compared to the general population. DM prevalence, DM control, and obesity rates increased over the years in this population. In 2019, HbA1c testing was marginally lower (OR = 0.88; 95% CI: 0.83-0.94) and uncontrolled DM (HbA1c > 9%) slightly more common among patients with SMI (OR = 1.22; 95% CI: 1.14-1.30), control worsened by decreasing SES. After adjustment, uncontrolled DM (adj. OR = 1.02; 95% CI: 0.96-1.09) was not associated with SMI. Cardio-metabolic morbidity among patients with SMI may be related to high prevalences of obesity and DM rather than poor DM control. Effective screening for metabolic diseases in this population and social reforms are required.

Perception of self-management and glycaemic control in people with type 2 diabetes receiving insulin injection therapy: A qualitative study

AIM

The aim of this study was to explore the experience of self-management and glycaemic control in Chinese people with type 2 diabetes receiving insulin injection therapy.

METHODS

A qualitative descriptive design was adopted with individual, semi-structured interviews. Participants were selected by purposive sampling. All face-to-face interviews were conducted between December 2020 and January 2021. The interviews were audio recorded and transcribed verbatim. Content analysis was used to analyse the interview data.

RESULTS

A total of 27 participants were recruited and individually interviewed. Three themes were generated: integrating insulin injection therapy into daily self-management; experiencing uncertainty when coping with suboptimal glycaemic control; and self-management programmes for optimal diabetes control.

CONCLUSION

All of our findings increase the understanding of self-management and glycaemic control in people with T2D receiving insulin injection therapy. Healthcare professionals should recognise the unmet needs of this cohort to promote their diabetes management. Appropriate and effective self-management programmes should be developed and implemented to alleviate the negative impacts of insulin injection therapy on diabetes management with consideration of cultural and personal context.

Individual, social and environmental factors influencing dietary behaviour in shift workers with type 2 diabetes working in UK healthcare: A cross-sectional survey

BACKGROUND

The present study aimed to understand the individual, social and environmental factors influencing dietary behaviour in shift workers with type 2 diabetes (T2D) working in UK healthcare settings.

METHODS

A cross-sectional study was conducted using data collected from an anonymous online survey. Participant agreement was measured using five-point Likert scale (strongly disagree to strongly agree) against 38 belief statements informed by the Theoretical Domains Framework (TDF) of behaviour change.

RESULTS

From the complete responses (n = 119), 65% worked shifts without nights, 27% worked mixed shift rota including nights and 8% worked only night shifts. The statements ranked with the highest agreements were in the TDF domains: Environment Context/Resources (ECR) - mainly identified as a barrier to healthy eating, Behaviour Regulation (BR) and intention (IN) - identified as enablers to healthy eating. For the belief statement 'the available options for purchasing food are too expensive' (ECR), 80% of night workers and 75% non-night workers agreed/strongly agreed. Taking their own food to work to prevent making unhealthy food choices (BR) had agreement/strong agreement in 73% of non-night and 70% night workers; 74% non-night workers and 80% of night workers agreed/strongly agreed with the statement 'I would like to eat healthily at work' (IN). Mixed shift workers agreed that following dietary advice was easier when working a non-night compared to a night shift (p = 0.002).

CONCLUSIONS

Access and affordability of food were identified as important determinants of dietary behaviour during shifts. The findings support interventions targeting the food environment for shift workers with T2D.

Staff experiences of diabetes care in residential care facilities for people with severe disabilities in Denmark: a mixed-methods assessment of access to screening for diabetes complications

OBJECTIVES

To identify the prevalence of diabetes among adults (>18 years) living in residential care facilities in Denmark and to identify the structural, practical, and individual barriers and drivers related to their participation in screening programmes.

DESIGN

SETTING: The register-based study included all residents living in residential care facilities in Denmark. The survey and qualitative analysis were carried out exclusively in the Capital Region of Denmark.

PARTICIPANTS

For the register-based study, we identified 11 620 residents of care facilities in Denmark (>18 years) and identified the number of residents with diagnosis codes of type 1 or type 2 diabetes or dispensed prescriptions of blood glucose-lowering medication. Staff from 102 psychiatric facilities housing adults with severe psychiatric disabilities were invited to participate in the survey. Of these, 56 facilities participated with one responder each, of which n=16 also participated in follow-up qualitative interviews.

RESULTS

Register-based study: of the residents at the facilities, 954 (8%) were diagnosed with diabetes. Descriptive statistics of responses and results from content analysis of interviews were summarised in five themes that illuminated how a screening programme could be tailored to the care facilities: (1) characteristics of residents and care facilities, (2) the care needs of residents, (3) the way care was organised, (4) the specific barriers and drivers for participating in programmes, (5) number of hours and settings for screening programmes.

CONCLUSION

To increase the participation of people living in psychiatric care facilities in screening programmes, future programmes should be tailored to the identified needs and barriers experienced by the residential care staff.

Non-Pharmacological Integrated Interventions for Adults Targeting Type 2 Diabetes and Mental Health Comorbidity: A Mixed-Methods Systematic Review

Objective

Adults living with Type 2 diabetes (T2D) and severe mental illness (SMI) disproportionally experience premature mortality and health inequality. Despite this, there is a limited evidence-base and evaluation of non-pharmacological integrated interventions that may contribute to improved patient experience and outcomes. To improve our understanding of how to optimise integrated care for this group, this review evaluates the effectiveness, acceptability, and feasibility of non-pharmacological integrated interventions for adults with SMI and T2D.

Methods

Studies from nine electronic databases were searched. Of the 6750 papers retrieved, seven papers (five quantitative and two qualitative) met the inclusion/exclusion criteria. A convergent integrated approach was used to narratively synthesise data into four main themes: effectiveness, acceptability, feasibility, integrated care.

Results

There is moderate evidence to suggest non-pharmacological integrated interventions may be effective in improving some diabetes-related and psychosocial outcomes. Person-centred integrated interventions that are delivered collaboratively by trained facilitators who exemplify principles of integrated care may be effective in reducing the health-treatment gap.

Conclusions

Recommendations from this review can provide guidance to healthcare professionals, commissioners, and researchers to inform improvements to non-pharmacological integrated interventions that are evidence-based, theoretically driven, and informed by patient and healthcare professionals' experiences of care.

Need for improved diabetes support among people with psychiatric disorders and diabetes treated in psychiatric outpatient clinics: results from a Danish cross-sectional study

INTRODUCTION

People with psychiatric disorders have increased risk of premature death partly due to diabetes. This study aims to explore the quality of diabetes care, diabetes management, diabetes support and well-being of people with psychiatric disorders and diabetes.

RESEARCH DESIGN AND METHODS

A total of 107 participants aged ≥18 years with diabetes and psychiatric disorders treated at psychiatric outpatient clinics in Denmark were recruited from August 2018 to June 2019. This descriptive cross-sectional study includes data from medical records on quality of diabetes care (eg, level and annual examination of hemoglobin A1c (HbA_1c)) and questionnaires on diabetes management (measured on items from the Summary of Diabetes Self-Care Activities Scale and diabetes distress based on Problem Areas in Diabetes Scale (PAID-5)), diabetes support (no, some or high support from eight potential support persons and experience of care actions measured on items from Patient Assessment of Chronic Illness Care) and well-being (WHO 5-Item Scale and self-rated general health).

RESULTS

The mean age was 52 years, 56% were men, the mean body mass index was 31.9 kg/m², the median HbA_1c was 53 mmol/mol (7.0%) and the mean blood pressure was 131/83 mm Hg. The proportion with annual measurements of HbA_1c was 93%, blood pressure 80%, cholesterol 93%, foot examination 77% and eye examination 75%. Fifty-one per cent had high diabetes distress (PAID-5 score ≥8). Diabetologists and general practitioners (39% and 37%) were the health professionals most frequently reported to provide high diabetes support.

CONCLUSIONS

This study highlights a need for improved diabetes support in people with psychiatric disorders and diabetes. Although a high proportion received appropriate diabetes care, we found high levels of diabetes distress, moderate levels of optimal self-management behaviors, low well-being and low diabetes support from psychiatric health professionals, while one-third of the population found it relevant to receive diabetes support from psychiatric health professionals.

Exploring the facilitators, barriers, and strategies for self-management in adults living with severe mental illness, with and without long-term conditions: A qualitative evidence synthesis

BACKGROUND

People living with severe mental illness (SMI) have a reduced life expectancy by around 15-20 years, in part due to higher rates of long-term conditions (LTCs) such as diabetes and heart disease. Evidence suggests that people with SMI experience difficulties managing their physical health. Little is known, however, about the barriers, facilitators and strategies for self-management of LTCs for people with SMI.

AIM

To systematically review and synthesise the qualitative evidence exploring facilitators, barriers and strategies for self-management of physical health in adults with SMI, both with and without long-term conditions.

METHODS

CINAHL, Conference Proceedings Citation Index- Science, HMIC, Medline, NICE Evidence and PsycInfo were searched to identify qualitative studies that explored barriers, facilitators and strategies for self-management in adults with SMI (with or without co-morbid LTCs). Articles were screened independently by two independent reviewers. Eligible studies were purposively sampled for synthesis according to the richness and relevance of data, and thematically synthesised.

RESULTS

Seventy-four articles met the inclusion criteria for the review; 25 articles, reporting findings from 21 studies, were included in the synthesis. Seven studies focused on co-morbid LTC self-management for people with SMI, with the remaining articles exploring self-management in general. Six analytic themes and 28 sub-themes were identified from the synthesis. The themes included: the burden of SMI; living with co-morbidities; beliefs and attitudes about self-management; support from others for self-management; social and environmental factors; and routine, structure and planning.

CONCLUSIONS

The synthesis identified a range of barriers and facilitators to self-management, including the burden of living with SMI, social support, attitudes towards self-management and access to resources. To adequately support people with SMI with co-morbid LTCs, healthcare professionals need to account for how barriers and facilitators to self-management are influenced by SMI, and meet the unique needs of this population.

Interventions involving own treatment choice for people living with coexisting severe mental illness and type 1 or 2 diabetes: A scoping review

AIM

The objective of this scoping review was to summarize, understand and provide an overview of the empirical literature on interventions involving own treatment choice for people with coexisting diabetes (type 1 and 2) and severe mental illness (SMI).

METHODS

This scoping review undertook a systematic literature assessment. Searches were performed in MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, the Cochrane Library and grey literature (OpenGrey, Google Scholar and Danish Health and Medicine Authority databases). Publications from 2000 to July 2020 were of interest. Studies were included if they involved the users' own choice of treatment.

INCLUDED STUDIES

RCT, intervention, cohort and case-based studies.

RESULTS

A total of 4320 articles were screened, of which nine were included. The review identified eight studies from the United States and one from Canada testing different interventions for people with SMI and diabetes (one diabetes education program, five randomized controlled trials, one retrospective cohort study, one naturalistic intervention program and one case vignette). The interventions described in the nine articles involved service users, the majority incorporated individualized healthcare plans, and all interventions were based on multidisciplinary teamwork.

CONCLUSIONS

Research in the area is limited. Care management interventions tend to focus on a single condition, paradoxically excluding SMI during enrolment. Interventions aimed at people with both conditions often prioritize one condition treatment leading to an unbalanced care.

Living with diabetes alongside a severe mental illness: A qualitative exploration with people with severe mental illness, family members and healthcare staff

AIMS

Diabetes is two to three times more prevalent in people with severe mental illness, yet little is known about the challenges of managing both conditions from the perspectives of people living with the co-morbidity, their family members or healthcare staff. Our aim was to understand these challenges and to explore the circumstances that influence access to and receipt of diabetes care for people with severe mental illness.

METHODS

Framework analysis of qualitative semi-structured interviews with people with severe mental illness and diabetes, family members, and staff from UK primary care, mental health and diabetes services, selected using a maximum variation sampling strategy between April and December 2018.

RESULTS

In all, 39 adults with severe mental illness and diabetes (3 with type 1 diabetes and 36 with type 2 diabetes), nine family members and 30 healthcare staff participated. Five themes were identified: (a) Severe mental illness governs everyday life including diabetes management; (b) mood influences capacity and motivation for diabetes self-management; (c) cumulative burden of managing multiple physical conditions; (d) interacting conditions and overlapping symptoms and (e) support for everyday challenges. People living with the co-morbidity and their family members emphasised the importance of receiving support for the everyday challenges that impact diabetes management, and identified barriers to accessing this from healthcare providers.

CONCLUSIONS

More intensive support for diabetes management is needed when people's severe mental illness (including symptoms of depression) or physical health deteriorates. Interventions that help people, including healthcare staff, distinguish between symptoms of diabetes and severe mental illness are also needed.

Identifying determinants of diabetes risk and outcomes for people with severe mental illness: a mixed-methods study

Background

People with severe mental illness experience poorer health outcomes than the general population. Diabetes contributes significantly to this health gap.

Objectives

The objectives were to identify the determinants of diabetes and to explore variation in diabetes outcomes for people with severe mental illness.

Design

Under a social inequalities framework, a concurrent mixed-methods design combined analysis of linked primary care records with qualitative interviews.

Setting

The quantitative study was carried out in general practices in England (2000–16). The qualitative study was a community study (undertaken in the North West and in Yorkshire and the Humber).

Participants

The quantitative study used the longitudinal health records of 32,781 people with severe mental illness (a subset of 3448 people had diabetes) and 9551 ‘controls’ (with diabetes but no severe mental illness), matched on age, sex and practice, from the Clinical Practice Research Datalink (GOLD version). The qualitative study participants comprised 39 adults with diabetes and severe mental illness, nine family members and 30 health-care staff.

Data sources

The Clinical Practice Research Datalink (GOLD) individual patient data were linked to Hospital Episode Statistics, Office for National Statistics mortality data and the Index of Multiple Deprivation.

Results

People with severe mental illness were more likely to have diabetes if they were taking atypical antipsychotics, were living in areas of social deprivation, or were of Asian or black ethnicity. A substantial minority developed diabetes prior to severe mental illness. Compared with people with diabetes alone, people with both severe mental illness and diabetes received more frequent physical checks, maintained tighter glycaemic and blood pressure control, and had fewer recorded physical comorbidities and elective admissions, on average. However, they had more emergency admissions (incidence rate ratio 1.14, 95% confidence interval 0.96 to 1.36) and a significantly higher risk of all-cause mortality than people with diabetes but no severe mental illness (hazard ratio 1.89, 95% confidence interval 1.59 to 2.26). These paradoxical results may be explained by other findings. For example, people with severe mental illness and diabetes were more likely to live in socially deprived areas, which is associated with reduced frequency of health checks, poorer health outcomes and higher mortality risk. In interviews, participants frequently described prioritising their mental illness over their diabetes (e.g. tolerating antipsychotic side effects, despite awareness of harmful impacts on diabetes control) and feeling overwhelmed by competing treatment demands from multiple morbidities. Both service users and practitioners acknowledged misattributing physical symptoms to poor mental health (‘diagnostic overshadowing’).

Limitations

Data may not be nationally representative for all relevant covariates, and the completeness of recording varied across practices.

Conclusions

People with severe mental illness and diabetes experience poorer health outcomes than, and deficiencies in some aspects of health care compared with, people with diabetes alone.

Future work

These findings can inform the development of targeted interventions aimed at addressing inequalities in this population.

Study registration

National Institute for Health Research (NIHR) Central Portfolio Management System (37024); and ClinicalTrials.gov NCT03534921.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.

Self-management of chronic disease in individuals with psychotic disorder: A qualitative study

PURPOSE

The aim of this study was to evaluate self-management by individuals with a serious mental illness and an additional chronic disease.

DESIGN AND METHODS

Heidegger's hermeneutic phenomenological approach was used. The study was carried out with 12 participants with a serious mental illness and an additional chronic disease.

RESULTS

The participants had a diagnosis of schizophrenia and diabetes (75%). Based on the data, the difficulties faced by the patients in chronic disease management were determined as three themes: (a) personal-related difficulties, (b) family and society-related difficulties, and (c) healthcare system-related difficulties.

PRACTICE IMPLICATIONS

Nurses' interventions to accurately inform other clinicians and leading professional groups in the community will support individuals with serious mental illnesses to improve their self-management by reducing the burden of stigma.

Self-Management Barriers Perceived by Patients with Type 2 Diabetes: A Confirmatory Factor Analysis

Background:

Self-management remains poor among most of the diabetic patients due to various individual and environmental barriers which affect it. These barriers should be identified and intervened promptly. The current study aimed to determine self-management barriers perceived by patients with type 2 diabetes.

Methods:

A cross-sectional study carried out on 681 patients with type 2 diabetes who referred to the diabetes center which is affiliated to Kerman University of Medical Sciences, Kerman, Iran during 2018. Through a structured interview, demographic and disease-related data were recorded and the Persian version of the modified Personal Diabetes Questionnaire (PDQ) was used to assess self-management barriers. The tool has four subscales including diet, medication, monitoring, and exercise barriers. The higher score in each subscale indicates a higher level of barriers in that section. Data analyzed by SPSS 20 using T-test, ANOVA, and multiple linear regressions.

Results:

The majority of the patients (62.8%) were female, married (78.3%) with monthly income 10 to 20 million IRRLs (78.4%) and the mean age of 55.65 ± 14.65 years. Body Mass Index, marital status, monthly income, and HbA1C significantly predicted the barriers' score. The instrument had excellent reliability (α = 0.95). In confirmatory factor analysis, the fit indices had approximately acceptable levels.

Conclusions:

The Persian version of modified PDQ had good psychometric properties and can be used as a valid and reliable instrument in the primary health care setting. The significant perceived barriers should be identified and intervened by health care providers through the comprehensive management of diabetic patients.

Perceptions and experiences of living with coexisting type 2 diabetes and severe mental illness: a scoping review

AIMS

To map existing research-based knowledge of everyday life and illness management among people with coexisting type 2 diabetes and severe mental illness, and to identify study designs, aims, populations and themes.

METHODS

A systematic literature search was performed on 16 April 2019 using Medline, Embase, PsycINFO, Cinahl, the Cochrane Library, and the Web of Science to conduct a scoping review. Included studies were summarized with regard to the quantity of research, the study designs, aims, populations and themes RESULTS: From 3406 records, we included 23 studies about everyday life and illness management among people with coexisting type 2 diabetes and severe mental illness. Four studies were qualitative (observations, interviews and focus groups), and 19 were quantitative (observational and interventions) and used questionnaires. Five themes emerged in the findings: (1) diet and exercise, but not other diabetes self-care activities, are consistently compromised in the target group; (2) psychiatric exacerbation diminishes diabetes self-care; (3) social support and high self-efficacy improve diabetes self-care; (4) use of healthcare services is compromised; and (5) quality of life and well-being is poor.

CONCLUSIONS

The limited research into the studied population's experiences with coexisting type 2 diabetes and severe mental illness is characterized by its heterogeneity in aims and methods and a strong focus on diabetes management and treatment. Further research focusing on the management of both conditions in everyday life is needed to improve specialized and integrated care targeting the population.

Physical health among people with serious mental illness in the face of COVID-19: Concerns and mitigation strategies

COVID-19 can worsen the physical health of individuals with serious mental illness, a vulnerable group already facing physical health disparities. COVID-19 is further reducing access to physical health care due to shutdown of services deemed "non-urgent" and overcrowding of emergency services. Management of chronic diseases, highly prevalent in this group, is undermined due to exacerbation of psychiatric disorders, reduction in availability of social support, and worsening of negative social determinants of health. In this commentary, we discuss the challenges experienced by this group and offer mitigation strategies to reduce: (1) inequalities in access to physical health care; and (2) disruptions to the management of chronic physical conditions in the face of COVID-19. Recommendations include coordinated efforts by health authorities, primary and mental health care organizations, researchers, policymakers, and other stakeholders. These efforts should ensure equitable access to physical health care and implementation of innovative programs to protect the physical health of people with serious mental illness during and following the pandemic.

Are diabetes self-management programmes for the general diabetes population effective for people with severe mental illness?: a systematic review

BACKGROUND

Diabetes self-management education programmes are effective in improving health outcomes in the general population with diabetes. However, it is not known if these programmes include people who also have a severe mental illness (SMI) and, if so, what their outcomes are. The aim of this review was to examine if evaluations of diabetes self-management education programmes included people with SMI, and if so, whether the interventions were beneficial for this population.

METHODS

The inclusion criteria for this systematic review, defined by PICOS criteria, were: Population - Adults with type 2 diabetes; Intervention - self-management education programme; Comparator - another active intervention or usual care; Outcomes of interest - inclusion of people with SMI and the clinical, behavioural and psychosocial outcomes in this population; Study design - randomised controlled trials. The following bibliographic databases were searched from January 2004 to April 2018: Cochrane Library, Medline, Embase, PsychINFO, Allied and Complimentary Medicine Database, Health Technology Assessment, NHS Economic Evaluations Database and CINAHL. Data were extracted on study characteristics, inclusion and exclusion criteria, participant and intervention characteristics, number of participants with SMI, and outcomes for people with SMI, if reported. Authors were contacted by email for missing data.

RESULTS

A total of 410 trials were included. At least 42% of trials did not recruit any participants with SMI. Only nine confirmed inclusion of participants with SMI, of which six provided data on the number recruited. These six trials recruited a total of 1009 participants, of whom 31 (3.1%) had SMI. It was not possible to assess intervention effectiveness for people with SMI as none of the trials reported outcomes for these participants.

CONCLUSIONS

This systematic review confirms that people with SMI are often excluded from trials of diabetes self-management education, resulting in a lack of an evidence base on which to base treatment paths for this vulnerable population. It cannot be assumed that programmes developed for the general diabetes population meet the needs of people with SMI. Future research needs to examine if and how these programmes could be adapted for people with SMI or if new programmes are required.

Exploring the Outcomes of a Pilot Education Program Tailored for Adults With Type 2 Diabetes and Mental Illness in a Community Mental Health Care Setting

OBJECTIVES

People with mental illness and type 2 diabetes are more likely to experience diabetes complications than the general population. Diabetes management can be improved with tailored lifestyle intervention content. The purpose of this pilot study was to investigate diabetes insights of mental health-care patients after participation in a tailored education intervention.

METHODS

A 12-session diabetes education program was created to address the learning needs and challenges that people with mental illness may experience. The program was assessed through conducting interviews with 6 participants combined with quantitative data to describe the population. Interviews were transcribed verbatim, assessed for quality and coded to identify relationships and meanings between identified themes.

RESULTS

Throughout the year of participation, blood sugar control and physical activity level improved for some and worsened for others. Weight remained stable and dietary intake patterns appeared to improve overall. Participants described the appropriateness of the teaching strategies and program structure developed, and all improved their understanding about diabetes and gained practical self-management knowledge. Opportunities for program improvement included extending care beyond the counselling room to address financial limitations, incorporating a practical activity component and creating opportunities for social support. Additionally, leaving some sessions as patient directed would further individualize education care.

CONCLUSIONS

Our study offers a concrete education program strategy that aligns with Diabetes Canada's self-management education guidelines to support the provision of diabetes care for people with mental illness. Modifying program delivery may help to curtail the increasing rates of morbidity and mortality currently observed in this population.

The Outcome of Structured Education in Adults With Type 2 Diabetes Mellitus and Substance Use Disorder: A Literature Review

OBJECTIVE

Structured diabetes education for patients is a cornerstone of therapy; it empowers the patients by giving them appropriate tools for the self-management of the illness. The objective of this work was to determine how substance use disorder influences the outcome of structured diabetes education in patients with type 2 diabetes mellitus, and whether patients with substance use disorder are less likely to benefit because of their addiction issues.

METHODS

Only clinical trials involving substance use, which were randomized, in the context of type 2 diabetes mellitus were included.

RESULTS

Literature was only available for alcohol use disorder, and there were no studies available on any other recreational substance use disorders and its effects on structured diabetes education. Out of 3 relevant studies, in the context of alcohol use disorder, 2 studies identified alcohol use by the patients as a limiting factor in receiving structured diabetes education. One study did not show any impact of alcohol on structured diabetes education.

CONCLUSIONS

More high-quality randomized controlled trials with better sample sizes are required to say with confidence if alcohol use affects the patient's ability to participate in structured educational programs for type 2 diabetes mellitus management.

Behavioral health conditions and potentially preventable diabetes-related hospitalizations in the United States: Findings from a national sample of commercial claims data

Objective

To characterize the relationship between potentially preventable hospitalizations (PPHs) for diabetes and behavioral health conditions in commercially insured working-age persons with diabetes in the United States.

Research design and methods

We retrospectively analyzed medical and pharmacy claims from services rendered between 2011 and 2013 for 229,039 adults with diabetes. Diabetes PPHs were identified using the Agency for Healthcare Research and Quality’s Prevention Quality Indicators v6.0 logic. We used negative binomial-logit hurdle regression models to explore the adjusted relationships between diabetes PPHs and schizophrenia, bipolar, depression, anxiety, adjustment disorder, alcohol use disorder, and drug use disorder.

Results

A total of 4,521 diabetes PPHs were experienced by 3,246 of the persons in the sample. The 20.83% of persons with one or more behavioral health conditions experienced 43.62% (1,972/4,521; 95% CI 42.18%-45.07%) of all diabetes PPHs, and the 7.14% of persons with more than one diagnosed behavioral health condition experienced 24.77% (1,120/4,521; 95% CI 23.54%-26.05%) of all diabetes PPHs. After adjusting for sociodemographic and physical health covariates, patients with depression, schizophrenia, drug or alcohol use disorders, or multiple behavioral health conditions were at significantly increased risk of experiencing at least one diabetes PPH, while patients with depression, drug use disorder, or multiple behavioral health conditions were at significantly increased risk of experiencing recurring diabetes PPHs over time.

Conclusions

A number of behavioral health conditions are associated with diabetes PPHs, which are often preventable with timely, high-quality outpatient care. The results of this study will enable clinicians, payers, and policy-makers to better focus outpatient care interventions and resources within the population of persons with diabetes.

Barriers to effective diabetes management - a survey of people with severe mental illness

BACKGROUND

People with severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have an increased risk of developing type 2 diabetes and have poorer health outcomes than those with diabetes alone. To maintain good diabetes control, people with diabetes are advised to engage in several self-management behaviours. The aim of this study was to identify barriers or enablers of diabetes self-management experienced by people with SMI.

METHODS

Adults with type 2 diabetes and SMI were recruited through UK National Health Service organisations and mental health and diabetes charities. Participants completed an anonymous survey consisting of: Summary of Diabetes Self-Care Activities (SDSCA); CORE-10 measure of psychological distress; a measure of barriers and enablers of diabetes self-management based on the Theoretical Domains Framework; Diabetes UK care survey on receipt of 14 essential aspects of diabetes healthcare. To identify the strongest explanatory variables of SDSCA outcomes, significant variables (p < .05) identified from univariate analyses were entered into multiple regressions.

RESULTS

Most of the 77 participants had bipolar disorder (42%) or schizophrenia (36%). They received a mean of 7.6 (SD 3.0) diabetes healthcare essentials. Only 28.6% had developed a diabetes care plan with their health professional and only 40% reported receiving specialist psychological support. Engagement in self-management activities was variable. Participants reported taking medication on 6.1 (SD 2.0) days in the previous week but other behaviours were less frequent: general diet 4.1 (2.3) days; specific diet 3.6 (1.8) days, taking exercise 2.4 (2.1) days and checking feet on 1.7 (1.8) days. Smoking prevalence was 44%. Participants reported finding regular exercise and following a healthy diet particularly difficult. Factors associated with diabetes self-management included: the level of diabetes healthcare and support received; emotional wellbeing; priority given to diabetes; perceived ability to manage diabetes or establish a routine to do so; and perceived consequences of diabetes self-management.

CONCLUSIONS

Several aspects of diabetes healthcare and self-management are suboptimal in people with SMI. There is a need to improve diabetes self-management support for this population by integrating diabetes action plans into care planning and providing adequate psychological support to help people with SMI manage their diabetes.

Mechanisms in endocrinology: Antipsychotic medication and type 2 diabetes and impaired glucose regulation

OBJECTIVE

There have been concerns about the effects of antipsychotics on weight gain and the development of type 2 diabetes (T2DM). This article aims to provide an up-to-date review on the evidence addressing this issue and the practical implications for the management of people taking antipsychotics in the context of T2DM.

METHODS

We carried out searches on MEDLINE/PUBMED and the ClinicalTrials.gov website in August 2017 using the terms 'antipsychotic' and 'diabetes' or 'glucose' citing articles published after 2006 preferentially.

RESULTS

Antipsychotics are associated with T2DM and are likely to exert a causal effect of uncertain magnitude. Children and adolescents appear especially vulnerable to these metabolic effects; as T2DM is not common in healthy younger people, the relative risk is more apparent. Antipsychotics act on glucose and insulin homeostasis in a variety of direct and indirect mechanisms. To reduce the increasing health inequalities among individuals with mental illness screening, monitoring and prevention of T2DM is important, as is improved diabetes care in this population.

CONCLUSION

It remains unclear whether these antipsychotic medications exacerbate an underlying predisposition to the development of T2DM or have a direct effect. Potential risks need to be weighed up and balanced between improved and lasting mental health benefits and any detrimental physical health side effects. Achieving parity of esteem between mental and physical health is a worldwide priority if we wish to improve life expectancy and quality of life in people with severe mental illness.

Interventions to increase access to or uptake of physical health screening in people with severe mental illness: a realist review

OBJECTIVES

To identify and evaluate interventions aimed at increasing uptake of, or access to, physical health screening by adults with severe mental illness; to examine why interventions might work.

DESIGN

Realist review.

SETTING

Primary, secondary and tertiary care.

RESULTS

A systematic search identified 1448 studies, of which 22 met the inclusion criteria. Studies were from Australia (n=3), Canada (n=1), Hong Kong (n=1), UK (n=11) and USA (n=6). The studies focused on breast cancer screening, infection preventive services and metabolic syndrome (MS) screening by targeting MS-related risk factors. The interventions could be divided into those focusing on (1) health service delivery changes (12 studies), using quality improvement, randomised controlled trial, cluster randomised feasibility trial, retrospective audit, cross-sectional study and satisfaction survey designs and (2) tests of tools designed to facilitate screening (10 studies) using consecutive case series, quality improvement, retrospective evaluation and pre-post audit study designs. All studies reported improved uptake of screening, or that patients had received screening they would not have had without the intervention. No estimation of overall effect size was possible due to heterogeneity in study design and quality. The following factors may contribute to intervention success: staff and stakeholder involvement in screening, staff flexibility when taking physical measurements (eg, using adapted equipment), strong links with primary care and having a pharmacist on the ward.

CONCLUSIONS

A range of interventions may be effective, but better quality research is needed to determine any effect size. Researchers should consider how interventions may work when designing and testing them in order to target better the specific needs of this population in the most appropriate setting. Behaviour-change interventions to reduce identified barriers of patient and health professional resistance to screening this population are required. Resource constraints, clarity over professional roles and better coordination with primary care need to be addressed.

Barriers and enablers of type 2 diabetes self-management in people with severe mental illness

BACKGROUND

People with diabetes and severe mental illness (SMI) experience poorer outcomes than those with diabetes alone. To improve outcomes, it is necessary to understand the difficulties that people with SMI experience in managing their diabetes.

AIMS

To identify barriers and enablers to effective diabetes self-management experienced by people with SMI and type 2 diabetes.

METHOD

Qualitative methodology using semi-structured interviews was employed. Development of the interview topic guide and analysis of the transcripts were informed by the Theoretical Domains Framework for behaviour change, which consists of fourteen theoretical domains that have been found to influence behaviour.

RESULTS

Fourteen people with SMI and type 2 diabetes took part in the study. Participants considered diabetes self-management to be important, were aware of the risks of poor diabetes control but struggled to follow recommended advice, particularly if their mental health was poor. Support from family and health professionals was considered an important enabler of diabetes self-management.

CONCLUSIONS

New approaches are required to support diabetes self-management in people with SMI. This study identified some of the important domains that may be targeted in new interventions.