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

Metabolic Monitoring for Adults Living with a Serious Mental Illness on a Second-Generation Antipsychotic Agent: A Scoping Review

Premature mortality in people living with a severe mental illness (SMI) is often attributed to multiple factors including the use of medicines such as antipsychotics. Second-generation antipsychotics (SGAs) are known to cause metabolic syndrome which can increase the risk of cardiovascular disease. Practice guidelines have recommended regular physical health monitoring, particularly of metabolic parameters, however, metabolic monitoring for people living with SMI using antipsychotics remains suboptimal. Therefore, highlighting the need for ongoing research. This scoping review aimed to provide an overview of current metabolic monitoring practices. We anticipate that this information will assist clinicians and policymakers and inform future research. The following databases were searched: MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Database of Systemic Reviews (Wiley), APA PsycInfo (Ovid) and Scopus (Elsevier Science Publishers). The target group was adults (aged ≥ 18) diagnosed with SMI (including bipolar disorder, major depressive disorder and psychotic disorders) and taking SGAs. In total, 44 studies from 14 countries were retrieved. Our findings highlighted that most studies conducted in hospitals did not report on metabolic monitoring practices. Additionally, the roles and responsibilities of healthcare professionals in metabolic monitoring for SMI were infrequently described and parameters such as waist circumference and BMI were often poorly monitored. The scoping review highlights that no streamlined approach towards metabolic monitoring currently exists. There is a need to stipulate and define the roles and responsibilities of all health professionals involved in metabolic monitoring in SMI to optimise care for these individuals. Moreover, there is a need for ongoing research, particularly in the community setting, to promote increased accessibility to metabolic monitoring for SMI.

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.

The development of type 2 diabetes management in people with severe mental illness in the Capital Region of Denmark from 2001 to 2015

BACKGROUND

Type 2 diabetes (T2D) treatment has changed markedly within the last decades. We aimed to explore whether people with severe mental illness (SMI) have followed the same changes in T2D treatment as those without SMI, as multiple studies suggest that people with SMI receive suboptimal care for somatic disorders.

METHODS

In this registry-based annual cohort study, we explored the T2D treatment from 2001 to 2015 provided in general practices of the Greater Copenhagen area. We stratified the T2D cohorts by their pre-existing SMI status. T2D was defined based on elevated glycated hemoglobin (≥48 mmol/mol) or glucose (≥11 mmol/L) using data from the Copenhagen Primary Care Laboratory Database. Individuals with schizophrenia spectrum disorders (ICD-10 F20-29) or affective disorders (bipolar disorder or unipolar depression, ICD-10 F30-33) were identified based on hospital-acquired diagnoses made within 5 years before January 1 each year for people with prevalent T2D or 5 years before meeting our T2D definition for incident patients. For comparison, we defined a non-SMI group, including people who did not have a hospital-acquired diagnosis of schizophrenia spectrum disorders, affective disorders, or personality disorders. For each calendar year, we assembled cohorts of people with T2D with or without SMI. We used Poisson regression to calculate the rates per 100 person-years of having at least one biochemical test (glycated hemoglobin, low-density lipoprotein cholesterol, estimated glomerular filtration rate, and urine albumin-creatinine ratio), having poor control of these biochemical results, taking glucose-lowering or cardiovascular medications, or experiencing a clinical outcome, including all-cause mortality and cardiovascular mortality. Three outcomes (cardiovascular events, cardiovascular mortality, and all-cause mortality) were additionally examined and adjusted for age and sex in a post hoc analysis.

RESULTS

From 2001 to 2015, 66,914 individuals were identified as having T2D. In 2015, 1.5% of the study population had schizophrenia spectrum disorder and 1.4% had an affective disorder. The number of people who used biochemical tests or had poor biochemical risk factor control was essentially unrelated to SMI status. One exception was that fewer LDL cholesterol tests were done on people with affective disorders and schizophrenia spectrum disorders at the beginning of the study period compared to people in the non-SMI group. This difference gradually diminished and was almost nonexistent by 2011. There was also a slightly slower rise in UACR test rates in the SMI groups compared to other people with T2D during the period. Throughout the study period, all groups changed their use of medications in similar ways: more metformin, less sulfonylurea, more lipid-lowering drugs, and more ACEi/ARBs. However, people with schizophrenia disorder consistently used fewer cardiovascular medications. Cardiovascular events were more common in the affective disorder group compared to the non-SMI group from 2009 to 2015 (rate ratio 2015 : 1.36 [95% CI 1.18-1.57]). After adjustment for age and sex, all-cause mortality was significantly higher among people with a schizophrenia spectrum disorder each year from 2003 to 2015 compared to the non-SMI group (rate ratio 2015 : 1.99 [95% CI 1.26-3.12]).

CONCLUSION

Persons with schizophrenia or affective disorders demonstrated the same treatment changes for T2D as those without SMI in general practice. The lower use of most types of cardiovascular medications among people with schizophrenia disorders indicates potential undertreatment of hypertension and dyslipidemia and remains throughout the study period. Cardiovascular events were most common among people with affective disorders, but this was not reflected in a higher proportion using cardiovascular preventive medications. This knowledge should be considered in the management of this vulnerable patient group.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

Schizophrenia and type 2 diabetes: Perceptions and understandings of illness management in everyday life

People with schizophrenia and type 2 diabetes face complex challenges in daily life and the management of both illnesses is burdensome. This qualitative interview study aimed to explore perceptions and understandings of the day-to-day management of schizophrenia and type 2 diabetes. Fourteen semi-structured interviews were conducted between January 2020 and October 2021 in the participants' respective mental health clinics, in their homes or by phone. Thematic analysis led to four themes representing participants' self-management strategies and perceived challenges. The first theme showed that participants use self-learned strategies for managing schizophrenia. In contrast, they perceived type 2 diabetes self-management as governed by a set of rules and guidelines given by health professionals. The second theme showed that both psychotic and negative symptoms present challenges to diabetes management. Theme 3 illustrated that participants consider their type 2 diabetes to be a very serious illness. They worried about potential long-term consequences and expressed wishes and motivation to improve their lifestyle. The final theme showed that participants discuss challenges related to their schizophrenia with family and friends but not type 2 diabetes. In conclusion, this study highlights the importance of considering individual challenges and everyday routines when supporting this population. It underlines the need for future research to further explore the complexity of managing the illnesses and to understand the needs for treatment and support.

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.