Although adults with serious psychiatric disorders are at high risk for diabetes, a large study led by UC San Francisco reveals that low-income patients on Medicaid are rarely screened for it. The findings support growing efforts to integrate mental health services and primary care to improve diagnosis and treatment of medical issues associated with mental illness, the researchers said.
Individuals with severe mental illness (SMI) are two to three times more likely to have type 2 diabetes than the general population. Many factors contribute to the increased risk, and treatment with antipsychotic medication raises the risk even further. The American Diabetes Association and American Psychiatric Association both recommend that providers do annual diabetes screening for any patients taking antipsychotic medications, but until now it has been unclear how often screenings actually occur.
The new study examined diabetes screenings in a cohort of 50,915 publically insured adults with SMI who were taking antipsychotic medication. The researchers found that more than 70 percent did not receive a diabetes-specific test. However, those who had at least one primary care visit in addition to mental health services were twice as likely to be screened.
"Our healthcare system is fragmented for people with mental illness. For example, the mental health electronic medical record is totally separate from their primary care electronic record, truly limiting the quality of care this vulnerable population can receive," said Christina Mangurian, MD, MAS, associate professor of clinical psychiatry at the UCSF School of Medicine and lead author of the study. "As a community psychiatrist, I see so many people who are untreated or under-treated for physical health problems because of this lack of integration."
In general, these people are dying of premature cardiovascular disease, she continued. They tend to smoke cigarettes, hardly exercise, and may deal with food insecurity as a result of poverty. On top of that, their antipsychotic medication disrupts metabolic function, causing them to gain weight rapidly, which can lead to insulin resistance and diabetes.
The study, published November 9 in the Journal of the American Medical Association Internal Medicine, is the first to examine diabetes screening in this high-risk population served in community mental health clinics. In an effort to integrate primary care and mental health, the California Department of Health Services' Data and Research Committee combined public mental health and medical records during a State Quality Improvement project, allowing the researchers to compare individuals across the two datasets.
They retrospectively identified 50,915 adults diagnosed with serious mental illness who were prescribed antipsychotic medication during two study periods: January 1, 2009 through December 31, 2009 and October 1, 2010 through September 1, 2011. Then, they examined the medical records to determine whether the patients received diabetes-specific screening, non-specific screening or no screening.
About 30 percent received a diabetes-specific screening and about 30 percent received no medical tests at all. Patients who had at least one primary care visit were more than twice as likely to be screened for diabetes as those who did not.
Integrated health care would make it easier for patients to get screening and treatment, said study co-author Penelope Knapp, MD, professor of psychiatry and behavioral sciences at UC Davis.
"We can do better," she said. "It's really important for individuals with medical and mental health problems to have their health care in one system. It's a no brainer that these should be integrated."
There are many factors that could explain why the majority of SMI patients in this study were never screened for diabetes, Knapp said. The study examined people with Medicaid, a program that provides health and medical services for low-income individuals and families. Although federally qualified health centers provide both primary care and mental health services, there are barriers.
"One of the barriers for not-so-wealthy people is that they can't see two providers on the same day. If the psychiatrist prescribes antipsychotics, that person may not be able to take off work another day for a follow up appointment with a physician," Knapp said.
An integrated health care system allows mental health and medical records to 'talk' to each other, an essential asset for patients with mental illness, who may be unable to communicate clearly. If the physician could access mental health records, they could see the diagnosis and prescription and immediately understand the risk of diabetes, Mangurian said. This is especially important for young patients.
"The young adults who develop a psychotic illness in college or high school--they are the ones I'm worried about," Mangurian said. "Diabetes in a young adult is not on a primary care doctor's radar. These doctors need to learn that if their patient has a diagnosis of schizophrenia or is taking an antipsychotic medication, they are at increased risk."
Other authors include Dean Schillinger, MD, Eric Vittinghoff, PhD, Jennifer Creasman, MSPH, Elena Fuentes-Afflick, MD, MPH, from UCSF and John Newcomer, MD, from the Charles E. Schmidt College of Medicine at Florida Atlantic University. The work was funded by an NIH Career Development Award, UCSF Hellman Fellows Award for Early-Career Faculty, and the UCSF Clinical and Translational Science Institute.
Knapp reported serving as medical director of the California Department of Mental Health during the study period.
UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy, a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences, as well as a preeminent biomedical research enterprise and two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children's Hospital San Francisco.
JAMA Internal Medicine