October 11, 2011

Detecting diabetes in the mentally ill Mental health service users form a vulnerable group in which the prevalence of diabetes is high yet screening for the condition remains poor Michael NashDIABETES IS A SIGNIFICANT publichealth concern, not only for the generalpopulation, but also for smaller popula-tion groups such as people from ethnicminorities and those with mental healthproblems. Mental health service users(MHSUs) are a vulnerable social group,at risk of exclusion due to the stigmaattached to mental illness. However,stigma can also act as a barrier toaccessing good (even standard) generalmedical services and appropriate physicalhealthcare.

The purpose of this article is to examinethe impact of diabetes on people with amental health problem. This article willexplore issues of prevalence, risk factorsfor diabetes and barriers to diabetes carefor MHSUs. Readers are asked to reflect ontheir own learning needs in relation to thesubject material.

General physical health of MHSUs The physical health of MHSUs is oftenpoor and this is clearly illustrated in poorhealth outcomes for this group. In respectto mortality, MHSUs have higher standard-ised mortality ratios (SMRs) for a range ofconditions, eg. the SMR for cardiovasculardisease is 250.' This means that MHSUs dieon average 2,5 times more often than thegeneral population from cardiovasculardisease.

Research also estimates that MHSUsdie between lotoisyears earlierthan thegeneral population,2 while a recent USstudy suggests that MHSUs die on average25 years earlier than the general popula-tion.3 In respect to morbidity, MHSUsexperience higher levels of illness than thegeneral population. For example, peoplewith schizophrenia have a significantlyhigher risk of colon cancerthan the gen-eral population.4 Research also suggests ahigher risk of developing ischaemic heartdisease, having a stroke or developinghypertension in people with schizophreniacompared to the general population.5Diabetes in MHSUs Diabetes, especially type 2, is emergingas a significant clinical concern for mentalhealth practitioners and MHSUs.This isdue, in part, to the general increase in theprevalence of diabetes. However, apartfrom this, MHSUs remain at a higher riskof diabetes than the general population.

For example, people with schizophreniahave an increased risk of type 2 diabetesdue to side-effects of medication, poorerhealthcare, poor physical health and lesshealthy lifestyles.6 The prevalence of type 2 diabetes inMHSUs is particularly worrying, withestimations that between 15% and 18%of people with schizophrenia may havePublication: Diabetes ProfessionalDate: Friday, October 07, 2011Page: 8Extract: 2 of 6Circulation: 2000Author: Michael NashHeadline: Detecting diabeties in the mentally ill diabetes, which is two to four times higher than in the general population.7 Research also suggests that people with schizophrenia are a high-risk group for abnormal glucose homeostasis8 and a sug- gestion that around 15% of patients with schizophrenia may have impaired glucose tolerance.9 Other metabolic disorders such as the metabolic syndrome (MetS) are also problematic for MHSUs.The reported prevalence of MetS in people with bipolar disorder is around 22-30%.'° Causes of increased prevalence in MHSUs The high prevalence of diabetes is linked to a combination of social factors, increased prevalence of, or exposure to, risk factors, side-effects of antipsychotic medication and healthcare organisation factors.

While the causes of diabetes in MHSUs are broadly similar to those in the general population, these risk factors can be more accentuated in vulnerable groups. There- fore similar risks are present but to a larger extent in MHSUs. We will now explore some reasons for the increased prevalence.

Social/actors MHSUs come from lower social classes and face high levels of poverty, social deprivation and social exclusion which impacts on general physical health, increasing the risk of specific conditions.

Social factors can be compounded by stigma which can contribute to economic problems such as high levels of unemploy- ment and income inequality. For instance, reliance on state benefits may mean that MHSUs cannot 'buy' into the healthy eating agenda of'j-a-day'. Instead they may opt for cheaper, but unhealthier, convenience food.

Diet Research shows that the diet of MHSUs are mainly high in fat and low in fibre," opting for convenience food may be a reason for this. In respect to fruit and veg- etable intake, people with schizophrenia eat under half of the UK Department of Health recommended intake of five-a-day (35 pieces per week), consuming only 16portions per week." Food labelling may also cause a problemas more often than not food labellingsystems can be confusing for consumers.13Whether or not MHSUs know what therecommended daily amounts of intake forsalt, calories or fruit and vegetables arelargely unknown. Health education andpromotion in this area should be a priorityas this may impact on how effectively foodlabelling is interpreted, eg. opting for low-calorie foods might appear healthy butthey may have high sodium content.

Sedentary lifestyle Combined with poor diet, a lack of physi-cal activity is also a risk factor for diabetes.

The label of sedentary lifestyle can conjureup images of'couch potatoes', or valuejudgements of laziness. However, the real-ity of physical inactivity for MHSUs is quitethe opposite of this. While low levels ofexercise have been found in MHSUs,14 exer-cise as an intervention is largely neglectedin mental healthcare.15 The side-effects of medications takenin the management of mental illnesscan inhibit the person becoming physi-cally active.This is because psychotropicmedications can cause movement disor-ders that make participation in exercisedifficult. Furthermore, psychotropicmedications can have a strong sedatingeffect which may make it difficult for anindividual to participate in exercise.

Symptoms of severe mental illness canhave a negative impact on an individual'slevels of motivation. For example, in severedepression psychomotor retardation isthe clinical term for a severe slowing ofnormal, or usual, body movement andthought processes. A lack of motivationis a negative symptom of schizophreniawhich can present as a barrier to theperson engaging in a physical activityprogramme.

Adverse drug reactions The pharmacological treatmentof mental illness has advanced withthe introduction of'new'atypicalantipsychotic medication.This medicationdiffers in its mode of action from olderPublication: Diabetes ProfessionalDate: Friday, October 07, 2011Page: 8Extract: 3 of 6Circulation: 2000Author: Michael NashHeadline: Detecting diabeties in the mentally ill medications by manipulating the levels of two neurotransmitters, serotonin and dopamine (older medications had more of an effect on dopamine only), which are seen to be important in symptoms of severe mental illness and mood. Atypical medications were also thought to have fewer disabling side-effects related to movement disorders.

However, what the new atypical medica- tions seern to have a higher propensity to cause are metabolic disorders. The recognition of the association between atypical antipsychotics and diabetes was first derived from case reports of severe, sometimes fatal, acute diabetic decom- pensation, including diabetic ketoacidosis (DKA).16Therefore, while side-effects might be fewer,fewer does not necessarily mean less severe.

Common metabolic side-effects of atypical antipsychotic medications include obesity or severe weight gain, hyperlipi- daemia, increased low-density lipoproteins and type 2 diabetes.'7 Weight gain can also be very rapid. Research has estimated a mean weight gain over a id-week period of 445kg with the drug dozapine and 4.i5kg with the drug olanzapine at standard doses.18 The
se medications are at the forefront of treatment of psychotic disorders.

A study examining the association of diabetes and antipsychotic medication found that for patients less than 40 years old, all of the atypical antipsychotics were associated with a significantly increased prevalence of diabetes.19 Atypical antip- sychotics are the first-line treatment for psychotic disorders, therefore there is a real risk that the age of onset of diabetes will be increasingly under 40 years of age.

In respect to risk factors for type 2 dia- betes, medication side-effects represent a unique risk factor to MHSUs. However, the dilemma is that this is a risk factor unlike poor diet and sedentary lifestyle which the individual can be empowered and educated to change.

AAHSUs may need to take the anti-psy- chotic medication to remain mentally well,even though it may increase their likeli-hood of developing a metabolic disorder,such as type 2 diabetes.This representsa dilemma for practitioners in respect tobalancing mental and physical health andwellbeing.

Negative staff attitudes Negative attitudes among healthcareprofessionals can constitute a major bar-rier to healthcare for MHSUs. Negativeattitudes are usually based on stereotypi-cal ideas about individuals with mentalhealth problems.The UK DisabilityRights Commission found that perceivednegative or discriminatory attitudes ofhealthcare staff was one of the most sig-nificant barriers to healthcare identifiedby MHSUs.20 Examples of negative attitudes includea therapeutic fatalism where practitionersdo not engage MHSUs in health educationor lifestyle changes because they thinkthey do not have the ability to change.21This might manifest itself in the idea that'you can't teach an old dog newtricks'.

If such attitudes prevail it may act as adisincentive to staff in promoting positivelifestyle choices and a barrier to physicalhealth for MHSUs.

Negative attitudes can also be mani-fested in the concept of diagnosticovershadowing. In this case professionalsre-label the AAHSUs' reports of physicalsymptoms as a manifestation of theirmental illness and they are not given alegitimate status.21 An example of this in relation to type2 diabetes might go like this: Dry mouthis a common side-effect of psychotropicmedication. When a client complains ofthis, they are usually advised to drink plentyof water. Drinking plenty of water will leadto more frequent urination. Polydipsiaand poly urea are key signs and symptomsof diabetes. If people are taking medica-tions that increase the risk of diabetes,complaining of thirst may be interpretedas a side-effect of medication rather than asymptom of diabetes.

Lack of effective monitoring and screening Poor recognition of signs and symptomsPublication: Diabetes ProfessionalDate: Friday, October 07, 2011Page: 8Extract: 4 of 6Circulation: 2000Author: Michael NashHeadline: Detecting diabeties in the mentally ill of diabetes has a compound effect of underdiagnosis where MHSUs then live with an untreated condition. Living with an untreated condition increases the risk of complications which may require more invasive interventions than would origi- nally be required.This is a reason why the health outcomes for MHSUs remain poor.

MHSUs may face increased exposure to risk factors, but screening for hypergly- caemia and dyslipidaemia occurs at very low rates in this client group.22 Despite an increased prevalence of metabolic disorders, less than half of the sample of MHSUs (41.3%) of a clinical audit had been screened for diabetes.2' However, monitoring and screening requires knowledge and skills and this is an area where mental health profession- als, especially nurses, need to develop.

For example, in a survey of mental health nurses,24 the majority of the sample self- rated their knowledge of diabetes care as only fair (40%).

However, even when MHSUs are diag- nosed with diabetes or cardiovascular disorders, research shows that even at that stage they may not receive treatment that the general population would have access to. Research found that in MHSUs diagnosed with diabetes, only 70% were receiving hypoglycaernic agents (only 38% of hypertensive patients were receiving anti-hypertensive drugs and 12% of people with hyperlipidaemia were receiving statins).15 Complications of diabetes As expert diabetes practitioners you will be aware of the complications of diabetes.

However, what you may not be aware of is the impact of these complications in MHSUs. For example, obesity is a common complication of diabetes and is one of the most common physical health problems in mental health.26 Delays in diagnosing diabetes results in prolonged exposure to raised blood glucose levels, which can cause visual impairment, blindness, kidney damage, potential renal failure and nerve damage.27 Delays will result in increased mortalityand morbidity, but these are usually atyounger ages than in the general popula-tion. For example, MHSUs experienceda three-fold increase in coronary heartdisease mortality at age 18 through 49compared to non-MHSUs,and deathrates from stroke were 2.5 times greaterin MHSUs younger than 50 than in thegeneral population.28 A study of survival rates for MHSUs withdiabetes found that people with schizo-phrenia or bipolar disorder and diabeteshad a significantly increased risk of deathafter adjusting for age and gender, com-pared to those with diabetes alone.29Why does diabetes go undetected? The inherent irony for people withsevere mental illness is that while theirrisk of developing type 2 diabetes is higherthan the general population, the detectionrates for diabetes remain low.30 There area number of factors that can explain whydiabetes goes undetected in MHSUs.

Firstly, at onset, diabetes is asympto-matic and physiological changes may beput down to the natural effects of theageing process. If professionals are notactively screening for this condition in vul-nerable groups like MHSUs, then diagnosiscan be delayed. Alternatively, if MHSUsand their carers are not educated abouttype 2 diabetes, then self-recognition ofsymptoms early on can delay diagnosis.

What can healthcare professionals do? Diabetes in MHSUs is a growing clinicalconcern and is destined to remain so forthe foreseeable future. The complexityof diabetes care, treatment and manage-ment is such that there is undoubtedlya skills deficit in mental healthcare.

Therefore what is required is closer jointworking between mental healthcare andgeneral adult, acute and primary careservices. This could take the form of'dia-betes in reach* to help educate and raiseawareness of screening for diabetes in thisvulnerable group.

If we use the model of primary, second-ary and tertiary intervention we can helpto focus this'in reach'. Therefore primary'in reach'would include diabetes healthPublication: Diabetes ProfessionalDate: Friday, October 07, 2011Page: 8Extract: 5 of 6Circulation: 2000Author: Michael NashHeadline: Detecting diabeties in the mentally ill education and promotion and screening for risk factors in order to prevent diabetes occurring, or to facilitate early diagnosis.

Secondary'in reach'would explore joint working to improve access to appropriate treatment and strategically present an opportunity to develop a multidiscipli- nary care pathway; including a treatment algorithm for diabetes that is cognisant of the unique risk which MHSUs' medica- tion may present. This would provide a firm evidence base from which to develop diabetes care and support professional education.Tertiary'in reach'would be focused on those that have suffered diabetes-associated complications that affect quality of life, and again this could lead to the development of a specific care pathway.

However, there is no need to reinvent the wheel. It's not a case of this being more work, but the same work in a dif- ferent context. Much has already been done; it just doesn't appear to have been done f
or MHSUs. Therefore mental health professionals need to reflect on their attitudes, knowledge and skills relating to diabetes, lifestyle risk factors, side-effects of medication and inter-professional working, while general/acute/primary healthcare professionals have to reflect on their attitudes towards MHSUs and see if these are unintentional barriers to diabetes care.

Funding such an initiative in such austere times will present difficulties.

However, this is a highly specific problem in a highly vulnerable group and one where the author believes a strong case for commissioning diabetes care/services forthis vulnerable group can be made.

As you know, there can be no status quo with diabetes. Investment now might carry initial costs, but will provide many benefits. To delay will only mean higher future costs in respect to treating complications.

Conclusion This article has reviewed the dispro- portionate picture of ill-health in MHSUs.

Physical health in general, and diabetesin particular, have not received the careand attention they deserve, even thoughthere is an increased prevalence and risk ofdeveloping type 2 diabetes.

The management of type 2 diabetesin MHSUs requires a close collaborationbetween mental and physical health serv-ices to ensure that this vulnerable patientgroup has access to the best healthcare.

However, groups such as the Diabetes Fed-eration of Ireland can contribute a wealthof expertise and experience in tackling thishealth issue in such an excluded group.

Michael Nash is a lecturer in psychiatricnursing at the School of Nursing andMidwifery,Trinity College DublinReferences on requestPublication: Diabetes ProfessionalDate: Friday, October 07, 2011Page: 8Extract: 6 of 6Circulation: 2000Author: Michael NashHeadline: Detecting diabeties in the mentally ill