Screening for diabetes in severe mental illness
Physical disorders are more prevalent in people with severe mental illness than in the general population. Furthermore the lifespan of people with severe mental illness is 10-20 years shorter compared to the general population. This excess mortality is mainly caused by physical illness, with the commonest cause being cardiovascular disease (CVD).
The excess cardiovascular mortality associated with severe mental illness is attributed, in part, to an increased risk of the modifiable coronary heart disease risk factors; obesity, smoking, diabetes, hypertension, and dyslipidaemia. Antipsychotic medication and other psychotropic medication can induce weight gain or worsen other metabolic cardiovascular risk factors while people with severe mental illness may have limited access to general healthcare with less opportunity for cardiovascular risk screening and prevention than a non-psychiatric population.
Figure 1Recently the European Psychiatric association supported by the European Association for the Study of Diabetes and the European Society of Cardiology proposed guidelines for screening and monitoring (overview see figure 1). The World Psychiatric association also reviewed the evidence for the association between severe mental illness and physical illnesses and proposed recommendations both on the individual level and a systems level to achieve somatic health care on a par with that of the general population.
Monitoring and treatment guidelines
Many physical health monitoring tests are simple, easy to perform and inexpensive, and therefore can and should be implemented in routine health care. Several of these simple and inexpensive measurements (e.g. body weight and blood pressure) can be routinely done by health workers other than doctors.
Screening and assessment of physical health should begin with the patient’s personal and family history, covering: diabetes mellitus, hypertension, cardiovascular disease (CVD) (myocardial infarction or cerebrovascular accident, including age at onset), smoking, diet, physical activity (see table 1). Secondly, blood glucose, lipid profile, body weight, waist circumference, blood pressure as well as some other non-metabolic measurements should be checked at baseline and measured regularly thereafter.
Table 1: Routine measurements for use in monitoring and evaluation of physical health in SMI patients with normal baseline values (WPA recomondation)
|Baseline||6 weeks||3 months||at least at 12 months and annually thereafter|
|Personal and family history||X|
|Smoking, exercise, dietary habits||X||X||X||X|
|Weight (body mass index)||X||X||X||X|
|Fasting plasma glucose||X||X1||X||X|
|Fasting lipid profile||X||X||X|
1This early blood sugar assessment to rule out precipitous diabetes onset has been recommended in Europe, but not in the US. 2If possible to have some reference values, or, if this is too expensive, only in case sexual or reproductive system abnormalities are reported 3only in case of sexual dysfunction that coincided with antipsychotic treatment or dose change
Psychiatrists should, regardless of the medication prescribed, monitor and chart body mass index (BMI) and waist circumference of every patient with severe mental illness at every visit, and should encourage patients to monitor and chart their own weight. Waist circumference seems to be a more useful measurement than BMI and can easily be done with a simple and inexpensive (waist) tape measure.
High blood pressure in people with severe mental illness is often missed. As the cost for measuring blood pressure is low and hypertension is a relevant CVD risk factor, blood pressure should be assessed routinely, even at every visit.
Fasting blood glucose and lipid profile
A baseline measure of plasma glucose concentration should be measured for all patients before starting treatment. In patients starting antipsychotic treatment, glucose measurements should also be carried out at baseline, 6 and 12 weeks to capture early cases of hyperglycaemia and then, at minimum, yearly. In cases where patients present non-fasting, it is preferable to conduct a random blood glucose test and/or glycated haemoglobin (HbA1C) test, rather than to miss the opportunity to screen (see table 1). Caution is needed in interpreting an HbA1c in situations where glucose can change rapidly, e.g. shortly after starting treatment.
Patients who have significant risk factors for diabetes (family history, BMI >=25 kg/m2, abdominal obesity, gestational diabetes, minority ethnicity) should have their fasting plasma glucose concentration or HbA1c
Flowchartmonitored at the same time points as other patients starting medication (baseline, week 6 and 12), but thereafter they need to be checked more frequently (approximately every 3-6 months). People who gain 7% or more of their baseline weight should also have their fasting plasma glucose concentration or HbA1c value monitored more frequently.
Because of its high mortality, special attention should be given to diabetic ketoacidosis (DKA). The signs and symptoms often develop quickly, sometimes within 24 hours.
Lipid profile (especially triglycerides and HDL cholesterol) should also be assessed at baseline and at 3 months, with 12-monthly assessments thereafter minimally (see flowchart).
A healthy diet, regular physical activity and quitting smoking are the key components of lowering the prevalence and impact of modifiable risk factors. Many people with severe mental illness do not know the components of a healthy diet. Patients should be advised to avoid juices and soft drinks containing sugar and, even, artificial sweeteners, as well as high calorie, high fat, and nutritionally poor food, such as fast food and unhealthy snacks. The importance of consuming healthy alternatives, such as fresh fruit and vegetables, fish, and lean meats in a balanced way, should be stressed by clinicians whenever possible. Although educating patients (as well as their family and caregivers) about healthy food is recommended, patients need to understand that lifestyle changes should be gradual. Most people who experience rapid weight loss without gradual behaviour modifications will return to their previous weight (see table 2).
Table 2: Examples of behavioural interventions to improve the health of patients with severe mental illness
|Area of concern||Educational suggested tools|
|Diet||Healthy eating behaviour|
|Cutting down on fast food|
|Increase healthy food items (fruits, vegetables, fish), decrease high glycemic index food items and mono-unsaturated fats|
|Decrease processed fat free food|
|Making healthy snack choices|
|Controlling portion size|
|Consume 4-6, but small meals|
|Eating more slowly|
|Minimizing intake of soft drinks with sugar and with artificial sweetener|
|Reading food labels|
|Learning to discern differences between physiological and psychological appetite and eating|
|Keeping food diaries/plans/exchange tables|
|Learning cooking skills|
|Healthy food shopping|
|Keeping activity diaries, daily activity list|
|Increasing physical activity such as moderate intensity walking|
|Reduce sedentary behaviours (TV watching, video/computer games, etc.)|
|Treating/reducing sedation and motor side-effects effects of medications|
Physical inactivity is one of the risk factors that theoretically can most easily be addressed and modified in individuals with severe mental illness. Physical activity can improve metabolic health status even in the absence of weight loss. However, in patients who are obese, physical exercise should be accompanied by proper diet to achieve significant weight loss. For example, if a patient walks for 1 hour per day, about 200 calories are burned.
Worldwide studies demonstrated that people with severe mental illness, compared with the general population, have a higher prevalence of ever smoking, heavy smoking and high nicotine dependence. Up to 85% of individuals with severe mental illness will die and/or have a reduced quality of life because of a tobacco-related disease. Cessation of smoking is associated with approximately a 50% decrease in the risk of coronary heart disease, and a 75% decrease in the risk of high/very high 10-year cardiovascular events. Therefore, people with severe mental illness should be strongly encouraged to stop smoking. However, smoking cessation has important implications for the management of patients taking clozapine (plasma concentrations double after stopping smoking).
Specific treatment advice on medication
Many psychiatrists are reluctant to switch medication, despite the presence of physical health issues because of the risk of relapse of the psychosis. Nevertheless, consideration should be given to switching medication when a people with severe mental illness gains significant amount of weight (>7% of initial weight), or shows high blood glucose, abnormal lipid profile, or other significant adverse during therapy. Another option is to add a pharmacological agent to reverse or prevent the medication-induced adverse event if life-style interventions are ineffective (e.g., metformin, statins for lipids ).
If diabetes or another severe physical illness has been diagnosed, the patient should be referred to specialist services, including diabetology, endocrinology and cardiology, to receive the appropriate health care.
^ De Hert M, Dekker JM, Wood D, Kahl KG, Holt RI, Möller HJ.Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). Eur Psychiatry. 2009 Sep;24(6):412-24. (Free downloable, available in Dutch, English, French, German, Italian and Spanish)
^ De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, Detraux J, Gautam S, Möller HJ, Ndetei DM, Newcomer JW, Uwakwe R, Leucht S. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011 Feb;10(1):52-77. (Free downloable, available in Arabic, Dutch, English, Spanish and Russian)
^ Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, Hennekens CH, Lambert M, Leucht S, Maj M, McIntyre RS, Naber D, Newcomer JW, Olfson M, Osby U, Sartorius N, Lieberman JA. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry. 2008 Apr;69(4):514-9.
^ Mitchell AJ, Vancampfort D, Sweers K, van Winkel R, Yu W, De Hert M. Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders--a systematic review and meta-analysis. Schizophr Bull. 2013 Mar;39(2):306-18.
^ Mitchell AJ, Vancampfort D, De Herdt A, Yu W, De Hert M. Is the prevalence of metabolic syndrome and metabolic abnormalities increased in early schizophrenia? A comparative meta-analysis of first episode, untreated and treated patients. Schizophr Bull. 2013 Mar;39(2):295-305.
^ Vancampfort D, Vansteelandt K, Correll CU, Mitchell AJ, De Herdt A, Sienaert P, Probst M, De Hert M. Metabolic syndrome and metabolic abnormalities in bipolar disorder: a meta-analysis of prevalence rates and moderators. Am J Psychiatry. 2013 Mar 1;170(3):265-74.
^ De Hert M, Detraux J, van Winkel R, Yu W, Correll CU. Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nat Rev Endocrinol. 2011 Oct 18;8(2):114-26.
^ De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht S, Ndetei DM, Newcomer JW, Uwakwe R, Asai I, Möller HJ, Gautam S, Detraux J, Correll CU. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level.World Psychiatry. 2011 Jun;10(2):138-51. (Free downloable, available in Arabic, Dutch, English, Spanish and Russian)
^ Vancampfort D, De Hert M, Skjerven LH, Gyllensten AL, Parker A, Mulders N, Nyboe L, Spencer F, Probst M. International Organization of Physical Therapy in Mental Health consensus on physical activity within multidisciplinary rehabilitation programmes for minimising cardio-metabolic risk in patients with schizophrenia.Disabil Rehabil. 2012;34(1):1-12.