Despite the fact that individuals with severe mental illness (SMI) are two to three times more likely to have type II diabetes than the general population, low-income patients on Medicaid are rarely screened for it, according to a new study led by the University of California, San Francisco (UCSF).
The findings support growing efforts to integrate mental health services with primary care to improve diagnosis and treatment of health issues associated with mental illness, the researchers said.
Although many factors contribute to the increased risk, treatment with antipsychotic medication raises the risk for diabetes even further. The American Diabetes Association and American Psychiatric Association both recommend that physicians conduct annual diabetes screening for any patients taking antipsychotic medications, but until now it has been unclear how often screenings actually occur.
For the study, researchers examined diabetes screenings in a group of 50,915 publicly insured adults with SMI who were on antipsychotic medication. The findings showed that over 70 percent of these patients 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 health care 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, M.D., M.A.S., 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.”
“Many of these patients are dying of premature cardiovascular disease,” said Mangurian. “They tend to smoke cigarettes, hardly exercise, and may deal with food insecurity as a result of financial problems.”
Even further, their antipsychotic medication disrupts metabolic function, causing them to gain weight rapidly, which can lead to insulin resistance and diabetes.
The study 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. This allowed the researchers to compare individuals across the two datasets.
The findings showed that about 30 percent of the patients with severe mental illness 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, M.D., professor of psychiatry and behavioral sciences at University of California, Davis.
“We can do better,” Knapp 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.
“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 followup appointment with a physician,” Knapp said.
An integrated health care system would allow mental health and medical records to “talk” to each other, an essential asset for patients with mental illness. 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.”
The findings are published in the Journal of the American Medical Association Internal Medicine< .