Managing Diabetes and Severe Mental Illness
By Matthew Garza
Schizophrenia or bipolar disorder could put you at greater risk for diabetes and complications, but why? Leading expert Professor Richard Holt shares insights into these two intertwined conditions.
Though the research is relatively limited, the connection between severe mental illnesses and the risk for development of diabetes is upsetting. Data shows that people with severe mental illnesses such as schizophrenia or bipolar disorder have reduced life expectancy, an increased risk for diabetes, and an increased risk of dying from complications related to diabetes. But researchers are only just starting to understand why this might be the case and how healthcare professionals can help improve outcomes for people living with these conditions.
One of the researchers leading the charge in this field is Richard Holt, a professor in Diabetes and Endocrinology at the University of Southampton in the UK. His work has been largely focused on interventions to support diabetes self-care for people with severe mental illness, particularly those with schizophrenia. At the 2022 Research Accelerating Psychosocial Innovations in Diabetes (RAPID) conference in Copenhagen, he shared insights and research on the connection between these connected conditions – with an emphasis on schizophrenia which is the focus of his research.
“Thankfully, there have been positive transformations in the way people with severe mental illness and diabetes are cared for over the last twenty years,” he said.
But even though this has been the case, outcomes have not improved. “The rates of diabetes in people with severe mental illness is about double…and the onset of diabetes [in this group] is about ten years earlier than the general population.” Additionally, the rates of obesity in this group are also about double that of the general population. This may be due, at least in part, to the use of medications for treating severe mental illness that can cause weight gain. And given the challenges related to getting people with schizophrenia to participate in research studies, these rates may actually be underestimated.
But what can be done about the increased risk for a diabetes diagnosis and the risk for worse diabetes-related outcomes in people with severe mental illness? According to Holt, it all comes down to prevention, detection, and support: Prevent diabetes (if possible) through lifestyle interventions and weight management, improve the detection of diabetes by placing greater importance on screening, and finally, after a diagnosis is made, support the person in the management of these two challenging conditions.
Prevention
Holt explained that, although there are not many studies on preventing diabetes in people with severe mental illness, there are studies on the effectiveness of weight management strategies in this group. Because so many of the medications used to treat severe mental illness are associated with weight gain which can put a person at greater risk for diabetes, researchers have explored whether weight management medications or lifestyle interventions can help.
In an article that looked at 17 lifestyle interventions and their success, one research team found that behavioral intervention could effectively prevent weight gain associated with medications for treating severe mental illness especially in people who were willing and able to engage in trials. The average participant across these trials had 3.12 kg (6.88 lbs) less weight gain compared to the control group who did not receive the interventions. These included everything from nutritional interventions to cognitive behavioral therapy. However, Holt emphasized that these trials were all relatively short (between 12 and 16 weeks) and small (with around 15 to 110 participants).
Other studies, such as the STEPWISE trial conducted by Holt’s team, actually showed conflicting results. In STEPWISE, at the one year follow up, there was no difference in weight gain between participants who received the intervention and those who did not.
Holt seemed to think that these conflicting results may be explained by differences in the trial participants. He said, “We need to think which of the groups of people with severe mental illness are going to respond well to lifestyle interventions.” and find ways to prevent diabetes and weight gain in the groups where these interventions may not work such as with weight management medications.
Studies show that certain medications like metformin or GLP-1 receptor agonists may help reduce weight gain in this group, with varying success.
Ultimately, healthcare providers need to be aware of the increased risk for obesity and diabetes that people with schizophrenia or other severe mental illnesses have. They also need to make sure the people they treat have access to lifestyle interventions or medications that can help with weight management. If you are someone with severe mental illness, or you have a loved one with severe mental illness, it’s important to ask your healthcare team to inform you about strategies for managing weight and preventing diabetes.
Detection
If preventing diabetes is not possible, the next step is detection. Glucose levels won’t be managed unless a person knows they have diabetes. Currently guidelines suggest that people with schizophrenia receive regular health screenings for A1C, blood pressure, fasting glucose, and lipids (among other measurements) at diagnosis, three months, and then annually after that.
Although these guidelines are in place, the percentage of people screened remains low, and many people go undiagnosed.
Holt expressed his frustration around this data. “Why is it so difficult to weigh someone, take their blood pressure, or take an [A1C] blood test?” he asked. The answer may be due to a number of reasons including:
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Not enough clarity on whose responsibility screening is.
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A lack of understanding around what, and when, to measure.
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A lack of confidence in interpreting results.
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Lack of access to the necessary equipment.
The longer a person remains undiagnosed, the greater their risk for other health complications. That’s part of the reason why screenings are necessary. For people with severe mental illness, or those with a loved one who has severe mental illness, talk to your healthcare team to make sure you receive these important screenings each year.
Support
“Managing diabetes is actually pretty complex, isn’t it? Imagine all of those challenges and then put on top of that managing a severe mental illness,” said Holt.
The reality is, when a person who has severe mental illness is diagnosed with diabetes, they may need additional support managing their glucose levels and their mental health. Finding out how to treat these two conditions with their competing demands can be a challenging balancing act.
Holt emphasized that for this group of people, some days managing severe mental illness may trump managing diabetes. It’s important for loved ones and healthcare providers to understand this. While diabetes treatment should follow standard guidelines as often as possible, people should also take into account the unique needs of those with severe mental illness and tailor their care plans accordingly.
This is particularly important, said Holt, because we know that people with severe mental illness and diabetes exhibit higher diabetes distress and are less likely to have support networks such as friends, family members, a complete healthcare team, and the larger diabetes community to help alleviate the burden of diabetes care.
Treatment programs
Currently, there are some small programs being researched that create tailored care and support networks for people with both severe mental illness and diabetes; so far, these programs have shown promise.
One is the DIAMONDS programme based in England. The DIAMONDS programme currently serves adults with severe mental illness and type 2 diabetes with a tailored self-management approach. The 16-week program includes individual weekly sessions with a trained facilitator (the “DIAMONDS Coach”), daily use of a paper-based workbooks (the “DIAMONDS Workbook”) with an optional digital app (“Change One Thing”), and optional monthly group sessions with peers and two DIAMONDS Coaches.
The aims of this program show the unique strategy such as identifying and addressing sleep problems and supporting participants with managing their diabetes within the context of fluctuating and low mood. The research team has made sure that through their DIAMONDS Voice initiative, the needs and experiences of people with both severe mental illness and diabetes are included in every step of the research and programme development process.
Another example of this kind of tailored support is the Fusion Clinic (Fusionsklinikken), established by the Steno Diabetes Center Sjaelland in Denmark. The Fusion Clinic provides outpatient treatment for adults with severe mental illness and diabetes through a combined effort between both diabetes and psychiatry healthcare professionals. Treatment includes specialized care for both the psychiatric and diabetes-related needs of each person including medication management and adjustment, health screenings for kidneys, eyes, etc., and education. It is adapted to each person’s individual needs and is revised with changes in the person’s mental and physical condition.
An opportunity to improve prevention and care
The bottom line is that people with severe mental illness are at an increased risk for both diabetes and obesity. But when people are able to advocate for better care for themselves and their loved ones, and healthcare providers understand the importance of prevention and screening – the gap in risk may be lessened.
And if a person with severe mental illness is diagnosed with diabetes, though treatment guidelines do not drastically change, individualized treatment that centers the specific needs of each person is vital. This kind of tailored care can improve outcomes and the quality of life for people at the intersection of these conditions.
