To the Editor: Recent policy recommendations and practice guidelines call for improved integration and coordination of psychiatric and medical care. The extent to which psychiatrists and other mental health providers should assume responsibility for mental health consumers' medical conditions requires further consideration, particularly for medical conditions that occur as a result of psychiatric interventions and perhaps also for preventive monitoring, screening, and education in regard to medical conditions that disproportionately affect psychiatric consumers.
Individuals with schizophrenia and other serious mental illnesses have rates of type 2 diabetes more than four times higher than the rate in the general population (1). The higher rates are likely attributable to a combination of lifestyle issues (including physical inactivity, poor nutrition, use of illicit substances, and smoking) and use of second-generation antipsychotic medications. We previously found that consumers with serious mental illness and diabetes had glycosylated hemoglobin (HbA1c) values that exceed those recommended by the American Diabetes Association; consumers for whom olanzapine was prescribed had higher HbA1c levels than those for whom other antipsychotic agents were prescribed (2). We also found that consumers in this cohort fell short of recommended goals for cholesterol levels and blood pressure control and evidenced lower quality of diabetes care as reflected by receipt of fewer recommended preventive and educational services (3,4). More effort may thus be required to provide optimal diabetes care to this vulnerable population.
To address this issue we examined involvement of community mental health providers in diabetes care in a cohort of 201 adults with type 2 diabetes and serious mental illness. Study participants were asked four questions that focused on the coordination of medical and psychiatric care during the past six months regarding whether or not their mental health providers asked about diabetes medications and behaviors, provided them with diabetes-related education, and asked to speak directly to their diabetes doctor.
Results indicate that mental health providers were engaged in some related care coordination. A total of 112 study participants (56%) reported at least one diabetes-related intervention by their mental health provider. Of these, 96 (48%) reported that mental health providers asked about diabetes behaviors and 78 (39%) reported being asked about diabetes medication. Given the poor diabetes outcomes related to HbA1C and the poor quality of care noted in this cohort, however, it is problematic that only 34 participants (17%) reported that their provider asked to speak with their diabetes doctor and 28 (14%) reported receiving any diabetes education.
Although these self-reported findings are limited by the absence of chart verification, they nonetheless suggest that mental health providers fall short of providing basic care coordination and counseling for consumers living with both serious mental illness and diabetes. Therefore, we strongly support efforts to increase mental health providers' involvement in the coordination of the medical and psychiatric care of consumers. Such efforts are squarely in line with recent calls to integrate health promotion services into the mental health system (5).
The authors are affiliated with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Goldberg is also affiliated with the Mental Illness Research, Education, and Clinical Center, Veterans Affairs Capitol Health Care Network, Baltimore.
The authors report no competing interests.
Dixon L, Weiden P, Delahanty J, et al: Prevalence and correlates of diabetes in national schizophrenia samples. Schizophrenia Bulletin 26:903—912, 2000
Dixon LB, Kreyenbuhl JA, Dickerson FB, et al: A comparison of type 2 diabetes outcomes among persons with and without severe mental illnesses. Psychiatric Services 55:892—900, 2004
Goldberg RW, Kreyenbuhl JA, Medoff DR, et al: Quality of diabetes care among adults with serious mental illness. Psychiatric Services 58:536—543, 2007
Kreyenbuhl J, Dickerson F, Medoff D, et al: Extent and management of cardiovascular risk factors in patients with type-2 diabetes and serious mental illness. Journal of Nervous and Mental Disease 194:404—410, 2006
Hutchinson D, Gagne C, Bowers A, et al: A framework for health promotion services for people with psychiatric disabilities. Psychiatric Rehabilitation Journal 29:241—250, 2006