DANIEL MOLLOY, MDMENTOR: JAMES STEPHEN, MD

Blood Glucose Control in a Schizophrenic Population in an Outpatient Setting

Schizophrenia

Meltzer H.Y., Bobo W.V., Heckers S.H., Fatemi H.S. (2008). Chapter 16. Schizophrenia. In M.H. Ebert, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds), CURRENT Diagnosis & Treatment: Psychiatry, 2e.

Complex psychiatric disorder with many medical and psychosocial complications.

Characterized by a heterogeneous mixture of clinical features psychosis (1).

Incidence: 10 to 40 / 100,000 population

High risk for poverty, unemployment, homelessness or inadequate housing, ill health, and poor access to health care(1).

Background

American Psychiatric Association. DSM-IV. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association, 1994: 273-315

Per DSM – IV TR (2), to diagnose schizophrenia, a patient must have at least 2 of the following:

Delusions Hallucinations Disorganized speech and/or Disorganized behavior, Negative symptoms (alogia, avolition, and flat affect).

These must be at least 6 months in duration and produce disturbances in work, self-care, and interpersonal relations.

Background

McGrath J, Saha S, Welham J, El Saadi O, Macauley C, Chant D. “ A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology.” BMC Med . 2:13 (2004).

Associated medical issues(3):

20% decreased life expectancy

Increased rates of cardiovascular and metabolic abnormalities.

Overall poorer health – related quality of life .

Background

‘Schizophrenia and Diabetes 2003’ Expert Consensus Meeting, Dublin, 3–4 October 2003: consensus summary, The British Journal of Psychiatry (2004) 184: s112-s114.

Prevalence of type 2 diabetes in schizophrenic populations can be 2–4 times higher than in the general population, 15–18%(4).

The exact reason in unclear, but likely to include

Poor dietSedentary lifestyleSubstance abuseFamily association - monozygotic twins/1st

degree relatives

Hemoglobin A1c

Diabetes Care January 2012 vol. 35 no. Supplement 1 S11-S63

Formed by the irreversible, nonenzymatic binding of glucose to the terminal end of the beta chain of hemoglobin

Serves as a predictable measure of average blood glucose over period of 90 – 120 days.

• ADA Clinical Practice Recommendations now recommend using HbA1c to diagnose diabetes using a NGSP-certified method and a cutoff of HbA1c ≥6.5%(5).

Hemoglobin A1c

Certain limitations to hemoglobin A1c are known:

Dependent on lifespan of RBC

Influenced by hemoglobin variety

Laboratory –dependent standardization

Antipsychotic medications

Gautam, S., and PS Meena. "Drug-emergent Metabolic Syndrome in Patients with Schizophrenia Receiving Atypical (second-generation) Antipsychotics." Indian Journal of Psychiatry 53.2 (2011): 128-33

Antipsychotic medications commonly used in the treatment of schizophrenia have a well – documented tendency to cause hyperglycemia and/or insulin resistance (6).

Particularly pronounced in patients receiving certain members of the class of second – generation antipsychotics(6).

Cause is not entirely elucidated

Rationale

• Quality outcome measurements are becoming an increasingly important aspect of day – to –day practice.

Rationale

Mittal, Dinesh, MD. "Does Serious Mental Illness Influence Treatment Decisions of Physicians and Nurses?" Lecture. American Psychiatric Assocation 2012 Annual Meeting. San Francisco. 20 May 2013. APA 166th Meeting. American Psychiatric Association, May 2013

Bias towards mentally ill patients influences healthcare provider decision making (4).

One study with standardized patient showed HCP less likely to prescribe appropriate therapies/medications to schizophrenic patients(4).

Also includes mental health professionals (4).

Aims

Primary Objective: To determine whether a difference in average blood glucose control exists between a schizophrenic and a non - schizophrenic population in an outpatient setting.

Aims

Secondary Objectives:

To determine whether an association exists between A1c levels and the number of healthcare contact events during study period.

To assess the prevalence of vascular disease between schizophrenic and non – schizophrenic patients.

Methods

Retrospective case – control study

IRB approval obtained prior to study commencement

Data collected over a one year period from April 2012 to April 2013

Chart – based; information obtained from EMR

Methods

Inclusion criteria:

Diagnosis of Schizophrenia

Treated in outpatient setting

At least one hemoglobin A1c obtained within the study period

Methods

Exclusion criteria:

End stage renal disease

Hemolytic anemia/ hemoglobinopathy

No hemoglobin A1c within study period

Methods

245 Schizophrenic patients identified.

72 diagnoses of Diabetes mellitus.

7 excluded due to exclusion criteria

Total of 65 patients included

Methods

A control cohort of 65 randomly sampled diabetic patients was recruited based on several matching variables:

Age Race Gender.

Variables

Age Gender Race BMI LDL level Triglyceride level HDL level Smoking status Number of clinic visits

during study period

Medications for schizophrenia

Use of Insulin therapy Anemia Kidney disease Vascular

complications

Statistical Analysis

ANCOVA, t-tests, chi-square (χ2) tests as appropriate.

SPSS software (SPSS Inc, Chicago, Illinois) was used for data analysis.

P<0.05 was considered significant

Variable Schizophrenic Nonschizophrenic

p-value

Age 56.46 56.02 0.81

Gender M 28F 37

M 30F 35

0.72

Race Caucasian 36AA 22Hisp 6

Caucasian 38AA 22Hisp 5

0.76

A1c 6.645 8.409 0.001

Number of Clinic visits

4.6 4.83 0.71

Smoking Y 29N 36

Y 20N 45

0.10

Kidney Disease

Y 10N 55

Y 10N 55

N/A

Variable Schizophrenic Nonschizophrenic

p-value

Mean Age 56.46 56.02 0.81

Gender M 28F 37

M 30F 35

0.72

Race Caucasian 36AA 22Hisp 6

Caucasian 38AA 22Hisp 5

0.76

A1c 6.645 8.409 0.001

Number of Clinic visits

4.6 4.83 0.71

Smoker Y 29N 36

Y 20N 45

0.10

Kidney Disease

Y 10N 55

Y 10N 55

N/A

Variable Schizophrenic

Nonschizophrenic

P-value

LDL 103.5 102.9 0.93

HDL 44.3 44.9 0.84

Triglycerides

158.4 190.5 0.21

Anemia Yes 15N o 50

Yes 10No 55

0.266

BMI 34.0 35.0 0.736

Diabetes treatment

Insulin 16Oral 43Diet 6

Insulin 36Oral 25 Diet 4

0.002

0.008 (without insulin)

Vascular complications

Schizophrenia P-valueYes No

0.001

Yes 6 22No 59 43

Schizophrenia and diabetes – associated vascular complications

Vascular complications defined as coronary artery disease, peripheral vascular disease, and cerebrovascular disease

Hemoglobin A1c inSchizophrenic patients treated with typical vs

Atypical Antipsychotics

Number of Schizophrenics

A1c

Typical Atypical Other p-value14 45 6

6.45 6.94 7.40 0.323

No. Variable P – value1 Age 0.0062 Gender 0.8203 Race 0.0304 Smoking status 0.3065 Anemia 0.5166 Number of clinic visits 0.4577 BMI 0.2728 Schizophrenia 0.001

Limitations of Study

Retrospective

Chart based

Multiple providers participating in patient care

Conclusions

1. There was a significant difference in the hemoglobin A1c between patients with schizophrenia {mean A1c 6.6, SD =1.3} and without schizophrenia {mean A1c 8.4, SD =2.6} after controlling the effect of age, race, gender, BMI, anemia and number of clinic visits (p <0.001).

Conclusions

2. There was a significant difference in the prevalence of vascular diseases between patients with schizophrenia {9.2%} and without schizophrenia {33.8%} after controlling the effect of age, race, gender, BMI, anemia and number of clinic visits (p <0.001).

Conclusions

3. There was no significant difference in the hemoglobin A1c between schizophrenic patients taking atypical antipsychotics {mean A1c 6.9, SD =1.1} and patients taking typical antipsychotics{ mean A1c =6.4, SD = 1.6} (p<0.323).

Conclusion/Discussion

A diagnosis of schizophrenia does not mean that a patient is incapable of managing their medical conditions.

Caretakers must be careful to avoid letting bias influence their decision – making.

Further prospective study may uncover reasons for this difference.

Acknowledgements

Srikrishna Varun Malayala, MBBS

Khalid J Qazi, MD, MACP

Henri Woodman, MD

Nikhil Satchidanand, PhD

Thank You