Comorbid Diabetes and Severe Mental Illness: Outcomes in an Integrated Health Care Delivery System

  • Christina MangurianEmail author
  • Dean Schillinger
  • John W. Newcomer
  • Eric Vittinghoff
  • Susan Essock
  • Zheng Zhu
  • Wendy Dyer
  • Kelly C. Young-Wolff
  • Julie Schmittdiel



Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood.


To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI.


Retrospective cohort study


269,243 adults with diabetes

Main Measures

Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring.

Key Results

Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21–1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87–0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02–1.05, p < .001; aRR 1.02; 95% CI 1.00–1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02–1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71–0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control.


Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control.


diabetes severe mental illness healthcare delivery system health outcomes 



Thanks to UCSF Assistant Clinical Research Coordinator Nicholas S. Riano, MAS, for his assistance in preparing the manuscript. Thanks to Dr. Constance Weisner for her scientific consultation on our findings and KPNC Psychiatry leadership (Drs. Don Mordecai and Mason Turner) for their thoughtful input on the draft.

Funding Information

All authors received support from a grant from the NIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (R03 DK101857). Drs. Schillinger and Schmittdiel received support from the Health Delivery Systems Center for Diabetes Translational Research (CDTR) (NIDDK P30 DK092924).

Compliance with Ethical Standards

The study received approval by the UCSF Committee of Human Research and the Kaiser Permanente Northern California Institutional Review Board.

Conflict of Interest

Dr. Mangurian was supported by an NIH Career Development Award (K23MH093689). Dr. Newcomer has grant support from Otsuka America Pharmaceutical Inc., consulting fees from Sunovion Pharmaceuticals, and he serves on a Data Safety Monitoring Board for Amgen, outside the submitted work. Dr. Schillinger received support from NIH Center grant P60MD006902. Dr. Essock received consulting income from the National Association of State Mental Health Program Directors and RAND Corporation. All remaining authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5489_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 19 kb)


  1. 1.
    Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis 2006;3(2):A42.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Mangurian CV, Schillinger D, Newcomer JW, Vittinghoff E, Essock SM, Zhu Z, et al. Diabetes and Prediabetes Prevalence by Race and Ethnicity Among People With Severe Mental Illness. Diabetes Care 2018. CrossRefGoogle Scholar
  3. 3.
    Osborn DP, Wright CA, Levy G, King MB, Deo R, Nazareth I. Relative risk of diabetes, dyslipidaemia, hypertension and the metabolic syndrome in people with severe mental illnesses: systematic review and metaanalysis. BMC Psychiatry 2008;8:84. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs 2005;19(Suppl 1):1-93.PubMedGoogle Scholar
  5. 5.
    Mangurian C, Newcomer JW, Modlin C, Schillinger D. Diabetes and Cardiovascular Care Among People with Severe Mental Illness: A Literature Review. J Gen Intern Med 2016:1-9. CrossRefGoogle Scholar
  6. 6.
    Rajkumar AP, Horsdal HT, Wimberley T, Cohen D, Mors O, Børglum AD, et al. Endogenous and Antipsychotic-Related Risks for Diabetes Mellitus in Young People With Schizophrenia: A Danish Population-Based Cohort Study. Am J Psychiatr 2017;174(7):686-94.CrossRefGoogle Scholar
  7. 7.
    Kreyenbuhl J, Dickerson FB, Medoff DR, Brown CH, Goldberg RW, Fang L, et al. Extent and management of cardiovascular risk factors in patients with type 2 diabetes and serious mental illness. J Nerv Ment Dis 2006;194(6):404-10. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Ford ES. Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: a summary of the evidence. Diabetes Care 2005;28(7):1769-78.CrossRefGoogle Scholar
  9. 9.
    Krein SL, Bingham CR, McCarthy JF, Mitchinson A, Payes J, Valenstein M. Diabetes treatment among VA patients with comorbid serious mental illness. Psychiatr Serv 2006;57(7):1016-21. CrossRefPubMedGoogle Scholar
  10. 10.
    Long JA, Wang A, Medvedeva EL, Eisen SV, Gordon AJ, Kreyenbuhl J, et al. Glucose control and medication adherence among veterans with diabetes and serious mental illness: does collocation of primary care and mental health care matter? Diabetes Care 2014;37(8):2261-7.CrossRefGoogle Scholar
  11. 11.
    Frayne SM, Halanych JH, Miller DR, Wang F, Lin H, Pogach L, et al. Disparities in diabetes care: impact of mental illness. Arch Intern Med 2005;165(22):2631-8. CrossRefPubMedGoogle Scholar
  12. 12.
    Gierisch JM, Beadles C, Shapiro A, McDuffie J, Cunningham N, Bradford D, et al. Health disparities in quality indicators of healthcare among adults with mental illness. 2014.Google Scholar
  13. 13.
    National Committee for Quality Assurance. HEDIS Measures. 2017.
  14. 14.
    American Diabetes Association. Standards of medical care in diabetes-2018. Diabetes Care. 2018;41(Supplement 1):S1-S159.CrossRefGoogle Scholar
  15. 15.
    Mangurian C, Schillinger D, Newcomer JW, Vittinghoff E, Essock S, Zhu Z, et al. Diabetes Screening among Antipsychotic-Treated Adults with Severe Mental Illness in an Integrated Delivery System: A Retrospective Cohort Study. J Gen Intern Med 2017. CrossRefGoogle Scholar
  16. 16.
    Mangurian C, Newcomer JW, Modlin C, Schillinger D. Diabetes and Cardiovascular Care Among People with Severe Mental Illness: A Literature Review. J Gen Intern Med 2016;31(9):1083-91. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Schmittdiel JA, Uratsu CS, Fireman BH, Selby JV. The effectiveness of diabetes care management in managed care. Am J Manag Care 2009;15(5):295-301.PubMedGoogle Scholar
  18. 18.
    Simoni-Wastila L, Zuckerman IH, Shaffer T, Blanchette CM, Stuart B. Drug use patterns in severely mentally ill Medicare beneficiaries: impact of discontinuities in drug coverage. Health Serv Res 2008;43(2):496-514.CrossRefGoogle Scholar
  19. 19.
    Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. Mental disorders and use of cardiovascular procedures after myocardial infarction. Jama. 2000;283(4):506-11.CrossRefGoogle Scholar
  20. 20.
    Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004;159(7):702-6.CrossRefGoogle Scholar
  21. 21.
    Morales J, Assumpcao-Morales M. The 2018 update of the American College of Physicians glycaemic management recommendations: An invitation to continued inertia? Diabetes, Obes Metab 2018;20(8):1809-11.CrossRefGoogle Scholar
  22. 22.
    Goldman ML, Spaeth-Rublee B, Pincus HA. The case for severe mental illness as a disparities category. Psychiatric services. 2018:appi. ps. 201700138.Google Scholar
  23. 23.
    Mangurian C, Newcomer JW, Vittinghoff E, Creasman JM, Knapp P, Fuentes-Afflick E, et al. Diabetes Screening Among Underserved Adults With Severe Mental Illness Who Take Antipsychotic Medications. JAMA Intern Med 2015;175(12):1977-9. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Morrato EH, Druss B, Hartung DM, Valuck RJ, Allen R, Campagna E, et al. Metabolic testing rates in 3 state Medicaid programs after FDA warnings and ADA/APA recommendations for second-generation antipsychotic drugs. Arch Gen Psychiatry 2010;67(1):17-24. CrossRefPubMedGoogle Scholar
  25. 25.
    Essock SM, Covell NH, Leckman-Westin E, Lieberman JA, Sederer LI, Kealey E, et al. Identifying clinically questionable psychotropic prescribing practices for medicaid recipients in new york state. Psychiatr Serv 2009;60(12):1595-602. CrossRefPubMedGoogle Scholar
  26. 26.
    Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362(7):590-9.CrossRefGoogle Scholar
  27. 27.
    Fernandez A, Schillinger D, Warton EM, Adler N, Moffet HH, Schenker Y, et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med 2011;26(2):170-6.CrossRefGoogle Scholar
  28. 28.
    Kunasegaran S, Beig J, Khanolkar M, Cundy T. Adherence to medication, glycaemic control and hospital attendance in young adults with type 2 diabetes. Intern Med J 2018;48(6):728-31.CrossRefGoogle Scholar
  29. 29.
    Kreyenbuhl J, Leith J, Medoff DR, Fang L, Dickerson FB, Brown CH, et al. A comparison of adherence to hypoglycemic medications between type 2 diabetes patients with and without serious mental illness. Psychiatry Res 2011;188(1):109-14.CrossRefGoogle Scholar
  30. 30.
    Kreyenbuhl J, Dixon LB, McCarthy JF, Soliman S, Ignacio RV, Valenstein M. Does adherence to medications for type 2 diabetes differ between individuals with vs without schizophrenia? Schizophr Bull 2010;36(2):428-35. CrossRefPubMedGoogle Scholar
  31. 31.
    Gorczynski P, Firth J, Stubbs B, Rosenbaum S, Vancampfort D. Are people with schizophrenia adherent to diabetes medication? A comparative meta-analysis. Psychiatry Res 2017;250:17-24.CrossRefGoogle Scholar
  32. 32.
    Young JQ, Kline-Simon AH, Mordecai DJ, Weisner C. Prevalence of behavioral health disorders and associated chronic disease burden in a commercially insured health system: findings of a case–control study. Gen Hosp Psychiatry 2015;37(2):101-8.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Christina Mangurian
    • 1
    • 2
    Email author
  • Dean Schillinger
    • 2
    • 3
  • John W. Newcomer
    • 4
  • Eric Vittinghoff
    • 5
  • Susan Essock
    • 6
  • Zheng Zhu
    • 7
  • Wendy Dyer
    • 7
  • Kelly C. Young-Wolff
    • 1
    • 7
  • Julie Schmittdiel
    • 7
  1. 1.Department of Psychiatry, Weill Institute of Neurosciences University of California, San FranciscoSan FranciscoUSA
  2. 2.UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General HospitalSan FranciscoUSA
  3. 3.UCSF Division of General Internal Medicine at Zuckerberg San Francisco General HospitalSan FranciscoUSA
  4. 4.Thriving Mind South Florida and Washington University School of MedicineSt LouisUSA
  5. 5.Department of Epidemiology and BiostatisticsUniversity of California, San FranciscoSan FranciscoUSA
  6. 6.Department of PsychiatryColumbia UniversityNew York CityUSA
  7. 7.Kaiser Permanente Northern California Division of ResearchOaklandUSA

Personalised recommendations