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