Blood Glucose Control in a Schizophrenic Population in an Outpatient - - PowerPoint PPT Presentation

D AN IEL M OLLOY, M D

M E N TO R : J A M E S S TE P H E N , M D

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 diet
• Sedentary lifestyle
• Substance abuse
• Family 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 28 F 37 M 30 F 35 0.72 Race Caucasian 36 AA 22 Hisp 6 Caucasian 38 AA 22 Hisp 5 0.76 A1c 6.645 8.409 0.001 Number of Clinic visits 4.6 4.83 0.71 Smoking Y 29 N 36 Y 20 N 45 0.10 Kidney Disease Y 10 N 55 Y 10 N 55 N/ A

Variable Schizophrenic Nonschizophrenic p-value Mean Age 56.46 56.02 0.81 Gender M 28 F 37 M 30 F 35 0.72 Race Caucasian 36 AA 22 Hisp 6 Caucasian 38 AA 22 Hisp 5 0.76 A1c 6.645 8.409 0.001 Number of Clinic visits 4.6 4.83 0.71 Smoker Y 29 N 36 Y 20 N 45 0.10 Kidney Disease Y 10 N 55 Y 10 N 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 15 N o 50 Yes 10 No 55 0.266 BMI 34.0 35.0 0.736 Diabetes treatment Insulin 16 Oral 43 Diet 6 Insulin 36 Oral 25 Diet 4 0.002 0.008 (without insulin)

Vascular com plications Schizophrenia P-value Yes No 0.001 Yes 6 22 No 59 43

Schizophrenia and diabetes – associated vascular complications

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

Hemoglobin A1c in Schizophrenic patients treated with typical vs Atypical Antipsychotics

Num ber of Schizophrenics A1c Typical Atypical Other p-value 14 45 6 6.45 6.94 7.40 0.323

No. Variable P – value 1 Age 0.006 2 Gender 0.820 3 Race 0.030 4 Smoking status 0.306 5 Anemia 0.516 6 Number of clinic visits 0.457 7 BMI 0.272 8 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