Blood Glucose Control in a Schizophrenic Population in

an Outpatient SettingDaniel Molloy, MD

James Stephen, MD

Schizophrenia

• 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.

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.

Background

• Potentially devastating socioeconomic consequences.

• Medical effects(2): 20% decreased life expectancyIncreased rates of cardiovascular and

metabolic abnormalitiesUnhealthy lifestyle (high rates of

smoking/substance abuse)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).

Background • Per DSM – IV TR (3), the delusions hallucinations disorganized speech and/or behavior, negative symptoms (alogia, avolition, and flat affect). This must be at least 6 months in duration and

produce disturbances in work, self-care, and interpersonal relations.

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

Background

• in 1887, Schizophrenia was first described as a distinct illness by Emil Kraeplin.

Dementia Praecox

• 1911 Bleuler first used the term “schizophrenia”

Rationale• Bias influences healthcare provider

decision making (4).• Study with standardized patient showed

HCP less likely to prescribe appropriate therapies/medications to schizophrenic patients(4).

• Also includes mental health professionals (4).

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

Hemoglobin A1c • Formed by the irreversible, nonenzymatic

binding of glucose to 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).

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

Hemoglobin A1c

• Limitations to hemoglobin A1c:Dependent on lifespan of RBCInfluenced by hemoglobin varietyLaboratory –dependent standardization

Antipsychotic medications

• 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 unclear, likely multifactorial

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

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.

• 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• IRB approval obtained prior to study

commencement• Data collected over a one year period from

April 2012 to April 2013• 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

•245 Schizophrenic patients identified.•Of these, 72 had diagnosis of Diabetes mellitus.•7 were excluded due to lack of A1c during the study period.•Total of 65 patients included

• A control cohort of 65 randomly sampled diabetic patients was recruited based on the matching variables of age, race, and gender.

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

• Use of atypical medications

• Use of Insulin therapy

Variable Schizophrenic Nonschizophrenic p-value

Mean Age 56.46 56.02 0.81

Gender M 28F 37

M 30F 35

Race Caucasian 36AA 22Hisp 6

Caucasian 38AA 22Hisp 5

0.

A1c 6.645 8.409 0.00

Number of Clinic visits

4.6 4.83 0.71

Smoking Y 29N 36

Y 20N 45

0.

Kidney Disease

Y 10N 55

Y 10N 55

0.

Variable Schizophrenic

Nonschizophrenic

P-value

LDL 0.93

HDL 0.84

Triglycerides 0.21

Anemia

BMI

No. Variable P – value1 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 0.000

Limitations of Study• Retrospective• Chart based• Multiple providers

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 6.4, SD =1.1} and patients taking typical antipsychotics{ mean A1c =6.9, SD = 1.6} (p<0.060).

Conclusion

• 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• Nikhil Satchidanand, PhD

• Thank You