The prevalence of diabetes mellitus and abnormal glucose metabolism in the inpatient psychiatric setting: A systematic review and meta-analysis

Association between depression and diabetes mellitus and the impact of their comorbidity on mortality: Evidence from a nationally representative study

BACKGROUND

Depression and diabetes mellitus (DM) are major chronic noncommunicable diseases that impair one's mental and physical well-being and impose substantial burdens on the health system. Depressed individuals have an increased risk of impaired blood glucose, weight gain and dyslipidemia which could induce poorer long-term survival.

METHODS

37,040 individuals from the National Health and Nutrition Examination Survey (NHANES) were included. Depressive symptoms were assessed by the Patient Health Questionnaire (PHQ-9) and classified by the total scores as no (0-4), mild (5-9), moderate (10-14), and severe (15-27). DM was determined based on self-reported medical history, clinical test results, and medication use. Logistic and Cox regression were the main statistical models. All analyses were based on weighted data from complex sampling.

RESULTS

The prevalence of DM was higher in depressed than non-depressed individuals (21.26 % vs. 13.75 %). The adjusted odds ratio (OR) (95 % CI) of comorbid DM increased with depression severity, from 1.00 (reference) for no depression, to 1.22 (1.09,1.36) for mild, 1.62 (1.37,1.92) for moderate, and 1.52(1.28,1.82) for severe depression. Comorbidity of DM and depression significantly associated with a higher risk of all-cause mortality, with a hazard ratio (HR) (95 % CI) = 2.09 (1.64,2.66).

LIMITATIONS

Dynamic demographic and metabolic data were not available.

CONCLUSION

Depression is associated with a higher risk of DM, which may be related to biological, socioeconomic, and medication-related factors. Comorbidity of the two worsens long-term survival. Therefore, blood glucose management and prevention of DM should be emphasized in depressed patients.

Implementation of an Electronic Clinical Decision Support System for the Early Recognition and Management of Dysglycemia in an Inpatient Mental Health Setting Using CogStack: Protocol for a Pilot Hybrid Type 3 Effectiveness-Implementation Randomized Controlled Cluster Trial

BACKGROUND

Severe mental illnesses (SMIs), including schizophrenia, bipolar affective disorder, and major depressive disorder, are associated with an increased risk of physical health comorbidities and premature mortality from conditions including cardiovascular disease and diabetes. Digital technologies such as electronic clinical decision support systems (eCDSSs) could play a crucial role in improving the clinician-led management of conditions such as dysglycemia (deranged blood sugar levels) and associated conditions such as diabetes in people with a diagnosis of SMI in mental health settings.

OBJECTIVE

We have developed a real-time eCDSS using CogStack, an information retrieval and extraction platform, to automatically alert clinicians with National Health Service Trust-approved, guideline-based recommendations for dysglycemia monitoring and management in secondary mental health care. This novel system aims to improve the management of dysglycemia and associated conditions, such as diabetes, in SMI. This protocol describes a pilot study to explore the acceptability, feasibility, and evaluation of its implementation in a mental health inpatient setting.

METHODS

This will be a pilot hybrid type 3 effectiveness-implementation randomized controlled cluster trial in inpatient mental health wards. A ward will be the unit of recruitment, where it will be randomly allocated to receive either access to the eCDSS plus usual care or usual care alone over a 4-month period. We will measure implementation outcomes, including the feasibility and acceptability of the eCDSS to clinicians, as primary outcomes, alongside secondary outcomes relating to the process of care measures such as dysglycemia screening rates. An evaluation of other implementation outcomes relating to the eCDSS will be conducted, identifying facilitators and barriers based on established implementation science frameworks.

RESULTS

Enrollment of wards began in April 2022, after which clinical staff were recruited to take part in surveys and interviews. The intervention period of the trial began in February 2023, and subsequent data collection was completed in August 2023. Data are currently being analyzed, and results are expected to be available in June 2024.

CONCLUSIONS

An eCDSS can have the potential to improve clinician-led management of dysglycemia in inpatient mental health settings. If found to be feasible and acceptable, then, in combination with the results of the implementation evaluation, the system can be refined and improved to support future successful implementation. A larger and more definitive effectiveness trial should then be conducted to assess its impact on clinical outcomes and to inform scalability and application to other conditions in wider mental health care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04792268; https://clinicaltrials.gov/study/NCT04792268.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49548.

Managing diabetes in the psychiatric in-patient setting: knowledge, attitudes and skills of healthcare professionals

AIMS AND METHOD

There is currently a lack of monitoring and standardisation of diabetes care in the National Health Service (NHS) psychiatric in-patient setting. We surveyed healthcare professionals in psychiatric in-patient units across England to understand current diabetes care. A 13-item questionnaire was piloted via think-aloud interviews. The survey was completed by healthcare professionals across 19 wards in 11 NHS mental health trusts. Results were analysed via descriptive statistics and thematic analysis.

RESULTS

Of 150 respondents, 98% agreed that addressing physical health needs was an important part of the mental health team's role; 68% agreed that they had adequate skills and knowledge to manage diabetes safely. Thematic analysis identified themes relating to individual, organisational and patient-level factors.

CLINICAL IMPLICATIONS

Psychiatric admission could be used opportunistically to improve the healthcare disparities for people with comorbid diabetes and severe mental illness. This national survey highlights areas that need to be addressed to optimise diabetes care in this setting.

Prevalence and clinical correlates of abnormal glucose metabolism in young, first- episode and medication-naïve outpatients with major depressive disorder

BACKGROUNDS

The high co-morbidity of abnormal glucose metabolism in depressed patients has been extensively studied, but few studies have explored abnormal glucose metabolism in young patients with major depressive disorder (MDD). This study aimed to examine the prevalence and clinical correlates of abnormal glucose metabolism in young patients with first-episode medication-naïve (FEMN) MDD.

METHODS

A cross-sectional study was conducted on 1289 young Chinese outpatients with FEMN MDD. All subjects were assessed on the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale (HAMA), Positive and Negative Syndrome Scale, and their sociodemographic information was collected, and blood pressure, blood glucose, lipid and thyroid hormone levels were measured.

RESULTS

The prevalence of abnormal glucose metabolism was 12.57% in young FEMN MDD outpatients. Thyroid stimulating hormone (TSH) levels and HAMA scale scores were associated with fasting blood glucose levels in patients with FEMN MDD (P<0.05), and TSH could differentiate patients with abnormal normal glucose metabolism from those without abnormal glucose metabolism (Area Under Curve of 0.774).

CONCLUSIONS

Our study showed a high prevalence of comorbid glucose metabolism abnormalities in young FEMN MDD outpatients. TSH may be a promising biomarker of abnormal glucose metabolism in young patients with FEMN MDD.

User accounts on received diabetes and mental health care in a Danish setting - An interview study

People with coexisting type 1 and 2 diabetes and mental illness have a higher mortality rate compared to the general population, among other reasons due to unregulated diabetes. One explanation might be the complexity of managing both conditions. In this interview study, we explored the accounts of delivered diabetes and mental health care of 16 individuals living with coexisting diabetes and mental illness in Denmark. A thematic analysis by Braun and Clarke was applied in the analysis. Some of the participants described the care for diabetes and mental illness to be inextricably linked to each other. Therefore, health care providers ought to focus and knowledge of both conditions as essential components in the care provided. The participants accounted for support needs in other settings beyond diabetes and mental health outpatient clinics, such as the family doctor, residential institutions, and community care. However, the inefficient collaboration between these health care settings is one of the barriers to supporting the participants' self-management.

All-cause and cause-specific mortality among people with severe mental illness in Brazil's public health system, 2000-15: a retrospective study

BACKGROUND

People with severe mental illness have a mortality rate higher than the general population, living an average of 10-20 years less. Most studies of mortality among people with severe mental illness have occurred in high-income countries (HICs). We aimed to estimate all-cause and cause-specific relative risk (RR) and excess mortality rate (EMR) in a nationwide cohort of inpatients with severe mental illness compared with inpatients without severe mental illness in a middle income country, Brazil.

METHODS

This national retrospective cohort study included all patients hospitalised through the Brazilian Public Health System (Sistema Único de Saúde [SUS]-Brazil) between Jan 1, 2000, and April 21, 2015. Probabilistic and deterministic record linkages integrated data from the Hospital Information System (Sistema de informações Hospitalares) and the National Mortality System (Sistema de Informação sobre Mortalidade). Follow-up duration was measured from the date of the patients' first hospitalisation until their death, or until April 21, 2015. Severe mental illness was defined as schizophrenia, bipolar disorder, or depressive disorder by ICD-10 codes used for the admission. RR and EMR were calculated with 95% CIs, comparing mortality among patients with severe mental illness with those with other diagnoses for patients aged 15 years and older. We redistributed deaths using the Global Burden of Diseases, Injuries, and Risk Factors Study methodology if ill-defined causes of death were stated as an underlying cause.

FINDINGS

From Jan 1, 2000, to April 21, 2015, 72 021 918 patients (31 510 035 [43·8%] recorded as male and 40 974 426 [56·9%] recorded as female; mean age 41·1 (SD 23·8) years) were admitted to hospital, with 749 720 patients (372 458 [49·7%] recorded as male and 378 670 [50·5%] as female) with severe mental illness. 5 102 055 patient deaths (2 862 383 [56·1%] recorded as male and 2 314 781 [45·4%] as female) and 67 485 deaths in patients with severe mental illness (39 099 [57·9%] recorded as male and 28 534 [42·3%] as female) were registered. The RR for all-cause mortality in patients with severe mental illness was 1·27 (95% CI 1·27-1·28) and the EMR was 2·52 (2·44-2·61) compared with non-psychiatric inpatients during the follow-up period. The all-cause RR was higher for females and for younger age groups; however, EMR was higher in those aged 30-59 years. The RR and EMR varied across the leading causes of death, sex, and age groups. We identified injuries (suicide, interpersonal violence, and road injuries) and cardiovascular disease (ischaemic heart disease) as having the highest EMR among those with severe mental illness. Data on ethnicity were not available.

INTERPRETATION

In contrast to studies from HICs, inpatients with severe mental illness in Brazil had high RR for idiopathic epilepsy, tuberculosis, HIV, and acute hepatitis, and no significant difference in mortality from cancer compared with inpatients without severe mental illness. These identified causes should be addressed as a priority to maximise mortality prevention among people with severe mental illness, especially in a middle-income country like Brazil that has low investment in mental health.

FUNDING

Bill and Melinda Gates Foundation, Fundação de Amparo a Pesquisa do Estado de Minas Gerais, FAPEMIG, and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil.

An implementation framework and a feasibility evaluation of a clinical decision support system for diabetes management in secondary mental healthcare using CogStack

BACKGROUND

Improvements to the primary prevention of physical health illnesses like diabetes in the general population have not been mirrored to the same extent in people with serious mental illness (SMI). This work evaluates the technical feasibility of implementing an electronic clinical decision support system (eCDSS) for supporting the management of dysglycaemia and diabetes in patients with serious mental illness in a secondary mental healthcare setting.

METHODS

A stepwise approach was taken as an overarching and guiding framework for this work. Participatory methods were employed to design and deploy a monitoring and alerting eCDSS. The eCDSS was evaluated for its technical feasibility. The initial part of the feasibility evaluation was conducted in an outpatient community mental health team. Thereafter, the evaluation of the eCDSS progressed to a more in-depth in silico validation.

RESULTS

A digital health intervention that enables monitoring and alerting of at-risk patients based on an approved diabetes management guideline was developed. The eCDSS generated alerts according to expected standards and in line with clinical guideline recommendations.

CONCLUSIONS

It is feasible to design and deploy a functional monitoring and alerting eCDSS in secondary mental healthcare. Further work is required in order to fully evaluate the integration of the eCDSS into routine clinical workflows. By describing and sharing the steps that were and will be taken from concept to clinical testing, useful insights could be provided to teams that are interested in building similar digital health interventions.

Prevalence of type 2 diabetes in psychiatric disorders: an umbrella review with meta-analysis of 245 observational studies from 32 systematic reviews

AIMS/HYPOTHESIS

Estimates of the global prevalence of type 2 diabetes vary between 6% and 9%. The prevalence of type 2 diabetes has been investigated in psychiatric populations but a critical appraisal of the existing evidence is lacking, and an overview is needed. This umbrella review summarises existing systematic reviews of observational studies investigating the prevalence of type 2 diabetes in people with a psychiatric disorder.

METHODS

We searched PubMed, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews from inception to 17 January 2021 and screened reference lists of included systematic reviews. On the basis of prespecified criteria, we included systematic reviews investigating the prevalence of type 2 diabetes in adults (aged ≥18 years) with a psychiatric disorder. Titles and abstracts of 5155 identified records and full texts of 431 selected studies were screened by two independent reviewers, based on predefined eligibility criteria and an a priori developed extraction form, following the PRISMA and MOOSE guidelines. Risk of bias was assessed with the ROBIS instrument. Data extracted from primary studies were synthesised using random-effects meta-analyses.

RESULTS

A total of 32 systematic reviews with 245 unique primary studies were identified and met inclusion criteria. Twelve had low risk of bias. They reported type 2 diabetes prevalence estimates ranging from 5% to 22% depending on the specific psychiatric disorder. We meta-analysed data for ten categories of psychiatric disorders and found the following prevalence estimates of type 2 diabetes: in people with a sleep disorder: 40%; binge eating disorder: 21%; substance use disorder: 16%; anxiety disorder: 14%; bipolar disorder: 11%; psychosis: 11%; schizophrenia: 10%; a mixed group of psychiatric disorders: 10%; depression: 9%; and in people with an intellectual disability 8%. All meta-analyses revealed high levels of heterogeneity.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes is a common comorbidity in people with a psychiatric disorder. Future research should investigate whether routine screening for type 2 diabetes and subsequent prevention initiatives for these people are warranted. PROSPERO registration no. CRD42020159870.

Using mixed methods to explore diabetes care in a medium-secure setting in England: A case study

BACKGROUND AND AIMS

Diabetes is highly prevalent among individuals with serious mental illness. Managing diabetes in forensic mental health settings presents unique challenges which are under-reported and poorly understood. This study aimed to explore diabetes care in a medium-secure setting and identify key areas for improvement.

METHODS

A single case study design used a retrospective chart review. Qualitative interviews and a focus group were analyzed using thematic analysis.

RESULTS

Prevalence of diabetes was over twice that of the general population and highest in female service users. Evidence suggests limited understanding and lack of diabetes education for staff and service users, and difficulties in accessing external diabetes recourses.

CONCLUSION

Constraints inherent to forensic mental health settings contribute to difficulties in accessing external resources and adequate diabetes education. Secure mental health services should adopt a collaborative approach to diabetes care and provide appropriate specialist training to both staff and service users.

Interventions involving own treatment choice for people living with coexisting severe mental illness and type 1 or 2 diabetes: A scoping review

AIM

The objective of this scoping review was to summarize, understand and provide an overview of the empirical literature on interventions involving own treatment choice for people with coexisting diabetes (type 1 and 2) and severe mental illness (SMI).

METHODS

This scoping review undertook a systematic literature assessment. Searches were performed in MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, the Cochrane Library and grey literature (OpenGrey, Google Scholar and Danish Health and Medicine Authority databases). Publications from 2000 to July 2020 were of interest. Studies were included if they involved the users' own choice of treatment.

INCLUDED STUDIES

RCT, intervention, cohort and case-based studies.

RESULTS

A total of 4320 articles were screened, of which nine were included. The review identified eight studies from the United States and one from Canada testing different interventions for people with SMI and diabetes (one diabetes education program, five randomized controlled trials, one retrospective cohort study, one naturalistic intervention program and one case vignette). The interventions described in the nine articles involved service users, the majority incorporated individualized healthcare plans, and all interventions were based on multidisciplinary teamwork.

CONCLUSIONS

Research in the area is limited. Care management interventions tend to focus on a single condition, paradoxically excluding SMI during enrolment. Interventions aimed at people with both conditions often prioritize one condition treatment leading to an unbalanced care.

Prevalence and major risk factors of type 2 diabetes mellitus among adult psychiatric inpatients from 2005 to 2018 in Beijing, China: a longitudinal observational study

OBJECTIVE

We aim to investigate the prevalence, trends, and major risk factors of type 2 diabetes mellitus (T2DM) among adult psychiatric inpatients in Beijing, China.

RESEARCH DESIGN AND METHODS

We did a longitudinal observational study using data from the Beijing Municipal Commission of Health and Family Planning Information Center, including 157 570 adult psychiatric inpatients in 19 specialized psychiatric hospitals from 2005 to 2018 in Beijing. Data on demographic characteristics and antipsychotic medication use were obtained from electronic health records. Schizophrenia, T2DM, and comorbidities were defined according to the International Classification of Diseases, 10th revision codes of discharge diagnosis. The overall prevalence of T2DM in adult psychiatric inpatients was calculated, and the annual prevalence of T2DM was calculated and adjusted to the overall participant population. Univariate and multivariate logistic regression analyses were performed to obtain crude ORs and adjusted ORs (aORs) on the risk of T2DM in patients with different demographic characteristics, schizophrenia, antipsychotic medication use, and different comorbidities. Age-specific prevalence of T2DM under a stratification of schizophrenia or other psychiatric disorders was calculated in the subgroup analysis.

RESULTS

Out of 157 570 adult inpatients, 16 939 had T2DM, with a prevalence of 10.75% (95% CI 10.60% to 10.90%). The prevalence was 11.63% (95% CI 11.37% to 11.88%) among patients with schizophrenia and 10.17% (95% CI 9.98% to 10.37%) among patients with other psychiatric disorders. During 2005-2018, the prevalence of T2DM in adult patients increased over the years, from an adjusted prevalence of 5.20% in 2005, to 10.98% in 2010, 12.50% in 2015, and 12.71% in 2018. Results from the multivariate analysis showed that increasing age, diagnosis of schizophrenia (aOR=1.23, 95% CI 1.18 to 1.29), and comorbidities of hypertension (aOR=3.09, 95% CI 2.97 to 3.22), lipid disorders (aOR=1.95, 95% CI 1.88 to 2.04), and fatty liver (aOR=1.93, 95% CI 1.84 to 2.03) were major risk factors of T2DM in adult psychiatric inpatients.

CONCLUSIONS

The prevalence of T2DM was high among adult psychiatric inpatients in Beijing, China. Elderly patients, those with schizophrenia, and those with hypertension, lipid disorders, and fatty liver had higher prevalence of T2DM. Prevention and treatment of T2DM are of utmost relevance in hospitalized psychiatric patients.

Meta-analysis of natural, unnatural and cause-specific mortality rates following discharge from in-patient psychiatric facilities

BACKGROUND

People discharged from in-patient psychiatric facilities have highly elevated rates of suicide, and there is increasing concern about natural mortality among the seriously mentally ill.

METHOD

A meta-analysis of English-language, peer-reviewed longitudinal studies of mortality among patients discharged from in-patient psychiatric facilities was conducted using papers published in MEDLINE, PsycINFO or EMBASE (from 1 January 1960 to 1 April 2018) located using the terms ((suicid*).ti AND (hospital OR discharg* OR inpatient OR in-patient OR admit*)).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* OR hospital* OR inpatient* OR in-patient* OR discharg*).ab. Pooled mortality rates for aggregated natural and unnatural causes, and the specific causes of suicide, accident, homicide, vascular, neoplastic, respiratory, gastrointestinal, infectious and metabolic death were calculated using a random-effects meta-analytic model. Between-study heterogeneity was investigated using subgroup analysis and metaregression.

RESULTS

The pooled natural death rate of 1128 per 100 000 person-years exceeded the pooled unnatural deaths of 479 per 100 000 person-year among studies with varying periods of follow-up. Natural deaths significantly exceeded unnatural deaths among studies with a mean follow-up of longer than 2 years, and vascular deaths exceeded suicide deaths among studies with mean period of follow-up of 5 years or longer.

CONCLUSION

Suicide may be the largest single cause of death in the short term after discharge from in-patient psychiatric facilities but vascular disease is the major cause of mortality in the medium- and long-term.

Study on Drug-Drug Interactions Between Chiglitazar, a Novel PPAR Pan-Agonist, and Metformin Hydrochloride in Healthy Subjects

Chiglitazar (CHI) is a potent and selective peroxisome proliferator-activated receptor potentially for the treatment of patients with type 2 diabetes mellitus (T2DM). An open-label, randomized, 3-period crossover and self-controlled study was conducted to investigate drug-drug interaction potential between CHI and metformin hydrochloride (MET). Eligible subjects received a single oral dose of CHI (48 mg), MET (1000 mg), or a combination in each period, followed by serial blood sampling collected for up to 48 hours postdose, and safety was assessed throughout the trial. The area under the plasma concentration-time curves from time 0 to 48 hours (AUC_0-48 h ) of CHI was similar following administration alone or with MET (AUC_0-48h , 12 540 ng·h/mL [9811-15 269 ng·h/mL] vs 12 130 ng·h/mL [9304-14 956 ng·h/mL]; 90% confidence interval [CI] of its geometric mean ratio [GMR], 89.7%-103.8%), whereas the maximum concentration (C_max ) of CHI was reduced during coadministration, as its 90%CI of the GMR was slightly outside the acceptance range for bioequivalence (C_max , 1620 ng/mL [1418-1822 ng/mL] vs 1420 ng/mL [1049-1791 ng/mL], 90%CI GMR, 77.%-94.1%). However, it was not considered clinically meaningful. The MET exposures remained consistent in the absence or presence of CHI (AUC_0-48 h , 12 570 ng·h/mL [10681-14 459 ng·h/mL] vs 13 190 [10973-15 407 ng·h/mL); 90%CI of GMR: 99.1%-110.5%; C_max , 1790 ng/mL [1448-2132 ng/mL] vs 1820 ng/mL [1510-2130 ng/mL]; 90%CI of GMR, 94.2%-110.9%). No moderate to severe adverse events were reported. Our study indicated no clinically significant pharmacokinetic drug-drug interaction between CHI and MET and demonstrated good tolerance in subjects. These results support future application of CHI in combination with MET for treatment of T2DM.

The prevalence of pre-diabetes and diabetes and their associated factors in Northeast China: a cross-sectional study

This study investigates the prevalence of pre-diabetes and diabetes and their associated risk factors among adults in Northeast China. A multistage stratified cluster sampling method was used to select adults from Jilin Province. Out of an initial recruitment of 23,050 individuals, 21,435 participants completed an interview and medical examination. The estimated prevalence of diabetes and pre-diabetes were 9.1% and 19.8%, respectively. The prevalence of hypertension, dyslipidemia, and obesity were the highest in participants with previously diagnosed diabetes. Participants who were previously diagnosed with diabetes were more likely to be aware of their hypertension and dyslipidemia status. Participants who were older, male, more educated, or who were widows or widowers were at greater risk for pre-diabetes. Similarly, those who were current drinkers or smokers, had higher BMI or waist circumference, had a family history of diabetes, or who reported they lived in urban areas or had low physical activity levels had increased pre-diabetes risk. The observed levels of diabetes and pre-diabetes in this study indicate that the medical authority needs to focus more attention in this area, and that health monitoring is essential to improving the health awareness of its residents.