DANIEL MOLLOY, MD MENTOR: JAMES STEPHEN, MD

Transcription

1 Blood Glucose Control in a Schizophrenic Population in an Outpatient Setting DANIEL MOLLOY, MD MENTOR: JAMES STEPHEN, MD

2 Schizophrenia 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). 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.

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

4 Background Associated medical issues(3): 20% decreased life expectancy Increased rates of cardiovascular and metabolic abnormalities. Overall poorer health related quality of life. 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).

5 Background 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/1 st degree relatives Schizophrenia and Diabetes 2003 Expert Consensus Meeting, Dublin, 3 4 October 2003: consensus summary, The British Journal of Psychiatry (2004) 184: s112-s114.

6 Hemoglobin A1c 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 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

7 Hemoglobin A1c Certain limitations to hemoglobin A1c are known: Dependent on lifespan of RBC Influenced by hemoglobin variety Laboratory dependent standardization

8 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 not entirely elucidated 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):

9 Rationale Quality outcome measurements are becoming an increasingly important aspect of day to day practice.

10 Rationale 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). 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 APA 166th Meeting. American Psychiatric Association, May 2013

11 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.

12 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.

13 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

14 Methods Inclusion criteria: Diagnosis of Schizophrenia Treated in outpatient setting At least one hemoglobin A1c obtained within the study period

15 Methods Exclusion criteria: End stage renal disease Hemolytic anemia/ hemoglobinopathy No hemoglobin A1c within study period

16 Methods 245 Schizophrenic patients identified. 72 diagnoses of Diabetes mellitus. 7 excluded due to exclusion criteria Total of 65 patients included

17 Methods A control cohort of 65 randomly sampled diabetic patients was recruited based on several matching variables: Age Race Gender.

18 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

19 Statistical Analysis ANCOVA, t-tests, chi-square (χ 2 ) tests as appropriate. SPSS software (SPSS Inc, Chicago, Illinois) was used for data analysis. P<0.05 was considered significant

20 Variable Schizophrenic Nonschizophrenic p-value Age Gender M 28 F 37 Race Caucasian 36 AA 22 Hisp 6 M 30 F 35 Caucasian 38 AA 22 Hisp A1c Number of Clinic visits Smoking Y 29 N 36 Y 20 N Kidney Disease Y 10 N 55 Y 10 N 55 N/A

21 Variable Schizophrenic Nonschizophrenic p-value Mean Age Gender M 28 F 37 Race Caucasian 36 AA 22 Hisp 6 M 30 F 35 Caucasian 38 AA 22 Hisp A1c Number of Clinic visits Smoker Y 29 N 36 Y 20 N Kidney Disease Y 10 N 55 Y 10 N 55 N/A

22 Variable Schizophrenic Nonschizophrenic P-value LDL HDL Triglycerides Anemia Yes 15 N o 50 Yes 10 No BMI Diabetes treatment Insulin 16 Oral 43 Diet 6 Insulin 36 Oral 25 Diet (without insulin)

23 Schizophrenia and diabetes associated vascular complications Schizophrenia P-value Yes No Vascular complications Yes 6 22 No Vascular complications defined as coronary artery disease, peripheral vascular disease, and cerebrovascular disease

24 Hemoglobin A1c in Schizophrenic patients treated with typical vs Atypical Antipsychotics Typical Atypical Other p-value Number of Schizophrenics A1c

25 No. Variable P value 1 Age Gender Race Smoking status Anemia Number of clinic visits BMI Schizophrenia 0.001

26 Limitations of Study Retrospective Chart based Multiple providers participating in patient care

27 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).

28 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).

29 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).

30 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.

31 Acknowledgements Srikrishna Varun Malayala, MBBS Khalid J Qazi, MD, MACP Henri Woodman, MD Nikhil Satchidanand, PhD

32 Thank You