Re-engineering healthcare: Preventing and managing comorbidity in mental health conditions

People with mental illness who develop diabetes often receive poor physical healthcare

Around 12% of people with severe mental illness (SMI) have diabetes mellitus. One of the many reasons for this comorbidity include genetic and environmental factors, how the SMI affects risk-taking behaviors, and treatment with atypical antipsychotics,^1,2 explained the first speaker.

Strategies to improve outcomes

Prevention of diabetes is the best strategy to improve the physical health outcomes for people with SMI, he said.

However, the effect of the SMI on behavior means that people with SMI often find it difficult to change their lifestyle – that is, stopping smoking, becoming more active, and avoiding “unhealthy” food — to lower their risk.

Screening for diabetes improves outcomes

Screening is another strategy to improve outcomes. However, despite its potential benefits, a systematic review of comparative studies found that; compared with people without a mental illness who have diabetes, those with a mental illness and diabetes are:

• less likely to be examined for eye or foot complications, despite more clinic visits;
• less likely to be screened for HbA_1c or cholesterol;
• receive less education;
• less likely to receive a statin³

The speaker noted that this inferior quality care might result from diagnostic overshadowing — that is, any symptoms the patient describes are ascribed to mental illness rather than diabetes.

Poor quality care might result from diagnostic overshadowing

He also noted that the reverse situation can occur, because people with diabetes have an increased prevalence of mental illness, and any symptoms patients with diabetes describe are ascribed to diabetes rather than mental illness.

The reason for the increased prevalence of mental illness among people with diabetes is not clear, but the speaker suggested that:

• changes in blood glucose are linked to changes in neurotransmitters in the brain, so there may be a biological explanation
• the heavy burden of self-management might play a role

A person-centered primary care-based collaborative care approach is the way forward

The poor health outcomes and current inequity experienced by people with SMI and diabetes can be addressed by keeping the patient at center of care was the message from the second speaker.

He advocated a person-centered approach in which the delivery of care for people with chronic conditions or associated risk factors focuses on integration in primary care and addresses multiple morbidities concurrently.

Such an approach needs to include proactive or opportunistic detection of physical illness, pharmacological and psychosocial interventions using a stepped care approach, long-term monitoring of both clinical and social outcomes and adherence support, and active participation of the patient in self-management.⁴

He suggested that this can be achieved with limited resources by reimagining how to integrate mental care into primary care using a collaborative care model,⁵ and highlighted evidence that such collaborative care is effective.⁶

Collaborative, coordinated, continuing, community-based, compassionate 

A change in attitude from “What is the matter with you?” to “What matters to you?”

The potential use of a “TEAMcare” model was also highlighted. In this model, the patient is at the heart of a team of three key players:

• a non-physician case manager, who provides education and information, adherence support, proactive monitoring, detecting early relapse, promoting healthy behaviors and lifestyle, and psychologic treatments;
• a primary care provider;
• psychiatric behavioral and medical supervision

The speaker also emphasized the importance of a “5C” (collaborative, coordinated, continuing, community-based, compassionate) approach for re-engineering person centered healthcare. Such an approach includes looking beyond the individuals with SMI and considering:

• any clustering of comorbidities, for instance in the home in terms of diet and pollution;
• the healthcare and other needs of their carers⁵