Extent and Management of Cardiovascular Risk Factors in Patients With Type 2 Diabetes and Serious Mental Illness

Abstract

Cardiovascular disease is the leading cause of death in Type 2 diabetes, which commonly occurs in patients with serious mental illnesses (SMIs). We determined the extent to which patients with diabetes and SMI, relative to diabetes patients without SMI, met American Diabetes Association goals for cholesterol and blood pressure, met criteria for the metabolic syndrome, and were prescribed medications known to reduce cardiovascular events. We found that less than half of diabetes patients, both with and without SMI, met recommended goals for cholesterol levels; even fewer had adequate blood pressure control. In addition, a substantial proportion of all diabetes patients met metabolic syndrome criteria. However, diabetes patients with SMI were less likely to be prescribed cholesterol-lowering statin medications, angiotensin-converting enzyme inhibitors, and angiotensin receptor blocking agents than diabetes patients without SMI. Patients with both diabetes and SMI are treated less aggressively for high cardiovascular risk than diabetes patients without mental disorders. KeywordsType 2 diabetes; serious mental illness; cardiovascular risk; metabolic syndrome In 2002, Type 2 diabetes affected approximately 6.3% of the US population at an estimated cost of $132 billion (American Diabetes Association, 2003;Engelgau et al., 2004). Type 2 diabetes is associated with a twofold to fourfold increased risk for major cardiovascular events and is considered a coronary heart disease risk equivalent that confers a level of risk equal to that in patients with pre-existing cardiovascular disease (CVD; Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). Cardiovascular and cerebrovascular complications of Type 2 diabetes account for 60% to 75% of deaths from this disease (Stamler et al., 1993). Metabolic abnormalities characteristic of Type 2 diabetes including insulin resistance and dyslipidemias contribute in part to the increased CVD risk, with emerging evidence suggesting that persistent hyperglycemia may also play a role (Nathan et al., 2003;Selvin et al., 2004 NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript frequent co-occurrence of hypertension, overweight and obesity, smoking, and reduced physical activity in patients with diabetes confers an additive CVD risk that exceeds the sum of their risks individually (Wilson et al., 1998). There is also mounting evidence that the cluster of risk factors that comprise the metabolic syndrome increases the risk for cardiovascular mortality , and by definition, would be expected to occur disproportionately in people with Type 2 diabetes.Persons with serious mental illnesses such as schizophrenia have an increased risk for Type 2 diabetes (Dixon et al., 2000) and other co-occurring medical conditions. Life expectancy in people with schizophrenia is 20% shorter than that of the general population (Newman and Bland, 1991), with the excess mortality largely attributed to higher rates of CVD (Brown et al., 2000;Os...

Use of medications to reduce cardiovascular risk among individuals with psychotic disorders and Type 2 diabetes

“…Consistent with this observation are findings of significantly elevated ten-year coronary heart disease risk in individuals with SMI , which is likely a consequence of this population's high rates of Type 2 diabetes (Dixon et al, 2000), metabolic syndrome (Kreyenbuhl et al, 2006;McEvoy et al, 2005), and other cardiovascular risk factors, such as obesity (Daumit et al, 2003), physical inactivity , poor nutrition (McCreadie, 2003), and cigarette smoking (de Leon et al, 1995).…”

“…This under-appreciation of risk may contribute to the high rates of cardiovascular morbidity and mortality and contrasts with some recent progress in achieving relatively adequate glycemic control in these patients (Dixon et al, 2004;Krein et al, 2006;Weiss et al, 2006). Previous reports have demonstrated that few persons with SMI and diabetes are achieving ADA recommended goals for cholesterol (Frayne et al, 2005;Kreyenbuhl et al, 2006;Weiss et al, 2006) or blood pressure (Kreyenbuhl et al, 2006;Weiss et al, 2006), which corresponds with reports of low rates of screening for cardiovascular risk factors, particularly for hyperlipidemia (Frayne et al, 2005;Goldberg et al, 2007;Krein et al, 2006). Further, previous crosssectional studies suggest that statins and ACE-inhibitors/ARBs are used infrequently in patients with SMI and diabetes (Kreyenbuhl et al, 2006;Weiss et al, 2006) who may reap particular benefits from these treatments.…”

“…Emerging evidence suggests that recognition and management of cardiac risk in individuals with SMI in general (Nasrallah et al, 2006), and in those with diabetes specifically, (Kreyenbuhl et al, 2006;Weiss et al, 2006), is problematic. This under-appreciation of risk may contribute to the high rates of cardiovascular morbidity and mortality and contrasts with some recent progress in achieving relatively adequate glycemic control in these patients (Dixon et al, 2004;Krein et al, 2006;Weiss et al, 2006).…”

Diabetes and Cardiovascular Care Among People with Severe Mental Illness: A Literature Review

“…65 In another study of diabetes patients, those with SMI were 29 % less likely to be prescribed cholesterol-lowering statin medications, and 20 % less likely to be prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blocking agents than diabetes patients without SMI. 66 In a large VA study (N = 313,586) of people with diabetes, failure to meet diabetes performance measures was more common among people with mental illnesses, adjusting for various confounders, with AOR1. 61 Several studies speculate whether access to care, care coordination, provider biases, or patient-specific factors contribute to the poor diabetes care for this population.…”

Primary Care Physician Perceptions on Caring for Complex Patients with Medical and Mental Illness

“…2 Mental illness significantly affects outcomes in patients with other chronic medical illnesses. [3][4][5][6][7][8][9][10] The concept of patient complexity, which encompasses the influences of multiple chronic diseases, demographic factors, and psychosocial issues on disease outcomes, 11,12 could prove helpful in understanding the interplay between co-occurring mental and medical illness. Although researchers have studied the deleterious effect of mental illness on medical illnesses, the experiences of providers and the clinical context in which they work to care for complex patients need further elucidation.…”