Diabetes Management in the Context of Serious and
Persistent Mental Illness
Clinical Practice Recommendations
EVIDENCE-BASED GUIDELINES FOR INTEGRATED CARE
Expert Reviewed Edition, March 2003
EDITED BY
Judith McDevitt, PhD, APRN, BC
CONTRIBUTORS
Judith McDevitt, PhD, APRN, BC
Marsha Snyder, PhD, APRN, CS
Bonnie Breitmayer, PhD, RN
Olimpia Paun, PhD, RN
Elizabeth Wojciechowski, PhD, RN, MS
EXPERT PANEL
Mark Amdur, MD
Betul A. Hatipoglu, MD
Philip Janicak, MD
Lauretta Quinn, PhD, RN
Mark Schneiderhan, PharmD
PRINCIPAL INVESTIGATOR
Lucy Marion, PhD, APN, CNP, FAAN
© 2003 by The Nursing Institute, College of Nursing
University of Illinois at Chicago
This work was supported by the Adah Wilson Fund for Nursing Education
The Chicago Community Trust, and the College of Nursing,
University of Illinois at Chicago
Contents
Contributors and Reviewers
Preface
.......……...…….………………………………………………………
v
....………………………………………………………………………………………………………………
vii
Introduction: Methods ……………………………….…………………………………………………………….
1.
Background: Serious and Persistent Mental Illness
Demographics of SPMI
…..…….………………………………………………………………………
Medications in the treatment of SPMI and diabetes risk
Social influences related to SPMI
4
…….………..………………………………………………
6
……………………………………..……………
Health care and other resources for treatment of SPMI
References
……………………..……
……………………………………………………………………………………………………
7
9
13
Personal Factors: Psychosocial Impacts of Serious and Persistent Mental Illness
Overview of SPMI illnesses
…………………………………..…..………………………..………
Self-efficacy in SPMI: stress and coping
Insight in SPMI
22
….……………………………………………………………………...
24
………………………………………………………………………………………..….
27
Affective response to SPMI
References
20
……………………………………………………….
Cognitive function in SPMI
3.
1
………………………..……
Previous health care experience in SPMI
2.
ix
…………………………………………………….……………..……
28
……………………………………………………………………………………………………
29
Clinical Practice Recommendations
Provide integrated care ……………..…………………………………………………………………….
36
Build a therapeutic alliance …….…………… ……………………………………………………….
38
Provide health information appropriately
39
……………………………………………………….
Optimize client self-management ……………………………………………………………………
40
Screen for diabetes ……………………………………………………………………….…………………
42
Diagnose diabetes
…………………………………………………………………….…………………
43
Treat pre-diabetes ………………………………………………….…………………….…………………
43
Provide comprehensive diabetes care ………………………………………………………………
44
Set appropriate goals for glycemic control …………………………………………………….
45
Provide case management ……………………………………………………………………….………
48
References ……………………………………………………………………….……………………………….
49
iii
Contents, Cont.
Appendices
A.
Recommended content areas for diabetes education in the context of SPMI…
B.
D.
Rehabilitation, psychoeducation, and skills training principles for diabetes
education in the context of SPMI ……………………………………………………………………...
Motivational interviewing and solution-focused methods for diabetes care in
the context of SPMI …………………………………………………………………………..……………….
Risk factors for diabetes in the context of SPMI ………………………………………………
61
63
E.
Diagnostic criteria for diabetes
………………………………………………………………………
64
F.
Comprehensive history and physical examination forms ……………………..…………
65
G.
Flow sheets, checklists, and patient logs for diabetes care in SPMI ……………….
70
C.
iv
58
59
Contributors
Judith McDevitt, PhD, APN, CNP
Family Nurse Practitioner, Centers for Integrated Health Care; Clinical
Assistant Professor of Nursing, Department of Public Health, Mental Health,
and Administrative Studies in Nursing, College of Nursing, University of
Illinois at Chicago
Marsha Snyder, PhD, APN, CNP
Psychiatric Clinical Nurse Specialist, Centers for Integrated Health Care;
Clinical Assistant Professor of Nursing, Department of Public Health, Mental
Health, and Administrative Studies in Nursing, College of Nursing, University
of Illinois at Chicago
Bonnie Breitmayer, PhD, RN
Associate Professor of Nursing, Department of Public Health, Mental Health,
and Administrative Studies in Nursing, College of Nursing, University of
Illinois at Chicago
Olimpia Paun, PhD, RN
Assistant Professor of Nursing, Aurora University, Aurora, Illinois
Elizabeth Wojciechowski, PhD, RN, MS
Education Program Manager, Rehabilitation Institute of Chicago
Expert Panel
Mark Amdur, MD
Medical Director, Thresholds Psychiatric Rehabilitation Centers, Chicago, IL
Betul A. Hatipoglu, MD
Assistant Professor of Clinical Medicine, Division of Endocrinology and
Metabolism, Department of Medicine, UIC Medical Center, University of
Illinois at Chicago
Philip Janicak, MD
Professor of Psychiatry and Pharmacology, College of Medicine, University of
Illinois at Chicago; Medical Director, Psychiatric Clinical Research Center, UIC
Medical Center, University of Illinois at Chicago
Lauretta Quinn, PhD, RN
Clinical Assistant Professor, Department of Medical-Surgical Nursing, College
of Nursing, University of Illinois at Chicago
Mark Schneiderhan, PharmD
Clinical Assistant Professor, Department of Pharmacy Practice, College of
Pharmacy, University of Illinois at Chicago
v
Peer Reviewers
Dawn Anderson, MS, APN, CNP
Family Nurse Practitioner, Centers for Integrated Health Care; Clinical
Instructor, Department of Public Health, Mental Health, and Administrative
Studies in Nursing, College of Nursing, University of Illinois at Chicago
Susan Braun, MS, APN, CNP
Project Director, Centers for Integrated Health Care; Clinical Instructor,
Department of Public Health, Mental Health, and Administrative Studies in
Nursing, College of Nursing, University of Illinois at Chicago
Nancy Burke, MSN, RN
Psychiatric Clinical Nurse Specialist, Centers for Integrated Health Care;
Clinical Instructor, Department of Public Health, Mental Health, and
Administrative Studies in Nursing, College of Nursing, University of Illinois at
Chicago
Sue Niezgoda, MSN, MSW, APN, CNP
Psychiatric Clinical Nurse Specialist, Centers for Integrated Health Care;
Clinical Instructor, Department of Public Health, Mental Health, and
Administrative Studies in Nursing, College of Nursing, University of Illinois at
Chicago
Diane R. Pineda, MS, APN, CNP
Family Nurse Practitioner, Centers for Integrated Health Care; Clinical
Instructor, Department of Public Health, Mental Health, and Administrative
Studies in Nursing, College of Nursing, University of Illinois at Chicago
Marlene Smith Sefton, PhD, APN, CNP
Family Nurse Practitioner, Centers for Integrated Health Care; Clinical
Assistant Professor, Department of Public Health, Mental Health, and
Administrative Studies in Nursing, College of Nursing, University of Illinois at
Chicago
Principal Investigator
Lucy Marion, PhD, APN, CNP, FAAN
Professor and Head, Department of Public Health, Mental Health, and
Administrative Studies in Nursing, College of Nursing, University of Illinois at
Chicago
vi
Preface
Since 1998, the Centers for Integrated Health Care of the UIC College of
Nursing, University of Illinois, have been providing primary and mental
health care for clients (called members) of the Thresholds Psychiatric
Rehabilitation Centers of greater Chicago. Our providers, all faculty of the
University of Illinois at Chicago, include family nurse practitioners and
psychiatric clinical nurse specialists from the College of Nursing and their
collaborating physicians from the Department of Family Medicine, University
of Illinois College of Medicine, and from Thresholds Psychiatric Rehabilitation
Centers.
One of the things learned very early after opening the Centers for Integrated
Health Care was that many patients, besides their serious and persistent
mental illness (SPMI), have poor nutrition, obesity, substance use,
hypertension, hepatitis C, asthma, and/or diabetes. Diabetes emerged as a
particularly difficult problem for patients because:
1.
2.
3.
The rates of diabetes may be higher in the mentally ill (14%) than
in the general population (6%), although why is not well
understood.
The newer antipsychotics, which have done so much for symptom
control, may be inducing or speeding up the development of
diabetes, either directly, through changes in glucose metabolism,
or indirectly, through the weight gain associated with several of the
newer antipsychotics.
Diabetes is harder to manage in the context of mental illness, for
many reasons:
a. The mental illness often has to come first, so the diabetes is not
managed consistently.
b. Diabetes is a self-managed disease, but patients with mental
illness often have difficulties managing their daily lives, even
without trying to care for a chronic illness like diabetes.
c. The mental illness may have associated cognitive deficits. This is
particularly true in schizophrenia, in which there are problems
with memory, sequencing, and executive function, all of which
are needed for effective diabetes self-management.
d. Because many with mental illness are not functioning
independently, caseworkers, families, and house managers may
also be involved. Setting goals and monitoring progress is more
complicated.
All of these factors add up to a greater burden of illness for patients living
with a mental illness and also with diabetes. These patients are at higher risk
for having poor glycemic control and developing complications of diabetes
than patients who do not also have a mental illness.
vii
As efforts continued to provide evidence-based diabetes care, it became
apparent that there were no guidelines to assist in managing the complex
problems being encountered. There were guidelines for diabetes care and
guidelines for mental illness treatment, but no guidelines for caring for
diabetes in the context of mental illness. Accordingly, a multidisciplinary
team was formed to study the problem and develop the guidelines needed.
The team included a nurse practitioner, an online education specialist, and
psychiatric clinical nurse specialists. Just as the aim is to provide integrated
primary and mental health care in the IHC clinics, the team drew on both
primary care and mental health expertise for developing these practice
recommendations. An expert panel was also recruited to review the work: a
diabetes nurse researcher and specialists in endocrinology, psychiatry, and
pharmacology. Most importantly, Dr. Lucy Marion obtained funding for this
project. With the support of the Adah Wilson Fund for Nursing Education, The
Chicago Community Trust, and the UIC College of Nursing, we had the
resources needed to complete this work.
The purpose of these recommendations is to provide evidence-based practice
guidelines for diabetes care in patients with a serious mental illness. The
guidelines are primarily intended for use in managing type 2 diabetes without
complications. The guidelines complement a web-based instructional module
created by Dr. Margaret Noyes, a family nurse practitioner and instructional
media expert. The module is designed for the clinical education of nurses and
other health professionals, and it can be accessed through
http://www.uic.edu/nursing/pma/services/diabetes/index.htm). The
guidelines and accompanying instructional module are the first in a series of
scholarly projects to be generated through the Centers for Integrated Health
Care.
J. M.
viii
Introduction: Methods
How to manage diabetes in the context of mental illness is a broad topic.
Diabetes management by itself has an extensive literature, and the research
on mental illness is vast. Asking how to manage diabetes in the context of
serious mental illness was potentially asking hundreds of sub-questions. It
was determined that a conceptual approach would assist in focusing the
study. To frame this work, it was decided to use a conceptual model of
nursing (Figure). This would help to focus the study on concepts related to
the care of patients in community settings, where health maintenance and
promotion are core activities. Health maintenance and promotion are
cornerstones of mental health care for successfully living in community
settings, just as they are in diabetes care.
evidence-based practice guidelines
THE DIABETES PROJECT
„
framing the problem
Time
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OUTCOMES
ASSESSMENT
•Background factors
-demographics
-social influences
-previous healthcare
-resources
• Personal factors
-stress and coping
-cognition, insignt
-feelings
INTERVENTIONS
Ì
• decisional control
Ê
Adherence
È
• affective support
• health information
• APN competence
-assessment
-treatment
-patient education
-follow-up
Æ
Glycemic control
Functional status
È
Satisfaction
with care
Quality of life
Adapted from C. Cox (1982).
Figure: A conceptual model for diabetes care.
The model chosen to frame this work was an adaptation of Cheryl Cox's
Interactional Model of Client Health Behavior (Cox, 1982). It has been used
in over 50 published studies and dissertations. At the UIC College of Nursing,
it has been adapted for several large ongoing research programs, including a
walking program for women (Wilbur et al., 2001) and STD prevention in
women (Marion, 2000).
As background for the clinical practice recommendations, the model was
used first to identify important areas to be considered in assessing patients.
ix
These included background factors pertaining to persons with serious and
persistent mental illness (SPMI) generally, i.e., demographics, medications,
social influences, previous health care experience, and health care resources
for persons with SPMI. Next, research was sought on personal factors known
to influence outcomes and which must be taken into account when providing
interventions. These factors included self-efficacy, cognition and insight, and
affective response SPMI.
The recommendations themselves were developed around the four areas for
intervention identified in the model: affective support, health information,
decisional control, and professional-technical competency. Since goal setting
is an important component of diabetes care, the outcome variable of
glycemic control was included in the clinical practice recommendations. A
more comprehensive selection will be made from the outcome variables
when the project is further evaluated in the future.
For each variable studied, the following process was used:
•
•
•
•
•
•
•
•
Define study questions
Identify and retrieve research pertaining to the study questions.
Assess the research methodologies used and determine the strength of
the evidence.
Identify research findings pertaining to the study questions.
Prepare evidence tables and write a summary of methods and findings.
Circulate the summary and tables to co-researchers for peer review.
Write the clinical practice guidelines based on the above reviews and
circulate to expert panel and peer reviewers.
Revise clinical practice guidelines according to reviews received.
The process outlined here represented a series of systematic literature
reviews that integrated knowledge in diabetes care with knowledge about
mental health treatment. The process followed standard practice for
preparing systematic reviews and critiquing scientific literature (American
Nurses Association, 1995; Cooper, 1998; Fink, 1998; Guyatt & Rennie, 2002;
McKibbon, 1999), although the time and resources available necessarily
delimited the work. Some specific decisions that were made included how
much to limit literature searches, how to process the evidence, and how to
weigh its strength. These will be discussed in more detail below.
Literature searches. Each review was initiated by searching for all reports of
quantitative and qualitative research in the subject area published in English
since 1995. For background areas such as demographics and social
influences (see Figure), the search focused populations living in the United
States, since the mental health care system here is different from that in
countries with national systems of health care and hence experience living
with a mental illness may be different. Reviews and meta-analyses were
sought where available. The primary databases consulted were Medline,
PsycINFO, and Cinahl accessed through Ovid. FirstSearch was used to locate
x
additional reports by researchers identified through the initial search of
Medline and PsycINFO.
Processing the evidence. The articles retrieved were coded according to the
variable represented in the conceptual model (see Figure) and their citations
imported from Ovid into the Reference Manager database for the project. The
lead researcher for the variable then reviewed each article and prepared
evidence tables and a summary analysis, conducting additional searches and
consulting the expert panel for the project for additional information as
appropriate. These were then used to write the clinical practice
recommendations presented here.
Weighing the evidence. A key consideration in conducting the reviews and
preparing the evidence tables was how to rate and weight research
methodologies. There are numerous approaches to evaluating research
methodologies. A relatively simple one is to use the global categories
adopted by the U.S. Preventive Services Task Force (Woolf et al., 1996) or
the Schizophrenia Patient Outcomes Research Team (PORT) funded by the
Agency for Health Care Policy and Research and the National Institute of
Mental Health (Lehman & Steinwachs, 1998). The categories are based on
the research design, with randomized controlled trials rated as the strongest
evidence. Expert opinion can be included in the absence of research but is
the weakest evidence. More complicated approaches are to use one of the
published tools for evaluating research. Many of these tools use scoring
systems that weight various characteristics of the research done based on
how important the characteristic may be for reliability and/or validity (Lohr &
Carey, 1999; Zaza et al., 2000) .
Problems with these methods are that first, little is known about their
reliability or validity. Second, these methods emphasize intervention research
and neglect describing how to evaluate descriptive and qualitative research
and integrate it meaningfully into an evidence analysis. Third, grading
hierarchies such as that used by the U.S. Preventive Services Task Force
reward internal validity at the expense of external validity, so that the
applicability of the research in the context of co-morbidities and community
populations remains unclear. In this project, there not only were no practice
guidelines for diabetes care in the context of SPMI; there was little published
research. The recommendations had to be based on what is known about
mental health care and diabetes care, which then had to be integrated and
applied to the problem of diabetes care when the client has a mental illness.
To negotiate these dilemmas, the following strategies were utilized. With
respect to research methodologies, it was decided to categorize the research
reports broadly according to design. The overall strength of the evidence
based on research designs represented then would be considered in the
summary analysis and in formulating the guidelines themselves. With respect
to external validity of the research reports, it was decided that the comorbidity focus of the project--diabetes and mental illness--as well as its
xi
grounding in community health care contexts--dictated an emphasis on
sample characteristics. Accordingly, together with study design, the
populations that have been studied to date were a key consideration in
evaluating the literature identified.
In writing the recommendations presented in Chapter 3, the following criteria
were applied for levels of evidence, as used in the PORT treatment
recommendations (Lehman & Steinwachs, 1998):
Level A:
Level B:
Level C:
Good research evidence with some expert opinion.
Fair research evidence with substantial expert opinion.
Based on expert opinion with minimal research evidence.
The criteria used in the PORT recommendations were selected because they
are clear, simple to use, and take into account the role of expert opinion at
all levels of evidence. In areas of practice in which there are few large,
randomized and well-controlled studies, expert opinion remains an important
resource while scientific knowledge and evidence-based practice advances
and develops.
In identifying expert opinion, the researchers relied on clinical experience
providing diabetes care in the context of SPMI, published expert reviews by
clinicians, and the expert panel for the study. The expert panel was asked to
review the initial draft of the recommendations and then rate their
agreement based on their own knowledge of the research and their own
clinical experience. If the recommendations needed modification, we asked
that they supply citations that would support making changes. Based on this
feedback, we the recommendations were then modified accordingly.
References
American Nurses Association, Committee on Nursing Practice
Standards and Guidelines (1995). Manual to develop guidelines. Washington,
DC: American Nurses Publishing.
Cooper, H. (1998). Synthesis research; A guide for literature reviews.
Thousand Oaks, CA: Sage.
Cox, C. (1982). An interaction model of client health behavior:
theoretical prescription for nursing. Advances in Nursing Science, 5 (1), 4156.
Fink, A. (1998). Conducting research literature reviews: From paper to
the Internet. Thousand Oaks, CA: Sage.
Guyatt, G., & Rennie, D. (Eds.) (2002). Users guides to the medical
literature; A manual for evidence-based practice. Chicago: American Medical
Association.
xii
Lehman, A. F., & Steinwachs, D. M. (1998). The Schizophrenia Patient
Outcomes Research Team (PORT) treatment recommendations.
Schizophrenia Bulletin, 24 (1), 1-10.
Lohr, K. N. & Carey, T. S. (1999). Assessing "best evidence": Issues in
grading the quality of studies for systematic reviews. Joint Commission
Journal on Quality Improvement, 25, 470-479.
Marion, L. (2002). Well woman program. Accessed on February 25,
2002, at http://www.uic.edu/nursing/pma/services/wellwoman/index.htm
McKibbon, A. (1999). PDQ evidence-based principles and practice.
Hamilton, Ont.: Decker.
Wilbur, J., Chandler, P., & Miller, A. M. (2001). Measuring adherence
to a women’s walking program. Western Journal of Nursing Research, 23 (1),
8-32.
Woolf, S. H., DiGuiseppi, C. G., Atkins, D., & Kamerow, D. B. (1996).
Developing evidence-based clinical practice guidelines: Lessons learned by
the U.S. Preventive Services Task Force. Annual Review of Public Health, 17,
511-538.
Zaza, S., Wright-De Aguero, L. K., Briss, P. A., et al. (2000). Data
collection instrument and procedure for systematic reviews in the Guide to
Community Preventive Services. American Journal of Preventive Medicine, 18
(1S), 44-74.
xiii
1
Background: Serious and Persistent
Mental Illness
Judith McDevitt and Elizabeth Wojciechowski
Serious and persistent mental illness (SPMI) is an umbrella term under which
reside a number of chronic psychiatric illnesses: schizophrenia, bipolar
illness, severe forms of major depression, obsessive-compulsive disorder,
and/or panic disorder. Any of these if coupled with a persisting functional
disability such as inability to manage self-care, maintain employment, or live
independently is considered an SPMI (Kessler et al., 1994; U.S. Department
of Health and Human Services [USDHHS], 1999).
For the purposes of these clinical practice guidelines, we will define SPMI only
as having schizophrenia, bipolar illness, or a severe form of major depression
together with a persisting functional disability. This definition excludes
obsessive-compulsive disorder and panic disorder in order to focus this
review on the common diagnoses among our clients, who are members of
Thresholds Psychiatric Rehabilitation Centers in Chicago, Illinois, receiving
health care through the Centers for Integrated Health Care, UIC College of
Nursing (http://www.uic.edu/nursing/pma/services/ihc/).
As background for managing diabetes in the context of SPMI, understanding
factors likely to affect all clients with SPMI provides a useful core of
information for providers. This chapter provides an overview of the
demographics of SPMI; the health status and risks, social influences, and
previous health care experiences of persons with SPMI; and resources for
the care and treatment of SPMI. Because some medications for SPMI may
affect diabetes risk, they are discussed here as well. The individual illnesses
comprising SPMI—schizophrenia, bipolar illness, and major depression—are
defined and discussed in more detail in Chapter 2.
Demographics of SPMI
About 28-30 percent of the U. S. population has a mental and/or addictive
disorder in a given year, including 20 percent with a mental disorder, 6
percent with an addictive disorder, and 3 percent who have a mental disorder
combined with an addictive disorder (Kessler et al., 1994; Regier et al.,
1993). Fortunately, SPMI affects only a portion of these. Best estimates for
1
CHAPTER 1: BACKGROUND FACTORS IN SPMI
the 1-year prevalence of the chronic illnesses considered an SPMI
are:schizophrenia, 1.3 percent; episode of major depression, 6.5 percent;
and bipolar illness (Types I and II), 1.7 percent (USDHHS, 1999).
In Illinois in 1990, 458,149 persons had SPMI, not including homeless or
institutionalized persons (Kessler et al., 1998). This translates to 4 percent
of the Illinois population considered as having SPMI and living in established
community settings in 1990.
The SPMIs among Thresholds members are distributed somewhat differently
than they are in national data. In 2002, 62 percent of members had
schizophrenia or non-affective psychosis, 29 percent had mood disorder
(bipolar disorder or major depression), and 17 percent had conduct or nonpsychotic anxiety disorder, alone or in combination with schizophrenia or
mood disorder. In terms of demographics, 90 percent of Thresholds members
were between the ages of 20 and 59, 57 percent were male, 46 percent were
White, and 47 percent were Black. About 5 percent were living with a spouse
or partner, while 71 percent were single and never married. Virtually all (98
percent) were on Medicare and/or Medicaid public insurance (personal
communication, Thresholds Research Department, February 5, 2003).
Mortality, disability, co-morbidity, and lifestyle. Persons with SPMI have
higher mortality rates than the general population (Felker et al., 1996). For
example, about 10-15 percent of patients hospitalized for major depression
commit suicide (Angst et al., 1999). Estimates vary, but patients with
schizophrenia appear to commit suicide at rates 8.5 times higher than the
general population (Harris & Barraclough, 1997).
Disability adjusted life years (DALYs) are the common metric used to
describe the burden of a disability and premature death resulting from the
disability. Mental disorders account for 15 percent of the burden of disease
and DALYs worldwide. Major depression, bipolar disorders, schizophrenia,
and obsessive-compulsive disorder are among the top 10 leading causes of
disability (Murray & Lopez, 1996).
In terms of medical co-morbidities, persons with depression have an average
of 2 chronic medical illnesses and a higher prevalence of hypertension and
arthritis than the general population (Wells et al., 1989, 1991). In a survey
of persons with SPMI, higher rates than the general population were reported
for hypertension (43.1 percent), diabetes (14.9 percent), and sexually
transmitted diseases (10 percent) (Dixon et al., 1999). To put these numbers
into perspective with respect to diabetes, in the 1994 Health Interview
Survey of the general population only 1.2% of persons 18-44 and 6.3% of
persons 45-64 had diabetes (Dixon et al, 2000). Type 2 diabetes may be 2-4
times more prevalent in SPMI than it is in the general population (Buse,
2002). Additional medical problems related to SPMI or treatments for mental
illness include sleep apnea, hyponatremia, obesity, arthritis, and movement
disorders (Bazemore, 1996).
2
CHAPTER 1: BACKGROUND FACTORS IN SPMI
Medical co-morbidities often go undiagnosed and untreated in persons with
SPMI (Felker et al., 1996). Indeed, there is evidence of unmet health care
needs that may be so substantial that they jeopardize successful mental
health treatment (Felker et al., 1996). In the schizophrenia Patient Outcomes
Research Team study, having more medical problems was associated with
worse perceived physical health, poorer mental health, and being more likely
to have attempted suicide (Dixon et al., 1999). In addition to their higher
rates of suicide and accidents, persons with SPMI appear to suffer excess
deaths from the same co-morbidities that affect the general population
(Brown, 1997). This may be because they lack access to appropriate regular
physical health care and so do not benefit from advances in health
promotion, disease prevention, and disease management reaching the
general population.
A salient example of the need for disease prevention and health promotion is
that persons with SPMI have multiple risk factors for cardiovascular disease.
In addition to higher than expected rates of hypertension (Dixon et al., 1999;
Kendrick, 1996) and diabetes (Dixon et al., 1999), persons with SPMI are as
obese or more obese than the general population (Allison et al., 1999;
Aronne, 2001; Davidson et al., 2001; Elmslie et al., 2000; Kendrick, 1996;
McElroy et al., 2002). Many highly effective and commonly used psychiatric
medications are associated with weight gain, so their use further increases
health risks for diabetes and hypertension (Green et al., 2000; Wirshing,
1999). The presence of obesity indicates nutritional deficits, particularly an
imbalance between calorie intake and energy expenditure.
Persons with SPMI are often physically inactive, resulting in low energy
expenditure. This physical inactivity is often a symptom of the mental illness.
In one survey of a clinic population in Australia, patients with mental illness
were half as likely to engage in light exercise and only one-quarter as likely
to engage in vigorous activity as the general population (Davidson et al.,
2001). Physical work capacity, an indicator of fitness, was low in recently
admitted psychiatric patients studied by Martinsen et al. (1989). Patients
with schizophrenia studied by Brown et al. (1999) had less leisure exercise
than the general population in the same age groups. Patients with SPMI had
low scores on exercise subscales of Pender’s Health Promoting Lifestyle
Profile, which measures actions and feelings (McManus, 1996). This lack of
physical activity in persons with SPMI contributes to weight gain and obesity
and increases risks for diabetes and cardiovascular disease (U. S. Preventive
Services Task Force, 1996).
Finally, persons with SPMI smoke at high rates. Estimates vary, but smoking
prevalence is 58%-88% in people with schizophrenia compared to 25% in
the general population (Addington, 1998; McCreadie & Kelly, 2000). In the
setting of diabetes and/or hypertension, smoking increases cardiovascular
risk. However, smoking cessation may be more difficult than it is in the
general population (Addington et al., 1998).
3
CHAPTER 1: BACKGROUND FACTORS IN SPMI
Medications in the treatment of SPMI and diabetes risk
Mental health treatment is efficacious for most mental illnesses (Mueser et
al., 2001; USDHHS, 1999). The major components of treatment are
psychosocial interventions, such as psychotherapy or counseling, and
medications to control symptoms and improve functioning. Often both
psychosocial and psychopharmacology interventions are combined,
increasing their effectiveness. Psychiatric rehabilitation programs such as are
available through Thresholds use both components of treatment. However,
medications used in psychopharmacology may have additional effects that
may be related to the development of diabetes, as will be discussed below.
Mental illness has been linked to diabetes for at least 80 years (Kooy, 1919).
The data show that the prevalence of type 2 diabetes in persons with
schizophrenia is at least 10 percent and may be as high as 24.5 percent
(McKee et al., 1986; Mukherjee, 1996). This is higher than the rate of
diabetes in the general population, which has been estimated at 7.8 percent
(Harris et al., 1998). Atypical antipsychotics in particular seem to be linked
to the development of diabetes, impaired glucose tolerance, insulin
resistance, and perhaps with diabetic ketoacidosis. Until recently, the
available evidence consisted of case reports. In 2000, we located 25 case
reports of persons with schizophrenia who developed hyperglycemia or
diabetes while on clozapine. In seven of these cases, there was either a
significant improvement or resolution of elevated blood glucose levels when
clozapine was discontinued. We also located 21 case reports of
hyperglycemia, diabetic ketoacidosis, or diabetes while on olanzapine and 3
case reports while on risperidone or quetiapine.
More recently, this literature has been critically reviewed (Haupt &
Newcomer, 2001) and larger studies have been published (Sernyak et al.,
2002; Wirshing et al., 2002) identifying relationships between antipsychotics
and elevated glucose (Haupt & Newcomer, 2001; Newcomer et al., 2002;
Wirshing et al., 2002), dyslipidemias (Haupt & Newcomer, 2001; Wirshing et
al., 2002), and diabetes (Haupt & Newcomer, 2001; Sernyak et al., 2002),
with atypical agents having greater effects.
A 5-year study found an impaired glucose tolerance in 36.6 percent of 82
patients treated with clozapine. Over the 5 years, 52 percent had a least one
fasting glucose level >140mg/dL and 67.1 percent had at least one fasting
glucose level >126/mg/dl (Henderson et al., 2000). In an intervention study
in which modified glucose tolerance tests were performed in 48 nondiabetic
patients with schizophrenia, patients on olanzapine or clozapine had
abnormal elevations in glucose, whereas those on resperidone or on typical
neuroleptics did not (Newcomer et al., 2002). The largest study (Sernyak et
al., 2002) compared atypical versus typical neuroleptics in 38,632 patients
treated in 1999 in Veterans Administration facilities. They found that patients
4
CHAPTER 1: BACKGROUND FACTORS IN SPMI
on the atypicals clozapine, olanzapine, and quetiapine were 9% more likely
to have diabetes than those on typical neuroleptics.
Naturalistic studies of clozapine indicate that although it may induce
hyperglycemia, the hyperglycemia may be reversible. In one study, 33%
(N=21) of 63 patients had a fasting blood sugar of >120mg/dL) while treated
with clozapine compared to 19 percent (N=13) in patients treated with
conventional antispychotics (p=0.07) (Hagg et al., 1998). In a study in
patients who had gained weight and/or developed diabetes during the first 6
months of treatment with clozapine (N=65), weight gain decreased and
glycemic control improved when quetiapine was added and clozapine was
gradually tapered (Reinstein et al., 1999), although as discussed above
quetiapine has also been associated with diabetes (Sernyak et al., 2002).
Psychiatric medications and weight gain. Definitions of weight gain have
differed among studies, with >7% over baseline commonly used. Weight gain
is of concern because an outcome of weight gain, obesity, is a known risk
factor for developing type 2 diabetes as well as hypertension, dyslipidemia,
cardiovascular disease, sleep apnea, and certain types of cancer (U.S.
Preventive Services Task Force, 1996).
All atypical antipsychotics have been associated with weight gain with the
exception of ziprasidone and aripiprazole (Janicak, personal communication,
2002). Clozapine seems to have the highest risk, with an average gain of 6.9
kg, followed by olanzapine (6.8 kg), quetiapine (5.0 kg), and risperidone (3.7
kg) (Taylor & McAskill, 2000). Proposed mechanisms of action explaining
weight gain during antipsychotic use include increased circulating leptin,
which regulates weight and may be the link between obesity and insulin
resistance (Hagg et al., 2001; McIntyre et al., 2001). Additionally, the effects
on weight gain of changes in the influence of monoamines such as serotonin
or in histamine signaling at the level of the hypothalamus; changes in
circulating androgen or prolactin levels; alterations in the action of
neurotransmitters, neuropeptides, and cytokines; and in adipose tissue, in
uncoupling proteins and peroxisome proliferator-activated receptors are all
being studied (McIntyre et al., 2001).
With respect to antidepressants, weight gain is a less common or rare side
effect with SSRIs compared to tricyclics (TCAs) and monamine oxidase
inhibitors (MAOIs) (Saur & Herrell, 1997). In depressed patients being
treated for diabetes, SSRIs may be hypoglycemic and cause weight loss,
whereas weight gain may accompany use of MAOIs and/or TCAs (Goodnick et
al., 1997, 2000). Valproate has been associated with weight gain in 50
percent of women taking this medication (Isojarvi et al., 1996), and patients
on lithium gain an average of 9 pounds and more if they are also on
antipsychotics, antidepressants, or both (Janicak et al., 2001).
Psychiatric medications and dyslipidemia. Newer atypical antipsychotics, in
addition to effects on glucose control and weight, may affect lipids. A
5
CHAPTER 1: BACKGROUND FACTORS IN SPMI
matched, nested, case-control analysis of 18,309 patients with schizophrenia
in Great Britain found a strong relationship between medication with
olanzapine and the development of hyperlipidemia compared with no
antipsychotic use (odds ratio, 4.65) and with conventional antipsychotics
(odds ratio, 3.36). Risperidone did not have these effects, either compared
with no antipsychotic use (odds ratio, 1.12) or use of conventional
antipsychotics (odds ratio, 0.81) (Koro et al., 2002). The specific lipid
fractions affected were not analyzed (total cholesterol versus HDL, LDL, or
triglycerides). However, case studies reporting severe triglyceride elevations
(> 600) with use of olanzapine and quetiapine even in the absence of
marked weight gain have appeared in the literature (Meyer, 2001).
Social influences related to SPMI
Many attitudes and beliefs about mental illness are erroneous, negative, and
rejecting (Link et al., 1999). Although the American public has a fairly
accurate idea of what causes mental illness and that these are chronic
illnesses needing treatment (Link et al. 1999), minorities may have other
explanations (Alvidrez, 1999; Guarnaccia & Parra, 1996; Jenkins, 1988;
Schnittker et al., 2000) and may be less likely to seek treatment for
themselves or a mentally ill family member (Schnittker et al., 2000).
Labeling may play an important role in social attitudes. When mental illness
is thought of as “nervios" (nerves), as it may be in Latino communities, the
accompanying beliefs seem to downplay the seriousness of the illness and
normalize ordinary care in family contexts as appropriate and sufficient
(Jenkins, 1988; Schorling & Saunders, 2000). When the label is mental
illness, family members are less tolerant (Parra, 1985) and even conceal the
diagnosis from others (Phelan et al., 1998). This is because of the pervasive
stigma attached to being mentally ill.
Living with a mentally ill person may be distressing and contribute to
caregiver burden. In mental health care, expressed emotion (EE) refers to
critical, hostile, intrusive, and emotional over involvement by family
members (Bellack & Mueser, 1993). High EE appears to be associated with a
higher risk of psychotic relapse for the mentally ill family member as well as
increased distress in the family, and these may reinforce each other in a
vicious circle (Mueser & Glynn, 1990). On the other hand, an accepting,
supportive, low EE family helps to buffer stress and may support gradual
improvements in functioning (Bellack & Mueser, 1993).
The stigma attached to mental illness includes the idea that the mentally ill
are violent, with substance use and schizophrenia perceived as the most
dangerous mental illnesses (Pescosolido et al., 1999). Perceptions of
dangerousness are widespread and persistent (Link et al., 1999; Pescosolido
et al., 1999; Phelan et al., 2001). There are ethnic differences in these
perceptions that persist despite having personal relationships with the
mentally ill (Whaley, 1997). There are gender differences as well, with
6
CHAPTER 1: BACKGROUND FACTORS IN SPMI
mentally ill women thought to be less dangerous than mentally ill men
(Schnittker, 2000). In reality, although there is an association between
violence and mental illness, the mentally ill commit only a small fraction of
violent crimes (Harvard Mental Health Letter, 2000).
The outcomes of perceptions of dangerousness include social distancing and
rejection. In that an important goal of mental health treatment is to integrate
the patient into society, social distancing is an everyday barrier that must be
constantly negotiated by the mentally ill, who because of their mental illness
may be less able to do so. Negative attitudes toward the mentally ill also
influence funding for mental health care as well as access to housing,
employment, and social support. To the extent that persons with SPMI
internalize these attitudes, they may also influence their feelings about
having a mental illness and confidence in their ability to care for themselves
and ultimately, the way they manage their mental illness and co-morbidities.
Previous health care experience in SPMI
Only half of those with any mental disorder report using mental health
services in 1 year (Regier et al., 1993; USDHHS,1999). Among patients with
SPMI, service use is slightly higher, with about 60 percent using services in 1
year (National Advisory Mental Health Council, 1993). Embarrassment about
having a mental problem, or having a family member who may have a
mental problem, prevents people from seeking care (U.S. Department of
Health and Human Services, 1999). Fear of being stigmatized by having a
mental illness may be an important contributor to the low rates of utilization
for mental health care in the United States.
Patients in treatment for mental illness make substantially more visits for
their mental health care, 14.3 visits per year (Narrow et al., 1993), than do
patients seen in ambulatory care overall, who make only 2.78 visits per year
(Cherry et al., 2001). Middle-aged patients make more visits than older or
younger patients (Walkup & Gallagher, 1999), as do women, women who live
alone, and persons who have more than one diagnosed mental illness
(Walkup & Gallagher, 1999). Schizophrenia is the most disabling mental
illness with the highest service use (Walkup & Gallagher, 1999). Patients
living below the poverty line get fewer and less intense services (Kessler et
al., 1998), and those living in rural areas may have less access to day
treatment and case management (Sullivan et al., 1996).
There is evidence that ethnic minorities utilize and receive mental health care
differently than Caucasian Americans (USDHHS, 2001). Some of these
differences may be due to cultural preferences, such as the reliance on family
and community networks. Other differences may be the outcomes of
differential treatment by the system and by providers in a system that is
perceived as based on race and class. For example, minorities in the United
States overall have lower socioeconomic status, and those in the lowest
strata are 2½ times more likely to be diagnosed with a mental disorder. This
7
CHAPTER 1: BACKGROUND FACTORS IN SPMI
may be due to higher life stress, more uncontrollable life events, and a
greater vulnerability to mental illness (USDHHS,1999). However, there are
also differences in the distributions of diagnoses made. African Americans are
more likely than Caucasian Americans to be diagnosed with schizophrenia,
the most disabling and stigmatizing mental illness, and less likely to be
diagnosed with depression (USDHHS, 1999, 2001). They are also
underrepresented in outpatient treatment settings, especially in privately
insured care, and are over represented in inpatient settings (USDHHS,1999,
2001).
Many African Americans hold negative attitudes toward the mental health
care system (Daila et al., 2000; Schnittker et al., 2000), reflecting a lack of
trust related to previous experiences of bias. In their contacts with the
mental health care system, African Americans have experienced overt racism
as well as slights or “micro insults” (U.S. Department of Health and Human
Services, 1999). Undocumented Latinos fear that information they provide
will be reported to immigration authorities and they will be deported if they
seek health care (USDHHS, 1999).
Differences in help seeking practices may also affect how minorities use
mental health care services. Traditionally, African Americans try to minimize
the significance of stress and to prevail over it through increased striving.
Mental health problems are often viewed as spiritual concerns. As a result,
African Americans may tend to delay seeking help until symptoms require
inpatient care. They also have higher use of emergency departments for
mental health problems than do other ethnicities (USDHHS, 1999). Among
minorities, ties to family and community are strong (Guarnaccia & Parra,
1996; USDHHS, 1999). Troubles are shared and decisions whether to seek
help are often made through families and their networks rather than on the
basis of medical advice.
Adherence to care. Inconsistency or failure in adhering to treatment
recommendations is pervasive in health care regardless of the health care
problem and is evident in mental health care as well. In patients with
schizophrenia, a 1986 review found a 1-year non-adherence rate of 41
percent for oral medications and 25 percent for depot medications (Young et
al., 1986). A 1997 summary of 15 other studies found a 1-month to 2-year
non-adherence rate of 55 percent (Fenton et al., 1997).
Across studies, correlates of non-adherence include recognized factors that
apply regardless of the diagnosis: disagreeable medication side effects, lack
of money and/or transportation, and/or a poor patient-provider relationship
(with consequent lack of trust in treatment recommendations). A few
correlates, however, seem unique to the problem of mental illness: greater
symptom severity and/or grandiosity (perhaps resulting in an inability to
attend to a continuing plan), and lack of insight (and perhaps denial of the
mental illness and thus the need for treatment) (Fenton et al., 1997).
8
CHAPTER 1: BACKGROUND FACTORS IN SPMI
Utilization of medical care. There is only limited information about utilization
of physical health care, but patients with a chronic mental illness appear to
delay and underutilize primary care. In a survey of outpatients with
schizophrenia, less than 70 percent of those who had 1 or more physical
health problems reported that the problem was being treated. The lowest
treatment rates were for hearing (41 percent) and dental care (46 percent).
Treatment rates were higher for diabetes (85 percent) and hypertension (81
percent) (Dixon et al., 1999). Further, utilization varies by psychiatric
diagnosis. An analysis of Veterans Administration data showed that patients
with a mental illness had fewer visits for medical care than patients without a
mental illness, and the more severe the illness was, the fewer visits they had
(Cradock-O’Leary et al., 2002). Young adults with schizophrenia and adults
of all ages with bipolar disorder were least likely to receive medical care.
In Arizona, mentally ill Medicaid recipients had 18 percent fewer claims for
physical health care than did those without mental illness. The mentally ill
used emergency services more often and outpatient care less often. For
example, genitourinary diagnoses accounted for 8 percent of outpatient
claims among those without mental illness but less than 1 percent of claims
for those with mental illness. Conversely, genitourinary diagnoses accounted
for 19 percent of inpatient claims for those with mental illness but less than 1
percent of claims for those without mental illness (Berren et al., 1999).
Delays and under utilization of care can result in emergency room use and
disproportionately high inpatient admissions for problems that are usually
handled on an outpatient basis in patients without mental illness. Delays also
place the mentally ill at higher risk for poor outcomes.
Health care and other resources for treatment of SPMI
The mental health care system is so fragmented that it has long been called
the "de facto" mental health care system (USDHHS, 1999; Regier et al.,
1978, 1993). The system consists of a set of diverse, loosely coordinated
services provided by a variety of caregivers. Overall, it falls seriously short of
the need, reaching less than 1/3 of those with mental and/or addictive
disorder in any one year (Regier et al., 1993).
Like other less serious mental disorders, care for SPMI is provided by a
variety of overlapping sectors. Between 29.5 percent (Kessler et al., 1998)
and 43.6 percent (National Advisory Mental Health Council, 1993) of those
with SPMI seeking care in 1 year obtain it though the specialty mental health
care sector. The general medical sector serves about 1/3 (National Advisory
Mental Health Council, 1993). Additionally, some 17 percent of patients with
SPMI have inpatient care during 1 year (National Advisory Mental Health
Council, 1993). Human services and self-help groups provide services for
patients with SPMI as well.
Multiple, coordinated, integrated services have the best outcomes (Chandler
et al., 1996; USDHHS, 1999), but because of the fragmented nature of the
system, clients with SPMI are at risk for receiving partial, intermittent, and
9
CHAPTER 1: BACKGROUND FACTORS IN SPMI
inadequate care (USDHHS, 1999). Where mental health care systems
provide stronger community support services, patients use few hospital days,
resulting in lower per-person costs (Dickey et al., 1997).
Several models of service delivery have evolved since the 1960's to provide
community-based mental health care, with varying degrees of success
(Mueser et al., 2001; USDHHS, 1999). Case management, assertive
community treatment, and psychosocial rehabilitation have all been studied
and have demonstrated positive results in terms of reduction in
hospitalization, successful community living, and employment.
Crisis care services intervene when clients are decompensating, suicidal, or
homicidal and then return them to their communities when they have been
stabilized. Dual diagnosis services provide combined treatment for patients
with an addiction disorder using the same providers and program as their
mental health care, and these have been shown to be effective. Self-help
groups, drop-in centers and hotlines, and family self-help organizations are
among ancillary services available for some patients. Federal policy
mandates that patients with mental illness be included on agency boards,
providing for advocacy for the mentally ill.
Insurance. Mental health care in the U.S. is funded by two main sources:
public and private. In the public sector, services are provided directly--or at
least are paid for--by local, state, or federal agencies and/or programs. In
the private sector, services are provided by private agencies or are paid for
by private insurance (USDHHS, 1999). In 1996, 63 percent of the U.S.
population had private insurance, mostly through employers; 13 percent had
Medicare; 12 percent had Medicaid; and 16 percent had no insurance at all
(USDHHS, 1999). Most patients with SPMI rely on Medicare, Medicaid, and
other government programs due to the high costs of their illness, their low
income, and their unemployed status.
Both the public and private sectors limit mental health care coverage and
often have different terms than coverage for general health care. In the
public sector, Medicare limits coverage on long-term care, keeping this as the
ongoing responsibility of state and local governments. With the advent of
managed care in the 1990s, carve-out, separately contracted behavioral
health plans have increasingly been used to control costs for mental health
care. By 1998, managed care covered 56 percent of Americans with private
insurance as well as 48 percent of Medicaid and l4 percent of Medicare
recipients. Of those in managed care plans, 72 percent were enrolled in
carve-out plans for behavioral health care (USDHHS, 1999).
The so-called “safety net” for the uninsured consists of various state and
local governmental programs, sometimes funded by federal block grants. For
these limited funds, the most seriously ill command most of the resources. A
recent estimate indicated state and local programs paid $2,430 per person
per year for those with SPMI, a dramatically higher figure than per capita
10
CHAPTER 1: BACKGROUND FACTORS IN SPMI
mental health expenditures via private insurance, Medicare, or Medicaid cited
above. After taking care of uninsured patients with SPMI, there were few
funds left: state and local programs paid only $40 per person per year for the
uninsured with milder mental illness (USDHHS, 1999).
Housing. Finding affordable, decent, safe housing is a difficult problem for
patients with SPMI. Poverty and stigma limit options, and discrimination
persists despite legislation against it (USDHHS, 1999). Among the lowincome disabled, which includes persons with SPMI, half are considered to
have “worst case” need for housing, and among the homeless, one-third are
estimated to be mentally ill (USDHHS, 1999).
The shared housing arrangements that evolved following deinstitutionalization—group homes and half-way houses—have been criticized as lesser
replications of the older practice of isolating the mentally ill in insane
asylums. That adults live in a group home apart from others, even if the
home is in the community, makes them more visible to their neighbors and
thus perpetuates the stigma of mental illness (Seilheimer & Doyal, 1996).
Surveys of the mentally ill indicate that what they really want for their living
arrangements is to live alone or with a partner or spouse in a permanent
home. The home should be integrated into a neighborhood, self-chosen, and
not assigned as a “slot” reserved for someone with a mental illness
(Seilheimer & Doyal, 1996).
To help patients live in communities successfully, they need individualized,
flexible, responsive services and supports, or what is now being termed
supported housing (USDHHS, 1999). Although no randomized trials of
supported housing have been done, some quasi-experimental studies have
shown that it can help to improve mental health and also self-management
ability (USDHHS, 1999).
Employment and income. Unemployment is pervasive among patients with
SPMI, with 90% or more unable to work consistently or at all (USDHHS,
1999). Many factors contribute to this, including cognitive deficits associated
with the SPMI, illness episodes, the effects of stigma and discrimination
against the mentally ill, and their own realistic job expectations. If the onset
of the illness was during school years, as is often the case in schizophrenia or
bipolar illness, patients also may have educational deficits that disqualify
them from higher-paying jobs and career advancement possibilities. Persons
with SPMI often test below the grade they achieved in school in both reading
and math. As a result of these deficiencies, many patients with SPMI who are
able to work are stuck in low-paying, menial jobs that don’t pay enough for
them to be self-supporting.
Patients with SPMI are usually poor, typically becoming dependent on public
assistance soon after their first hospitalization (USDHHS, 1999). In the 1994
National Health Interview Survey, 23% of participants who said they had a
mental or emotional illness had incomes falling below the poverty line,
11
CHAPTER 1: BACKGROUND FACTORS IN SPMI
compared to 10.3% of the general household population surveyed (Willis et
al., 1998).
Sources of income for patients with SPMI who cannot work include disability
through Social Security Insurance; rent and utilities subsidies and other kinds
of programmatic assistance; and informal sources such as families and
friends. For both health insurance and income assistance, these
arrangements are fragile and require frequent attention to maintain
documentation of eligibility. If patients are able to gain employment, benefits
may be reduced or discontinued and must be reapplied for when they again
become unemployed (USDHHS, 1999).
Employment is associated with improved quality of life as well as clinical
outcomes. For example, working is associated with reduced symptoms in
patients with schizophrenia (USDHHS, 1999). Because of these benefits as
well as the potential of employment to enable economic self-sufficiency,
current goals in psychiatric rehabilitation include developing supported
employment for patients with the potential for transitioning to competitive
employment (Marder, 2002).
For patients, the support required for successful employment is individualized
and may include self-care and social skills training, vocational testing and job
training, and employer support. For employers, the accommodations required
do not appear to be costly and mainly involve appropriate orientation and
training of supervisors, providing on-site attention, and allowing flexible and
part-time work schedules (USDHHS, 1999). Studies of supported
employment indicate that persons with SPMI can be successfully
competitively employed (Mueser et al., 2001).
Mental health research. A resource that has benefited many patients with
SPMI and that holds even greater promise for the future is the scientific
knowledge coming out of mental health research. Advances in screening,
assessment, and treatment, including the large array of psychotropic
medications and community-based care modalities now available, provide
many effective options for care.
Data show that for the diagnoses falling under the umbrella of SPMI,
treatment is much more effective than placebo and that treatment efficacy is
comparable to other types of general medical care, for example, surgery
(National Advisory Mental Health Council, 1993). Efficacy of treatment has
been demonstrated for less disabling mental illnesses as well, such as
anxiety disorders. Because of these advances, mental health providers now
have the basis for increasing scientifically sound decisions. Instead of or in
addition to expert opinion that has long prevailed as the criterion for decision
making, mental health treatment now has a developing body of clinical trials
and quasi-experimental studies that provide the evidence needed for best
care. If patients have access to this care, they may have the opportunity for
improved outcomes.
12
CHAPTER 1: BACKGROUND FACTORS IN SPMI
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19
2
Personal Factors: Psychosocial Impacts of
Serious and Persistent Mental Illness
Bonnie Breitmayer, Marsha Snyder, and Olimpia Paun
Many of the defining characteristics of serious and persistent mental illness
(SPMI) have direct implications for health care and self-care. Mental illness
may affect motivation and hinder self-confidence, including confidence in the
ability to care for oneself. Cognitive deficits may accompany and even
precede the development of psychosis. Emotional distress may be so great
that self-care is not possible.
Poor motivation, low self-efficacy, distress, and difficulties in learning and
retaining information may in turn affect the ability to attain and maintain
self-care. Because diabetes is in many ways a self-managed disease,
understanding these defining characteristics of SPMI and their
interrelationships is an important component of diabetes care. Before
examining these psychosocial impacts of SPMI, we will define and describe
the SPMIs themselves in more detail.
Overview of SPMI illnesses
In psychiatry, mental illnesses are classified in the Diagnostic and Statistical
Manual of Mental Disorders, now in its 4th edition (DSM-IV, American
Psychiatric Association, 1994). The manual uses a taxonomy based on
symptoms, and the codes assigned are all official codes in the International
Classification of Diseases system of the World Health Organization, which is
the worldwide system for diagnosis, classification, and statistical reporting of
diseases. The brief descriptions below are from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition—Primary Care Version (American
Psychiatric Association, 1995). The purpose of the primary care version is to
“provide a framework tailored to educating primary care providers about
mental disorders that is compatible with the standard approaches used in
specialty mental health care (i.e., DSM-IV)” but which is concise and userfriendly for application in primary care settings.
Schizophrenia. This common SPMI is a psychotic disorder typified by bizarre
behavior, disturbances in perception and ideation, and impaired memory
(American Psychiatric Association, 1997). There are five diagnostic codes
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CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
related to psychotic symptoms in the DSM-IV-PC, depending on the duration
and presentation. Schizophrenia is defined as:
• A disturbance that lasts for at least 6 months and includes at least 1
month of active-phase symptoms (e.g., delusions, hallucinations,
disorganized speech, grossly disorganized or catatonic behavior,
negative symptoms).
• There must be significant impairment in one or more major areas of
functioning (e.g., work, interpersonal relationships) for most of the
time since the onset of the disturbance, and the functioning must be
significantly lower than that prior to the onset of the disorder. (p. 132)
The negative symptoms of schizophrenia are the most difficult to treat and
most seriously impair functioning. They may include a flat affect, poverty of
speech, inability to initiate or participate in activities, and loss of interest or
pleasure. Physical inactivity may be an expression of these negative
symptoms. Onset is typically in the late teens to early 20s.
In 2002 62 percent of Thresholds members had schizophrenia or a related
psychotic disorder (personal communication, Thresholds Research
Department, February 5, 2003).
Bipolar illness. This affective or mood disorder occurs in two forms. Bipolar I
disorder includes a manic episode along with depressive episodes, while
bipolar II is less severe and includes a hypomanic episode along with
depressive episodes. Bipolar illness runs in families, and onset is typically in
the early 20s. The DSM-IV-PC defines the more severe bipolar I disorder as:
A disorder characterized by one or more manic episodes and most
typically one or more major depressive episodes. A manic episode is
defined as a distinct period of abnormally and persistently elevated,
expansive, or irritable mood that lasts for at least 1 week,
accompanied by some of the following symptoms: grandiosity,
decreased need for sleep, talkativeness, distractibility, increase in
goal-oriented activity, and excessive involvement in activities that
have a high potential for painful consequences. (p. 149)
In 2002 29 percent of Thresholds members had a mood disorder, including
bipolar or major depression (personal communication, Thresholds Research
Department, February 5, 2003).
Major Depression. This affective or mood disorder is the most common SPMI.
Major depression is distinguished from other disorders of depressed mood by
its duration and the extent of symptoms. Additionally, other mood disorders
and psychotic disorder must be ruled out. The DSM-IV-PC defines major
depression as:
A. At least five of the following symptoms have been present during
the same 2-week period, nearly every day, and represent a change
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CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
from previous functioning. At least one of the symptoms must be
either (1) depressed mood or (2) loss of interest or pleasure:
(1) Depressed mood (or alternatively can be irritable mood in
children and adolescents)
(2) Markedly diminished interest or pleasure in all, or almost all,
activities
(3) Significant weight loss or weight gain when not dieting
(4) Insomnia or hypersomnia
(5) Psychomotor agitation or retardation
(6) Fatigue or loss of energy
(7) Feelings of worthlessness or excessive or inappropriate guilt
(8) Diminished ability to think or concentrate
(9) Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan
for committing suicide
B. Symptoms are not better accounted for by a mood disorder due to
a general medical condition, a substance-induced mood disorder, or
bereavement (normal reaction to the death of a loved one).
C. Symptoms are not better accounted for by a psychotic disorder
(e.g., schizoaffective disorder).
Although major depression is the most common SPMI, less than 10% of
Thresholds members have this as their primary diagnosis (personal
communication, July 26, 2000, August 3, 2000, and October 2, 2000, M.
McCoy, Thresholds Annual Program Evaluation and Outcomes Report FY99).
Self-efficacy in SPMI: stress and coping
An important psychosocial variable that influences coping with a chronic
illness is self-efficacy. Self-efficacy refers to personal judgments regarding
one’s ability to successfully engage in behavior that will lead to a desired
outcome. Persistence and effort expended at a task are influenced by
confidence in the ability to achieve success. Avoidance behavior is likely to
result when an individual engages in activities in which the chances of
success are low (Bandura, 1977a, 1977b).
There is evidence to support the positive effect of self-efficacy in coping
responses to chronic conditions and in particular to diabetes (Anderson et al.,
2000; Bernal et al., 2000; Grey et al., 2000; Lo, 1999;Via & Salyer, 1999).
More specifically, self-efficacy has been found to predict self-care behaviors
for individuals with diabetes (Bernal et al., 2000; Chen, Yeh & Lin, 1998;
Hurley & Shea, 1992). In mainstream diabetes care, being able to perform a
range of self-care behaviors successfully is considered essential.
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CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
In diabetes care, attention has also been directed to the influence of selfefficacy in facilitating behavioral change. Psychosocial self-efficacy refers to
being able to successfully address psychosocial issues such as being able to
manage stress, obtain support, and deal with uncomfortable situations
(Anderson et al., 2000). Individuals who report greater levels of
psychosocial efficacy report a more positive outlook about their life and
diabetes (Anderson et al., 2000; Via & Salyer, 1999). In examining factors
related to compliance with recommended diabetes care, Lo (1999) suggested
that successful compliance is associated with family support, rapport with
health professionals, and the absence of chronic stress.
Despite the utility of self-efficacy in thinking about diabetes care, it is not
prominent in literature regarding SPMI. Persons with SPMI struggle with high
levels of stress and anxiety, inaccurate definitions of self, and issues of
control. Coping with these issues is a primary, everyday task that may
precede the development of self-efficacy.
Stress and coping are themselves intertwined with self-care and adherence
to recommended care. The relationship of stress and the ability to follow a
health regime is well supported (Lo, 1999; Cox & Gonder-Frederick, 1992).
The neural stress–diathesis model of schizophrenia proposed by Wuerker
(2000) integrates biological, psychological, and sociocultural factors and
explains the relationship between the amount of stress experienced and the
stress tolerance threshold. When stress becomes overwhelming, as occurs in
mental illness, self-care and adherence to care are not possible. Indeed,
overwhelming stress can precipitate exacerbation of the SPMI.
Perese (1997) identified that the amount of stress along with stress appraisal
and coping resources predicted return of the psychobiologic symptoms of
mental illness. As an example, auditory hallucinations, a common symptom
experienced by those who suffer from schizophrenia, can be extremely
anxiety provoking. Individuals with schizophrenia who experience auditory
hallucinations and cope with this stressor by attributing these internal events
to an external source feel less in control of their thoughts. They use worry or
rumination to attempt to find meaning or sort out internal and external
reality (Baker & Morrison, 1998). These ineffective coping strategies
increase stress without helping to resolve symptoms.
However, even individuals in early psychosis can cope with day-to-day
stressors if they perceive that they have social support, feel they have some
self-efficacy, and can flexibly use problem-focused coping strategies
(Macdonald et al., 1998). Persons with SPMI can identify indicators of their
illness and learn to use problem solving to determine what to do to cope
when the indicators occur (Hamera et al., 1992). When people are able to
learn to cope with their symptoms they are able to take responsibility for
themselves and even provide support for others (Sallett, 1999).
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CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
Using grounded theory, Williams and Collins (1999) identified that in
schizophrenia, the struggle for control is a central theme. Coping on several
fronts, individuals with schizophrenia must attempt to simultaneously
manage not only their stress and symptoms of the illness, but also their own
self-image, somehow moderating the ideal they may once have had versus
their actual, realized self-concept with its accompanying baggage of stigma
and symptoms. They also struggle with feelings of social incompetence and
isolation while paradoxically experiencing the pressure associated with the
relationship expectations of others.
Self-confidence is thought to be the core of self-esteem, with self-efficacy
being this confidence (Juhasz, 1989). Individuals whose self-concept is
directly related to the label of mental illness report feelings of low selfesteem, hopelessness, and low levels of self-efficacy (McCay & Seeman,
1998; Perese, 1997). Feelings of helplessness and hopelessness can
generate from both the experience of stigma and ineffective attempts to
control symptoms. However, work by Lysaker et al. (2001) suggests an
interesting contradiction: higher levels of neurocognitive impairment and an
avoidant coping style can be linked with greater hope, self-efficacy, and wellbeing because they shield the individual from subjective distress. Lysaker et
al. (2001) suggest on the basis of these findings that rehabilitative strategies
to improve neurocognition and decrease avoidant coping may inadvertently
have a negative effect.
Thus in SPMI, perceptions experienced and the support available will affect
the individual’s response to the psychobiologic symptoms and stigma they
experience. These in turn will influence the levels of stress and control.
Neurocognitive deficits and avoidant behavior seem to provide a buffer to
subjective distress. However, these can also provide a challenge to clinicians
who are promoting self-management behaviors, not only for the SPMI, but
also for diabetes care. Cognition and the impact of neurocognitive deficits will
be discussed in more detail below.
Cognitive function in SPMI
Cognitive function has been defined by Neisser (1967) as all processes by
which sensory input is transformed, reduced, elaborated, stored, recovered and
used. It includes such functions as attention, perception, sensation, problemsolving ability, visual-spatial ability, and concept formation. Attention to
cognitive functioning is highly relevant because a broad range of cognitive
deficits characterizes various mental illnesses. These deficits are related to
functional outcomes in the community and so are likely to influence the ability
to learn and implement a diabetic regimen.
Because cognitive deficits are most common in schizophrenia, the most
prevalent SPMI among Thresholds members, this discussion will focus on the
literature pertaining to schizophrenia. Potentially the use of atypical
antipsychotic drugs may be able to improve cognitive function in schizophrenia,
24
CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
but which impairments, which drugs, and to what extent improvements can be
expected remain to be studied (Meltzer, Park, & Kessler, 1999). In the
meantime, cognitive impairments must be considered when planning care.
Patients with schizophrenia present with impaired working memory, negative
symptoms and psychomotor poverty syndrome (McGrath, Chapple, & Wright,
2001). Across all tasks, patients with schizophrenia or schizoaffective disorder
perform poorly in relation to normal controls on memory (global verbal,
nonverbal and selective); motor dexterity; attention; general intelligence;
spatial ability; executive function (volition, planning, purposive action and selfmonitoring of behavior); and language and tactile transfer (Heinrichs &
Zakzanis, 1998). In fact, Green and Nuechterlein (1999) state, "practitioners
now believe that schizophrenia can legitimately be viewed, in essence, as a
disorder of neurocognition" (p. 309).
Among cognitive tasks that have been studied, the largest effect sizes
differentiating normal controls from subjects with schizophrenia were those for
global verbal memory, performance IQ, continuous performance (a measure of
attention), and verbal fluency (the ability to generate search strategies to
retrieve information from memory) (Heinrichs & Zakzanis, 1998).
Some authors believe that the absence of a single deficit or profile of deficits
indicates that poor performance on apparently discrete tests is due to a single,
generalized deficit. Others (e.g., Heinrichs, 1993) believe that there are
subgroups of patients with distinct profiles of neurocognitive performance.
Some researchers even believe that there may be subgroups of patients who
meet current diagnostic criteria for schizophrenia but are nearly
neurocognitively normal (Palmer et al., 1997). However, to date there is no
clear evidence of a single neurocognitive deficit or even a specific profile of
deficits characteristic of schizophrenia.
Although cognitive impairments in schizophrenia are heterogeneous, varying
from person to person, they do appear to be consistent over time. Studies have
shown cognitive impairments to remain stable across months and years,
regardless of baseline neurocognitive status, changes in clinical state, and/or
the presence or absence of symptoms (Heaton et al, 2001; McGrath et al.,
1997; Rund & Borg, 1999).
The presence of neurocognitive deficits in schizophrenic patients has been
recognized for decades, but investigation of their relationship to functional
outcome is recent. Only when it became apparent that amelioration of positive
symptoms had little effect on functional outcome did investigators begin
attempts to identify those cognitive deficits that may restrict patients' ability to
retain, relearn, or acquire new skills that are required for everyday functioning
and thus may be candidates for therapeutic intervention.
One recent review found that neurocognition predicted 40 to 50 percent of the
variance in measures of social and adaptive functioning (Green et al., 2000).
They reviewed multiple studies using laboratory tests of memory (immediate,
25
CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
or "working" memory as well as secondary memory, the ability to acquire and
store information over several minutes or longer), vigilance level, verbal
fluency and executive function. They found that psychosocial skill acquisition,
which refers to the learning of basic life skills such as medication management
and conversational skills, was predicted by tests of secondary and immediate
verbal memory in four or more studies and by executive function and vigilance
level in two to three. Community functioning/daily living, which included such
outcomes as occupational functioning, social attainment, and "degree of
independent living”—outcomes that might encompass skills needed for diabetes
self-management—was robustly (4 or more studies) predicted by executive
function, secondary verbal memory, and verbal fluency.
Green and colleagues (2000) also reported results of four meta-analyses, one
for each of four domains of neurocognition: secondary verbal memory,
immediate verbal memory, executive function, and vigilance level. The
dependent variable was a composite of all outcome domains. The estimated
pooled rs ranged from .20 (vigilance) to .40 (immediate verbal memory). A
pooled r of .20 would be considered small to medium and the r of .40 would be
considered medium to large. The authors concluded that their meta-analyses
convincingly demonstrate that each of the four neurocognitive constructs has
significant relationships with functional outcome.
There may be differences in the cognitive deficits of schizophrenia compared to
those found in other mental illnesses (Mitrushina et al., 1996). The
Neurobehavioral Cognitive Status Examination was administered to 103
consecutively admitted inpatients with SPMI as part of their diagnostic workup. The lowest performance for all diagnoses was in memory, with
schizophrenia and schizoaffective patients having the most severe deficits.
Patients with major depression, mania, or psychosis also had memory deficit
but scored significantly higher. Patients with schizophrenia or schizoaffective
disorder had the lowest ability to spontaneously recall information and were
helped more by recognition than category cues, indicating difficulties with
encoding and processing information. They also had impairments in abstract
reasoning (Mitrushina et al., 1996).
The implications of these studies are twofold:
1. In general, neither positive nor negative symptoms may be particularly
predictive of the ability to carry out activities of daily living such as
diabetes self-care. This is an important corrective to the emphasis in
most clinical settings on the monitoring and control of symptoms rather
than assessing and working with cognitive deficits in order to improve
functional outcomes.
2. In planning diabetes care for persons with SPMI, the presence and
extent of cognitive deficits must be assessed, taken into account in
planning interventions, and considered in determining appropriate
follow-up. Memory and executive function impairments can substantially
hinder the ability of persons with SPMI to carry out diabetes self-care.
26
CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
Insight in SPMI
A difficulty many individuals with SPMI experience is that they are unable to
acknowledge their illness and as a result are noncompliant with treatment.
Insight involves agreement by the patient with the clinician’s viewpoint
regarding their presenting diagnosis and recommended treatment, whereas
awareness is primarily an acknowledgement from the patient’s perspective
that they are ill and that the illness has contributed to unemployment,
hospitalizations, and differences between self and others in appearance and
functioning (Amador et al., 1994; Hayashi, 1999).
Poor insight is most prevalent in schizophrenia but is also found in
schizoaffective and major depressive disorders (Amador et al., 1994). In one
study (Pini et al., 2002), insight was poorer in patients with schizophrenia or
bipolar depression than it was in patients with a schizoaffective disorder or
major depression with psychotic features. Poor insight includes severe selfawareness deficits, such as awareness of having a mental disorder,
understanding the consequences of the disorder, and recognizing such
events as hallucinations, delusions, thought disorders, and having a flat
affect as symptoms of the disorder (Amador et al., 1994). Having poor
insight is associated with poorer functioning psychosocially (Amador et al.,
1994), so that it may impact such outcomes as occupational functioning, social
attainment, and self-management ability.
Insight or awareness of illness can be explained from both motivational and
deficit perspectives. From a motivational perspective, poor insight is an
attempt by the individual to preserve self-esteem, whereas from a deficit
perspective, poor insight is the result of cognitive deficits (Mohamed et al.,
1999). In a study of schizophrenia, poor insight and misattribution of
negative symptoms were associated with executive functioning deficits,
providing further support for the deficit position (Mohamed, 1999).
Hayashi et al. (1999) have suggested that both awareness and insight play a
role in patient willingness to accept treatment but that these are separate
processes. With respect to insight, a lack of insight is significantly correlated
with grandiosity (Hayashi et al., 1999), a greater severity of symptoms
(Williams & Collins, 2002), and less use of mental health services (Haro et
al., 2001). Patients with less insight have lower levels of depression and
higher levels of self-deception (Moore et al., 1999). Good insight, on the
other hand, is associated with higher levels of depression (Hayashi et al.,
1999) perhaps because the severity of the illness and its implications have
been acknowledged.
With respect to awareness, frontal lobe dysfunction contributes to symptom
misattribution rather than poor symptom awareness in persons with
schizophrenia (Smith et al., 2000). Self-esteem seems to aid acceptance of
treatment but also enhances denial that treatment is needed. In an
examination of factors related to awareness, life satisfaction rather than self27
CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
esteem emerged as the single significant factor (Hayashi, 1999).
Psychosocial interventions that improve life satisfaction and help support the
development of a realistic self-esteem may promote increased awareness.
In planning diabetes care for individuals with SPMI, it is important to consider
that difficulties with insight may not only hinder treatment of the SPMI, but
they may also affect the extent to which the diabetes and its implications are
understood. Successful diabetes care is enhanced when the patient can
develop a knowledgeable awareness of the diabetes as it affects him or her.
Affective response to SPMI
Emotions influence the individual’s ability to solve problems in everyday
situations. Emotions are aroused by (1) the problem itself, (2) appraisal of
the problem and expectation regarding beliefs in ability to solve the problem,
and (3) usual approaches to problem solving. Emotions generated prior to
and during problem solving can inhibit or facilitate ability to engage
successfully in the problem solving process. Feelings of fear,
disappointment, or failure will inhibit performance at problem solving, as will
high levels of arousal. High levels of arousal for an extended period of time
will eventually result in exhaustion, fatigue, and depressive affect that will
decrease motivation and the ability to engage in problem solving. Emotions
also influence how individuals will label a problem, recognize a problem,
choose a solution, and evaluate its outcome effectiveness
(D’Zurilla & Nezu, 1999).
During acute psychosis and the aftermath of a psychotic episode, depression
can be a major feature. Patients suffer with hopelessness, helplessness, and
a fragile sense of well being (Lysaker et al., 2001). These depressive
syndromes persist and are prevalent in the years following the acute episode.
Menzies (2000) in a review of the literature found rates of depression in
schizophrenia to range between 30% and 60% and cite several studies that
indicate that patients treated with neuroleptics are more likely to exhibit
depressive disorders. However, O’Connor (1994) asserts that psychotropic
medication moderates the amount of stress experienced by schizophrenic
patients, increasing their stress threshold, particularly to internal stressors.
Depression and anxiety have consistently shown a strong association with
lowered satisfaction and subjective quality of life (Huppert et al., 2001).
In addition to depression, loss of “affectivity” is a prominent disturbance in
schizophrenia (Taylor & Liberzon, 1999). Vegetative symptoms such as
anhedonia, social withdrawal, insomnia, anergia, or preoccupations or
ruminations over past failures are symptoms commonly reported as negative
symptomatology. Of course, these are associated with major depression and
the depression of bipolar illness as well. Negative syndrome, or type II
schizophrenia, is characterized by deficits in cognitive, affective and social
functions (Kay, Fiszbein,& Opler, 1987).
28
CHAPTER 2: PSYCHOSOCIAL IMPACTS OF SPMI
Some negative symptoms may be related to information processing deficits.
Davis and Stewart (2001) suggest that people with paranoid schizophrenia
demonstrate information processing bias in response to negative verbal
communication, and they interpret the communication as void of any affect.
However, information processing may be intact in other SPMI diagnoses.
With respect to flat affect, for example, there may be a reduction in
emotional display, but not experienced emotion. Studies of patients with flat
affect show that they experience the same intensity of emotion to stimuli as
patients without schizophrenia (Sison et al., 1996). Also, Silver and Shlomo
(2002) reported that although chronic schizophrenics may score high on tests
for anhedonia, this outward expression of negative symptoms does not relate
to their internal emotional experience.
Similar to persons who suffer from chronic conditions, persons with SPMI,
particularly schizophrenia, experience uncertainty both from the nature of
symptoms and from the unpredictability of the disease. For some the
uncertainty associated with schizophrenia provides opportunity for hope,
while for others it promotes a sense of dread (Baier, 1995). Hoffmann et al.
(2000) point out that the outcomes of having schizophrenia depend not only
on the disorder, but also how the person interacts with the disorder.
Hopelessness develops when the person perceives that he or she cannot
control the disorder or its consequences, surrendering to stigma, negative
self-concept, and an external locus of control. Instead of actively coping, the
individual gives up. Unless this can be reversed, successful rehabilitation
becomes far more difficult.
Affective response to SPMI can be powerful and overwhelming. Providers
must be sensitive to the suffering endured and remember that negative
symptoms do not necessarily indicate the absence of emotions. Reaching
across affective responses to convey support and confidence may be critical
for maintaining hope. Active coping is a requisite not only for living with an
SPMI, but also for living with diabetes.
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34
3
Diabetes Management in the Context of SPMI:
Clinical Practice Recommendations
Diabetes management in the context of serious and persistent mental illness
(SPMI) presents a number of formidable challenges. The features and
consequences of SPMI impact self-care generally, and diabetes self-care in
particular (Table 1). Overlapping these factors are factors related to the
diabetes itself. Even without the complications of SPMI, anxiety is a common
symptom of hypoglycemia, and stress contributes to hyperglycemia. Thus
mental state and diabetes can exacerbate each other and negatively impact
self-care. Yet because caring for diabetes involves many aspects of everyday
living, effective self-care is essential. In the context of SPMI, it therefore
appears critical that primary care providers monitor and take into account
mental state and its effect on self-care.
The purpose of these recommendations is to provide evidence-based practice
guidelines for diabetes care in patients with a serious mental illness. The
guidelines are primarily intended for use in screening, diagnosing, and
managing type 2 diabetes without complications, whether the diabetes
preceded or followed development of the mental illness. They are not
intended to duplicate existing guidelines for diabetes care in outpatients,
such as guidelines for nutrition, exercise, or hypertension or lipid control,
since excellent resources already exist. Rather, the recommendations are
intended to provide guidance about what may be different about diabetes
care when the client also has a serious mental illness.
A positive attitude is associated with compliance with diabetes care, just as it
is in mental health care. Like people with SPMI, people who are living with
diabetes want support from health care professionals, yet their perspectives
on their illness and its place in their lives may differ from those of their
providers. Balancing self-care of the diabetes with the rest of their lives may
be more important to them than maintaining strict glycemic control. These
differing perspectives must be kept in mind when providing care.
The interventions presented here are organized according to the intervention
variables in the conceptual model guiding this work (Cox, 1982; see p. 6).
These are: affective support, health information, decisional control, and
professional-technical competence in providing diabetes care. While these
variables surely overlap, separating them is useful for the purposes of
identifying practice recommendations.
35
CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
Each recommendation includes a brief rationale with references to the
literature reviews in this report (Chapters 1 and 2) and other key evidence.
The level of evidence for each recommendation is also indicated. As
explained in the Introduction (p. viii), the levels are:
Level A:
Level B:
Level C:
Good research evidence with some expert opinion.
Fair research evidence with substantial expert opinion.
Based on expert opinion with minimal research evidence.
The recommendations for professional-technical competence in providing
diabetes care are based on the practice recommendations of the American
Diabetes Association published annually (ADA, 2002a). They provide
guidance for how the ADA recommendations can be implemented in the
context of SPMI.
In 2002 the ADA began grading recommendations, with the highest level (A)
representing evidence from well-conducted randomized controlled trials and
the lowest level (E) representing expert opinion (a 5-level system rather than
the 3 levels used here). For example, recommendations for blood pressure
measurement and control, lipid management, and aspirin therapy are based
on A level evidence, while the need for immunizations is based on C level
evidence. See the ADA recommendations for levels of evidence for other
specific components of care (ADA, 2002a).
Throughout the following recommendations, we refer the reader to the
appendices accompanying this report. These provide assessment tools, a flow
sheet, and checklists for diabetes care in the context of SPMI.
Affective support
Recommendation 1: Provide integrated care. Where possible, integrate
physical with mental health care so that primary and mental health
providers, caseworkers, and clients can directly work together for improved
outcomes. (Level of evidence: C.)
Rationale. Persons with SPMI delay seeking health care (Cradock-O’Leary et
al., 2002). They experience barriers to primary health care that go beyond
whether or not they have insurance. Cognitive, behavioral, and social factors
that characterize mental illness as well as barriers to access make patients
unwilling or unable to engage in offered treatment or receive routine
preventive services (Berren et al., 1999; Druss et al., 2002; van de Hoef et
al., 2001). Mental health programs and clinics provide the only entrée into
health care for many. However, staff is trained and focus on mental health
service needs of the mentally ill, not their physical health care.
One way to address this problem is to have the mental health care provider
assume oversight of primary care as well and coordinate primary and
preventive services (Goldman, 2002). Psychiatrists assuming this “principal
36
CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
Table 1. Requirements for diabetes care in relation to SPMI
Requirements for
Diabetes Care
Self-care ability
Self-care tasks
Obtain regular care
Possible Barriers Related To
Features and Consequences of SPMI
Impaired executive function
• Difficulties in making independent
decisions, planning, or problem solving
Negative symptoms a
Positive symptoms b
Depression
Stress and anxiety
Stigma and engulfment
Inconsistent access to primary care
Low income
Learn about diabetes
Self monitor blood glucose level
Cognitive deficits:
• Low attention and concentration
• Motor dexterity impairment
• Spatial impairment
• Concrete thinking
• Impaired executive function (as above)
• Respond poorly in groups
Maintain weight control
Consume recommended diet
Obtain regular exercise
Stop smoking
Medications increase weight
Low income
Live in group and hotel settings
Smoking relieves stress and increases
pleasure
Take prescribed medications
Cannot afford medication co-pays
Cognitive deficits (as above)
Inconsistent access to primary care
a
Positive symptoms are an excess in or distortions of normal functions (hallucinations,
delusions, thought disorders, disorganized speech, disorganized or catatonic behavior).
b
Negative symptoms are a lessening or loss of normal functions such as affective blunting,
reduced fluency of thought and speech, withdrawal and inability to initiate and carry through
goal-directed activity; and inability to experience pleasure.
SPMI = Serious and persistent mental illness.
37
CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
care” role would manage common disorders “in the context of the special
needs of the underlying [psychiatric] disease,” coordinate referrals to
specialists for other disorders, provide patient education and counseling, and
see that clients receive preventive care (Goldman, 2002). However, the
feasibility and effectiveness of this service delivery model has not been
studied.
Alternatively, an integrated service delivery model was studied in a Veterans
Affairs mental health clinic in which the intervention group received primary
care and case management in a nurse-managed clinic from nurse
practitioners emphasizing preventive care, patient education, and
collaboration with mental health providers. The intervention group had more
visits, received more preventive health services, and had better health than
the comparison group receiving usual care without increasing costs (Druss et
al., 2001).
Recommendation 2: Build a therapeutic alliance. Where possible, assign
each client to one primary care provider in order to support trust building, a
therapeutic alliance, and continuity of care. (Level of evidence: C.)
Rationale. It is important that the health care provider establishes and
maintains a supportive, therapeutic alliance with the person who suffers from
an SPMI. This alliance forms the foundation on which treatment can be
conducted and through which the patient is able to develop trust. To ensure
continuity and development of an alliance, the same practitioner should work
with the patient (Bachrach, 2000). Creating an atmosphere in which the
patient feels free to discuss feelings or negative experiences with treatment
recommendations will facilitate adherence to the treatment plan (American
Psychiatric Association, 2002; Bachrach, 2000).
Patients with schizophrenia experience a great deal of uncertainty related to
the neurocognitive deficits characteristic of the disorder (Baier, 1995).
Neurocognitive deficits impair ability to accurately express emotion as well as
interpret affect expressed by others (Archer et al., 1992; Hoschel & Irle,
2001; Streit et al., 2001). As a result, many persons with schizophrenia
identify interpersonal relationships as causing stress in their lives (MacDonald
et al., 1998). Because persons with schizophrenia experience greater stress
and uncertainty related to interpersonal relationships, managing the
environment to provide increased support and structure will help to manage
stress. One way to do this is through consistent practitioner relationships
(Macdonald et al., 1998; Stuart & Lauria, 2001, Weiden & Havens, 1994).
In diabetes care, lowered stress and good relationships with health
professionals are factors associated with patient success in complying with
health recommendations (Lo, 1999), just as they are in mental health
treatment. A therapeutic alliance with one primary care provider is especially
important for persons with SPMI who also must learn to live with diabetes,
which requires follow-up, lifestyle changes, adherence to care, and
consistency in management.
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
Health information
Recommendation 3: Provide health information appropriately. Provide
individualized diabetes education covering all ADA-identified content areas
(Level of evidence: B) using psychoeducational and skills training principles
for mental health rehabilitation (Level of evidence: C). These include use of
an education protocol followed by periodic “booster sessions” to provide
continuous reinforcement so that knowledge gains are not lost (Level of
evidence: C).
Rationale. The national standards for diabetes self-management education
address 15 content areas (Funnell & Haas, 1995) (see Appendix A). The
standards specify that methods and materials should be planned with the
target population in mind, taking into account type of diabetes, age, and
individual learning needs, so that not all areas may need to be taught to each
client (Funnell & Haas, 1995).
Priority areas for diabetes self-management include diet and exercise, selfmonitoring of blood glucose, medication adherence, psychosocial adjustment,
and avoidance of adverse outcomes (ADA, 2000; Funnell & Haas, 1995). For
persons with SPMI, content should also address the special issues involved
with living with both an SPMI and diabetes (Appendix A).
Patient education is associated with improved outcomes, with structured
sessions including planned teaching having the best outcomes (Theis &
Johnson, 1995). Educational and psychosocial interventions are effective in
diabetes care, particularly for glucose control and knowledge, with diet
instruction having the strongest effects (Padgett et al., 1988).
In mental health care, therapies combining support, education, and
behavioral and cognitive skills training are recommended for treatment of
schizophrenia (Heinssen et al., 2000; Lehman & Steinwachs, 1998).
Knowledge and compliance are improved by patient education, with
compliance especially improved when behavioral components are included
(Merinder, 2000).
Interactive educational interventions providing support, information, and
management strategies for patients with SPMI and their families are useful,
brief, and inexpensive (Pekkala & Merinder, 2001). However, the cognitive
deficits of SPMI must be taken into account in planning appropriate patient
education. Although there is some evidence that the novel (atypical)
antipsychotics may improve cognitive function more than conventional
antipsychotics (Keefe et al., 1999), effects are modest (Harvey & Keefe,
2001) and there are still residual cognitive impairments remaining (Keefe et
al., 1999). Cognitive rehabilitation using repetitive laboratory-based
exercises to train memory, attention, and processing has not been shown to
be effective (Hayes & McGrath, 2001; Suslow et al., 2001) and appears to
have little impact on everyday functioning (Mueser et al., 2001; Penn &
Mueser, 1996; Suslow et al., 2001).
39
CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
Thus finding ways to compensate for or work around deficits is indicated,
since remediation is unlikely. Rehabilitation, psychoeducation, and skills
training principles for mental health rehabilitation that can be adapted for
patient education in diabetes care are outlined in Appendix B.
In diabetes education, interventions delivered to groups are as effective as
individualized instruction in improving glycemic control and delivering key
content (Rickheim et al., 2002), and certainly group education is more cost
effective. However, group education may have limitations given the cognitive
deficits of SPMI. Treatment may be more effective when administered in an
individual or family context (Mojtabai et al., 1998) because difficulties with
attention, memory, and the ability to apply learned skills are so pervasive in
SPMI (Fine, 1994).
With respect to skills training, learning decreases over time and may not
generalize to everyday functioning (Dilk & Bond, 1996), so that overlearning,
reinforcement, and individualized coaching are needed to apply and maintain
learning. An “errorless learning” approach may be more effective than group
instruction (Green, 1998). This approach begins with simple tasks with a high
likelihood of success and then introduces task demands so gradually that a
high level of success is maintained. Such an approach must necessarily be
tailored to each client and assumes an ongoing patient-provider relationship
(Bachrach, 2000).
Although group-focused strategies have been used in the management of
schizophrenic disorders, caution is presented in the literature (American
Psychiatric Association, 2002; Weiden & Havens, 1994; Green, 1998;
Bellack, Gold, & Buchanan, 1999). When group teaching is planned, careful
patient assessment is imperative in order to prevent inadvertent stress and
worsening of symptoms. Excessive affective expression, confrontation, and
probing within a group setting can be overly stimulating and stress inducing
to the schizophrenic patient. Management of these patients in a group
setting therefore requires a skilled leader who can set limits and structure
the group environment to accomplish the desired learning (American
Psychiatric Association, 2002).
Decisional control
Recommendation 4: Optimize client self-management. Develop and
support diabetes self-management based on individualized client assessment
in collaboration with the mental health care team (see Flow Sheet, Appendix
G). After basic competencies in diabetes care have been accomplished
(Recommendation 3 and Appendix A), consider use of motivational
interviewing and solution-focused therapy methods now being developed for
mental health care to further support decisional control and help develop
effective problem solving (Appendix C) (Level of evidence: C).
Rationale. Optimizing self-management is important in both diabetes and
mental health care. According to the Joint Commission on Accreditation of
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
Healthcare Organizations and the Center for Mental Health Services (1995),
the goal of psychiatric rehabilitation is to “maximize and maintain an
individual’s optimal level of functioning, self-care, independence, and quality
of life, and to minimize other symptoms and impairments” (p. 3). All such
services should be provided with respect for the client’s “dignity, autonomy,
positive self-regard, and civil rights” (p. 6).
The ADA’s 2002 clinical practice recommendations state that the plan for
care should represent “an individualized therapeutic alliance among the
patient and family, the physician, and other members of the health care
team,” with the emphasis on patient self-management. The plan should be
made and agreed on collaboratively, involving the patient in problem solving
and taking into consideration the patient’s age and life situation (ADA,
2002d). Self-management training is effective in type 2 diabetes, and
interventions involving patient collaboration are more effective than didactic
teaching for improving outcomes of glycemic control, weight, and lipid
profiles (Norris et al., 2001).
In the context of SPMI, depression or negative symptoms such as anergia
(inability to initiate or participate in activities) or anhedonia (loss of interest
or pleasure) can work against the development of the motivation and selfefficacy needed for successful diabetes self-management (see Table; Chapter
2). Stress and energy level also may vary on a daily or weekly basis,
depending on the SPMI and its severity. As a result, clients with SPMI vary in
their self-management ability, with self-management ability often changing
depending on the status of the mental illness and what stressors are being
experienced. Because of these variations, individual assessment is necessary
and must be ongoing.
There are many possible indicators of self-management ability that may be of
assistance in determining the amount of support that is needed to
accomplish diabetes care. In the Thresholds system, these indicators include
medication and money management arrangements and the degree of
independent living the member is able to attain. Sources of information
include the client, the Thresholds Emergency Face Sheet, the client’s
caseworker, and family members. Additionally, as part of ongoing evaluation,
caseworkers rate client progress using the Multnomah Community Ability
Scale twice a year. This is a general functional assessment scale that is
sensitive to changes over time, and results if available may be helpful in
gauging self-management ability.
The issues surrounding patient participation in decision-making by the
mentally ill are just beginning to be studied (Eisen et al., 2000). Motivational
interviewing is a client-centered method that elicits from clients their own
motivation to change and a personal decision and plan for change. The
approach seeks to develop a discrepancy between current behavior and
important personal goals and thus trigger intrinsic motivation for change
(Miller, 1996; Shinitzky & Kub, 2001). Solution-focused therapy focuses on
the strengths and positive attributes the person brings to treatment, the
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
construction of future positive goals, and the specific actions needed to reach
the goals (Hagen & Mitchell, 2001). Both methods seek to engage patient
collaboration in treatment.
Client-centered methods such as motivational interviewing have been used to
improve compliance in diabetes care (Anderson et al., 1995; Doherty et al.,
2000; Pill et al., 1998; Smith et al., 1997), with psychiatric treatment (Kemp
et al., 1998) and for treatment of addiction in psychiatric patients (Swanson
et al., 1999). However, although the stages of change utilized in motivational
interviewing have been studied in mixed groups of psychiatric patients, it has
not yet been established whether their use is appropriate in the treatment of
schizophrenia (Addington et al., 1999; Bellack & DiClemente, 1999). This is
because the model addresses changes in intentional behavior, but inability to
sustain intentional behavior is one of the hallmarks of schizophrenia (see
Chapter 2). Indeed, the cognitive deficits of schizophrenia interfere with a
number of functions required for successful behavioral self-management, and
these may be compounded by the pathophysiology of the diabetes (Cox &
Gonder-Frederick, 1992).
Professional-technical competence in diabetes care
Recommendation 5: Screen for diabetes. Screen patients for diabetes
with fasting (preferred) or casual plasma glucose testing prior to starting
antipsychotic medications. Screen every 2-3 months during the first year of
use and confirm positive results with diagnostic testing (see
Recommendation 6, below). (Level of evidence: C). If diabetes or prediabetes (defined as impaired fasting glucose or impaired glucose tolerance)
develops after starting antipsychotics, consider medication-related
hyperglycemia as a possible cause. (Level of evidence: B). Begin treatment
of the diabetes or pre-diabetes and consider changing to another
antipsychotic if this is feasible within the treatment program. If the patient
attains normoglycemia after changing the antipsychotic, it may be possible to
decrease or discontinue diabetic medications as well.
Consider ongoing use of antipsychotic medications as a risk factor for
developing diabetes. Assess all clients for risk factors for diabetes, including
use of antipsychotic medications (Appendix D). Screen at-risk clients
annually with fasting (preferred) or casual plasma glucose testing. (Level of
evidence: C.) Screen clients with known impaired fasting glucose or known
impaired glucose tolerance annually and treat for pre-diabetes (see
Recommendation 7, below).
Rationale. The prevalence of obesity and lack of physical activity in patients
with SPMI (Allison, 1999; Brown et al., 1999; Davidson et al., 2001;
Kendrick, 1996; Martinsen et al., 1989) places them at higher risk for
developing diabetes (ADA, 2002c,d; Appendix D). Because of their SPMI,
patients may not be aware of the symptoms of diabetes. Medical comorbidities often go undiagnosed and untreated in persons with SPMI (Dixon
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
et al., 1999; Druss et al., 2002; Felker et al., 1996), warranting annual
screening for diabetes.
Recommendations for screening are based on ADA guidelines (ADA, 2003;
Engelgau et al., 2000) and on research associating diabetes with
antipsychotics (Buse, 2002). Some antipsychotics appear to precipitate
diabetes or accelerate its onset in susceptible patients, including clozapine
(Lund et al., 2001), chlorpromazine, olanzapine, quetiapine (Haupt &
Newcomer, 2001; Sernyak et al., 2002), and haloperidol (Wirshing et al.,
2002). The mechanisms are not well understood, but they may include
alterations in glycemic control and/or may be an indirect outcome of the
weight gain associated with use of these medications (Hagg et al., 1998;
Haupt & Newcomer, 2001; Henderson et al., 2000; McKee et al., 1986;
Mukherjee, 1996). Certain medications produce hyperglycemia that may
resolve when the medications are discontinued. Glucocorticoids and nicotinic
acid are examples (ADA, 2002c); this may also be true with certain
antipsychotics (Reinstein et al., 1999).
Recommendation 6: Diagnose diabetes. The criteria for diagnosing
diabetes are listed in Appendix E. If casual (nonfasting) plasma glucose is ≥
200 and the patient has symptoms (polyuria, polydipsia, unexplained weight
loss), diagnose diabetes. If fasting plasma glucose is ≥ 126 mg/dl, confirm
the result on another day with a second fasting plasma glucose test. If the
result is ≥ 126 mg/dl, diagnose diabetes. If fasting plasma glucose is < 126
mg/dl but diabetes is still suspected, obtain the HbA1C value. If the value is
6-7, diagnose pre-diabetes and begin lifestyle interventions (see
Recommendation 7, below.) If the value is >7, the patient most likely has
diabetes and should begin treatment (Level of evidence: A). To facilitate
timely diagnosis when diabetes is suspected, the HbA1C value can be drawn
at the same time as the initial fasting plasma glucose.
Ask about symptoms of diabetes routinely during health care visits,
whenever reviewing systems (see Appendix F), and perform diagnostic
testing when symptoms are present.
Rationale. Recommendations for diagnosing diabetes and identifying prediabetes are based on ADA guidelines (ADA, 2002d; Engelgau et al., 2000)
and on studies investigating the sensitivity of the HbA1C test (Little et al.,
1988, 1994), including a meta-analysis (Peters et al., 1996). A HbA1C cut
point of 7% has a sensitivity of 99.6% in subjects with diabetes (Peters et
al., 1996). The HbA1C test is more acceptable and convenient than the oral
glucose tolerance test that is considered the “gold standard” (American
Diabetes Association, 2003), and the decision to treat rests on HbA1C results
rather than results from the oral glucose tolerance test in any event (Peters
et al., 1996).
Recommendation 7: Treat pre-diabetes. In patients with impaired fasting
glucose or impaired glucose tolerance (pre-diabetes), begin lifestyle
interventions related to diet and exercise (ADA, 2002b,c). Assess
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
cardiovascular risk prior to beginning an exercise program (ADA, 2002b; see
tool, Appendix G). If lifestyle interventions are ineffective after a 3- to 6month trial, consider adding metformin 850 mg twice a day if there are no
contraindications to its use such as liver or kidney disease or medication
interactions. (Level of evidence: A.)
Rationale. In patients with elevated fasting or impaired glucose tolerance,
lifestyle interventions including a healthy, low-calorie diet and moderate
intensity physical activity of at least 150 minutes per week have been shown
to reduce the incidence of diabetes by 58% (Knowler et al., 2002). These
findings corroborate previous work showing that diet and exercise can
prevent diabetes (Pan et al, 1997; Tuomilehto et al., 2001). Metformin, 850
mg twice a day, is less effective than lifestyle intervention but has been
shown to reduce the incidence of diabetes by 31% (Knowler et al., 2002).
The lifestyle intervention necessary to obtain these results is intensive. It
requires physical activity such as brisk walking almost every day and
adherence to a low calorie, low-fat diet. In the Diabetes Prevention Program,
lifestyle interventions were supported by a 16-week curriculum provided to
the participants. The curriculum can be obtained at
http://www.bsc.gwu.edu/dpp/manuals.htmlvdoc.
Because of the SPMI, lifestyle interventions may be more difficult to attain
and maintain than they are in the general population. Although research is
needed to ascertain their relative impact, cost factors, lack of support,
cognitive deficits, stress, and the course of the SPMI may be barriers to
consistent implementation. Therefore, the addition of metformin may be a
way to help prevent diabetes while continuing to implement lifestyle changes.
Recommendation 8: Provide comprehensive diabetes care. Implement
ADA standards of medical care (ADA, 2002d) and recommendations for
nutrition, exercise, and self-monitoring of blood glucose (ADA, 2002b,c, e),
taking into account self-management ability, cognitive deficits, status of the
SPMI, and available environmental supports. These should include an initial
comprehensive history and physical exam (Appendix F), regular follow-up,
patient education, and specialty referrals (Appendix G). In appropriate
patients, self-monitoring of blood glucose can be facilitated by use of a
simple log (Appendix G), and use of a food and activity log may assist in
improving nutrition (Appendix G). (Level of evidence: A-C.)
Rationale. The ADA Clinical Practice Recommendations address diagnostic
testing and therapeutic interventions that are known to improve health
outcomes in patients with diabetes. The recommendations address
classification, screening, and diagnosis; the initial evaluation and plan of
care; nutrition, exercise, and self-monitoring of blood glucose; and
prevention and management of diabetes complications related to
cardiovascular disease (hypertension, dyslipidemia, smoking). Screening and
management of nephropathy, retinopathy, neuropathy and foot care, and
preventive care are also covered. Levels of evidence vary from randomized
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
controlled trials (e.g., smoking cessation) to expert opinion (e.g., measure
blood pressure at every visit) (ADA, 2002d). See ADA recommendations for
evidence levels for other specific components of care (ADA, 2002a-e; 2003).
The cognitive and motivational deficits common in SPMI will influence the
client’s ability to learn diabetes self-management and to follow through with
recommended care and referrals (Chapter 2). Therefore, assessing for these
deficits must be included not only in the initial work-up but also as part of
ongoing follow-up. Unfortunately, this review was unable to identify a
validated, reliable tool for measuring cognitive deficits that would be
appropriate for clinical use. Ideally, findings from such a tool could be used
to tailor diabetes self-management education by taking the client’s particular
cognitive deficits into account. Lacking such a tool, assessment must be done
on a case-by-case basis and kept updated (see flow sheet, Appendix G).
Variations in the course and severity of the SPMI may affect stress level,
coping ability, diabetes self-management, and glycemic control (Chapter 2).
Accordingly, care tools such as flow sheets should integrate standards of
diabetes care with considerations related to the SPMI in order to facilitate
appropriate care planning.
The diabetes care flow sheet, blood glucose log, and food and activity log
(Appendix G) incorporate assessments for integrated mental and physical
health care for patients with diabetes. It indicates all the services needed
over a year with space to record dates provided or referred. Goals for blood
pressure, lipids, and microalbumen values are included along with a chart to
track self-management education. The flow sheet requests a yearly
consultation with the client’s caseworker or the psychiatric clinical nurse
specialist regarding functional level, status and prognosis of the SPMI, and
considerations related to any cognitive deficits to be taken into account in
planning care. The glucose and food and activity logs include visual analog
scales for the client to record levels of stress and energy for the week as a
way to measure effects of the SPMI. Visual analog scales are a simple way
for clients to rate their experiences and perceptions and have been
extensively used in pain research (Lorig et al., 1996). By using the scales,
stress and energy levels and their fluctuations can be “part of the
conversation” when clients return for care.
Recommendation 9: Set appropriate goals for glycemic control. (Level
of evidence: B.) Glycated hemoglobin, or HbA1C, measures the patient’s
average level of glycemia during the preceding 2-3 months and thus is an
indicator of how well the diabetes is being controlled (ADA, 2002e). HbA1C
testing is recommended every 3-6 months (ADA, 2002d, e). Goals, cut
points, and actions recommended with reference to HBA1C are shown in
Table 2. To use these goals and cut points, the HbA1C test should be
performed in a laboratory certified as traceable to DCCT methods, ensuring
that the results meet standards for precision and accuracy (ADA, 2002e).
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
Rationale: Reducing HbA1C to 7% or less is associated with fewer
microvascular complications and is recommended by the ADA (2002d). The
risk of microvascular complications rises markedly when HbA1C is > 8%
(Gaster & Hirsh, 1998). It is not yet known if glycemic control reduces
macrovascular complications. However, less strict goals may be appropriate
for some patients, based on their age and life expectancies, co-morbidities,
and their ability to understand and adhere to a plan of diabetes care (ADA,
2002d; level of evidence: C). Gaster and Hirsch (1998) suggest a HbA1C
range of 7-8% as appropriate for most patients with type 2 diabetes. An
initial target HbA1C range of 7-8% is consistent with ADA recommendations.
Many patients will be able to achieve values <7% with appropriate
medication and self-management, including self-monitoring of blood glucose
and lifestyle changes in the areas of nutrition and physical activity.
Table 2. Goals and cut points for glycemic control
HbA1c
Recommended Action
Initial Goal (new patients)
<7%
Desirable
7-8%
Acceptable
Regular diabetes visits with HbA1C
testing every 3 months
Regular diabetes visits with HbA1C
testing every 3 months, with
additional diabetes education as
needed based on individualized
assessment
Goal (established patients)
<7%
Regular diabetes visits with HbA1C
testing every 3-6 months
Cut points for additional intervention
a
Sources
ADA, 2002d
Gaster & Hirsch,
1998
ADA, 2002d
8-9.5%
Take action: based on individual
patient factors, Ç patient education,
co-manage with PCNS and/or
caseworker, refer, start or change
medications, start or Ç SMBG,
and/or Ç visit frequency
ADA, 2002
> 9.5%
Emergency action may be needed;
rule out ketoacidosis. Continue
action: co-manage with PCNS and
caseworker, add or change
medications, start or Ç SMBG, Ç
visit frequency. If persisting > 3
months, refer for endocrinology
consultation and/or management
Cut point based on
HCFA/HEDIS QI
indicator (Kaegi,
1999)
a
Non-pregnant adults.
Note: To use these goals and cut points, the HbA1C test should be performed in a
laboratory certified as traceable to DCCT methods, ensuring that the results meet standards
for precision and accuracy (ADA, 2002e).
In the practice guideline for type 2 diabetes published by the American
Academy of Family Physicians (AAFP) and the ADA (Woolf et al., 2000), no
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
goal or cut point for glycemic control was identified. Instead, these authors
stated "because of differences in patients' life expectancies and comorbidities, it is inappropriate to set a uniform target glycated hemoglobin
level for all patients with type 2 diabetes" (p. 41). Although they concluded
that "the better the control, the lower the risk of complications" (p. 41), they
recommended that providers consider whether the benefits expected from
better control outweigh the cost, inconvenience, and potential risks of
pursuing strict glycemic control.
Hypoglycemia is a risk in pursuing glycemic control. The risk of severe
hypoglycemia is greatest for patients with type 1 diabetes, whereas in
patients with type 2 diabetes, minor hypoglycemia without sequelae is more
common (Woolf et al., 2000). The risk of hypoglycemia is low when patients
are managed using the newer classes of oral medications. These include the
alpha-glucosidase inhibitors, which interfere with glucose digestion and
absorption; biguanides (such as metformin), which inhibit glucose production
in the liver; and the thiazolidinediones, which improve utilization of glucose
in tissue (Rosak, 2002). However, cost may be an issue, depending on
insurance coverage.
It should be noted that self-monitoring of blood glucose and following diet
and activity recommendations requires self-discipline and a regular supply of
the proper equipment, the resources to obtain the right kinds of foods, and
access to safe and comfortable settings in which to exercise. Frequent visits
for diabetes care may entail taking time off from work, making child care
arrangements, and finding transportation. Consistently taking medications
assumes that the co-pay or the entire cost of the prescriptions ordered is
affordable. All of these may add up to harms for the patient and must be
weighed against the potential benefits of glycemic control based on each
patient's situation (Woolf et al., 2000).
Serious and persistent mental illness is a significant co-morbidity that
complicates diabetes care. The patient may have emotional and
cognitive/behavioral deficits that interfere with understanding and
successfully managing the diabetes. The course of the mental illness may
dictate when and to what extent managing the diabetes can be pursued. The
time and resources that must be expended for the mental illness may limit
the time and resources for diabetes care. The support system the patient has
may be focused on the mental illness, relegating the diabetes to the
background. All of these may make attaining glycemic control more difficult.
Given these considerations, it seems prudent with new patients to initially
pursue conservative goals for glycemic control in the context of SPMI, with a
HbA1C of < 7% desirable and 7-8% acceptable. Until the individual patient's
particular abilities, preferences, resources, and risks are well understood,
conservative goals can be used as a "middle ground" while avoiding the
complications of hypo- and hyperglycemia. However, patients need to
understand the consequences of hyperglycemia over the long term. As part
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
of their initial or “booster” diabetes education, patients should identify their
own glycemic goal and plan for attaining it.
The indicator of choice to monitor glycemic control, HbA1C, should be
measured regularly, every 3-6 months (ADA, 2002d, e) (Level of evidence:
C). For some patients (e.g., patients with no insurance), fasting or random
plasma glucose is a lower cost alternative ($5.42 versus $13.42 at Medicare
2001 rates). In a study done in urban African Americans with diabetes, a
plasma glucose of 200 mg/dl predicted a HbA1C of > 8% with 90% accuracy
if done fasting and 80-85% if collected randomly (El-Kebbi et al., 1998).
While plasma glucose cannot replace the HbA1C, it is a useful indicator of
control in between HbA1C testing.
The need for tailoring care and goals to the circumstances of the individual
patient seems particularly appropriate to consider when managing diabetes
in the context of SPMI. Good glycemic control helps to prevent complications
of diabetes, but goals must be tailored for each patient. Regular, continuing
care can help build collaborative patient-provider partnerships and
accomplish the tailoring needed to ensure optimum outcomes. In this regard,
however, it is important to note that it is the collaborative partnership
process that is critical for supporting the best outcomes. A risk of setting
cutoffs as quality indicators is that providers become so focused "on the
numbers" that they do not attend to this process, thus putting the proverbial
cart before the horse (Pill et al., 1999).
Recommendation 10: Provide case management. Provide outreach and
case management services in collaboration with the mental health care team
in order to assure necessary immunizations, medications, and health care
supervision (Level of evidence: B). Provide periodic reviews on the elements
of diabetes care for case managers and other members of the mental health
care team (Level of evidence: C).
Co-manage with psychiatric-mental health nursing the clients identified as
requiring greater support because of the SPMI, situational stress, cognitive
deficits, or other factors compromising diabetes self-management ability
(Level of evidence: C).
Rationale. Multiple, coordinated, integrated services have the best outcomes
in mental health care (Chandler et al., 1996; USDHHS, 1999). Where mental
health care systems provide community support services, clients use fewer
hospital days, resulting in lower per-person costs (Dickey et al., 1997).
Several models of service delivery have evolved since the 1960's, with
varying degrees of success (Mueser et al., 2001; USDHHS, 1999). In addition
to mental health care, providing support for clients so they can live and work
in their communities is one important trend. Studies indicate that supported
housing can help to improve mental health and self-management ability
(USDHHS, 1999) and that persons with SPMI can be successfully employed if
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CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
they receive supportive services (Mueser et al., 2001). Case management is
one example of the supportive services that may be provided.
Diabetes care is complex, requiring patient education, regular visits for
health care, and referrals for specialty care. Coordination with mental health
case workers and other service providers may be needed in order to
accomplish the required care. For example, work or treatment schedules may
need to be coordinated with appointments for health care, and the client may
be unable to prioritize the priorities involved because of cognitive
impairments. If an appointment is given without alerting the caseworker, the
patient may continue the usual schedule and miss the appointment.
If case management is provided, care can be coordinated. This may
strengthen diabetes care and improve outcomes, just as it does in mental
health care. In the integrated service delivery model studied by Druss et al.
(2001), clients received both primary care and case management services.
The staffing was 1 FTE provider to .5 FTE case management services, and
the case management included collaboration with mental health providers.
This staffing mix produced better outcomes than the comparison group
receiving usual care (Druss et al., 2001).
The psychiatric-mental health nurse can provide expertise in mental health
care, including counseling, psychobiological interventions, stress
management, health teaching and promotion, and case management
(American Nurses Association, 1994). For selected clients requiring more
support, consultation or co-management with psychiatric-mental health
nursing can help to resolve issues and plan the most appropriate care and
follow-up.
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51
CHAPTER 3: CLINICAL PRACTICE RECOMMENDATIONS FOR DIABETES MANAGEMENT IN SPMI
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52
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55
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57
APPENDIX A
Diabetes education in the context of SPMI: Recommended
curriculum content areas a, b
1. Overview of diabetes
2. Stress and psychosocial adjustment
3. Living with diabetes and an SPMI
4. Family involvement and social support
5. Nutrition
6. Exercise and activity
7. Medications
8. Self-monitoring of blood glucose and how to use results
9. How nutrition, exercise, and medications affect blood glucose levels
10. Preventing, detecting, and treating acute complications
11. Preventing, detecting, and treating chronic complications
12. Foot, skin, and dental care
13. Strategies for behavior change, setting goals, reducing risk factors,
and solving problems
14. Benefits, risks, and ways to improve glucose control
15. Preconception care, pregnancy, and gestational diabetes
16. How to use health care and community resources
a
Based on M. M. Funnell & L. B. Haas (1995), National standards for diabetes selfmanagement programs. Diabetes Care, 18 (1), 100-116.
b
The curriculum should contain all content areas, but not all areas may be
appropriate for a particular patient.
58
APPENDIX B
Rehabilitation, psychoeducation, and skills training principles
for diabetes education in the context of SPMI
Psychosocial rehabilitationa
Enable each individual to develop to the fullest extent possible
Recognize the existence or impact of mental illness
Provide individualized care: a strong personal relationship between the
patient and rehabilitation caregiver
Recognize the importance of environmental factors
Base training on realistic life situations
Provide one-on-one training
Incorporate all available supports
Exploit the client’s strengths
Restore hope
Defining work broadly, assume that work is possible, enriching, and a desirable goal
for most clients
Address medical, social, and recreation life concerns in a comprehensive plan of care
Involve patients actively in their own treatment
Rehabilitation is an ongoing process: provide for continuity of care
Psychoeducation and skills training
Develop a skills training prescription based on assessment of the patient’s function in
his or her own environment. b Assessment can use direct observation, evaluations by
others, and self report. c
1.
In which setting is behavior deficient, and in which is it competent?
2.
What cognitive and behavioral competencies are necessary in that
environment for successful performance?
3.
Which competencies are displayed now and which are lacking now?
4.
What are the cognitive barriers to learning and performing these
competencies?
5.
Are there natural reinforcers to support the new competencies?
6.
Is the patient motivated to learn the needed competencies?
59
Psychoeducation and skills training, cont.
Address motivational deficits d:
1.
2.
3.
5.
6.
First engage the patient in the program
Build efficacy by experiencing success with simple activities
Practice skills before helping clients to set a goal of using them
Encourage participation in setting modest goals the patient is comfortable
with
Help the client understand that he/she is the one who creates change
Address cognitive deficits
b, c
:
1.
Provide highly structured sessions
2.
Use a modular approach and prioritize learning needs to most important first
3.
Base teaching on realistic life experiences of everyday living
4.
Break didactic material down into small units.
5.
First learn to perform the elements, and then learn to combine them
6.
Overlearn a few specific and narrow skills that can be used automatically in
stressful and key situations, emphasizing the most important information
needed.
7.
Memory and attention:
a.
Use auditory and visual presentation
b.
Use learning aides: handouts, flip charts, video modeling, color
highlighting
c.
Provide focused, clear instructions
d.
Repeat material and return demonstrations within and across sessions
8.
Emphasize behavioral rehearsal with immediate positive feedback
a.
Provide constant positive verbal reinforcement
b.
Prompt patients as many times as needed
9.
Train to 80% mastery of knowledge and skills as determined by role-play
a
Bachrach, L. L.(2000). Psychosocial rehabilitation and psychiatry in the treatment of
schizophrenia--what are the boundaries?. [Review] Acta Psychiatrica Scandinavica (Suppl.),
102(407), 6-10.
b
Heinssen, R. K., Liberman, R. P., & Kepelowicz, A. (2000). Psychosocial skills training
for schizoprenia: Lessons from the laboratory. Schizophrenia Bulletin, 26 (1), 21-46; and
Bellack, A. S., & DiClemente, C. C. (1999). Treating substance abuse among patients with
schizophrenia. Psychiatric Services, 50 (1), 75-80.
c
Tsang, H. W.-H. (2001). Applying social skills training in the context of vocational
rehabilitation for people with schizophrenia. Journal of Nervous and Mental Diseases, 189 (2),
90-98.
d
Chin-Yu, W., Chen, S., & Grossman, J. (2000). Facilitating intrinsic motivation in
clients with mental illness. Occupational Therapy in Mental Health, 16 (1), 6-9.
60
APPENDIX C
Motivational interviewing and solution-focused methods for
diabetes care in the context of SPMI
________________________________________________________________
Motivational interviewing
a
Specific training and supervision is recommended
Personal characteristics of interviewer: therapeutic empathy, warmth
Goal:
Elicit, consolidate client’s motivation for behavioral change
Approaches:
Open-ended questions, reflective listening, reframing, supporting
Session format:
Begin with open-ended questions and end with a summary reflection.
Session content depends on stage of readiness to change:
Stage of Change
Session content
Precontemplation
Good and not so good things about the current behavior
Contemplation
Reasons to change or not change
Preparation
Ideas about how change could occur
Action
What’s working and feelings about that
Problem solving for when things don’t work
Key strategies:
Express empathy: elicit client’s own perceptions of problems,
concerns, reasons for change, and optimism regarding change
Give feedback of assessment findings to develop discrepancy
and instill motivation
“Roll” with resistance—don’t confront it
Support the perception that change is possible and that the
client can do it
Solution-focused therapyb
Definition:
Focuses not on problems but on the patient’s strengths; the
working relationship between nurse and client; the client’s
future positive goals; and the actions needed to reach the goals
Approach:
Ask the client to identify their most important problem from
their perspective, e.g., “What’s bothering you the most today
about taking care of your diabetes?”
61
Solution-focused therapy,b cont.
Ask “scaling questions” to find out how big the problem is,
using a scale of 0 (not at all) to 10 (the worst it’s ever been).
Ask exception and difference questions to discover small
solutions. — i.e., “when was it different from the rating you
gave?” Also ask, “how did you do that?” to identify and
reinforce coping strategies.
Ask the “miracle question” to help the client imagine what life
would be like without the problem. Preface by saying it takes a
little imagination! :
Suppose while you were asleep, a miracle happened and the
problem is solved. When you wake up,
How would you know the miracle happened?
How would other people know the miracle happened?
What else would be different the day after the miracle
happened? Be as specific and concrete as possible.
Give homework to try out some of the strategies identified
above or to try out one of the differences the “miracle” would
make.
a
Miller, W. R. Motivational enhancement therapy: Description of counseling approach.
In Approaches to drug abuse counseling. Nashville, TN: Dual Diagnosis Recovery Network /
National Institute on Drug Abuse. Accessed February 13, 2002, at:
http://www.dualdiagnosis.org/library/nida_00-4151/9.html.
b
Hagen, B. F., & Mitchell, D. L. (2001). Might within the madness: Solution-focused
therapy and thought-disordered clients. Archives of Psychiatric Nursing, 15 (2), 86-93.
62
APPENDIX D
Risk factors for diabetes in the context of SPMIa
Age ≥ 45
F
Family history of diabetes
F
Parents or siblings
F
BMI
Habitual physical inactivity
F
Gets “little or no exercise”
Race/ethnicity
F
Overweight
b
Impaired fasting glucose
d
c
≥ 25 kg / m2
African American, Hispanic
American, Native American,
Asian American, Pacific Islander
F
≥ 110 to 126 mg / dl
F
≥ 140 to 200 mg / dl
Hypertension
F
≥ 140/90 mm Hg
Low HDL cholesterol
F
≤ 35 mg / dl
Elevated triglycerides
F
≥ 250 mg / dl
History of gestational diabetes
F
A baby weighing > 9 lb
Polycystic ovary syndrome
F
Antipsychotic medication
F
Impaired glucose tolerance
e
Clozapine, olanzapine,
risperidone, quetiapine
a
Based on: American Diabetes Association (2003). Screening for type 2 diabetes. Diabetes Care,
26 (Suppl. 1), S21-S24.
b
May not apply to all ethnic groups.
c
For BMI, go to http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm or use the calculator at
http://www.nhlbisupport.com/bmi/ .
d
Fasting = no caloric intake for at least 8 h before testing.
e
After a glucose load of 75 g taken 2 h before testing.
Actions Recommended
Screen at-risk clients annually with fasting (preferred) or casual plasma
glucose testing.
Follow patients with impaired fasting glucose or impaired glucose tolerance
with regular screening and begin lifestyle interventions related to nutrition
and exercise. Lifestyle interventions including a healthy, low-calorie diet and
moderate intensity physical activity of at least 150 minutes per week reduce
the incidence of diabetes in persons with elevated fasting or impaired glucose
tolerance (Knowler et al., 2002).
63
APPENDIX E
Diagnostic Criteria for Diabetes
Test
Fasting
b
PG
Normal
a
Pre-Diabetes
Diabetes
c
< 110 mg/dl
≥ 110 and < 126 mg/dl
HbA1C
<6
6-7
Casual (nonfasting) PG
≥ 200 mg/dl and symptoms (polyuria, polydipsia,
unexplained weight loss)
≥ 126 mg/dl
>7
Note: A diagnosis of diabetes can be confirmed on another day with second fasting plasma
glucose, random plasma glucose (if symptoms are present), or with a HbA1C, which can be drawn at
the same time as the initial fasting plasma glucose if desired.
a
Based on: American Diabetes Association (2003). Screening for type 2 diabetes. Diabetes Care, 26
(Suppl. 1), S21-S24, and A. L. Peters, M. B. Davidson, D. L. Schriger, & V. Hasselblad (1996). A clinical approach
for the diagnosis of diabetes mellitus: An analysis using glycosylated hemoglobin levels. Journal of the American
Medical Association, 276 (15), 1246-1252.
b
No caloric intake for at least 8 hours.
c
Impaired fasting glucose.
64
APPENDIX F
Comprehensive History and Physical Examination Forms
65
UIC
University of Illinois at Chicago Nursing Institute, College of Nursing
Nursing and Health Care Associates Integrated Health Care Centers
integrating primary and mental health care for optimum wellness
Date
Name: last
first
Comprehensive History
DOB:
Age:
ID#
CC/HPI:
Smoker: non ____PPD____Stage: precon, con, prep, act, maint AAAA
Medications: Med sheet updated
Allergies: Front sheet updated
Drug, food, environmental and reaction
Hospitalizations: yr and reason
Medical History: Problem List Updated
Surgeries:
Suicide-Homicide/ Ideation-Atmpt
Psychiatric History- Hospitalizations:
Family History: Mother
Age
Health Problems
Father
Immun/Screen: See HM
Habits:
Td
Tobacco Hx
Quit
HepB
Alcohol
Last use
Pneum
Rec Drugs
Last use
Influ
IV Drugs
MMR
Caffeine
PPD
Exercise
HIV
Environ Exposure
Revised: 04/01/01
Over
66
Comprehensive History page 2
Name:
last
first
Social History:
Occupation
Education
Living Arrangement
Support-Relatives-Friends
Location of Children +/or Parents
GYN History: Last Pap
Hx Abn Pap
LMP
Duration
G
P
Delivery
Misc
PMS Sx
Ab
Premature
Gest Diabetes
abn:
does
ROS: circle=complaint
Living Children:
Other perinatal problems:
Mammo: (last)
BSE: knows
Menarche
Interval
Hx of breast prob:
x / yr.
strike through = denied
Gen.: fatigue malaise night sweats
not circled= NA (not asked or not appropriate)
wt ∆
Weight nl
recent∆
Head: HA dizziness lightheaded
Eyes: tearing pain
itch
vision∆
blurring
Last eye exam
double
Ears: hearing∆, pain
N M T: congestion nasal drip pain swelling
Resp: pain sob cough produtive
jaw click taste ∆
tooth pain
Last dental visit
wheeze exer intol
Heart: Pain pounding exer intol irreg beats ankle swelling
Breast: pain tender lumps discharge
GI-bowel: pain crampimg nausea vomiting diarrhea constipation ∆ in pattern bloody black
24° Diet:
Gyn: pain, abn discharge abn bleeding abn odor itch
GU: ∆ in urination urgency pain burn freq hesitency ∆ in stream cloudy foul smell
Sexual History: Active
Satisfied
STD's
Current # partners
Lifetime #
Contraception
Dom Violence-Unwanted touch
MS: Pain tenderness swelling
Neuro: dizziness weakness
inability to move joint fully
numbness
tingling
∆ walking
∆ balance
Sleep: prob falling asleep prob staying asleep early awake
Usual sleep
Endo: >thirst > hunger >urine heat intol cold intol
Heme-Immune: bruising
bleeding
Skin: dry sores rash nail∆ hair∆
Mood: even anxious depressed hypomania/mania agitated
Suicidal Ideation
Plan
Hallucinations auditory visual threatening to self or others
Time:
❏ 20
❏ 30
❏ 40-50
❏ 60
❏ 90
Revised: 04/01/01
67
Signature:
hrs
UIC
University of Illinois at Chicago Nursing Institute, College of Nursing
Nursing and Health Care Associates Integrated Health Care Centers
integrating primary and mental health care for optimum wellness
Date
Name:
Comprehensive Physical Examination
last
first
Ht.
Wt
DOB:
T:
P:
Age:
RR:
Gen
Apperarance
NAD, dressed and groomed
Head
Head and Scalp
Normal appearance
Eyes
Conjunctiva and lids
Muscles/nerve
Pupils and iris
Fundoscopic
ENMT
Ext. Ears & Nose
TM and canal
Nares
Lips, teeth & gums
Oropharynx
Normal, no scars, masses
Normal TM and auditory canal
NL mucosa, septum, & turbinates
Normal
NL mucosa, tonsils, & pharynx
Neck
Palpate nodes
Thyroid exam
Resp.
Lungs
NT, no lymphadenopathy
Nontender, not enlarged
Breath sounds clear & equal
Auscultate
Carotid
Pedal pulses
Edema/veins
NL heart sounds, no murmurs
Normal amplitude, no bruits
Symmetric & palpable bilaterally
None
Inspect
Palpate
Rectal
Occult blood
Symmetric
No masses, tenderness or discharge
+BS, soft, NT
no organomegaly, masses
NL tone, no hemorrhoids
Guiac negative
Ext. & vag.
Cervix
Uterus
Adnexa
No lesions, no discharge
No CMT, no lesions
NT, mobile, not enlarged
NT, not enlarged
GU
Scrotum
Penis
Prostate
NL scrotal contents, no hernia
No deformities
NL size, nontender, no masses
M/S
Spine
Extremities
NEURO
CN
DTR
Sensation
NT, aligned, normal ROM
No deform, NT, normal ROM
Normal muscle mass, strength & tone
CN II-XII intact
DTR intact and symmetrical
Sensation intact to light touch
Inspect
No rashes, lesions, or ulcers
Judgement-Insight
Orientation
Memory
Mood and Affect
Appropriate
0x3 -time, place, person
NL recent & remote memory
NL mood, appropriate affect
CV
Breast
GI
GYN
SKIN
PSYCH
Abdomen
BP:
Comments
Normal
EOM intact, no nystagmus
PERRL and iris symmetrical
Discs sharp-no exudates, hemorrhage,
leaking, a-v narrowing or nicking
Lab, Procedures, or Labs completed::
Revised 04/01/01
Over
68
ID#
initial
Comprehensive Physical Examination page 2
Name:
last
first
Assessment:
Plan:
RTC:
Time:
Signature:
❏ 20
❏ 30
❏ 40-50
❏ 60
❏ 90 min.
Revised 04/01/01
69
APPENDIX G
FLOW SHEETS, CHECKLISTS, AND PATIENT LOGS FOR DIABETES
CARE IN THE CONTEXT OF SPMI
70
UIC
University of Illinois at Chicago Nursing Institute, College of Nursing
Nursing and Health Care Associates Integrated Health Care Centers
integrating primary and mental health care for optimum wellness
Diabetes Care Flow Sheet
Date
Name: last
first
Age of onset:
Type I
Age:
ID#
a
Complications :
2
GUIDE FOR EACH FOLLOW-UP VISIT
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Visit Component
Weight (goal =
)
BP (goal < 135/80)
SMBG results
Episodes of hypo/hyperglycemia?
Changes in self-care? In SPMI?
Problems with adherence?
S/S complications?
Other illnesses?
Current meds
Psychosocial issues
Diet, exercise
Smoking
Follow-up of pending referrals
Self-management education
b
SERVICES PROVIDED EVERY 3-6 MONTHS
Laboratory Test
Date
Result
Date
Result
Date
Result
Date
Result
Hemoglobin A1C (%)
LFTs (if on statin)
ANNUAL AND OTHER SERVICES
Exam / Test / Service
CW/PCNS consult
b
Physical exam
Date
Result
Exam / Test / Service
See other side
Dilated eye exam
See H & P
Cardiovascular risk
Fasting lipid profile
Podiatry Visit Dates
Result
ECG (baseline +)
U/A (with microscopic)
HDL (>45)
Microalbumin (< 55)
LDL (<100)
ACE/ARB (if > 55)
Triglycerides (<200)
Daily ASA ordered
CMP, TSH
Influenza vaccine
CBC
Pneumovax (q 6 y until 65)
a
Result
c
Total cholesterol
● monofilament feeling present
Date
Monofilament foot
exam (annually, but
more often if at risk)
#1
At risk?
#2
❏
Yes
❏
No
#3
#4
O monofilament feeling absent
Frequency recommendations are based on ADA guidelines for patients with a diagnosis of stable diabetes. More frequent
monitoring is required for patients who have complications or are not meeting treatment goals.
b
Document self-management education and CW/PCNS consults on side 2 of this Flow Sheet.
c
Use cardiovascular and exercise risk assessment tool.
Diabetes Self-Management Education and Support
Name: last
first
Age:
ID#
Self-management indicators
Medication management arrangements
Money management arrangements
Degree of independent living
Employment
MCAS date & score /Other
CW / PCNS consultations
Status and effects of SPMI?
Cognitive needs?
SELF-MANAGEMENT EDUCATION
(V=verbal W=written D=demonstration RD= return demonstration)
Date Provided
Education Topic
Hypoglycemia (symptoms; causes; treatment = 15 Gm CHO, 5
lifesavers, 4 oz OJ; call office if >2x/week)
Hyperglycemia (symptoms, causes, treatment)
SMBG (desired range rationale, fingerstick technique, interpretation,
frequency, recording, disposal of supplies, comprehension
Stress and psychosocial adjustment; living with an SPMI and diabetes
Benefits, risks, and ways to improve glucose control
Strategies for behavior change, setting goals, reducing risk factors, and
solving problems
Family involvement and social support
Nutrition ((effects on DM control, calorie level: __________,
written diet plan given / food log homework given)
Exercise and activity (effects on DM control, exercise plan)
Oral hypoglycemic agents (dose, action, times, side effects)
Insulin (type/dose, action & timing, storage, injection sites and rotation,
injection technique training, disposal of syringes)
Foot, skin, and dental care
Sick day guidelines (indications, diet, medication adjustment)
How to use health care and support services
Overview of diabetes (pathophysiology, diagnosis)
Goals of treatment (BS, BP, Hgb A1C, lipids)
Rationale for goals: prevent complications (cardiovascular, eye, kidney,
peripheral vascular, neuropathy)
Preconception care, pregnancy, and gestational diabetes
Emergency contacts, Medic Alert bracelet
Initial
Review
Review
Review
Review
UIC
Date
Name: last
University of Illinois at Chicago Nursing Institute, College of Nursing
Nursing and Health Care Associates Integrated Health Care Centers
integrating primary and mental health care for optimum wellness
Cardiovascular and Exercise Risk Assessment Tool
first
Age:
ID#
Directions: Use this tool once a year to assess risk for exercise in patients with diabetes.
Potential Complication
Cardiovascular disease
Considerations
Plan
Risk factors:
F Age > 35
F Diabetes > 10 years
F Smoking
F Dyslipidemia
F Male or postmenopausal female
Refer for stress testing if 1 or more risk factors are
present unless only low intensity exercise is planned
(<60% of maximal heart rate).
If ECG changes are present, refer for radionuclide
stress testing.
F Family history (CAD in women < age
65 or men < age 55)
F Proliferative retinopathy or micro-
albuminuria
F Peripheral vascular disease
F Autonomic neuropathy
Peripheral arterial disease
Symptoms and signs:
F Intermittent claudication
Smoking cessation, exercise
F Cold feet, decreased or absent pedal
Refer for vascular studies if blood flow to feet or toes is
questionable
pulses, subcutaneous tissue
atrophy, hair loss
Retinopathy
Active proliferative diabetic retinopathy
on dilated eye exam
Avoid strenuous activities, pounding, jarring, or
Valsalva maneuver
Nephropathy
Overt nephropathy (>200 mm/min
albumin excretion)
Discourage high intensity and strenuous exercise
Neuropathy: peripheral
Loss of protective sensation in feet as
evidenced by:
Treadmills, prolonged walking, jogging, and step
exercise are contraindicated. Plan non-weight-bearing
exercise such as swimming, cycling, rowing, chair and
arm exercises
F Diminished deep tendon reflexes
F Impaired vibratory sense
F Inability to detect a 10 g
monofilament
Neuropathy: autonomic
Autonomic nervous system changes as
evidenced by:
F Resting pulse >100
F Systolic fall >20 mm Hg upon
standing
Refer for rest or thallium stress testing.
Monitor for hypo- or hypertensive response to
exercise.
Avoid exercise in hot or cold environments. Maintain
adequate hydration.
F Other skin, papillary, gastrointestinal,
or urinary disturbances
From American Diabetes Association (2000). Clinical practice recommendations 2000. Diabetes Care, 23 (Suppl. 1),
S50-S54, and JNC VI Risk Stratification and Treatment Recommendations, accessed April 1, 2002 at
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc6card.pdf
UIC
1-Week Blood Glucose Log
Date
FOR:
University of Illinois at Chicago Nursing Institute, College of Nursing
Nursing and Health Care Associates Integrated Health Care Centers
integrating primary and mental health care for optimum wellness
first
last
After you have checked your blood glucose, write down the number on the log below. Bring this log to
your next visit with ___________________on_______________________________at____________
DAY OF THE WEEK
BEFORE
BREAKFAST
BEFORE LUNCH
BEFORE DINNER
BEFORE BEDTIME
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
Please mark an “X” on the line below to describe your stress level during the past week:
High
No stress |_____________________________________________| stress
Please mark an “X” on the line below to describe your energy level during the past week:
High
No energy |_____________________________________________| energy
UIC
University of Illinois at Chicago Nursing Institute, College of Nursing
Nursing and Health Care Associates Integrated Health Care Centers
integrating primary and mental health care for optimum wellness
1-Week Food and Activity Log
Date
FOR:
first
last
Write down the foods you eat and drink and your physical activity each day. Bring this log to your next
visit with ______________________on___________________________________at______________
DAY OF THE
WEEK
BREAKFAST
LUNCH
DINNER
SNACK
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
Please mark an “X” on the line below to describe your stress level during the past week:
High
No stress |_____________________________________________| stress
Please mark an “X” on the line below to describe your energy level during the past week:
High
No energy |_____________________________________________| energy
PHYSICAL
ACTIVITY