People with severe mental illness (SMI) have a 20-year life expectancy shortfall, due to premature cardiovascular disease. Antipsychotic medications are associated with obesity and heightened diabetes risk. Achieving the benchmarked standards of diabetes care in SMI is challenging, due to a number of factors. The profound effect of antipsychotic change on diabetes management is presented, highlighting that non-patient factors may have a greater than appreciated impact on health in SMI.
A 40-year old man with longstanding schizophrenia required clozapine after mental health deterioration. Diabetes developed within four years. Despite frequent contact with diabetes services and multiple medications (including insulin >200 units/d), glycemic control remained poor over the ensuing 6 years. Antipsychotic review was initiated by diabetes services, with a negotiated and gradual switch to another antipsychotic, aripiprazole. Within 4 months, weight, HbA1c and insulin requirements fell, sustained over two years (Figure).
This case highlights several important lessons for diabetologists and psychiatrists caring for people with SMI and diabetes. First, our patients can become trapped within service provisions where a therapy (such as clozapine) appears to become perpetual. Second, as diabetologists we may need to extend our influence to question whether an antipsychotic prescription might be revised, if diabetes or obesity occur or diabetes control deteriorates. It illustrates that a profound individual improvement in diabetes control and complications risk can be effected by coordinated interdisciplinary collaboration, in arguably one of our most vulnerable patient groups. Partnership and collaboration between endocrinologists and psychiatrists to achieve our shared goal of improved physical health in SMI, will help reduce this tragic life expectancy gap.