The link between schizophrenia and diabetes

Data from metabolic monitoring informs the decision to switch and metabolic consequences of switching. Conducting monitoring at baseline, when starting an antipsychotic, when switching to a high-liability agent, 3 months after the switch, and then annually provides data needed to consider switching or initiating medical and behavioral or lifestyle interventions.

Facilitate early diabetes treatment. Clinicians who are most closely involved in caring for patients with schizophrenia often are best situated to screen for diabetes. I have found that without a close working relationship with my patients’ primary care practitioners, patients may experience a long delay in receiving care. After your patient is diagnosed with diabetes, establish a relationship with diabetes treatment providers and work with your patient to ensure they engage in diabetes care.

Contribute to diabetes chronic disease management. Mental health practitioners can complement diabetes care in patients with serious mental illness by:

• navigating the health system and negotiating for service on patients’ behalf
  
• promoting positive relationships among diabetes and mental health treatment teams
  
• evaluating and treating depression that may be comorbid with diabetes
  
• assessing treatment capacity, self-care deficits, cognitive functioning, psychotic symptoms, negative symptoms, etc., that impact diabetes self-care and collaborating with diabetes care providers to support patients.
  

Start with a low-liability agent

Patients who are early in the course of psychotic illness are most susceptible to the metabolic effects of antipsychotics.¹³ The average weight gain observed with olanzapine was 34 lbs at 2 years in first episode psychosis patients (mean age 24 ± 4.9).³⁴ Metabolic consequences with medium-liability second-generation antipsychotics—such as quetiapine and risperidone—are extreme, particularly in children, adolescents, and young adults (age 35,36 Although frank diabetes is uncommon in early psychosis because patients are, to a certain extent, protected by insulin compensation—increased insulin secretion maintains glucose levels within a therapeutic range—diabetes risk is increased, and hyperinsulinemia and hypertriglyceridemia are early markers of metabolic strain. Also, response to initial antipsychotic treatment—possibly independent of the agent selected—is robust in early psychosis.³⁷

For these reasons, it is important to initiate schizophrenia treatment with low metabolic liability agents and reserve more potent agents with high metabolic liability for patients who do not respond adequately.

Related Resources

• American Diabetes Association. www.diabetes.org.
  
• International Diabetes Federation. www.idf.org.
  
• Framingham Heart Study. Coronary heart disease (10-year risk). www.framinghamheartstudy.org/risk/coronary.html.
  
• National Cholesterol Education Program. Risk assessment tool for estimating your 10-year risk of having a heart attack. https://hp2010.nhlbihin.net/atpiii/calculator.asp.
  

Drug Brand Names

• Clozapine • Clozaril
  
• Metformin • Glucophage
  
• Olanzapine • Zyprexa
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  

Disclosure

Dr. Cohn is a speaker for Pfizer Canada.