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Diabetes Mellitus, Type 2: Risk in Psychiatric Conditions

What We Know
Individuals with severe psychiatric conditions are at greater risk than the general

population for developing diabetes mellitus, type 2 (DM2)(1,2,3,4,5,6,7,8,9,10,11,13)

DM2 prevalence estimates vary but are generally higher for individuals with
schizophrenia, schizoaffective disorder (i.e., a disorder characterized by signs and
symptoms that are similar to those of schizophrenia but less severe), bipolar disorder

(BD; also called manic depression), and depression(2,3,4,6,7,9,10,11)

The prevalence of DM2 among persons with schizophrenia is thought to be 24times

higher than among the general population(1,6,8,11)

The increased risk of DM2 in patients with schizophrenia is thought to result from both
genetic and environmental factors(1,6)
Individuals with schizophrenia commonly have a family history of DM2(1)

Environmental factors associated with schizophreniaincluding poor health behaviors

(e.g., an unhealthy diet, lack of exercise, smoking), poverty, unhealthy living
conditions, and treatment with antipsychotic medications (see below)are risk factors
for DM2(2,6,8,11)
Some evidence suggests that schizophrenia may be an independent risk factor for
DM2, patients with schizophreniawhether on an antipsychotic treatment regimen or

nothave higher levels of intra-abdominal fat than healthy controls(6)

Individuals with BD have an increased prevalence of weight gain and metabolic
syndrome, which are major risk factors for DM2, in comparison to individuals without
ICD-10
E11

Authors
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA

Reviewers
Darlene Strayer, RN, MBA
Cinahl Information Systems, Glendale, CA
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA

Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA

BD(9)
Depression is thought to predict the onset of many medical conditions, including

DM2(3,4,5,10,12)
Research reports indicate that the prevalence of DM2 is 34 times higher among patients

treated for depression than among the general population(4)

Several factors associated with depression are believed to contribute to the onset of DM2
and to poor DM2 outcomes(5,10,12)
Depression may activate neuroendocrine and inflammatory responses that result in
increased circulating levels of cortisol and other hormones that negatively affect
insulin resistance and contribute to poor glycemic control. In addition, patients with
depression are more likely than those without depression to be overweight or obese
and to engage in unhealthy behaviors (e.g., smoking, lack of physical activity) that are
associated with increased DM2 risk(5,10,12)
Depression affects adherence to treatment regimens by decreasing motivation for

regular exercise and healthy eating(5,12)

- Depression is associated with an increased DM2 symptom burden. An increased risk
for complications, disability, and adverse outcomes typically develops, and comorbid
depression and DM2 lead to increased health care utilization and expenditures(10,12)

October 18, 2013

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright2014, Cinahl Information Systems. All rights
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or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

- Authors of a recent meta-analysis of 10 studies including 42,363 participants found that the presence of depression in
patients with DM2 increased risk of mortality by 50%(12)
The association between depression and DM2 may be attributable to a common etiologic process rather than a
cause-and-effectrelationship(7)
For example, low birth weight and childhood adversity are risk factors for developing both depression and DM2 later in
life
Use of certain psychotropic medications is associated with increased risk for DM2(1,4,6,11,13)
Some antipsychotic medications are associated with hyperglycemia, hyperlipidemia, obesity, and increased risk for
new-onsetDM2(2,4,6,11,13)
Certain antipsychotic drugs (e.g., second-generationantipsychotic agents; e.g., cloZAPine, OLANZapine, risperiDONE,
QUEtiapine) used in the treatment of psychological disorders that can cause weight gain as a side effect; however, no
direct relationship has been established between treatment-related weight gain and the development of DM2(2,13)
It is widely thought that many antipsychotic medications are associated with insulin resistance and impaired insulin
secretion(2,11,13)
Authors of a systematic review and meta-analysis published in 2008 found preliminary evidence that, compared to
first-generation antipsychotic agents, the second-generationantipsychotic agents cloZAPine, OLANZapine, risperiDONE,
and QUEtiapine are associated with a small increased risk of DM2 in patients with schizophrenia. They recommend
that all patients receiving any type of antipsychotic agent for treatment of schizophrenia undergo regular screening for
DM2(13)
Successful treatment of psychiatric conditions in patients with DM2 may result in increased adherence to the prescribed
treatment regimen for glycemic control(2,8)
Patients with high-risk psychiatric conditions should be routinely screened for DM2 even when antipsychotic medications
are not prescribed(2,9)
Patients should be fully informed of the risks of antipsychotic medications(9)
Individualized advice on healthy lifestyle choices should be given to all patients(2,6,8)
Risk-reduction strategies (e.g., lifestyle changes, including diet and exercise) for DM2 used in the general population may
not be effective in patients with a psychiatric diagnosis; patients with a psychiatric diagnosis often lack motivation to be
involved in their own care and to change unhealthy behavior patterns

What We Can Do
Learn about the increased risk of DM2 in patients with certain psychiatric conditions so you can accurately assess your
patients personal characteristics and health education needs; share this information with your colleagues
Collaborate with your hospitals continuing medical education department to provide education for all clinicians regarding
the increased risk of DM2 in patients with specific psychiatric diagnoses, appropriate screening, and patient education(9)
Encourage discussion about the need for close communication regarding patient care among mental health, primary care,
and DM2 specialist clinicians(8)
Alert clinicians regarding any medication warnings from drug manufacturers describing increased risk associated with
DM2, appropriate monitoring, and treatment(9)
Educate your patients that depression and anger are common in individuals coping with chronic disease, that effective
treatment for both DM2 and psychiatric conditions is available, and that improvement of medical outcomes and
psychological well-being are usual treatment results(8)
Help your patients identify ways that anger and depression can become barriers to DM2 self-management as well as steps
to overcome these barriers
Educate about lifestyle changes to improve health, including attention to weight management through diet and exercise(9)
Encourage your patients to ask their primary care or specialist clinician for a referral to a mental health clinician for
appropriate treatment of any psychiatric signs and symptoms; encourage your patients to ask their mental health clinician for
a referral to a DM2 specialist clinician if they are concerned about DM2 risk factors

Coding Matrix
References are rated using the following codes, listed in order of strength:
M Published meta-analysis
SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)

RV Published review of the literature

RU Published research utilization report
QI Published quality improvement report
L Legislation

C Case histories, case studies

PGR Published government report

G Published guidelines

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

References
1. Bresee, L. C., Majumdar, S. R., Patten, S. B., & Johnson, J. A. (2010). Diabetes, cardiovascular disease, and health care use in people with and without schizophrenia.
European Psychiatry, 26(5), 327-332. (R)
2. De Hert, M., Dekker, J. M., Wood, D., Kahl, K. G., Holt, R. I., & Mller, H. J. (2009). Cardiovascular disease and diabetes in people with severe mental illness position
statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology
(ESC). European Psychiatry, 24(6), 412-424. (X)
3. Demakakos, P., Pierce, M. B., & Hardy, R. (2010). Depressive symptoms and risk of type 2 diabetes in a national sample of middle-aged and older adults: The English
longitudinal study of aging. Diabetes Care, 33(4), 792-797. (R)
4. DynaMed. (2013, July 1). Risk factors for diabetes mellitus type 2. Ipswich, MA: EBSCO Publishing. Retrieved July 25, 2013, from http://search.ebscohost.com/login.aspx?
direct=true&db=dme&AN=270053 (GI)
5. Golden, S. H., Lazo, M., Carnethon, M., Bertoni, A. G., Schreiner, P. J., Diez Roux, A. V., & Lyketsos, C. (2008). Examining a bidirectional association between depressive
symptoms and diabetes. JAMA, 299(23), 2751-2759. (R)
6. Hultsj, S. M., & Hjelm, K. (2012). Organizing care for persons with psychotic disorders and risk of or existing diabetes mellitus type 2. Journal of Psychiatric & Mental Health
Nursing, 19(10), 891-902. doi:10.1111/j.1365-2850.2012.01874.v (SR)
7. Kivimki, M., Tabk, A. G., Lawlor, D. A., Batty, G. D., Singh-Manoux, A., Jokela, M., & Vahtera, J. (2010). Antidepressant use before and after the diagnosis of type 2
diabetes: A longitudinal modeling study. Diabetes Care, 33(7), 1471-1476. (R)
8. Kreyenbuhl, J., Dixon, L. B., McCarthy, J. F., Soliman, S., Ignacio, R. V., & Valenstein, M. (2010). Does adherence to medications for type 2 diabetes differ between individuals
with versus without schizophrenia?. Schizophrenia Bulletin, 36(2), 428-435. (R)
9. Lee, N. Y., Kim, S. H., Cho, B., Lee, Y. J., Chang, J. S., Kang, U. G., & Ahn, Y. M. (2010). Patients taking medications for bipolar disorder are more prone to metabolic
syndrome than Korea's general population. Progress in Neuro-psychopharmacology and Biological Psychiatry, 34(7), 1243-1249. (R)
10. Lin, E. H., Rutter, C. M., Katon, W., Heckbert, S. R., Ciechanowski, P., Oliver, M. M., & von Korff, M. (2010). Depression and advanced complications of diabetes: A prospective
cohort study. Diabetes Care, 33(2), 264-269. (R)
11. Ogawa, M., Miyamoto, Y., & Kawakami, N. (2011). Factors associated with glycemic control and diabetes self-care among outpatients with schizophrenia and type 2 diabetes.
Archives of Psychiatric Nursing, 25(1), 63-73. (R)
12. Park, M., Katon, W. J., & Wolf, F. M. (2013). Depression and risk of mortality in individuals with diabetes: A meta-analysis and systematic review. General Hospital Psychiatry,
35(3), 217-225. doi:10.1016/j.genhosppsych.2013.01.006 (M)
13. Smith, M., Hopkins, D., Peveler, R. C., Holt, R. I., Woodward, M., & Ismail, K. (2008). First- v. second-generation antipsychotics and risk for diabetes in schizophrenia:
Systematic review and meta-analysis. British Journal of Psychiatry, 192(6), 406-411. (M)