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Maria Sirois, RN, BSN, CDE Slide 2 Objectives Identify the impact of depression and other serious mental illnesses on diabetes management Identify which psychotropic medications are likely to elevate blood sugars Define strategies to assist their clients to make lifestyle changes to reduce diabetes risk and improve diabetes self-management Slide 3 Complications of Diabetes Slide 4 Slide 5 2011 National Diabetes Fact Sheet Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. The risk for stroke is 2 to 4 times higher among people with diabetes. In 2005-2008, of adults aged 20 years or older with self-reported diabetes, 67% had blood pressure greater than or equal to 140/90 mmHg or used prescription medications for hypertension Slide 6 Mental Illness Slide 7 Types of Serious Mental Illnesses MOOD DISORDERS Major Depression Bipolar Disorder (manic-depressive) Dysthmia Schizophrenia Psychotic Mania Schizoaffective Disorder Panic Attacks Post Traumatic Stress Disorder Obsessive Compulsive Disorder PSYCHOTIC DISORDERS ANXIETY DISORDERS Slide 8 SMI=Vulnerable Population Slide 9 Maine Data 65.4 percent of Mainers under age 65 with a diagnosis of SMI have five or more medical conditions or co- morbidities 25 percent have been diagnosed with diabetes 37 percent have pre-diabetes or metabolic syndrome Slide 10 Depression Patients with diabetes have a high rate of major depression, estimated at 15-20% (2-9% general population) Depression in patients with diabetes is associated with higher medical symptom burden At one mental health agency, a health screen revealed 56% of the 133 patients with SMI were seen in the ED for both mental health and medical care In one study of 879, major depression was associated with a 2.31-fold increase in the odds of missing one or more prescribed medications over the previous 7 days Slide 11 Mental Health Medications Slide 12 Schizophrenia & Bipolar Treatment Clozaril (Clozapine) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) Aripiprazole (Abilify) Highest Risk Medium Risk Low Risk Slide 13 Me tabolic Effects of Antipsychotic Medications Relative Risk for Metabolic Side Effects Weight GainDiabetesWorsening Lipid Profile Clozapine+++++ Olanzapine+++++ Quetiapine+++/- Risperidone+++/- Ziprasidone+/--- Aripiprazole+/--- Slide 14 Depression Treatment Fluoxetine (Prozac) Citalopram (Celexa) Sertaline (Zoloft) Paroxetine (Paxil) Escitalopram (Lexapro) Slide 15 Anti-Anxiety Treatments Clonazepam (Klonopin) Lorazepam (Ativan) Alprazolam (Xanax) Buspirone (Buspar) Slide 16 Treatment Considerations Risk vs Benefit Risk Screen for Diabetes If patients develop symptoms of hyperglycemia, serum glucose should be obtained. If overweight with normal glucose level, consider referral to dietician for weight reduction If overweight with elevated glucose level, consider referral to endocrinologist and/or diabetes education which includes dietician Slide 17 The Challenge Slide 18 How Do We Move From This? Medical Plan of Care Mental Health Plan of Care Slide 19 To This? Mental Health Plan of Care Medical Plan of Care Slide 20 MeHAF Grant Work Diabetes Educators completed Lunch & Learns at each of the six partner mental health agencies Facilitated 2 six week monthly diabetes support groups at mental health facilities rather than Diabetes Center Grocery gift cards were provided as an incentive to attend sessions Sessions with hands on, concrete examples resulted in improved compliance Attendees who lives alone or had the ongoing support of mental health staff did better with diabetes management Slide 21 Barriers to Improved Glycemic Control Slide 22 Barriers to Glycemic Control Mental illness (depression, schizophrenia, bipolar) May be in denial due to no or few symptoms Memory lapses and mental status alterations Limited energy Distorted perceptions of illness and health Difficulty keeping up with ADLs, not able to juggle all the balls to manage diabetes Diabetes occurs at a younger age in this population and can require insulin sooner More sedentary lifestyle Slide 23 Barriers to Glycemic Control Financial Limited income making healthier foods difficult to afford Less likely to have own transportation and be dependent on someone else for transportation Less likely to be living in own apartment Less money for recreation Medications Likely to cause weight gain/insulin resistance General issue with medication compliance Difficulty waking in the morning Slide 24 Barriers to Glycemic Control Limited Physical Activity May be physically or emotionally unable to walk outside alone good days and bad days Need frequent coaching to be physically active Limited opportunity for exercise in the evening when patient may have most energy Unable to appreciate benefits of physical activity Low Self Esteem Peer Pressure Slide 25 Barriers to Glycemic Control Living Situation Communal kitchen with shared food May have limited input into grocery shopping choices and meal selections May not have cooking facilities available Vending machines may generate profit for group home No nutritional resources available May be homeless or live alone, no one to observe client for symptoms of hypoglycemia. Slide 26 Barriers to Glycemic Control Client Rights Clients have a right to make decisions about their healthcare that may be detrimental to their health Also free to make decisions about food choices Tend to have more risk factors: No regularly scheduled physical activity Weight gain, hypertension & hyperlipidemia related to medications Lack of primary care provider Slide 27 Barriers to Glycemic Control Alcoholics Increased risk for hypoglycemia if taking insulin or most oral agents Impaired judgement related to diabetes management and food choices Increased levels of triglycerides Increased risk of complications especially pain related to neuropathy Hypoglycemia symptoms may be confused with intoxification and not treated Increased risk of seizures and cardiac arrythmias Slide 28 Strategies to Overcome Barriers Slide 29 Barriers to Glycemic Control Addiction Denial is a large part of addition and diabetes Impact of illicit drugs on blood glucose levels are not well studied except for anecdotal data Cocaine and marijuana thought to increase blood sugar levels Ecstasy due to high energy levels, may not recognize need to eat Withdrawal symptoms may impede eating Lack of structure in life to facilitate regularly scheduled meals and blood glucose testing. Increased risk of complications Slide 30 Strategies to Overcome Barriers Diabetes education Individual Frequent short contacts Educator must have good understanding of this population Financial Bring diabetes education to mental health sites Develop healthy meal plans and have client review sale flyers and complete shopping list Farmers Market for fresh produce (in season) Slide 31 Medication Complete Diabetes Risk Screen Consider Risk vs Benefit in relation to diabetes risk Encourage lifestyle changes to minimize side effects Physical Activity Plan physical activity for when client has higher energy (i.e. evenings) Walking meetings with clients Encourage walking when out on local trips Posters with suggested stretching exercises Y scholarships Strategies to Overcome Barriers Slide 32 Low Self Esteem Encourage clients with good understanding of healthy lifestyle to take leadership role with groups Peer Pressure/Group Decision Making Community support workers and DSP provide coaching to clients to encourage clients to make healthier meal choices Purchase cookbooks with nutritional information included in recipes Client Rights Support for healthy behaviors so behavior will be repeated Strategies to Overcome Barriers Slide 33 Living Situations Possibility of locked cabinets so clients with diabetes are able to keep healthy snacks available Carb education posters in eating areas Stock vending machines with water and diet soda Encourage clients to test blood sugar at bedtime to prevent lows during the night Lack of primary care provider Assist client to obtain a provider and review expectations about missed appts Advocate for clients with pcp office concerning missed appts HIPPA release if necessary Strategies to Overcome Barriers Slide 34 Mental Health Medications Slide 35 Depression Treatment Fluoxetine (Prozac) Citalopram (Celexa) Sertaline (Zoloft) Paroxetine (Paxil) Escitalopram (Lexapro) Slide 36 Anti-Anxiety Treatments Clonazepam (Klonopin) Lorazepam (Ativan) Alprazolam (Xanax) Buspirone (Buspar) Slide 37 Me tabolic Effects of Antipsychotic Medications Relative Risk for Metabolic Side Effects Weight GainDiabetesWorsening Lipid Profile Clozapine+++++ Olanzapine+++++ Quetiapine+++/- Risperidone+++/- Ziprasidone+/--- Aripiprazole+/--- Slide 38 Schizophrenia & Bipolar Treatment Clozaril (Clozapine) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) Aripiprazole (Abilify) Highest Risk Medium Risk Low Risk Slide 39 Treatment Considerations Risk vs Benefit Risk Screen for Diabetes If patients develop symptoms of hyperglycemia, serum glucose should be obtained. If overweight with normal glucose level, consider referral to dietician for weight reduction If overweight with elevated glucose level, consider referral to endocrinologist and/or diabetes education which includes dietician Slide 40 Improved Diabetes Care Adopting a health screen for consumers with SMI Collecting data on consumers health, exercise, health risk behavior, and relationship to primary care Linking consumers to a welcoming primary care practice, preferably with case managers Training the mental health workforce on the health status and needs of consumers Slide 41 Improved Diabetes Care Collaborating with community resources such as the Cooperative Extension Service, Healthy Maine Partnerships, and food pantries Setting up diabetes education for MH staff Setting up diabetes education for consumers Adapting diabetes education and support models to better fit people with SMI Slide 42 Case Studies Slide 43 Case Study #1 Paul is a 32 yr old male who has a 14 yr history of drug addiction. His father is an alcoholic who has been in and out his life since he was a baby but has provided no financial or emotional support. His estranged from his mother and 2 siblings. He is currently living with his girlfriend and her 7 yr old daughter. He has been clean for the last six months and goes to a methadone clinic daily. He was diagnosed with Type 2 diabetes five years ago but his diabetes management has been sporadic at best although he did lose 50 lbs likely related to drug abuse. Slide 44 Case Study #1 Due to drug withdrawl, he often experiences morning nausea and vomiting and often is only able to eat one meal per day. He is not working and does not have a car. Finances are limited and patient will likely have to move out of his girlfriends house since their relationship has deteriorated. He does have a primary care provider who he has a good relationship with but if he and his girlfriend break up, he has no transportation to the office. He has been working on his MaineCare application but has missed several deadlines and has not produced needed paperwork. Slide 45 Case Study #2 Jane is 34 yr old female who presents for insulin management and DSMT education. Patient was diagnosed with diabetes but wasnt told whether she had Type 1 or Type 2 and was started on basal and bolus insulin. Patient is currently between primary care providers and therefore is not able to obtain an endocrinology referral. Patient lives with her 7 yr old son and her boyfriend Slide 46 Case Study #2 Patient lives in an area with minimal public transportation other than one transportation service for MaineCare patients so getting to appointments is a challenge for her. Patient has multiple mental health issues including PTSD, anxiety disorder and bipolar. She is disabled. Patient does not understand carb counting so she tends to eat the same foods so I dont have to look up the carbs. She no showed the scheduled appointment with the RD CDE. She is receiving conflicting information about whether she needs to limit her carbs or only count them. She has lost 20 lbs in the last 6 months. Slide 47 Case Study #2 Initially blood sugars went often over 400 but more recently have been under 200 approximately 40% of the time. Patient does not have much insight into the cause of the elevations although she admits she missed insulin doses. When patient is questioned, becomes upset and tearful saying she thought she was doing better. Patient is overwhelmed by the diagnosis and has been hospitalized twice since the original diagnosis. She states she doesnt feel like she can get any support unless she hurts herself. Slide 48 The End