Disease Management in Homeless Mentally Ill Diabetics: A Review.
Kelly Johnson
Department of Nutritional Sciences
The University of Texas at Austin
338W Issues in Nutrition and Health
Spring 2013
ABSTRACT
Background and Objectives: Of the more than 1.24 million homeless adults in 2010, 26.2% had a serious mental illness. There is an increasing amount of literature that link type two diabetes mellitus to various mental illnesses. The purpose of this review is to examine the literature on mentally ill diabetics and homeless diabetics to draw parallels in order to create programs that better target the combined population.
Design/Methods: Articles on caring for either homeless diabetics or mentally ill diabetics were collected using PubMed and PMC search engines. Inclusion criteria were human trial original research articles published after 2002. Exclusion criteria were any articles that did not address care or management of the disease, and articles that dealt with physiological link between diabetes and mental illness.
Results: Six articles testing different interventions or calling for a new intervention were gathered and analyzed. Five of the articles showed statistically significant results in HbA1c levels, fasting glucose levels, hospital/medication use or some combination of the four. The homeless diabetic population seemed to benefit from the use of an insulin pen, a homeless oriented clinic, and a more structured systematic approach to care. The mentally ill diabetic population seemed to benefit from an increased focus on medication adherence, a focus on more frequent clinic visits and a mentally ill tailored education program.
Conclusion: An intervention for the combined population could include a focused approach to medication adherence, more frequent contact with a primary care physician, and orienting education around the particular needs of the mentally ill/homeless diabetic population.
INTRODUCTION
In 2010 there were 25.8 million people in the United States with type two diabetes mellitus (T2DM), a number that grows every year [1]. Although it is difficult to obtain data due to a reduced utilization of or access to clinics, the US homeless population likely has a proportionally higher rate of T2DM than the general population [2, 3]. Diabetes is a difficult disease to manage in a stable environment. A homeless diabetic often experiences barriers to planning glucose intake and managing medication and exercise around the instability of their daily life. They face difficulty keeping their stress levels low, their insulin stored at the proper temperature, and managing their co-morbidities such as retinopathy and mental illness [4].
Among the more than 1.24 million adults who spent at least 1 night in an emergency shelter or transitional housing program in 2010, 26.2% had a serious mental illness [5]. There is an increasing amount of literature that ties T2DM to various mental illnesses [6]. Research has shown both that diabetes management can cause increased anxiety and depression and that some mental illnesses could be a risk factor for diabetes independently [7]. A person with schizophrenia could be twice as likely to have diabetes compared to someone without a mental illness [8]. Not only can diabetes and mental illness be causally linked, the presence of a mental illness such as depression may increase mortality and decrease quality of life during the course and management of diabetes [9, 10]. A diagnosis for T2DM under these conditions could be a very difficult disease to manage.
Type 2 diabetes mellitus and many of its effects can be significantly slowed or even reversed by a healthy lifestyle and careful planning of glucose consumption, exercise, and sometimes insulin administration. A unique healthy lifestyle educational program that is tailored to individuals with schizophrenia has shown favorable results [11].
There are no studies done that focus on diabetic management or care in the mentally ill/homeless population. The purpose of this review is to examine both the literature on mental illness and diabetes and the literature on homelessness and diabetes to draw parallels that may help create programs that better target the mentally ill/homeless population in their diabetes management and care.
METHODS
A search was conducted for articles that covered the topic of diabetic care and management in homeless populations and diabetic care and management in populations with mental disorders. All of the six original research articles chosen covered the topics individually with minimal crossover (whether stated or not) in that some of the homeless population had a mental disorder and some of the mental health clients were homeless. The articles were published between 2002 and 2011 and were collected using PubMed and PMC. Keywords searched included diabetes, homelessness, T2DM, mental disorders, mentally ill, schizophrenia, type 2 diabetes, management, care, shelter, and insulin. Exclusion criteria included any articles on the subject before 2002, review articles, articles that did not address care or management of the disease, and articles that dealt with the physiological link between diabetes and mental illness. Inclusion criteria were human trials and original research articles.
RESULTS
Because this review focused on T2DM, the six studies had an average participant age range of 45 to 55 [12-17]. Four of the studies were less than a year in duration [12-14,16] and four of the studies had over 80% male participants [12,13,16,17]. The number of participants in the six studies ranged from 13 to 17,045. Four of the studies measured successful diabetic care outcomes by HbA1c levels [12-15], one measured successful diabetic care outcomes by fasting glucose levels [16] and one measured quality of care by adherence to medication [17]. Two of the studies measured satisfaction of care through surveys [12,16] while two others measured quality of care through the amount of hospital and emergency department visits. Four of the studies tested a new method of care [12-14,16] while two looked at disparities between urban vs. suburban and schizophrenic vs. non-schizophrenic populations in level of care and management and suggested new methods to be tested as a result of their findings [15,17].
Blood Labs
Homeless: At the end of the prospective cohort study implementing the use of insulin pens vs. traditional vial and syringe insulin injection methods, HbA1c levels showed a statistically non-significant decrease of 1.44% from 10.36% to 8.92% after a period of six months (p=0.087 vs. baseline) [12]. HbA1c levels of the intervention group at the end of the retrospective prolective cohort study implementing a new homeless oriented primary care protocol showed a decrease of 2.3% while the control group showed an increase of 0.2% (p=0.03) [13]. The new homeless oriented primary care protocol differed from the control protocol by including open access to clinics, assigning a consistent primary care provider to the participants and integrating homeless specific services onsite [14].
In the retrospective cohort study that implemented the Chronic Disease Electronic Management System (CDEMS) into health centers providing care to at risk populations, the percentage of HbA1c levels at <7% grew from 31-39% (p=<.05) [14].
Mentally Ill: In the prospective cohort study focusing on a mentally ill centered diabetes education, nutrition counseling, and exercise instruction, 27% of the participants at baseline were within ADA guidelines of fasting glucose levels [16]. After six months of intervention, 40% of fasting glucose measurements were within the guidelines [16].
Hospital/Medication Use
Homeless: In the retrospective prolective cohort study that looked at a homeless oriented primary care protocol vs. the traditional method, the number of primary care visits/person in the first six months were 5.96 vs. 1.63 for the control group and in the second six months were 2.01 visits to 1.31 in the control group (p=0.05) [13]. In the same study they measured the percentage of emergency department visits that were a non-emergency [13]. They found that in the second six months a 13.2% proportion of emergency department visits by the intervention group were non-emergencies compared to 38.6% of the control group (p< .01)[13].
Mentally Ill: In a population based longitudinal study advocating more focused primary care in mental health clients, those who had diabetes were at an increased risk of hospitalization (45.2% vs 45.0% for non mental health clients, adjusted OR/RR=1.20) and were seen to have a decreased use of recommended pathology tests (37.2% vs 42.9% for non mental health clients, adjusted OR/RR=0.84) [15]. In the retrospective cohort study focusing on adherence to medication, 43% of diabetic patients with schizophrenia were categorized as nonadherent while 52% of diabetic patients without schizophrenia were categorized as nonadherent (p< .001) as defined by filled prescriptions from the hospital [17].
Participant Satisfaction
Homeless: In the prospective cohort insulin pen study, 88% of the participants said that using the pen was convenient and many were reported to have anecdotally expressed satisfaction with the pen [12].
Mentally Ill: In the prospective cohort study focusing on regular diabetes education, nutrition counseling, and exercise instruction, the residents reported a satisfaction rating (from the Diabetes Empowerment Scale Short Form) of 4.33 on a 5 point scale. They also reported a rating of 4.33 on their self-efficacy to feel better about having diabetes and 3.78 on their self-efficacy to ask for support in the caring of their diabetes [16].
DISCUSSION
Because mental illness and homelessness often go hand in hand, it is important to begin looking at what could be cross-over interventions to lower HbA1c levels and reduce diabetic complications. All of the studies in this review showed either potential successful interventions or proved a need for a certain type of intervention. Five articles in the review showed decreases in HbA1c or fasting glucose levels, decreases in hospitalization, or decreases in emergency department use [12-16]. For the homeless, these interventions included switching from a vial and syringe to an insulin pen [12], switching to a primary care system that focused on a homeless oriented care approach [13], and switching to a more systematic primary care approach which included reaching out to patients, providing incentive to physicians to meet target indicators and access to a computerized diabetes patient registry [14]. For the mentally ill, these interventions (or proposed interventions) included special attention to mental health clients at the primary care level [15], regular diabetes education classes , nutrition counseling, exercise instruction [16], and special attention to nonadherence of medications in the mentally ill population [17].
Some apparent successful interventions common to both homeless and mentally ill populations include a focused approach to medication adherence [12,17], more frequent contact with a primary care physician [13,14,16], and orienting education around the unique needs of the population [12-17]. Another tactic that seemed to benefit at least the homeless population was offering additional incentive to both the client and the physician for improved blood glucose levels [14]. The studies showed that both homeless and mentally ill populations were underserved in the health care world resulting in negative results in the health of the population and in the financial aftermath [14,15].
Although on the surface these studies seem to have statistically significant results that could lead to a new intervention, many of them have room for improvement. Most of the articles in this review are retrospective [13,14,16]. A disadvantage of using a retrospective study for the validity of the results is that the controls can be selected with bias. Because of the nature of the studies there also could have been a bias in recall or in selection. Some of these studies also used the same sample as their own control [12,16]. A better design for these studies would have been to match them with an external control group in order to see more clear results. Another potential source of error is that the sample size was usually very small, especially in the homeless studies [12,13,16]. A larger sample size could produce more convincing evidence. The last and most obvious problem with these articles in answering the question of what sort of intervention would be best for this population is that they only focus on either homelessness or mental illness and diabetes [12-17]. A preferable study design would include both.
Because of the varying nature of the studies in statistical significance, number of participants, and focus of research, the results did not lend themselves to a detailed intervention program. The results do however provide a basic outline and a great starting point for more research on a cross-over intervention program to control blood glucose levels and diabetic complications in the homeless mentally ill population. Taking mental illness into consideration when performing interventions on homeless populations may prove to give extremely effective results and may be the missing link to many of the studies in this review.
CONCLUSION
Intervention programs for mentally ill homeless diabetics should center around a more focused approach to care that takes into consideration the populations specific barriers to good health. Future research efforts should focus on testing focused diabetic interventions in a homeless population while noting specific mental diseases. Because the homeless population and the mentally ill population are taxing on our healthcare system, an intervention that keeps them out of the hospitals and emergency departments and into the clinics receiving primary, preventative care is a necessary step in the search for low cost universal health care and would benefit the population’s quality of life greatly.
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