Those living with mental disorders face a more daunting road to recovery once they receive a diabetes diagnosis.
For starters, they’re much more likely to develop the disease in the first place. And, once they do, they’re also a lot less likely to receive the routine monitoring and the latest treatments.
That’s the conclusion of a sweeping new systematic review and meta-analysis published online this week in The Lancet Psychiatry, which examined diabetes care across more than 5.5 million people worldwide.
The findings suggest that gaps in care – more so than any behavior – might help explain why people with mental illness die earlier from cardiometabolic disease.
Methodology
Researchers analyzed data from more than four dozen cohort and case-control studies conducted across Australasia, Asia, Europe, and North America. About 15% of the participants reported a diagnosed mental disorder, which ranged from depression to dementia to schizophrenia. Most of them also had type 2 diabetes.
Across that diverse population, a single pattern emerged. People with mental disorders were less likely to receive recommended diabetes monitoring. More specifically, compared with individuals without mental illness, they had reduced odds of undergoing HbA1c testing, retinal eye exams, kidney function checks, cholesterol measurements, and foot examinations.
Bottom line? The authors conclude that having any mental disorder slashed the likelihood of receiving recommended diabetes monitoring by 19%. These gaps persisted despite multiple sensitivity analyses.
“This is the first comprehensive synthesis to map diabetes quality-of-care indicators to established benchmarks,” the authors write, noting that earlier studies often produced inconsistent or fragmentary results.
The inconsistencies extended beyond monitoring to treatment patterns – especially when it came to newer therapies. People with mental disorders were also far less likely to receive GLP-1 receptor agonists. In the pooled analysis, patients with mental illness had roughly one-quarter the odds of receiving a GLP-1 agonist compared with those without a psychiatric diagnosis.
At the same time, they were much more likely to receive an insulin treatment. That pattern persisted for both the overall mental disorder group and for those with more severe mental illness, such as bipolar disorder or schizophrenia.
But Why?
The explanations are complex as they are varied. Higher insulin use could reflect a more advanced disease state by the time patients enter care, longer periods of untreated diabetes, or differences in diabetes subtype.
And less reliance on GLP-1 agonists could be the result of cost barriers, an overabundance of prescriber precaution, or nagging concerns about psychiatric side effects (regardless of likelihood).
Notably, the review found that people with mental disorders used physical health services more often than those without. This, of course, hints that access to care isn’t the primary obstacle. Instead, the authors argue, care fragmentation and clinical complexity might prevent that contact from translating into effective diabetes management.
The disparities varied by diagnosis. Severe mental illness translated to lower rates of retinal and foot examinations. Major depressive disorder, for example, was associated with reduced foot exams and lower use of antihypertensive medications. Dementia stood out as particularly high risk, with dramatically lower rates of HbA1c testing, eye exams, and kidney monitoring.
Country-level analyses suggested that health system design makes a huge difference. Huge monitoring gaps stood out in studies from Denmark, Finland, France, and Australia. Results from the United Kingdom and the United States appeared to be less straightforward. In one U.S. Medicaid study, researchers struggled to identify similar disparities. This could suggest that coordinated care structures can close the gap.
Conclusions?
The findings echo a growing consensus in mental and physical health research that excess mortality among people with mental illness isn’t a foregone conclusion. How health systems are organized, how the care is coordinated, and which patients benefit from medical advances are all mitigating factors.
“Addressing these disparities has the potential to reduce the increased mortality associated with mental disorders,” the authors conclude.
The authors call for targeted interventions to improve diabetes monitoring and equitable access to newer therapies – GLP-1 agonists, in particular – among people with mental illness.
They also reinforce the need for large, real-world trials that test integrated care models capable of delivering high-quality diabetes care within psychiatric and primary-care settings.
At a time when diabetes treatments are rapidly evolving (and improving), the study offers a crucial reminder. Innovation doesn’t guarantee equity. Without massive efforts to bridge mental and physical health care, some of the patients who need help the most will find themselves left behind, maintaining a grim status quo.
Further Reading
Managing Weight, Metabolic Syndrome, and Diabetes in Schizophrenia Patients
Semaglutide Injections Boost Metabolic Health in Schizophrenia
