Managing Diabetes in People with Severe Mental Illness

Why the Risk Is Higher

• Medication effects antipsychotics (especially olanzapine, clozapine) and some mood stabilisers can cause weight gain, insulin resistance and dyslipidaemia.
• Lifestyle factors higher rates of smoking, sedentary behaviour, poor diet and disrupted sleep patterns.
• Biological links chronic stress, inflammation and hypothalamicpituitaryadrenal axis dysregulation associated with SMI can impair glucose metabolism.
• Healthcare disparities reduced access to routine screening, fragmented services and stigma often delay diagnosis and treatment.

Screening and Early Detection

Guidelines recommend annual metabolic monitoring for all adults on antipsychotic medication. Key measures include:

• Fasting plasma glucose or HbA1c
• Weight, BMI and waist circumference
• Blood pressure
• Lipid profile

Integrate these checks into psychiatric appointments or community mental health visits to minimise additional appointments.

Individualised Treatment Plan

1. Medication Review

When possible, consider switching from highrisk antipsychotics to agents with a more favourable metabolic profile (e.g., aripiprazole, ziprasidone). Any change must be balanced against psychiatric stability and done in consultation with the prescribing psychiatrist.

2. Lifestyle Interventions

Evidence shows that modest weight loss (510% of body weight) can markedly improve insulin sensitivity.

• Nutrition: Offer simple, culturally appropriate advice increase fibre, reduce sugary drinks, choose whole grains and lean protein. Referral to a dietitian experienced with SMI is ideal.
• Physical activity: Encourage at least 150minutes of moderate aerobic activity per week, broken into short sessions (1015min) if needed. Groupbased exercise programmes can improve motivation.
• Smoking cessation: Nicotine increases insulin resistance. Provide behavioural support and consider nicotinereplacement therapy.

3. Pharmacologic Diabetes Management

Firstline oral therapy is metformin, which also aids modest weight loss. Dose titration should start low (500mg daily) and increase to 1,000mg twice daily as tolerated. For patients with significant hyperglycaemia or contraindications to metformin, consider adding a secondline agent such as a GLP1 receptor agonist, which can further promote weight loss. Insulin may be required for advanced disease but should be introduced with clear education and support.

Addressing Barriers to Adherence

Patients with SMI often face challenges that impede regular medication use and selfcare.

• Memory and organisation: Use pillboxes, smartphone reminders, or involve a support worker.
• Sideeffect concerns: Discuss potential hypoglycaemia, gastrointestinal upset, and weight changes openly; make adjustments promptly.
• Healthliteracy: Provide information in plain language and use visual aids. Revisit concepts regularly.
• Stigma and trust: Foster a therapeutic alliance, involve peersupport specialists, and respect patient autonomy.

Coordinated Care Models

Integrated services that bring together psychiatry, primary care, diabetes educators and social workers achieve the best outcomes.

• Shared electronic health records allow every team member to see latest labs, medication changes and appointment notes.
• Joint clinics a mentalhealth clinician and a diabetes nurse practitioner see the patient together, reducing duplicate visits.
• Carecoordination roles a designated case manager can schedule appointments, arrange transport, and follow up on test results.

Monitoring and Ongoing Review

Regular review intervals are essential:

• Every 3 months HbA1c, weight, blood pressure, medication sideeffects.
• Every 6 months lipid profile, kidney function, retinal screening.
• Annually comprehensive foot exam and discussion of longterm goals.

Adapt the plan as mental health status changes; for example, a depressive episode may reduce activity levels and necessitate tighter glucose monitoring.

Support for Caregivers and Families

Education of families improves adherence and early detection of problems.

• Teach them to recognise signs of hyper or hypoglycaemia.
• Encourage involvement in grocery shopping and meal preparation.
• Provide resources on local peersupport groups for both mental health and diabetes.

Key Takeaways

1. People with SMI are at higher risk of diabetes due to medication, lifestyle and biological factors.
2. Annual metabolic screening must be embedded in psychiatric care.
3. Management is most effective when it combines medication review, lifestyle support, appropriate diabetes drugs and coordinated multidisciplinary care.
4. Addressing practical barriers memory aids, healthliteracy, stigma is essential for adherence.
5. Regular monitoring, flexible plans and caregiver involvement sustain longterm success.

Further Resources

• National Institute for Health and Care Excellence (NICE) guideline NG28 Diabetes in adults: management.
• American Diabetes Association Standards of Care 2024, Chapter on Diabetes and Mental Health.
• World Health Organization Integrated care for mental health and noncommunicable diseases.
• Local mentalhealth authority diabetes liaison team (contact details vary by region).