Best Practices: Optimizing Care for People With Serious Mental Illness and Comorbid Diabetes

Innovative methods that combine cognitive and social approaches might improve both mental health outcomes and general medical outcomes among people with serious mental illness and diabetes. We have developed a group-based psychosocial treatment that blends psychoeducation, problem identification, goal setting, and behavioral modeling and reinforcement. The intervention—Targeted Training in Illness Management (TTIM)—has been adapted to the primary care setting and is targeted at individuals with serious mental illness and diabetes. A key feature of the intervention is the use of peer educators with serious mental illness and diabetes to teach and model self-management. Groups are co-led by nurses with expertise in diabetes management.

Among individuals with serious mental illness, the effects of medical comorbidity, including diabetes and related conditions, are devastating, including a reduction in life span of approximately 25 years. Although no treatment approach can address all barriers to good outcomes, approaches that may be particularly successful include the following. First, location in a primary care setting can take advantage of the ability to monitor diabetes, manage crises, and integrate the intervention with ongoing primary care. Although it could be argued that the intervention would be just as effective if located in a mental health setting in which the appropriate infrastructure was present, it is likely that this would be more costly and require greater modifications to most existing care settings than is practical. Second, peers who have serious mental illness and diabetes can model and support recovery efforts. Not only is the use of peers effective, but it takes advantage of strengths in the community, including cultural matching that may enhance recovery efforts. Individuals with serious mental illness and diabetes often feel isolated and marginalized because they are unaware of the wide prevalence of serious mental illness and diabetes and they know few individuals who effectively comanage these serious comorbid illnesses.

A third important element is a focus on self-management. For some individuals with serious mental illness and diabetes, interacting with others who have the same illnesses can be transformative and empowering, motivating them to become more active in their own care and leading to substantial improvements in depression, psychosis, and metabolic parameters. Fourth, the most practical approaches should use staff who are already likely to be present in a care system. As with our intervention, use of diabetes nurses who are already embedded in many primary care settings requires only an incremental increase in training and effort to target a population that is likely present in these clinics but that may be underserved.

Although conducting an intervention that involves nurses or other clinicians, peer educators, and groups of patients with serious mental illness and diabetes imposes a fairly extensive organizational burden (such as the need to schedule and implement groups, train peer educators, and follow-up with participants over a period of at least several months), the changes in outcome could save health care entities time and resources in the long run through reduced need for medications, emergency room visits, and hospitalization.

Few interventions specifically focus on individuals with serious mental illness and diabetes, and fewer still are practical for implementation in real-world settings. Given the enormous burden caused by serious mental illness and diabetes, there is a critical need for further exploration and development of multidimensional approaches that concurrently target mental health and general medical health. TTIM, which energizes individuals to take an active role in their own care and which concurrently addresses both mental health and general medical health, is an example of an emerging best practice. Research is needed on service models that holistically address the health needs of persons with serious mental illness and diabetes. In addition, health policy makers should develop better ways to serve people who may receive mental health treatment and general medical care in different locations by helping providers to implement these best practices and compensating systems that do so.

This study was supported by a Bridge Funds grant from Case Western Reserve University (CWRU) School of Medicine and the Department of Psychiatry, University Hospitals Case Medical Center, and by grant UL1RR024989 from CWRU Clinical and Translational Science Awards (CTSA). The CTSA is a component of the National Institute of Health (NIH) and NIH Roadmap for Medical Research. The contents of this report do not necessarily represent the official view of the National Center for Research Resources or the NIH.

Dr. Sajatovic has received research grants from GlaxoSmithKline, AstraZeneca, Pfizer, Merck, and Ortho-McNeil Janssen; she is a consultant to the Cognition Group and to United Biosource Corp. The other authors report no competing interests.