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BACKGROUND: Premature mortality due primarily to cardiovascular disease in those with schizophrenia is the largest lifespan disparity in the US. Twenty percent of people with SMI have diabetes, a major driver of cardiovascular mortality, however very little evidence exists to guide management of diabetes in this population. We tested a behavioral group intervention to improve diabetes knowledge, activity level, diabetes self-management skills and self-efficacy for managing diabetes, using a reverse integrated care model, bringing diabetes expertise into the community mental health setting. The primary outcome was change in hemoglobin A1c (HbA1c) following the 16-week behavioral intervention. METHODS: Sixty-one adults with SMI and either HbA1c >6.5, HbA1c>6.0 and on metformin, or with known diagnosis of diabetes gave informed consent and were randomly assigned to initial 16-week group program or wait list control followed by group program. Paired t-tests were conducted to evaluate within-subject change during the 16-week intervention. Planned sub-group analyses were conducted for subjects whose baseline measurements met criteria for high risk (e.g., HbA1c>6.5, systolic blood pressure >130mmHG). RESULTS: Thirty individuals (49%) were considered to have been exposed to the intervention, defined as attendance at a minimum of five groups, and were included in the analysis. Mean HbA1c was 7.4 at baseline and 6.87 at the end of the intervention (t=-2.56, DF=29, p=0.016). Patients with baseline HbA1c >6.5 had a mean HbA1C of 8.0 at baseline and 7.3 at 16 weeks (t=-2.44, DF=20. p=0.024). Mean weight at baseline was 222lbs and 219lbs at week 16 (t=-2.04, DF=29. p=0.05). There were no pre-post changes in blood pressure overall. However, systolic blood pressure for those with baseline >130mmHg was reduced from 138.8 to 125.8, (t=-3.94, DF=13. p=0.002) and diastolic blood pressure for those with baseline >80mmHg was reduced from 90.8 to 79.8, (t=-4.25, DF=14, p=0.001). Patients with an average step count (steps/day) below 5000 showed an improvement of 2056 steps/day (p=0.036). Significant improvements were additionally seen in measures of diabetes knowledge (t=2.64, DF=27, p=0.013). DISCUSSION: This reverse-integrated care behavioral intervention was feasible in a community mental health setting, well-accepted, socially relevant, and effective in those exposed to the intervention, resulting in a 0.53-point reduction in HbA1c for the entire sample and a 0.7 point reduction in HbA1c for those with the poorest glycemic control. A larger multi-site trial of the intervention is needed to validate the efficacy of the intervention that, if replicated, could significantly reduce the morbidity and mortality associated with diabetes in those with SMI. |
