Drug-induced Diabetes “One More Burden for the Mentally Ill”

The truth, however, is inescapable-the cover-up no longer sustainable as
thousands of patients with drug-induced diabetes come out of the shadows.

Clozapine (Clozaril) and its far more widely prescribed first-cousins,
olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel) and
ziprasidone (Geodon)-are inducing a debilitating, lethal disease–diabetes.
The New York Times reports "Studies have indicated that dozens of these
patients died from diabetes-related complications."

Indeed, diabetes is a chronic debilitating lethal disease:
In 1985 "the diabetes mortality rate was 8.5 per 100,000 person-years with
diabetes as the underlying cause of death, 31.5 per 100,000 person-years
with diabetes as an underlying or contributory cause, and 82.7 per 100,000
person-years if all deaths among diabetic individuals were counted." [1]

In 2003, "Of 10 152 total deaths in 1970-1994, 1384 (13.6%) met the criteria
for prevalent diabetes mellitus..The mortality burden associated with DM
increased significantly between 1970 and 1994." [2]

These antipsychotics are the very drugs recommended in psychiatry’s
prescribing manuals as first line treatments.
The Times report evades
entirely the matter of responsibility borne by these drugs’ manufacturers,
psychiatry’s leadership and institutions that have, for over a decade,
promoted the increased use of these drugs–even for children as young as
two. They have done so while concealing the deadly effects produced by the
drugs.

Dr. Donna Ames Wirshing, a psychiatrist at the West Los Angeles Veterans
Administration Medical Center acknowledges that: "Most psychiatrists barely
look at their patients."  When she asked 30 psychiatrists how many monitored
their patients’ weight by weighing them; 3 hands went up.

To his credit, Dr. Jeffrey Lieberman, Chairman of psychiatry at Columbia
University, a foremost schizophrenia researcher and an early enthusiastic
promoter of Clozapine and the atypical antipsychotics that followed, appears
to have turned a corner. After analyzing thedata -which has yet to be
released-from the government-sponsored, CATIE study, he has acknowledged the
drugs’ lethal effects:

"It’s bad enough that these people have mental illness, and then they take
treatments and they bring on diabetes..Sort of a cruel irony in this is that
all of the drugs do it to some degree, but the ones that have the most
effect cause the most weight gain and metabolic side effects. There’s
increasing discomfort that these are driving up deaths and lowering quality
of life."

But other influential psychiatrists continue to keep their eyes shut, lest
their corporate grants and consultancies received from these drugs’
manufacturers dry up.  Indeed, Dr. Gail Daumit, an assistant professor of
medicine at Johns Hopkins observed: "Psychiatrists are literally watching
patients balloon up before their eyes."

This demonstrates how little psychiatrists understand (or care about) real
medical diseases and the prevention of such diseases. Mental disorders do
not meet the definition of physical, medical diseases, and psychiatry lacks
basic scientific tools.

In 2000, Dr. John Geddes of Oxford analyzed 52 published reports involving
12,649 patients, noting that the claimed benefits were fraudulent: the
studies were rigged by comparing "excessive doses" of the comparator drug
(Haldol) to the newly marketed drugs. Thus, Dr. Geddes concluded:  "there is
no clear evidence that atypical antipsychotics are more effective or are
better tolerated than conventional antipsychotics."
[3]

We challenge those psychiatrists who continue to claim that "These drugs are
enormously beneficial," as if the benefits outweigh the lethal effects, to
show evidence. 

The Big Lie about these deadly drugs was disseminated by an interdependent
juggernaut: At the apex are the manufacturers of psychotropic drugs,
followed by the beneficiaries of these companies largesse:  

1. psychiatrists and their professional organizations-including the American
Psychiatric Association, the American College of Neuropsychopharmacology,
American Academy of Child and Adolescent Psychiatry;
2. state mental health systems;
3. industry-funded support groups and organizations that claim to be
"patient advocates;" 4. government oversight and funding agencies-including
the FDA, the National Institute of Mental Health, the Substance Abuse and
Mental Health Services Administration, and the Veterans Affairs
Administration;
5. medical journals that publish fraudulent, biased reports;
6. the media that has grown dependent on drug advertising  

When confronted with the indisputable harm resulting from antipsychotic
drugs, Dr. Kenneth Duckworth, medical director for the National Alliance on
Mental Illness (no longer called National Alliance for the Mentally Ill)
answers like a well-trained robot who has been programmed to look at the
world through drug industry lenses. Thus, he accepts the death sentence
dealt to patients rather than question the drug-focused paradigm that is
killing them.
"I think the field has been passive. We viewed [drug-induced diabetes] it
that we do symptoms and you run your life."

References:
1. JW Ochi, LJ Melton, PJ Palumbo and CP Chu , A population-based study of
diabetes mortality Diabetes Care, Vol 8, Issue 3 224-229, 1985.
2. Randal J.  et al, Trends in the Mortality Burden Associated With Diabetes
Mellitus: A Population-Based Study in Rochester, Minn, 1970-1994
Arch Intern Med. 2003;163:445-451.
3. Geddes, J, "Atypical Antipsychotics in the Treatment of Schizophrenia:
Systematic Overview and Meta-Regression Analysis," British Medical Journal,
2000, 321:1371-1376.

Contact: Vera Hassner Sharav
veracare@ahrp.org

http://www.nytimes.com/2006/06/12/health/12diabetes.html?
THE NEW YORK TIMES
June 12, 2006
In Diabetes, One More Burden for the Mentally Ill
By N. R. KLEINFIELD

Dr. John Newcomer is a psychiatrist who generally treats people with severe
ailments of the mind and spirit. But before his patients sit down, before he
hears about their clammy paranoia or renegade voices, Dr. Newcomer wants to
know about their waist size.

He steers them to a scale to learn their weight. He orders a blood sugar
test. If big numbers come up, he begins a conversation about Type 2 diabetes
, a disease associated with obesity  that is appearing with alarming
frequency among the mentally ill.

"Uncontrolled diabetes can ruin a person’s life as much as uncontrolled
schizophrenia ," said Dr. Newcomer, a professor of psychiatry at Washington
University  School of Medicine in St. Louis.

In fact, among the mentally ill, roughly one in every five appear to develop
diabetes – about double the rate of the general population. This is a
little-recognized surge, but one that is jolting mental health
professionals into rethinking how they care for an often neglected
population.

For decades, psychiatrists have worried primarily about patients’ mental
states, making sure they did no harm to themselves or others because of
unrelenting voices or a smothering depression.

Far more of the mentally ill, however, die today from diabetes and
complications like heart disease  than from suicide. Given that mental
health specialists are often the only doctors a mentally ill diabetic ever
sees, some have begun to debate the customary limits of psychiatric
practice, deciding to pay much more attention to physical ailments.

In particular, psychiatrists must confront the fact that diabetes, marked by
dangerously high blood sugar, is often aggravated, if not precipitated, by
some of the very medicines they prescribe: antipsychotic pills that have
been linked to swift weight gain and the illness itself.

"It’s bad enough that these people have mental illness, and then they take
treatments and they bring on diabetes," said Dr. Jeffrey Lieberman, chairman
of the psychiatry department at the Columbia University  College of
Physicians and Surgeons.

Treating the diabetic mentally ill can be formidable. The regimen of blood
testing, dieting  and exercise that controls Type 2 diabetes is often beyond
the attentions of the mentally ill. For patients, the task of taming two
debilitating illnesses can haunt their lives. Michael Schiraldi, 44, a
Manhattan man who has both schizoaffective disease and diabetes, said his
mental illness, now stabilized, was the lesser of his concerns.

"I can’t really control the diabetes," he said. "I might die from it."

The doctors who regard diabetes as a galloping threat to the mentally ill
acknowledge that many in their profession still dispute, or ignore, its
consequences. Dr. Newcomer said colleagues often whine about how hard it is
to weigh patients. " ‘Oh’, they’ll say, ‘there’s no scale’ or ‘It’s in a
closet someplace,’ " he said.

Yet he says he hopes other doctors will eventually share his perspective as
diabetes expands among the mentally ill and deepens into an even graver
problem.

Betrayals of Body and Mind

Carole Ernst doesn’t know how she got diabetes.
Genes? Her mother had it.
Lifestyle? She eats more than she should, exercises less than advisable.
Or was it the pills that shushed the TV?
The TV no longer speaks to her. She stared levelly at the set in her messy
room. It was blessedly quiet.

She is 53 and has battled mental illness since childhood. The pills for her
illness, diagnosed as schizoaffective disorder, have helped. But she feels
they have also made her fat around her abdomen, the kind of fat that can
lead to diabetes.

So even though Ms. Ernst feels better mentally – she no longer imagines
everyone despises her – diabetes has been a crippling insult to her troubled
psyche. In the late hours, alone in her room on the Lower East Side of
Manhattan, trapped in the undertow of two potent diseases, she runs on
empty.

"Some nights, the only thing I can do is read my Bible," she said. "I look
in there to find answers. They’re hard to find."

Diabetes on top of mental illness asks a lot of a person, and of society.
Mental illness is itself a money sponge, an expense borne largely by tax
dollars. But that cost may be dwarfed by the bill to manage the heart
attacks and amputations that diabetes bestows.

With numerous mental institutions emptied, patients often live in lightly
supervised settings. Many occupy adult homes that struggle, for good reasons
and bad, at providing basic services and are poorly equipped to treat
diabetes. Others live on their own, sometimes in boxes beneath bridges or
crumpled in doorways.

Imagine taking on diabetes if you live alone and find living itself to be a
handful.
"I try not to drink sugared sodas, but sometimes I forget," Ms. Ernst said.
"I’ll buy candy – Mary Janes or banana cookies. I know I’m not fooling
anybody – it’s my arms and legs they’re going to cut off – but sometimes I
get the craving for something sweet."
She sat at a round table in her room, a cool evening of early spring,
cradling a stuffed bunny. She flicked a small smile. "I’m sorry it’s not
neater," she said, looking around. "I’m trying."

Ms. Ernst embodies the difficulty of confronting the two diseases with all
their complexities. She takes clozapine for her mind because she can’t
manage without it. She has diabetes and can’t defeat her weight.
"Disgusting, that clozapine," she said. "Makes you eat everything under the
sun." She takes a lineup of other drugs, too, not all positive for her
weight. She had hit 250, fought her way to 198, and is now at 221.

She lives at Gouverneur Court, a residence run by a nonprofit organization,
where about 15 of the 66 mentally ill residents have diabetes. "Some say
they don’t have it, but they do," said Abby Stuthers, the nurse who works
there. "Or they say they have a little diabetes."

Ms. Ernst freely recounts her callused life. Her marriage exploded. Once she
was smacked in the face with a glass ashtray. She opened her mouth – every
tooth was missing.  Now diabetes. Her blood sugar has been O.K., but her
vision has worsened. And she is inconsistent, prey to the fury of her
demons.

Susanne Rendeiro, a family nurse practitioner who serves as her primary care
physician, said Ms. Ernst misses half her appointments. Recently, in
reviewing her drugs, Ms. Rendeiro asked about her blood pressure   pills.
Puzzled, Ms. Ernst said she was not on blood pressure pills. Mrs. Rendeiro
said she had supposedly been taking them for two years. "I want to be the
best I can be," Ms. Ernst said. "Nobody changes overnight."

Treatment and Cruel Ironies

There was always a lot else wrong with the mentally ill – heart problems and
cancer   and H.I.V., as well as diabetes. But for psychiatrists and
clinicians it was enough to worry about mental needs that beggared the
imagination.

The spread of diabetes, however, is making the physical conditions
impossible to ignore. "Psychiatrists are literally watching patients balloon
up before their eyes," said Dr. Gail Daumit, an assistant professor of
medicine at Johns Hopkins Medical Institutions.

This has been especially true since the advent of so-called atypical
antipsychotic drugs in the early 1990’s. Studies indicate that these drugs
can alter glucose metabolism and stimulate weight gain, particularly in
people predisposed to diabetes.

"Sort of a cruel irony in this," said Dr. Lieberman of Columbia, "is that
all of the drugs do it to some degree, but the ones that have the most
effect cause the most weight gain and metabolic side effects. There’s
increasing discomfort that these are driving up deaths and lowering quality
of life."

Some cases have been striking: a patient packing on 50 pounds in mere
months, for example. Diabetes arrived as quickly, and sometimes subsided if
the drugs were halted. In certain instances, there was no weight gain, but
still diabetes came, often in patients who were already heavy. Studies have
indicated that dozens of these patients died from diabetes-related
complications.

The Food and Drug Administration requires atypical antipsychotics to bear
warning labels about diabetes risk, though drug makers say patients taking
them who develop diabetes were destined to get it anyway.

Robin Stigliano’s psychiatrist has her taking Haldol by injection as well as
one of the drugs most closely associated with weight gain, Zyprexa. They
have helped her schizophrenia, but Ms. Stigliano, 37, who lives in a
Brooklyn adult home, has seen her weight soar to 241 pounds from 150. And
when she gets her Haldol infusion every three weeks, all she wants to do is
sleep. "It’s my favorite activity," she said.

Without the drugs, psychiatrists believe, many high-functioning patients
would find themselves in institutions or jail. "These drugs are enormously
beneficial," said Dr. P. Murali Doraiswamy, head of biological psychiatry at
Duke University. "But they have an Achilles heel."

A few years ago, Dr. Doraiswamy reported a case of a mentally ill person who
got diabetes and was prescribed insulin. The impact of having two serious
conditions overwhelmed him. He wound up trying to kill himself by insulin
overdose.

Some researchers think it is possible the rash of diabetes stems in part
from mental illness itself. Studies associate the onset of diabetes with
depression. The mentally ill are also at high risk because they tend to eat
poorly, get little exercise and have limited access to health care.

In a 2003 survey, the city’s health department found that about 17 percent
of adults who reported symptoms of a mental illness, or 52,000, have
diagnosed diabetes. Elsewhere, rates are as great or greater. Even these
estimates may be low, experts said, because the mentally ill see doctors
sporadically and their illnesses may be underdiagnosed.

The rates of diabetes and obesity are nudging Dr. Doraiswamy and others in
his field – in modest ways thus far – toward prevention, toward screening
people for diabetes before choosing drugs and connecting better with primary
care doctors.

"This wouldn’t be a big problem if most mentally ill patients had a primary
care provider, but they don’t," said Dr. Newcomer at Washington University.
"And it’s never been part of the game plan for the psychiatrist to write the
prescription for your blood pressure medicine or your diabetes medicine."

He feels change is imperative. "The days when I don’t do windows can’t go
on," he said.

Dr. Kenneth Duckworth, medical director for the National Alliance on Mental
Illness, agreed. "I think the field has been passive," he said. "We viewed
it that we do symptoms and you run your life."

Stimulating change is not easy. Psychiatrists have a problem simply getting
patients to stay on their drugs. Resources are inadequate.

"Psychiatry is historically a couch and the chair," Dr. Duckworth said. "How
do you get movement into the equation?"

He said that he weighed his patients, checked sugars. But few psychiatrists
are set up to do this. Treating diabetes, they say, was not what they were
trained to do. And where, they ask, do they find time in 15-minute
appointments?

"Most psychiatrists barely look at their patients," said Dr. Donna Ames
Wirshing, a staff psychiatrist at the West Los Angeles Veterans
Administration Medical Center. She recently asked 30 how many weighed their
patients; 3 hands went up.

Dr. Wirshing and her husband, Dr. William Wirshing, are experimenting with
the use of nutrition and exercise coaches for mentally ill patients.

Couches could be replaced with exercise bikes. Or, as Dr. David Hellerstein,
associate professor of clinical psychiatry at Columbia’s College of
Physicians and Surgeons, noted, "Instead of having the patient lie down and
you say, ‘So tell me why you fight with your brother,’ you could say to the
patient, ‘Let’s take a walk around the block while you tell me about why you
fight with your brother.’ "

For the most part, however, psychiatrists confront the knotty questions
without ready answers.

If some 10 percent of schizophrenics kill themselves, and clozapine is the
only antipsychotic medication demonstrated to significantly reduce suicide,
but it has grave side effects, like its association with diabetes, is it
miracle or monster? Or both?

"When I chat with patients, about clozapine, I say, ‘This may give you your
mind back, but it may hurt your body,’ " Dr. Duckworth said. "I think of it
as psychiatric chemotherapy. Your hair won’t fall out, but you may get
diabetes."

How do patients respond? "Some say, ‘If this will give me my mind, I’ll take
anything,’ " he said. "Some say, ‘There’s nothing wrong with me, why are we
even having this conversation?’ About 60 percent of schizophrenics don’t
recognize that they have it. There are very few easy answers in my line of
work."

Housing the Ill and Diabetic

Surf Manor squats on the tip of Coney Island, one of the dozens of
profit-making adult homes in the city where thousands of the mentally ill
live. Residents complain about the food. Activities are light on exertion.
The week’s offerings are taped to the wall: dominoes, blackjack, manicures,
jewelry class.

So the men and women eat, sleep, smoke, watch TV, sleep – then do it all
over again. Unsurprisingly, those who live there say, dozens of the 200
residents struggle with diabetes.

These often-troubled homes where so many of the mentally ill are housed,
frequently grumbling about inadequate attention to their needs and their
dignity, can be hideously difficult places for someone at high risk for
diabetes. And that is basically everyone who lives there.

Leslie Hinden, a chatty man of 51, sat listlessly in the lounge, near the
junk food dispensers. He’d be buying sweets but was broke from binging.

He has had schizoaffective disease – characterized by symptoms of
schizophrenia and depression – for most of his life. Sometimes he hears
Indian war whoops in his head. About 17 years ago, he picked up diabetes,
too.

His blood sugar was 289 that morning, he said. A normal fasting blood sugar
reading is below 126 milligrams per deciliter.

"I cheated," he said. "Last night I ate two eclairs. Had a Coke. A lot of
times I don’t cheat and it goes up to 300. I don’t know what to do."

Why the binge last night? "I don’t know," he said. "I felt scared."

A recent State Department of Health sampling of 19 homes found that nearly a
quarter of residents had diabetes. The homes say they do what they can. Some
have diabetes sections in the dining halls, where occupants get a sugar-free
dessert.

"I’m not a doctor, but we’re very helpful," said Mordechai Deutscher, the
case manager at Surf Manor, who said he did not think the home had many
diabetics. "The people here are doing very well."

Even mental health advocates have not given diabetes much attention. The
Commission on Quality of Care and Advocacy for Persons with Disabilities, a
state watchdog agency, said it has never examined diabetes prevalence or
care.

At Surf Manor, Mr. Hinden, like the other diabetic residents, cannot have a
blood sugar meter or give himself insulin. Needles are considered perilous.
He depends on the staff. But no one prescribes motivation or understanding.
And where diabetes requires vigilant self-management, illnesses like
schizophrenia often mean memory problems and lack of drive.  "I’ll be honest
with you, I don’t understand diabetes," Mr. Hinden said. "I don’t understand
it at all."

Joseph Franklin, 47, sat down, all 300-plus pounds of him. He said he has
been taking diabetes drugs for seven years. "It’s just in case," he said. He
said he was bipolar: "I couldn’t see people with shoes on. If I saw someone
with shoes on, it could do something to my forehead."  He spread out some
greeting cards he had made. He leaned close. "Listen, I don’t want everyone
to hear this," he said, "but it’s very possible that, unless the doctor made
a mistake, I do have diabetes."

A stoic man of great girth named Lee Symons, 57, nodded. He had it, too. He
hears guitars and banjos thrumming in his head.
Was he trying to diet?
"No one told me to," he murmured.
What about the diabetes?
"As long as it doesn’t hurt, I don’t mind it," he said. "It’s just
diabetes."

Copyright 2006 The News York Times

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