Psychosomatics 46:418-424, October 2005
doi: 10.1176/appi.psy.46.5.418
© 2005 Academy of Psychosomatic Medicine
Diabetes Knowledge Among Persons With Serious Mental Illness and Type 2 Diabetes
Faith B. Dickerson, Ph.D., M.P.H.,
Richard W. Goldberg, Ph.D.,
Clayton H. Brown, Ph.D.,
Julie A. Kreyenbuhl, D.Pharm., Ph.D.,
Karen Wohlheiter, M.S.,
LiJuan Fang, M.S.,
Deborah Medoff, Ph.D., and
Lisa B. Dixon, M.D., M.P.H.
Received Aug. 30, 2004; revision received Dec. 7, 2004; accepted Jan. 25, 2005. From the Sheppard Pratt Health System; and the Departments of Psychiatry and Epidemiology, University of Maryland School of Medicine, Baltimore. Address correspondence and reprint requests to Dr. Dickerson, Sheppard Pratt Health System, 6501 N. Charles St., Baltimore, MD 21204; fdickerson{at}sheppardpratt.org (e-mail).
|
ABSTRACT
|
Type 2 diabetes is an important medical condition associated with serious mental illness. The authors studied the disease-specific knowledge about diabetes in a sample of 201 psychiatric outpatients with a diagnosis of schizophrenia or major mood disorders, all of whom had type 2 diabetes. In a multivariate analysis, disease-specific diabetes knowledge was associated with higher cognitive functioning, a higher level of education, and recent receipt of diabetes education. Disease-specific diabetes knowledge predicted lower levels of perceived barriers to diabetes care. Gaps in diabetes knowledge may be reduced by specialized interventions that take into account the cognitive deficits of persons with serious mental illness.
|
INTRODUCTION
|
Type 2 diabetes is a highly prevalent chronic medical condition affecting approximately 4% of the U.S. general population.1 Persons with schizophrenia have a particularly high risk for type 2 diabetes, and the estimated prevalence in this group ranges from 16% to 25%.2,3 Persons with major mood disorders are also at higher risk for type 2 diabetes, compared with the general population.4,5 The reasons why persons with serious mental illness are more prone to develop diabetes are not known with certainty but may include the high prevalence of obesity in this group and the use of second-generation antipsychotic medications.6,7 Some studies have suggested that the higher rate of type 2 diabetes in persons with schizophrenia predates the widespread use of second-generation antipsychotic medications.8 The relatively high rate of diabetes may contribute to the excess mortality among persons with serious mental illness.9
In the general population, disease-specific knowledge about diabetes is an important element of diabetes self-management and is a focus of diabetes education programs.10,11 Diabetes knowledge may enhance coping with the illness and may improve adjustment to the illness.12 However, knowledge about diabetes has been found to be insufficient by itself to ensure optimal diabetes outcomes.13 As in other chronic medical disorders, illness-specific knowledge is one component of effective self-management. The other components include behavioral skills, cognitive problem-solving abilities, and a sense of efficacy in bringing these capabilities to bear to affect disease outcome.11,14
Research on diabetes in individuals with schizophrenia and other serious mental illnesses has focused largely on diabetes incidence and prevalence. The study of diabetes outcomes or diabetes-specific knowledge among persons with mental illness and co-occurring diabetes has been limited. Persons with serious mental illness have clinical characteristics that may limit their fund of information about diabetes and other medical problems. These characteristics include cognitive impairment, which can disrupt attention, learning, and motivation.15 Persons with serious mental illness are also vulnerable to various psychiatric symptoms that may further impede attention to, and understanding of, co-occurring medical problems.
In a previous report, we found that mean hemoglobin A1c levels exceeded recommended levels among persons with either schizophrenia or major mood disorder who were receiving community-based psychiatric treatment.16 Consistent with the current literature, diabetes knowledge alone was not associated with glycemic control in this group.
The purpose of the study reported here was to perform a more detailed analysis of disease-specific diabetes knowledge in this group of psychiatric outpatients with serious mental illness and type 2 diabetes. This study investigated the extent to which diabetes knowledge was associated with psychiatric variables such as psychiatric diagnosis (schizophrenia versus major mood disorder), psychiatric symptoms, and cognitive impairment, as well as with the receipt of diabetes education. In addition, we examined the association between diabetes knowledge and adherence to diabetes treatment as well as the perceived benefits and barriers of diabetes care.
|
METHOD
|
Subjects
We recruited psychiatric outpatients with type 2 diabetes and either schizophrenia or major mood disorder who met the following inclusion criteria: 1) age 18–65 years; 2) current medical record diagnosis of type 2 diabetes; 3) current medical record diagnosis of schizophrenia, schizoaffective disorder, or a major mood disorder (bipolar disorder or recurrent major depression); 4) English speaking; and 5) ability to provide informed consent. Persons were recruited from six public or private outpatient mental health clinics in urban and suburban communities in the Baltimore area. To obtain representative groups of patients with the two mental disorders and type 2 diabetes, we attempted to identify every patient at each outpatient clinic who met the study eligibility criteria. Psychiatrists and clinic staff reviewed complete patient rosters to identify potential subjects who were then approached by research assistants. The Institutional Review Board of the University of Maryland School of Medicine and of each participating facility approved the study. Assessments were conducted between September 1, 1999 and September 30, 2002.
Among those who were identified as eligible, 22 (18%) individuals with schizophrenia and 10 (9%) individuals with major mood disorder declined to participate. Decliners did not significantly differ from participants in age, gender, or race (all p>0.05).
Assessments
After providing written informed consent, each participant met in person with a research staff member for an interview lasting approximately 2.5 hours that included the measures described in the following sections.
Knowledge about diabetes
Disease-specific diabetes knowledge was assessed by the general subscale of the Diabetes Knowledge Test, a standardized measure to assess diabetes knowledge among affected individuals.17 The items on this test are designed to be representative of the larger domain of illness-specific diabetes knowledge appropriate for individuals with type 2 diabetes. The score is calculated as the percentage of correct answers on 14 multiple-choice test items that assess knowledge about diabetes-related matters, such as dietary choices and blood glucose testing. Examples of test items include "Which is the highest in fat: low-fat milk, oranges, corn, or honey?" "Infection is likely to cause: an increase, a decrease, or no change in blood glucose?"
Demographic variables
Demographic variables included age, gender, race (Caucasian versus non-Caucasian), and education (five categories ranging from eighth grade or less to college degree or more).
Diabetes-related variables
Variables that measured the overall severity of patients’ diabetes history were included. Variables in this set included age at diabetes onset, duration of diabetes illness, and current receipt of insulin. Participants were also asked to report whether they had received diabetes education (written material, informal information, counseling, or a formal class) in the past 6 months.
Psychiatric variables
Psychiatric symptoms were measured with the total score of the Colorado Symptom Index (CSI), a self-report measure on which respondents indicate the frequency with which they experienced 14 psychiatric symptoms.18 Cognitive functioning was assessed by the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), a brief test battery that yields scores on five subscales (immediate memory, visuospatial construction, attention, language, and delayed memory) and a total score.19 The RBANS total score is an age-adjusted standard score with a mean of approximately 100 and a standard deviation of approximately 15.
Adherence to diabetes treatment
Adherence to diabetes care was measured with the Summary of Diabetes Self-Care Activities, which measures the patient’s self-reported frequency of completing prescribed diabetes self-care activities, including diet, exercise, and glucose testing, in the past week.20
Benefits of and barriers to diabetes care
Scales used to assess benefits of and barriers to diabetes care were drawn from the Diabetes Health Belief Scales.21 These scales were developed for persons with non-insulin-dependent diabetes. The benefits scale has five items and asks the participant to rate on a 7-point scale the extent to which he or she agrees or disagrees with statements about the consequences of diabetes care, including, for example, "Careful planning of diet and exercise helps control diabetes." The barriers scale has five items and asks the participant to rate the extent to which he or she agrees or disagrees with statements about obstacles to diabetes care, including, for example, "The diabetes diet makes eating out hard,"and "It is not possible to control diabetes."
Statistical Analysis
Bivariate associations were assessed between diabetes knowledge scores and the demographic, psychiatric, and diabetes-related variables. Associations between the diabetes knowledge score and dichotomous variables were analyzed with one-way analyses of variance; associations with continuous measures were analyzed with Pearson’s product-moment correlations. Variables that were significantly associated with diabetes knowledge scores in bivariate analyses (p<0.05) were entered into a multiple regression analysis of diabetes knowledge.
We then used Pearson’s product-moment correlation to examine the bivariate associations of diabetes knowledge with adherence to and perceptions about the benefits of and barriers to diabetes treatment. For variables that were significantly associated with diabetes knowledge in bivariate analyses (p<0.05), multiple regression analysis was used to control for other variables that are associated with the dependent variable. In these analyses we used diabetes knowledge as an independent variable and the adherence, benefits, and barriers variables as dependent variables. Analyses were performed with the Stata Statistical Package, version 8.0 (Stata Corp., College Station, Tex.).
|
RESULTS
|
Subjects
The study participants were 201 persons with major mental illness, of whom 100 had schizophrenia and 101 had a major mood disorder. The mean age was 51.1 years (SD=8.6, range=27–66). A total of 97 (48%) participants were male. Ninety-nine (49.5%) were Caucasians, 90 (45%) were African Americans, and 12 (5.5%) were members of other racial groups. The mean educational level was completion of high school or the General Equivalency Diploma. Summary characteristics of the study group are shown in Table 1. Most participants were in active psychiatric treatment. A total of 197 of 201 (98%) participants had had an outpatient visit for mental illness in the previous 6 months, 192 of 197 (98%) reported that they had seen a psychiatrist in the previous 6 months, and antipsychotic medications were currently prescribed for 140 of 201 (70%).
View this table:
[in this window]
[in a new window]
|
TABLE 1. Characteristics of Persons With Serious Mental Illness and Type 2 Diabetes (N=201) in a Study of Patients’ Knowledge About Diabetes
|
Diabetes Knowledge Test Scores
The mean percentage of correct responses on the Diabetes Knowledge Test was 53.6% (SD=18%, range= 14%–100%). Items with the highest percentage of correct responses were those inquiring about the best way to take care of the feet (78% of participants correctly endorsed examining and washing the feet daily) and about the medical condition that is usually not associated with diabetes (77% correctly endorsed the correct response, lung problems). Items with the lowest percentage of correct responses included those that inquired about the duration of time in which glucose control is measured by hemoglobin A1c (24% responded correctly), which of four food choices has the highest level of dietary fat (26% responded correctly), and the effect of unsweetened fruit juice on blood glucose level (35% responded correctly).
Correlates of Diabetes Knowledge
As shown in Table 1, the score on the Diabetes Knowledge Test was significantly associated with psychiatric diagnosis; the mean diabetes knowledge score was lower among participants with schizophrenia (mean=48.6%, SD=17.3%) than among those with mood disorders (mean=58.6%, SD=17.5%) (F=16.62, df=1, 199, p< 0.0001). The Diabetes Knowledge Test score was also significantly associated with educational level (r=0.37, N= 201, p<0.0001), score on the total score of the RBANS cognitive test (r=.56, N=200, p<0.0001), receipt of diabetes education (F=6.74, df=1, 99, p<0.02), and Caucasian versus non-Caucasian race (F=8.17, df=1, 199, p=0.005). The diabetes knowledge score was not significantly associated with age, gender, total psychiatric symptoms, age at diabetes onset, duration of diabetes, or current receipt of insulin (all p>0.05). In a regression analysis of diabetes knowledge score that included the variables that were significant in the bivariate analyses, education, receipt of diabetes education, and total cognitive score remained significant and together predicted approximately 38% of the variance in knowledge scores (F=22.92, df=5, 194, p<0.0001, R2=0.37), as shown in Table 2. Diagnosis and race were no longer significant when the effects of the other variables were controlled.
View this table:
[in this window]
[in a new window]
|
TABLE 2. Determinants of Diabetes Knowledge Test Score in Persons With Serious Mental Illness and Type 2 Diabetes (N=200)a
|
Also, as shown in Table 1, diabetes knowledge was not significantly associated with measures of adherence to diet, adherence to glucose testing, or adherence to exercise (all p>0.05).
The analysis of the bivariate association between diabetes knowledge and knowledge about the benefits of and barriers to diabetes care indicated a significant association with knowledge about benefits (r=0.15, N=201, p<0.04) and barriers (r=–0.28, N=201, p<0.0001). Other variables that were significantly correlated with knowledge about barriers were cognitive score, educational level, and psychiatric symptoms; these variables were included in a subsequent regression analysis of data for the barriers knowledge score. The following variables were not significantly associated with knowledge about barriers: receipt of insulin, age, gender, race, age, diagnosis, and receipt of diabetes education. When the effects of the cognitive score, education, and total psychiatric symptoms were controlled, the association between diabetes knowledge and knowledge of barriers to care remained significant (t=–2.63, df=199, p=0.009). The association between diabetes knowledge and knowledge of the benefits of diabetes care did not remain significant in a multivariate analysis that included total psychiatric symptom score and race—variables that were associated with knowledge of the benefits of care in bivariate analyses.
|
DISCUSSION
|
Our findings raise several important concerns about diabetes knowledge in this population. The mean score on the diabetes knowledge test for the persons with serious mental illness in our study was 53.6%, suggesting considerable gaps in illness-specific information for the group as a whole. It is noteworthy that 76% of the participants did not correctly identify the duration of blood glucose level measured by hemoglobin A1c and 41% did not correctly identify the best method of testing blood glucose. For the questions about diet, 70% did not correctly identify the definition of a "free food." The knowledge score of the schizophrenia group was significantly lower than that in a non-mentally ill group with type 2 diabetes, as we previously reported.16 The relatively poor diabetes knowledge score of the participants in the current study was lower than that reported in other detailed studies of diabetes knowledge among persons with type 2 diabetes from the general population.17,22,23
We found that the diabetes knowledge of the persons with serious mental illness in our study was associated with their performance on a cognitive screening battery, and this association persisted when the effect of psychiatric diagnosis was controlled. This finding is consistent with the results of a study of veterans with insulin-treated type 2 diabetes who were not selected on the basis of having a psychiatric disorder and who were assessed with the Diabetes Knowledge Test and a cognitive screening test.22 Cognitive deficits are widespread among individuals with serious mental illness. The mean level of cognitive performance among the participants in the current study was comparable to that in other studies that have used the same cognitive battery to test persons with major mental illness.24 Recognition of these cognitive deficits may be important in the development of specialized diabetes education for persons with mental illness. Educational strategies to minimize the cognitive load may be helpful. Successful didactic interventions for adults with schizophrenia and other serious mental illnesses have emphasized instruction in specific and narrowly defined skills, strategies for breaking material into small units, aids to reduce requirements of memory and attention, frequent repetition of important content, and opportunities for behavioral rehearsal.25
Our findings are similar to those from studies of persons with serious mental illness and other chronic medical disorders. Among persons with serious mental illness and HIV, cognitive deficits are associated with both less knowledge of HIV26 and lower adherence to HIV treatment regimens.27 The presence of cognitive deficits and other clinical characteristics of persons with mental illness has informed the development of specialized treatment interventions for HIV.28 Our results indicate that a similar approach may be helpful for persons with serious mental illness and comorbid diabetes. Such an approach may also be important in addressing the full range of other co-occurring medical problems that are prevalent in this population.
The fact that the receipt of diabetes education was associated with more diabetes knowledge when the effect of other variables, such as cognitive level, were controlled suggests that patients obtain some benefit from the diabetes information they receive. Diabetes education is an element of the American Diabetes Association assessment of the quality of diabetes care.29 However, only 48% of the participants in our study reported having received any diabetes education in the previous 6 months. It is possible that the persons in our study did not correctly recall whether they had received such education. Nevertheless, our results suggest that diabetes knowledge should increase if more persons with serious mental illness and co-occurring diabetes are instructed specifically about diabetes. Such education may be provided either by patients’ primary care providers or psychiatric clinicians.
Among the participants in our study, the level of diabetes knowledge was not significantly correlated directly with the level of glycemic control or with adherence measures. Consistent with the diabetes literature, our findings indicate that knowledge is not sufficient in and of itself to effect biological outcomes or compliance with specific diabetes treatment regimens. As noted by Glasgow,10 disease-specific diabetes knowledge may be a process or mediating variable that interacts with other factors to affect self-care, which then may affect short- and long-term health outcomes.
Future studies should be performed to identify the particular aspects of diabetes knowledge that are most needed by patients in order to promote diabetes self-care that leads to improved health outcomes. The Diabetes Knowledge Test assesses the major domains of information relevant to type 2 diabetes; however, there may be other kinds of information that are important for patients who are faced with a persistent and serious medical illness such as diabetes. In addition, diabetes information may be more useful when it is presented along with specific ways in which this information can be implemented in the person’s day-to-day life.
We found a significant and inverse association between diabetes knowledge and perceived barriers to diabetes care. The less diabetes knowledge persons had, the more they were likely to perceive diabetes treatment as disruptive and burdensome. Although other factors may be operative, this association suggests that better knowledge about diabetes enables patients to feel more accepting and optimistic about their diabetes treatment. In this way, knowledge may help to foster the kind of self-efficacy that is considered important in the management of a chronic medical disorder.30
One limitation of this study was its cross-sectional design, which did not allow us to determine the temporal relationship among the variables under study. We also could not determine the quality or intensity of diabetes education among the participants who reported having received specialized diabetes education, and we relied on participants’ self-reports that they received this education. It is also likely that participants’ specific psychiatric symptoms affected their response to diabetes and their knowledge about the disorder. We had limited data on the participants’ psychiatric history, and so we were not able to examine the effect of variables related to the course of their psychiatric illness. However, to our knowledge, this study is the first to characterize a relatively large cohort of persons with serious mental illness and long-standing co-occurring diabetes with detailed information about their psychiatric status as well as their diabetes condition, including their performance on a standardized test of their diabetes knowledge. We also had a relatively high rate of participation from the study population. Diabetes and other components of the metabolic syndrome are receiving increasing attention as potential iatrogenic effects of antipsychotic medication. This development creates greater responsibility for us to understand patients’ needs regarding diabetes knowledge, as well as to understand how knowledge of this and other medical disorders may improve medical outcomes for this population.
|
REFERENCES
|
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, National Diabetes Surveillance System: Prevalence of diabetes: number (in millions) of persons with diagnosed diabetes, United States, 1980–2003. http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm
- Mukherjee S: High prevalence of type II diabetes in schizophrenic patients (abstract). Schizophrenia Res 1995; 15:195
- Dixon L, Weiden P, Delahanty J, Goldberg R, Postrado L, Lucksted A, Lehman A: Prevalence and correlates of diabetes in national schizophrenia samples. Schizophr Bull 2000; 26:903–912
- Eaton WW: Epidemiologic evidence on the comorbidity of depression and diabetes. J Psychosom Res 2002; 53:903–906[CrossRef][Medline]
- Regenold WT, Thapar RK, Marano C, Gavirneni S, Kondapavuluru PV: Increased prevalence of type 2 diabetes mellitus among psychiatric inpatients with bipolar I affective and schizoaffective disorders independent of psychotropic drug use. J Affect Disord 2002; 70:19–26; erratum: 2003; 3:301–302
- Citrome L, Jaffe A, Levine J, Allingham B, Robinson J: Relationship between antipsychotic medication treatment and new cases of diabetes among psychiatric inpatients. Psychiatr Serv 2004; 55:1006–1013.[Abstract/Free Full Text]
- Leslie DL, Rosenheck RA: Incidence of newly diagnosed diabetes attributable to atypical antipsychotic medications. Am J Psychiatry 2004; 161:1709–1711[Abstract/Free Full Text]
- Braceland FJ, Meduna LJ, Vaichulis JA: Delayed action of insulin in schizophrenia. Am J Psychiatry 1946; 102:108–109
- Harris EC, Barraclough B. Excess mortality of mental disorder. Br J Psychiatry 1998; 173:11–53[Abstract/Free Full Text]
- Glasgow RE: Outcomes of and for diabetes education research. Diabetes Educ 1999; 25(suppl 6):74–88
- Hill-Briggs F: Problem solving in diabetes self-management: a model of chronic illness self-management behavior. Ann Behav Med 2003; 25:182–193[CrossRef][Medline]
- Fain JA, Nettles A, Funnell MM, Charron D: Diabetes patient education research: an integrative literature review. Diabetes Educ 1999; 25(suppl 6):7–15
- Arseneau DL, Mason AC, Wood OB, Schwab E, Green D: A comparison of learning activity packages and classroom instruction for diet management of patients with non-insulin-dependent diabetes mellitus. Diabetes Educ 1994; 20:509–514
- Lorig K, Steward A, Ritter P, Gonzalez V, Luarent D, Lynch J: Outcome Measures for Health Education and Other Health Care Interventions. Thousand Oaks, Calif, Sage Publications, 1996
- Rund BR, Borg NE: Cognitive deficits and cognitive training in schizophrenic patients: a review. Acta Psychiatr Scand 1999; 100:85–95[Medline]
- Dixon LB, Kreyenbuhl JA, Dickerson FB, Donner TW, Brown CH, Wohlheiter K, Postrado L, Goldberg RW, Fang L, Marano C, Messias E: A comparison of type 2 diabetes outcomes among persons with and without severe mental illnesses. Psychiatr Serv 2004; 55:892–900[Abstract/Free Full Text]
- Fitzgerald JT, Funnell MM, Hess GE, Barr PA, Anderson RM, Hiss RG, Davis WK: The reliability and validity of a brief diabetes knowledge test. Diabetes Care 1998; 21:706–710[Abstract]
- Shern DL, Wilson NZ, Coen AS, Patrick DC, Foster M, Bartsch DA, Demmler J: Client outcomes II: longitudinal client data from the Colorado Treatment Outcome Study. Milbank Q 1994; 72:123–148[CrossRef][Medline]
- Randolph C: RBANS Manual: Repeatable Battery for the Assessment of Neuropsychological Status. San Antonio, Psychological Corporation, 1998
- Toobert DJ, Glasgow RE: Assessing diabetes self-management: the Summary of Diabetes Self-Care Activities Questionnaire, in Handbook of Psychology and Diabetes: A Guide to Psychological Measurement in Diabetes Research and Practice. Edited by Bradley C. Amsterdam, Harwood Academic, 1994, pp 351–375
- Lewis KS, Jennings AM, Ward JD, Bradley C: Health belief scales developed specifically for people with tablet-treated type 2 diabetes. Diabet Med 1990; 7:148–155[Medline]
- Murata GH, Shah JH, Adam KD, Wendel CS, Bokhari SU, Solvas PA, Hoffman RM, Duckworth WC: Factors affecting diabetes knowledge in type 2 diabetic veterans. Diabetologia 2003; 46:1170–1178[CrossRef][Medline]
- McLean MT, McElnay JC, Andrews WJ: The association of psychosocial and diabetes factors to diabetes knowledge. Int J Pharm Pract 2001; 9(Sept suppl):R9. http://www.pjonline.com/IJPP/bpc2001/ijpp_bpc2001_r09.pdf.
- Dickerson, FB, Boronow JJ, Stallings C, Origoni AE, Cole SK, Yolken RH: Cognitive functioning in schizophrenia and bipolar disorder: comparison of performance on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Psychiatry Res (in press)
- Bellack AS, Mueser KT, Gingerich S, Agresta J: Social Skills Training for Schizophrenia. New York, Guilford, 1997
- McKinnon K, Cournos F, Sugden R, Guido JR, Herman R: The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness. J Clin Psychiatry 1996; 57:506–513[Medline]
- Hinkin CH, Castellon SA, Durvasula RS, Hardy DJ, Lam MN, Mason KI, Thrasher D, Goetz MB, Stefaniak M: Medication adherence among HIV+ adults: effects of cognitive dysfunction and regimen complexity. Neurol 2002; 9:1944–1950
- Kelly JA: HIV risk reduction interventions for persons with severe mental illness. Clin Psychol Rev 1997; 17:293–309[CrossRef][Medline]
- Mensing C, Boucher J, Cypress M, Weinger K, Mulcahy K, Barta P, Hosey G, Kopher W, Lasichak A, Lamb B, Mangan M, Norman J, Tanja J, Yauk L, Wisdom K, Adams C: National standards for diabetes self-management education. Diabetes Care 2003; 26(suppl 1):S149-S156
- Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M: Effect of a self-management program on patients with chronic disease. Eff Clin Prac 2001; 4:256–262[Medline]
This article has been cited by other articles:
|
|
|
|
 
D. Dickinson, J. M. Gold, F. B. Dickerson, D. Medoff, and L. B. Dixon
Evidence of Exacerbated Cognitive Deficits in Schizophrenia Patients With Comorbid Diabetes
Psychosomatics,
April 1, 2008;
49(2):
123 - 131.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. W. Goldberg, J. A. Kreyenbuhl, D. R. Medoff, F. B. Dickerson, K. Wohlheiter, L. J. Fang, C. H. Brown, and L. B. Dixon
Quality of Diabetes Care Among Adults With Serious Mental Illness
Psychiatr Serv,
April 1, 2007;
58(4):
536 - 543.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. P. Weiss, D. C. Henderson, J. B. Weilburg, D. C. Goff, J. B. Meigs, E. Cagliero, and R. W. Grant
Treatment of Cardiac Risk Factors Among Patients With Schizophrenia and Diabetes
Psychiatr Serv,
August 1, 2006;
57(8):
1145 - 1152.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2005
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
