In our sample of adults with a diagnosis of type 2 diabetes receiving diabetes care in community health care settings, we found that those individuals with type 2 diabetes and schizophrenia who smoke were significantly less likely to receive services and treatments known to improve cardiovascular outcomes. Other studies have shown disparities in diabetes care among those with diabetes and mental illness in VA populations [5
], and in community clinics[3
] as well as lack of metabolic monitoring in patients with schizophrenia receiving antipsychotics; [10
] however, ours is the first to evaluate the potential additional impact of smoking. Smoking may affect delivery of medical care at the patient (e.g., non-adherence)[11
], provider (e.g., competing demands) or system level.
This study has several limitations. First, because this is a cross-sectional study, we are limited to discussing associations rather than causality. Second, we were unable to determine whether or not patients actually received the prescribed medication. Third, we use chart diagnoses of schizophrenia. Fourth, we were not able to confirm actual diagnoses for hypertension or hypercholesterolemia. However, if there were prevalence differences among these disorders in our sample, we believe that those with schizophrenia would have a greater likelihood of having these disorders and suggest that our results may in fact underestimate the reported differences. Fifth, we did not quantify smoking using biological measures. Finally, the small sample sizes limited our ability to test interactions and may have put us at risk for a type 2 error particularly with respect to detecting a difference in receipt of smoking cessation counseling.
Previous research has shown that persons with schizophrenia have a life expectancy that is approximately 20% lower than the general population[12
], with mortality rates attributed to cardiovascular disease more than any other cause [9
]. Considering that smoking increases the risk for cardiovascular mortality among those with diabetes, and those with schizophrenia smoke at rates that are twice the general population, efforts to increase awareness and improve delivery of services to this vulnerable group of patients are warranted.