title: Mental illness and intensification of diabetes medications: an observational cohort study.
abstract: BACKGROUND
  Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians' decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.
  
  
  METHODS
  In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003-2004, by MHC status.
  
  
  RESULTS
  Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0-14, 15-30 and 31-180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.
  
  
  CONCLUSIONS
  For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.
authors.affiliation: Department of Veterans Affairs HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA. susan.frayne@va.gov.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Frayne
authors.forename: Tyson H
authors.initials: TH
authors.lastname: Holmes
authors.forename: Eric
authors.initials: E
authors.lastname: Berg
authors.forename: Mary K
authors.initials: MK
authors.lastname: Goldstein
authors.forename: Dan R
authors.initials: DR
authors.lastname: Berlowitz
authors.forename: Donald R
authors.initials: DR
authors.lastname: Miller
authors.forename: Leonard M
authors.initials: LM
authors.lastname: Pogach
authors.forename: Kaajal J
authors.initials: KJ
authors.lastname: Laungani
authors.forename: Tina T
authors.initials: TT
authors.lastname: Lee
authors.forename: Rudolf
authors.initials: R
authors.lastname: Moos
mesh_terms: D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000188:drug therapy*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D008297:Male; D001523:Mental Disorders / Q000150:complications*; D008875:Middle Aged; D014481:United States; D014728:Veterans
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents