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.
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.