Reducing Health Disparities Among People with Serious Mental Illness

“Psychiatrists need to pay attention to weight, lipid levels, blood pressure, and exercise in our patients with serious mental illness,” declares psychiatrist Dale Svendsen, M.D., medical director at the Ohio Department of Mental Health and co-author of the NASMHPD report. “The psychiatrist of the future is going to have to be more of a general physician than in the past, and our training programs are going to need to adapt.” In Those With Serious Mental Illness Suffer From Lack of Integrated Care, in Psychiatric News January 5, 2007, Vou. 42, No. 1, Pg. 5 Mark Moran summarizes the National Association of State Mental Health Program Directors (NASMHPD) report “Morbidity and Mortality in People With Serious Mental Illness.” Emphasizing the recommendation that people with serious mental illness “be designated as a distinct health-disparities population under the federal government’s initiative to reduce disparities in health outcomes.”  Perhaps psychiatrists need to pick the stethoscope back up again…. and actually  touch their patients.

Moran goes on to look at compelling data: In a study of people (25 to 44 years old) with serious mental illness in Massachusetts over a six year period, the cardiovascular rate was nearly seven times that of the general population. In another study in Ohio, state psychiatric hospital discharges were tracked over a six year period. People who had been hospitalized there died at three times the expected rate, primarily due to cardiovascular disease. The average loss of life was a startling 32 years. The NASMHPD report drew clear connections between antipsychotic medications in the development of metabolic syndrome in people with serious mental illness, particularly when multiple medications are prescribed. Their recommendations include integration of behavioral health and physical health, promotion of  the recovery model, supporting wellness, and the implementation of care-coordination models.

In the nearly four years since this was published, there has been a marked increased in focus on the serious health disparities of this vulnerable population. The question remains whether there has been an improvement in overall health among this group. While ongoing studies must be conducted to adequately address this question, I am encouraged by the concentration on the issue. The National Council for Community Behavioral Healthcare, the Mental Health Corporation of America, Association of Healthcare Research and Quality, the Carter Center, the Collaborative Family Healthcare Association, National Institute of Mental Health, Substance Abuse and Mental Health Services Admistration, National Association of State Mental Health Program Directors, Institute for Clinical Systems Improvement, Collaborative Care Research Network, Health Resources and Services Administration, and a variety of other national and state associations have initiatives directed toward integration efforts. These efforts include new programs, partnerships, grants, learning collaboratives, and research. APS Healthcare of Georgia’s Disease Management division is working on an initiative with various community behavioral health organizations to create a ‘Virtual’ Medical Home. This novel approach is led by Dr. Bob Climko, Senior Medical Director. Health indicators in people with serious mental illness are monitored through telephonic health coaching and Medicaid claims data made available to providers.

It is hopeful that this increased focus will result in a significant increase in longevity for people with serious mental illness. In the words of UN Secretary General Ban Ki-moon, “Let us recognize that there can be no health without mental health.” It would appear that the reverse is true as well: There can be no mental health without health.

Behavioral Health and Primary Care Integration

 

Where do people who suffer from behavioral health disorders receive healthcare services? The answer is:  It depends.  It largely depends on the severity of their symptoms, it seems.    

According to Dr. Gary Oftedahl of the Institute for Clinical Systems Improvement in The DIAMOND Initiative: A First Year Report approximately 75 percent of all patients with depression are treated by their primary care providers. The typical patient in this setting likely presents with mild to moderate symptoms and has commercial health insurance. Should the primary care provider suggest a referral to a behavioral health professional, the patient would have a low probability of following through with the referral. The stigma associated with behavioral health care blocks the path to specialty behavioral healthcare. It is more socially acceptable to receive services in a primary care setting. Historically, primary care providers have done a fair job in treating behavioral health disorders.   

There is another group of people to consider. Individuals who suffer from serious mental illness, addictive diseases, co-occurring mental illness and addictive diseases, or severe emotional and behavioral disorders tend to seek treatment with specialty behavioral healthcare providers.   This population is much more likely to follow through with treatement in behavioral healthcare settings than in primary care. The typical patient presents with severe symptoms and is uninsured, under-insured, or has Medicaid or Medicare. Unfortunately, this group is also less likely to follow through with primary care prevention or treatment needs.  A 2009 study published in the Journal of the American Board of Family Medicine (JABFM), Health Care for Patients with Serious Mental Illness: Family Medicine’s Role reports that cardiovascular disease is the leading cause of death among people with serious mental illness; approximately two to three times that of the general population. Causes are attributed to poor access to and use of quality health care.  Negative cardiometabolic effects of some new medications increase rates of obesity, diabetes, and hyperlipidemia. Symptoms often go untreated until emergency services are required. 

The integration of behavioral health and primary care is a viable solution to accessing needed services. However, it is not possible to have one model that works for everyone. Some people are most comfortable (and therefore, much more likely to follow through with treatment) obtaining all healthcare services in a primary care setting. In this medical/healthcare home model, behavioral health services are integrated into primary care settings. A behavioral health professional works closely with primary care staff, often immediately available for a consult. The patient is able to receive both primary care and behavioral health services concurrently.

The integration of primary care into the behavioral health setting is most effective with the second group, individuals who suffer from serious mental illness or other behavioral health disorders. One way of creating this medical/healthcare  home model is for a primary care provider to work collaboratively onsite with the behavioral health provider in the behavioral health setting. This partnership ensures the total healthcare of the patient. An effective model is illustrated in this 2010 abstract published in the American Journal of Psychiatry A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study by Dr. Ben Druss, et al. 

The concept of medical/healthcare home offers new and exciting insights into how we approach healthcare needs among individuals with behavioral health needs. Perhaps it is the key to eliminating the health disparities of this vulnerable population.