Members of the mental health community are working on ways to improve coordination of primary care and mental health in an effort to decrease early death among individuals with serious mental illness.
Individuals being treated for serious mental illness by public mental health systems die 25 years earlier, on average, than do members of the general population, according to a report released last fall by the National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. About 60% of these premature deaths are attributable to medical conditions such as cardiovascular and pulmonary disease.
The report, “Morbidity and Mortality in People with Serious Mental Illness,” outlines the factors contributing to this disparity in death and disease.
“This is a virtual epidemic of death,” said Dr. Joseph Parks, medical director for the Missouri Department of Mental Health and president of the NASMHPD Medical Directors Council.
The report has become a sort of “rallying point,” Dr. Parks said. NASMHPD is in the process of drafting a position paper on this topic and has held a series of meetings with stakeholders throughout the mental health community.
The report found that the increased mortality and morbidity is attributable in large part to preventable conditions such as cardiovascular disease, diabetes, respiratory diseases, and infectious disease, including HIV/AIDS. Mental health patients also are at greater risk for death and disease because they have generally higher rates of smoking, alcohol and drug use, poor nutrition and obesity, and unsafe sexual behavior.
Second-generation antipsychotic medications also have been associated with weight gain, diabetes, dyslipidemia, insulin resistance, and metabolic syndrome, according to the report.
Access to health care is another significant factor in the higher morbidity and mortality among the seriously mentally ill, the report noted.
The report recommends a variety of national, state, and clinician-level solutions including:
▸ Designating the seriously mentally ill as a health disparities population.
▸ Adopting national surveillance activities on the health status of individuals with serious mental illness.
▸ Improving access to physical health care services.
▸ Promoting coordinated and integrated mental and physical health care services.
▸ Increasing Medicaid funding to cover smoking cessation and weight reduction treatments for seriously mental ill patients.
▸ Improving comprehensive health care evaluations by physicians.
One key strategy to improving coordination is moving toward the co-location of mental health and primary care services, Dr. Parks said. The body of literature on integrating care shows coordination that requires patients to shuttle from one clinic to another often breaks down over time.
Co-location models generally involve either a nurse practitioner providing primary care at a mental health site or a clinician providing psychiatric care in a primary care setting. This type of physical proximity allows providers to work off the same chart and see each other in the hallway.
This could, in turn, lead to informal discussions that improve patient care, Dr. Parks said.
There's been a piecemeal movement toward co-location, he said, with federally qualified community health centers and community mental health centers leading the way. All new federally qualified community health centers have been required to provide mental health services, along with dental care and substance abuse services.
The problem with moving toward co-location is that historically, physical health care, mental health care, and substance abuse treatment have all been separated, said Dr. Mary Ellen Foti, state medical director for the Massachusetts Department of Mental Health.
“You basically have diagnosis identified treatment silos in many states,” she said.
In addition, primary care physicians may be reluctant to take referrals of patients with serious mental illness because they feel inadequately prepared to deal with those unique issues. And many psychiatrists feel inadequately trained to handle even basic medical conditions.
It's not that providers aren't willing to coordinate their care, it's that they don't have the systems to do it well, said Dr. Foti, who was one of the editors of the NASMHPD report.
Dr. Foti is optimistic about making progress because the report takes the first step in identifying the problems and providing recommendations and solutions. Now state and federal agencies can begin to design quality improvement programs that target patients' risk factors for disease. For example, patients with serious mental illness are obviously in need of smoking cessation programs.
The implementation of evidence-based treatment guidelines combined with the widespread adoption of electronic medical records could also go a long way in improving care for the seriously mentally ill, said Dr. Clifford K. Moy, a psychiatrist based in Austin, Tex., and associate medical director for the Texas Medicaid and Healthcare Partnership.