WASHINGTON ― In a new white paper, the American Psychiatric Association (APA) called on its members to do more to address the physical health of patients with serious mental illness (SMI), noting that such patients are more likely to die at a younger age ― 10 to 25 years sooner ― than the general population.
Most of the excess deaths in these patients are due to general medical conditions, such as diabetes and cardiovascular disease. Only about 30% of the conditions arise because of genetic factors, 40% are associated with health behaviors, and 20% are due to lack of access to good medical care, isolation, poverty, or lack of social support, said Ben Druss, MD, MPH, chair of the APA work group responsible for the new document, which was issued at a briefing in here.
Psychiatry’s Role in Improving the Physical Health of Patients With Serious Mental Illness is the result of the work of an APA expert panel that was convened in 2016. The panel examined and analyzed randomized trials and peer-reviewed literature to determine what works, said Saul Levin, MD, MPA, FRCP-E, CEO, and medical director of the APA.
The report’s recommendations include the following:
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Psychiatrists should receive more training in outpatient medical care during internships, residencies, and throughout their career, and there should be opportunities for cross-training with medical, substance use, and social services providers.
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Psychiatrists should step into leadership roles in delivery systems to help facilitate better communication and use of patient registries.
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More research is needed to determine what models work best to improve the physical health of patients with SMI.
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Payment models should incorporate incentives for providing ancillary services, such as case management and wellness interventions.
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Psychiatrists should advocate at the state and federal levels for better medical treatment for people with SMI and that premature mortality in the population be treated as a public health issue.
Holistic Approach Needed
“It’s about rediscovering our commitment in caring overall for patients with serious mental illness,” Dr Druss, professor and Rosalynn Carter Chair in Mental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, told Medscape Medical News.
More than a century ago, psychiatrists typically worked with inpatients, addressing every aspect of care. As mental health care moved into the community, there was less of a focus on people with more serious mental health conditions, said Dr Druss.
The pendulum is swinging back, and many safety net providers are essentially serving as frontline mental health and physical health clinicians, but more needs to be done, he added.
Julia Harris, MPH, the primary care transformation manager with TennCare, Tennessee’s Medicaid program, agreed. She said that despite an 8-year effort to integrate behavioral and physical healthcare for TennCare recipients, those with behavioral health problems are still not having all of their needs addressed. The TennCare recipients with behavioral health problems account for 20% of the state’s Medicaid population, but about 40% of the state’s total Medicaid spending.
Five percent of those behavioral health patients account for about half of behavioral health spending, said Harris. TennCare determined that patients with schizophrenia, bipolar disorder, and depression were the highest-cost adults with behavioral health needs.
Those data have been used to inform Tennessee Health Link, a program begun in 2016 to more closely manage people with SMI. The state received funding from the Center for Medicare & Medicaid Services’ Center for Medicare and Medicaid Innovation, which covers 90% of the program costs for 2 years, said Harris.
Individuals with schizophrenia, bipolar disorder, homicidal ideation, suicide attempts, or self-injury are flagged. If they also have one or more behavioral health–related inpatient admissions, crisis stabilization unit admissions, or residential treatment facility admissions and have additional diagnoses, such as substance use disorder or other behavioral disorders, they are given a higher level of case management and services, including care coordination, health promotion and education, family support, and referral to social supports.
Behavioral health providers are rated on quality measures that include screening for obesity and diabetes, as well as diabetes care. Primary care providers are measured on some mental health parameters, such as rate of inpatient psychiatric admissions.
Clinicians receive quarterly performance reports. Importantly, the state has established a system that alerts care coordinators ― almost in real time ― if their patients have an admission to an emergency department or inpatient unit.
Adrienne Kennedy, a member of the board of directors of the National Alliance on Mental Illness, called the excess deaths among those with serious mental illness the “canary in the mine” and warned of the dangers of a lack of integration and connection in caring for the whole person.
“If we fix this, we fix a lot of things across the entire system,” said Kennedy, whose son died in 2016 at age 31 from untreated type 1 diabetes and untreated mental illness.
Kennedy and her family, including her husband, who had been nominated for a Nobel Prize, did everything possible to keep their son well but were often stymied by a lack of coordination between mental and physical health providers, she said at the briefing.
“We look at this population and say, what is needed here will teach what’s needed across the board in all kinds of different ways,” said Kennedy. “I see it as the tip of a fabulously important iceberg of human care and good medical care ― training, treatment, and integration,” she said.
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