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Panel advises psychiatrists to target risk factors, general medical comorbidity

An expert panel assembled by the American Psychiatric Association Integrated Care Workgroup offered recommendations based on clinical evidence, literature and legislation relevant to mental health to help psychiatrists provide patients with serious mental illness with the best care to improve physical health.

“More than a decade has passed since data published by the National Association of State Mental Health Program Directors showed that people with serious mental illness treated in the public mental health system were dying, on average, 25 years earlier than the general population,” Benjamin G. Druss, MD, MPH, department of health policy and management, Rollins School of Public Health, Emory University, and colleagues wrote in Psychiatric Services. “However, little progress has been made in rectifying this disparity, and recent data indicate that the mortality gap for those with serious mental illness remains substantial.”

The panel conducted a systematic review of relevant literature and recent policy developments to create new recommendations. They found that patients with serious mental illness have higher rates of general medical illness than the general population in all disease categories, and they also have higher rates of mortality related to cardiovascular, respiratory and infectious diseases. In addition, they found that patients with serious mental illness more often have higher rates of common modifiable risk factors — tobacco use, substance use, poor diet and lack of physical activity — than the general population. These patients are also more likely to have economic disadvantage and chronic stress, as well as adverse effects related to medications. Lastly, these patients are at risk for receiving poor-quality medical care due to lack of insurance, the expense of care, stigma and the symptoms of mental illness, which can affect medication adherence.

Clinical studies have shown the effectiveness of interventions targeting cardiovascular risk factors among people with serious mental illness, such as smoking cessation and weight loss interventions, according to Druss and colleagues. Recent research also supports using systematic coordination and collaboration among treating providers to improve care.

In the past decade, federal legislation has improved insurance coverage and tested new models of care delivery that could benefit people with serious mental illnesses, such as the 2008 Mental Health Parity and Addiction Equity Act, the Affordable Care Act (ACA) and the 21st Century Cures Act. However, the repeal of the ACA threatens federal matching for Medicaid expansion and subsidies for insurance exchanges, eliminates essential health benefit requirements, restricts funding for demonstration projects that support care coordination and cuts funding for the public health and social safety net, according to the researchers.

Based on their findings, the APA expert panel recommends training programs in outpatient general medical care during internships, psychiatry residency and combined medical/psychiatry residency programs. They advise practicing psychiatrists take CME programs and cross-training opportunities with general medical, substance use and social services providers. In mental health and primary care delivery systems, psychiatrists can help implement population models and integrated payment systems.

The authors suggest psychiatrists advocate for new payment structures among payers, for better Medicaid rates like those in federally qualified health centers and for the expansion of prospective payment models like certified community behavioral health clinics. In terms of the federal government, experts should encourage surveillance and monitoring efforts to track the health of people with mental illness and provide regulatory oversight and enforcement of existing policies to ensure insurance coverage, access and quality of care for these patients, according to the authors.

“Psychiatrists can provide a range of services to address the poor health of patients with serious mental illness,” Druss and colleagues wrote. “These activities can include screening for general medical conditions; counseling patients to reduce cardiovascular risk factors; treating adverse health behaviors, including smoking; limiting side effects from psychotropic medications; coordinating with general medical care providers; and providing general medical services for patients who do not currently have primary medical providers.”

Further research remains necessary in many areas including: long-term interventions for cardiovascular risk factors and health-risk behaviors, and their effect on all-cause mortality; interventions in real-world settings; improving engagement in care; family support interventions; and collaborations with other disciplines and community partners to help the most socially and economically vulnerable populations. – by Savannah Demko

Disclosures: Druss reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.