What Can Psychiatrists Do for People With SMI?

In this month’s column, Drs. Chwastiak and Druss, two of our nation’s leading experts in integrated care, outline timely opportunities for psychiatrists to improve the lives of patients with severe and persistent mental illness using the core principles of collaborative care. —Jürgen Unützer, M.D., M.P.H.

There is a growing call for psychiatrists in public mental health settings to assume greater oversight of the general medical care of their patients with serious mental illness. With training in medicine and expertise in health behavior change, psychiatrists are in a unique position to bridge the gap between behavioral health and medicine and to reduce the barriers to high-quality medical care for their patients. The core principles of collaborative care provide a framework for the work that needs to be done.

Management of cardiovascular risk factors should be patient-centered and evidence-based. Psychiatrists must consider the metabolic side effects of psychotropic medications and discuss these with patients so that they can make an informed decision. Schizophrenia treatment guidelines, such as those from the United Kingdom National Institute for Health and Care Excellence (NICE), are clear that psychiatrists are responsible for the adverse metabolic effects of the medications they prescribe and should try to minimize these complications. Here are other guidelines for psychiatrists:

• Avoid off-label use of antipsychotic medications, especially when there are more metabolically neutral options.

• When antipsychotic medications are necessary, choose ones with lower metabolic risk.

• Review ongoing medication requirements and consider lowering doses or switching medications when there is evidence of significant metabolic impact (such as weight gain of 7 percent of body weight or new-onset hyperlipidemia).

• Avoid antipsychotic polypharmacy whenever possible.

Patients should have regular screenings for chronic medical conditions and preventive services, such as cancer screening and immunizations against infectious diseases. Guidelines for metabolic monitoring for patients treated with antipsychotic medications and have been available since 2004, and annual screening for hypertension, diabetes, and dyslipidemia is recommended.

Screening alone, however, is insufficient to improve clinical outcomes—we must intervene to address the medical problems of people with serious mental illness (SMI). Smoking and obesity are the two main causes of preventable mortality in the general population and explain a substantial proportion of the premature mortality of persons with SMI. Pharmacotherapy is effective for smoking cessation, and evidence-based lifestyle interventions that promote weight loss have been adapted for patients with SMI, but these treatments are not widely available in community mental health centers.

We have a tremendous opportunity to translate these important research findings into changes in health care provided in real-world clinical settings and improve clinical outcomes. Psychiatrists should provide counseling on lifestyle modification and smoking cessation, taking into consideration the social determinants that contribute to poor physical health in many patients with SMI. For example, cooking skills can be taught in classes at community mental health organizations, and nutritional information and recipes should consider budgets for food. All patients with SMI should have access to evidence-based lifestyle modification programs, and psychiatrists should advocate for such programs to be implemented in the settings where they work.

Psychiatrists should implement a population-based approach to management of medical problems, including cardiovascular risk factors. Modeling on the chronic-disease management programs of our primary care colleagues, we can start by defining the populations that need targeted proactive treatment for chronic medical conditions. Registries (lists of patients currently involved in treatment along with outcomes being tracked) are critical for monitoring treatment and evaluating outcomes. A registry could be used, for example, to monitor the metabolic screening of a psychiatrist’s patient panel or diabetes performance measures among all patients at a community mental health organization who have comorbid diabetes.

Patients with chronic medical conditions need timely medical follow-up, and treatment should be adjusted when disease is poorly controlled. Because patients with SMI typically have frequent contact with psychiatrists, a psychiatrist may be the physician in the best position to monitor medical disease control and quality of care. To ensure that patients are receiving adequate treatment, psychiatrists should maintain knowledge about treatment guidelines and performance measures for chronic medical conditions such as hypertension, hyperlipidemia, and diabetes. Active engagement in management of chronic medical conditions for patients with SMI may require establishing a system of consultation with primary care and specialty colleagues, or retraining psychiatrists in general medical skills learned in medical school. Efforts are under way to address workforce issues, including changes in psychiatry residency curricula and courses such as “Primary Care Skills for Psychiatrists” offered at APA’s annual meeting.

Training in medicine provides psychiatrists with a unique skill set to provide health care for the whole person. We need the vision to tackle medical illness proactively and much earlier in the course of illness. To lead models such as behavioral health homes, we will have to develop new competencies and accept accountability for medical outcomes. Our patients face a terrible burden of medical morbidity and premature mortality. This is a time for us to be advocates and agents of change. ■