Professional News
Untreated Chronic Illness Blamed for High Mortality
Psychiatric News
Volume 43 Number 16 page 7-24

Contrary to what may be a popular belief, a person with serious mental illness is more likely to die of a heart attack or complications from diabetes than by suicide.

Misperceptions about the health care needs of people with mental illness extend even to health care professionals, which may be one of the reasons such patients are dying prematurely—25 to 30 years earlier than other Americans, according to federal health statistics. This gap in life expectancy is an increase from the 10- to 15-year mortality difference in the early 1990s between individuals with mental illness and others.

To reverse this trend, advocates for people with mental illness recently called for federal intervention, including improving the tracking of these individuals' physical and mental health; removing obstacles to their receiving quality, integrated physical and mental health care; and encouraging primary care providers to work in close proximity in the same facility with mental health clinicians to improve provision of that care.

"We have to get past the point of psychiatrists saying 'I don't do that internal medicine stuff,' and internists saying 'I don't want to take all of the time that people with mental illness need,'" said Joe Parks, M.D., medical director of psychiatric services for the Missouri Department of Mental Health.

Parks and other mental health experts briefed congressional staff in June on the need for federal efforts to reverse the declining life expectancy for people with serious mental illness. The briefing was organized by the Senate Mental Health Caucus.

It was Park's 2007 report that identified the lower life expectancy of people with serious mental illness compared with the general population and that dispelled the "suicide" stereotype behind the early deaths. Early deaths, Parks said, were largely due to untreated or undertreated nonmental chronic health conditions. Among the leading preventable medical conditions driving the increased morbidity and mortality in this population were metabolic disorders, cardiovascular disease, and diabetes mellitus.

Park's research also found a high prevalence of modifiable risk factors, including obesity and smoking. Cigarette use, he noted, is so widespread among people with serious mental illness that they now smoke about 44 percent of all cigarettes sold in the United States. "We really need to focus on smoking because it is a big opportunity" to prevent disease and death, Parks said.

The prevalence of risk factors among people with serious mental illness is exacerbated by poor health care access among this population and by the stigma they face—even from medical professionals, according to a consensus of the literature.

Similar health disparities exist even in populations with broad access to health care, such as veterans, said Barbara Mauer, a health care consultant in Seattle. Mauer, who has studied the issue, blamed both the negative attitudes of health care providers toward mental illness and a failure to educate patients to seek both needed mental and primary health care.

Research studies designed to address disparities between mental health care and general health care have found health improvements when nurse case managers coordinate both mental and physical care for each patient, while educating and giving patients new skills to better manage their own illnesses.

Analysis of one nurse case manager pilot program found that medical problems were newly detected by staff in one-third of participating patients taken to a mental health facility for evaluation and treatment. At the same time, there was an increase in disease-prevention health care provided to these patients.

Another pilot program approached the challenge of split—and therefore fragmented—mental and general health care from the behavioral health care side by placing nurse practitioners in mental health clinics. In one such program in Massachusetts, the nurse practitioners ensured that the mental health patients also received general health care services.

A Colorado pilot program that is addressing health care providers' negative attitudes toward mental illness and improving access to care has found some success. The integrated care program in Summit County combined the staffs of a community health center and a mental health clinic to create "care teams" of general and mental health care providers within a facility that had previously emphasized general health care. The program provided training for the mental health staff in the common physical health care needs of people with mental illness and educated the general health care providers on signs that patients may also need mental health and substance abuse treatment.FIG1

Among the biggest impacts of the program was the improved communication it encouraged between two traditionally separate organizations, to the extent that both were comfortable referring patients and seeking additional information from the other side of the program.

"It's important to share our knowledge and share our ignorance," said Helen Royal, a nurse in the program.

Advocates at the congressional briefing said the federal government can encourage such pilot programs by including funds for them in their established grant programs.

Also, the Community Mental Health Services Improvement Act (S 2182 and HR 5176) would create a new grant program through the Substance Abuse and Mental Health Services Administration (SAMHSA) to fund the co-location of primary care services within mental health organizations. The legislation, which would provide $50 million in grants for the first year of a five-year program, was included in draft legislation to reauthorize SAMHSA, but that legislation has stalled for the year.

Supporters are optimistic that the grant program will be revived in Congress next year, along with efforts to require insurers to cover smoking cessation and obesity treatment programs.

The text of S 2182 and HR 5176 can be accessed at<http://thomas.loc.gov> by searching on the bill numbers.

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