Psychiatrists have known for several years of the substantial vulnerability and dangerously increased morbidity and mortality in the patients we treat. Some of this vulnerability is directly related to the sequelae of mental illness, but most is attributed to increased burden from nonpsychiatric illness and resultant shortened lifespan in those with mental illness. The 2006 report of the National Association of State Mental Health Program Directors, “Morbidity and Mortality in People With Serious Mental Illnesses,” stated that we, as a field, own this problem. Although challenging to address, this growing psychiatric epidemic falls squarely on our laps.
The numbers are sobering. People who have severe mental illness (SMI) die up to 25 years earlier when compared with the general population. For those who have schizophrenia, up to 60 percent of the reduced lifespan and increased mortality is directly related to metabolic disorders (for example, diabetes), respiratory illness (for example, chronic obstructive pulmonary disease), infections (for example, influenza, HIV, viral hepatitis) and suboptimal prevention and treatment of common cancers (for example, breast, cervical, and colon cancers)—not suicide or other psychiatric causes. People with mental illness smoke almost half of all cigarettes purchased in the United States and are twice as likely to smoke cigarettes, compared with those without mental illness. Individuals with SMI are three times more likely to have chronic bronchitis, five times more likely to suffer from emphysema, and at least twice as likely to die early from vascular disease.
According to the Centers for Disease Control and Prevention, over 40,000 people die each year from vaccine-preventable diseases. Many individuals with mental illness have suboptimal primary care, do not receive proper vaccinations, and are more susceptible to infectious diseases. Those with chronic mental illness are more than twice as likely to acquire and receive poor treatment for hepatitis B and C. People with SMI are up to 10 times more likely to be infected with HIV. Although the incidence of most common cancers does not seem to be increased in those with mental illness (except for cervical cancer), this group of people is more likely to have limited evidence-based screening, suboptimal treatment, and worse overall outcomes, including increased mortality, when compared with those without SMI.
How can we, as a profession, reverse this dangerous course for many of our patients? I believe cross-education between primary care and behavioral health is an essential part of the solution. Primary care providers can benefit from learning “primary care psychiatry” (that is, diagnosis and treatment of mild to moderately severe anxiety, mood, psychotic, and substance misuse disorders, or AMPS disorders), and psychiatrists can benefit from reviewing the basics of preventive medicine (with a focus on primary and secondary prevention of common cardiac, pulmonary, infectious, metabolic, and oncologic disorders). Numerous models of integrated care have been proposed, and laws have been developed to support these innovative models. How can primary care providers and psychiatrists fully participate in these collaborative models without the longitudinal training to do so?
One small step toward the goal of addressing health care disparities in people with SMI is to train medical students, psychiatry residents, and psychosomatic fellows how to effectively and routinely screen for common medical conditions that disproportionately and adversely affect patients with mental illness. If a screening test is positive, this provides an opportunity for the physician to explore options for treatment with the patient, emphasizing the importance of establishing long-term primary medical care. Psychiatrists (and trainees) are well positioned to discuss with patients the importance of primary and preventive medical care in the psychotherapeutic setting.
In an effort to address the need for integrative care and education, American Psychiatric Publishing will soon make available two texts on collaborative and preventive care. These books collectively serve as an “integrated care curriculum” and will be valuable clinical resources for both trainees and practicing psychiatrists. More about these books will appear in a future issue. ■