Board Approves Statement on Role in Reducing Physical Health Disparities
Abstract
The statement is broadly worded to allow for a range of ways in which psychiatrists can be involved in the management of common medical conditions, depending on clinicians’ competence, confidence, and training.
Attention to the common medical conditions that are often comorbid with mental illness is an essential component of psychiatric practice, according to a position statement approved by the APA Board of Trustees at its meeting in June in Washington, D.C.
This may include screening for common medical conditions, counseling patients to reduce preventable cardiovascular risk factors, taking steps to limit the harm that can come from use of psychotropic medications, monitoring the medical care being delivered by other medical providers, or engaging in management of some common medical conditions when warranted by the clinical situation and with appropriate support and training. The position statement further calls for education of psychiatrists and trainees in primary care skills and for funding for that education (see box).
Statement Outlines Psychiatry’s Role in Patients’ Overall Health Care
Screening for common medical conditions, counseling patients to reduce preventable cardiovascular risk factors, limiting harm that can come from use of psychotropic medications (including use of existing guidelines from APA and the American Diabetes Association), and monitoring the medical care being delivered by other medical providers are essential components of psychiatric practice.
Psychiatrists should identify patients receiving no or suboptimal primary care and may intervene when most appropriate based on their identified competencies, local resources, and patient preferences for care. Co-management of common medical conditions when clinically necessary should be recognized as a potential component of the overall care of patients with mental illnesses (when this occurs, appropriate reimbursement should also be made).
Appropriate primary care training in the treatment of common medical conditions, including the leading determinants of mortality in populations with serious mental illnesses, should be made available to psychiatrists seeking to better manage physical health conditions in patients with mental illnesses. Furthermore, APA and partner organizations such as the AMP should increase efforts to provide adequate training and clinical experience throughout the spectrum of medical education from residency and fellowship levels to continuing medical education for the psychiatric workforce.
The scope of this endeavor should include development of measurable competencies in the screening for common medical disorders, knowledge of age and culturally appropriate disease prevention concepts, and current approaches to the treatment of common medical conditions.
APA and AMP support the development of partnerships between primary care providers and psychiatrists to provide consultation and oversight in the management of chronic medical conditions in a variety of settings.
APA and AMP support the development of guidelines that clarify the clinical circumstances in which psychiatrists may become involved in the management of common medical disorders for a subset of their patients.
APA and AMP advocate for appropriate funding for training psychiatrists in primary care skills to work confidently and competently in a variety of settings, both traditional and nontraditional, such as in public mental health clinics and outreach services to immigrant and homeless populations.
APA and AMP should continue to support the research, development, and wider implementation of integrated models of health care including outcome studies for psychiatrists treating the conditions contributing to increased mortality.
The position statement was jointly written by members of APA’s Work Group on Integrated Care and the Association of Medicine and Psychiatry (AMP). Before being approved by the Board, it was reviewed and supported by the APA Council on Health Care Systems and Financing, Council on Geriatric Psychiatry, Council on Psychosomatic Medicine, Council on Medical Education and Lifelong Learning, American Association of Community Psychiatrists, and Academy of Psychosomatic Medicine.
“Many patients with serious mental illness experience high rates of medical disorders, including tobacco-related pathology, obesity, hypertension, hyperlipidemia, and diabetes,” said APA President Renée Binder, M.D. “The position statement approved by the Board of Trustees points out that psychiatrists have medical training that distinguishes us from other mental health disciplines. Psychiatrists can develop partnerships with primary care providers in order to improve the health status and medical care of their patients. They can also play a vital role by screening for common medical conditions, counseling patients to reduce preventable cardiovascular risk factors, and limiting harm that can come from use of psychotropic medications.”
She added, “The position statement also supports the development of guidelines that clarify the clinical circumstances in which psychiatrists may become involved in the management of common medical disorders for a subset of their patients. And it asserts that APA will advocate for appropriate funding for training psychiatrists in primary care skills to work confidently and competently in a variety of settings.”
Authors of the position statement who spoke with Psychiatric News say APA’s endorsement of the need for psychiatrists to play a role in the care and management of patients with common medical conditions is crucial to the field and will promote further awareness, research, and training to fulfill the core tenets of the position statement.
Very prominent in the development of the position statement was Robert McCarron, D.O., director of Integrated Internal Medicine/Psychiatry Education at the University of California, Davis School of Medicine, and a past president of the Association of Medicine in Psychiatry. McCarron told Psychiatric News that he believes it is important for APA to collaborate with other organizations in forwarding the cause of integrated care of patients with serious mental illness and general medical conditions. And he said the collaboration of members of the Association of Medicine in Psychiatry in developing the position statement was vital.
McCarron also said many of the principles in the position statement are reflected in “Preventive Medical Care in Psychiatry: A Practical Guide for Clinicians,” released in November, 2014 by American Psychiatric Publishing and co-edited by McCarron. (His fellow editors are Glen L. Xiong, M.D., Craig R. Keenan, M.D., and Henry A. Nasrallah, M.D.) The book was written for psychiatrists in training and in clinical practice, as well as other health care providers who wish to learn an evidence-based and user-friendly approach to prevent commonly encountered, treatable, and potentially deadly illnesses in their patients.
Lori Raney, M.D., chair of the APA Work Group on Integrated Care, noted that for almost a decade it has been known that the lifespan of people with serious mental illness is 20 to 30 years shorter than that of the general population, exacerbated by a host of factors in the preceding decade including the introduction of second-generation antipsychotics.
“Although screening for some metabolic changes began in 2004 after the publication of new guidelines, this has not been sufficient to limit the continued morbidity and mortality,” Raney said.
Lori Raney, M.D., notes that the position statement outlines specific steps that psychiatrists should be taking as part of the routine care they provide to their patients.
Raney said the statement draws on the pioneering work of psychiatrist Benjamin Druss, M.D., M.P.H., whose research has focused on health disparities among people with serious mental illness and who has published research from the Primary Care Access and Referral Study (PCARE) showing that a medical care management intervention for patients in community mental health centers improves rates of preventive care services and overall health outcomes.
“We are trained as physicians first and then as psychiatrists,” said Raney. “The position statement encourages psychiatrists to take responsibility for the oversight of medical care for our patients and outlines specific things we should be doing as part of routine care. In certain situations in which psychiatrists are willing and feel competent, they can consider providing some basic treatment themselves. They should seek out additional training in treating common medical conditions if they feel they need it.”
Raney said the Primary Care Skills for Psychiatrists course offered at APA’s annual meeting and IPS: The Mental Health Services Conference (formerly known as the Institute on Psychiatric Services) has drawn an increasingly large attendance and is an important resource for clinicians seeking to sharpen their primary care skills.
Jeffrey Rado, M.D., incoming AMP president and a coauthor of the statement, emphasized that the statement is meant to incorporate a range of ways that psychiatrists can be involved in the management of medical conditions.
Eric Vanderlip, M.D., says the position statement approved by the Board puts APA’s imprimatur on a call for psychiatrists to play a role in the management of common medical conditions that accompany mental illness.
“We intended the statement to be very broad in terms of what role a psychiatrist might play, from helping to co-manage conditions, screening for those conditions, or simply helping to coordinate care with a primary care clinician,” Rado told Psychiatric News. “The statement doesn’t say that every single psychiatrist should be doing all of these things. It depends on the setting they are working in and their level of competence and confidence and training.”
The Association of Medicine and Psychiatry is an interdisciplinary clinical and scientific group that promotes high-quality patient care for those with combined illness, develops guidelines for services and training experiences specifically designed to address the problems of these patients, and fosters basic and clinical research in this area. Rado says many members are double-boarded in primary care and psychiatry, but some are psychiatrists who are interested in the interface between medicine and psychiatry.
Erik Vanderlip, M.D., also a coauthor, emphasized the immense value of the APA imprimatur. “The position statement is a call to action to psychiatrists to remember our medical roots and recognize that the epidemic of health problems among people with serious mental illness is still happening and that we have a role in addressing these problems,” he told Psychiatric News. “It gives psychiatrists the permission from APA—the leading policymaking body on the standards of care for psychiatry—to expand the scope of their practice and to take responsibility for the physical health conditions of their patients.” ■
The text of the Position Statement on the Role of Psychiatrists in Reducing Physical Health Disparities in Patients With Mental Illness is posted in APA’s Policy Finder here.
