APA: Don’t Forget About Physical Health in Treating Mental Illness
New payment models, better education, and stronger advocacy key to change
Washington Correspondent, MedPage Today |
WASHINGTON — People with serious mental illness die 10 to 25 years earlier than the rest of the population, and mental health experts spoke of ways to reverse this trend at a briefing on Thursday hosted by the American Psychiatric Association (APA).
Two-thirds of people with serious mental illness die from natural causes, not psychiatric ones — “they just do so at higher rates,” said Benjamin Druss, MD, of the Rollins School of Public Health at Emory University in Atlanta.
Druss chaired a working group charged by the APA with examining psychiatry’s role in improving physical health for people with serious mental illness.
The causes for these premature deaths are co-occurring chronic physical conditions such as cardiovascular issues, infectious diseases, diabetes, and hypertension, he explained.
Another factor contributing to the gap in life expectancy is due to the difficulty this population has in accessing medical care, Druss said. Also, psychiatric medications have certain side effects, which lead to weight gain, diabetes, and other cardiovascular problems. People with serious mental illness also tend to be less physically active, have poor diets, and often have substance use disorders.
Stress, social isolation, and poverty can exacerbate these problems, he continued.
Related to the briefing, the APA released a white paper released a white paper with detailed recommendations for improving the physical health of patients with serious mental illness. The document is the final product of an APA working group that convened in 2016, and their findings are based on peer-reviewed literature.
Speaking broadly, Druss said that lifestyle interventions — such as helping people quit smoking and lose weight — integrated care mangers that help coordinate behavior health and primary care, and self management groups, led by peer support workers with “lived experience” of mental illness, have all been shown to have an impact on these individuals’ physical and mental health and quality of life.
Druss listed the following specific APA recommendations from the working group he chaired:
- Provide training programs in outpatient medical care during psychiatry internships and residency programs
- Encourage psychiatrists to advocate for population models and integrated payment systems that would enhance communication, incorporate patient registries, and enact evidence-based interventions
- Increase research to evaluate programs that target improving the physical health of people with serious mental illness
- Urge psychiatrists to push for “enhanced Medicaid rates” that mirror federally qualified health centers
- Support federal health policies that would help track and monitor the health of people with serious mental illness
- Engage with state policymakers including Medicaid directors and other state mental health authorities
Druss and several panelists also specifically highlighted the connection between diabetes and mental health providers and stressed the critical need for mental health providers to be literate in medical issues — for example, knowing how to recognize dangerously high hemoglobin levels.
Panelists also discussed new and recent interventions that aim to improve care for people with serious mental illness and target the problem of premature mortality.
Glenda Wrenn, MD, director for the Kennedy-Satcher Center for Mental Health Equity at the Morehouse School of Medicine in Atlanta, agreed with Druss that mental health professionals need more training in medical issues. People with serious mental illness have died because their physical health problems have been overlooked, she said. For example, patients have died from delirium tremens — confusion brought on by extreme dehydration, often related to alcohol withdrawal.
One intervention that she believes is having an impact is the Substance Abuse and Mental Health Service Administration’s Sequential Intercept Model, which focuses on five key “intercept” points where people with behavioral issues can be connected with services and diverted from the criminal justice system.
Payment can also be a clear-cut driver for change, said Julia Harris, MPH, primary care transformation manager for Tennessee’s Medicaid program, TennCare.
“It’s not that providers don’t want to do the right [thing], but when you pay for stuff, people pay attention,” she said.
In 2016, using a $65 million state innovation grant from the Center for Medicare and Medicaid Innovation (CMMI), TennCare launched Tennessee Health Link, a health home model, targeting individuals with the highest behavioral health needs.
People with schizophrenia, bipolar disorder, homicidal ideation, or suicidal ideation are automatically eligible, as is anyone who has had a behavioral health-related inpatient admission or an admission for crisis stabilization. Participants can also be referred by their provider, Harris explained.
What the program does differently is hold behavioral health providers accountable for physical health measures, she said. It provides a customized curriculum to help providers learn from each other and quarterly performance reports, so they can assess the quality of their care.
Another important feature is a care-coordination tool offering “near real-time access” of emergency room admissions: “It’s giving providers access to information that they never had access to before,” Harris said.
Lauren Swanner, RN, of Mosaic Community Services, a subsidiary of Sheppard Pratt Health System, Inc., based in Timonium, Maryland, spoke of her own work in a health home model.
One clear focus for all mental health providers should be on the side effects of the medications they give patients, she said.
She noted that she saw one patient who hadn’t had a bowel movement in 2 weeks, because of her medications. Swanner sent that patient directly to the emergency room. She ended up needing a colostomy.
“We’re trying to treat their brain, and we’re getting their body sick while doing it,” said Swanner, noting the importance of finding a medication regimen that patients can comply with, without endangering their health.
A different report from the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC), an offshoot from the 21st Century Cures Act, is due out next week.