Editorials

Improving Care For Patients with Serious Mental Illness



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Am Fam Physician. 2008 Aug 1;78(3):314-315.

  Related Article

In this issue of American Family Physician, Kiraly and colleagues highlight common medical comorbidities and potential medication interactions in patients with serious mental illness.1 Primary care physicians commonly care for patients with serious mental illness, who often have comorbid medical illnesses that are untreated, under-treated, or undiagnosed. Although persons with serious mental illness have a greater chronic disease burden than the general population, they receive primary care treatment much less often. Only one half of persons with serious mental illness report seeing a regular physician or nurse practitioner for health care.2

Many aspects of serious mental illness can contribute to inadequate medical care. Symptoms from mental illness can impair the person's ability to recognize and interpret important medical symptoms and communicate concerns to a physician. Cognitive problems can make it difficult for patients to remember medical recommendations and plan for future health care needs.35 Economic barriers also present significant challenges for this population. One third to one half of persons with serious mental illness are at or near the federal poverty level, and nearly 80 percent of these persons are unemployed.59 Difficulty finding transportation, attending medical appointments, and paying for medications can also make receiving optimal care more challenging.

Kiraly and colleagues note that lack of health insurance, decreased access to care, and cost are important barriers to adequate health care in patients with serious mental illness.1 In addition, high rates of nonadherence to treatment can inhibit health care in this population. More than one half of patients with serious mental illness report that they do not take their psychiatric and other medications regularly and that they have difficulty keeping appointments and recognizing symptoms.5,10 Patients sometimes avoid medical care because of negative past experiences or a fear of hospitalization.11 Others report delaying care because they do not think their symptoms will be taken seriously.12

Resources or referrals to help patients with serious mental illness access medication assistance programs, health insurance, or disability support may decrease the economic difficulties that these patients face.3,11 In addition, when prescribing medications for homeless patients with serious mental illness, physicians should inquire about whether the patient will be able to store the medications properly. Physicians should also pay attention to adverse effects such as sedation and impaired alertness, which can affect the patient's safety.13  Table 1 presents strategies for addressing potential barriers to adequate primary care.

As new research has highlighted the medical risks associated with serious mental illness and the psychiatric medications used for treatment, physicians have debated who is best suited to oversee the medical care of these patients. The American Psychiatric Association recommends that physicians work with psychiatrists to manage medical issues, but that psychiatrists also maintain basic skills for screening and monitoring medical diseases common in these patients (e.g., cardiovascular and respiratory diseases, diabetes).14

If working independently, physicians and psychiatrists may lack important health information about the patient; therefore, a growing number of organizations have called for better collaboration between primary care and mental health professionals.3,9 This may involve seeking patient permission for health care professionals to share notes, lists of medications, and hospitalization data as well as joint contact with caregivers to share ideas and information. If the locations of medical services are close, coordinating patient appointments may be helpful.

Kiraly and colleagues outline important elements of medical care for patients with serious mental illness.1 Although it may require extra effort to ensure high-quality care in these patients, primary care physicians who recognize the challenges and work with patients to encourage ongoing relationships can have a significant impact on the morbidity and mortality in this under-served population.

Table 1

Strategies for Addressing Potential Barriers to Adequate Primary Care in Persons with Serious Mental Illness

Barriers Strategies

Medical

High rate of chronic disease

Screen regularly

Medication adverse effects

Monitor medications and laboratory testing results

High rate of tobacco use

Urge tobacco cessation as a key health intervention

Unhealthy behaviors (e.g., poor diet, lack of exercise, lack of safe sexual practices)

Offer preventive care to all patients

Medical visits typically occur only for acute care instead of for chronic conditions

Encourage follow-up appointments for chronic disease and preventive care

Disparities in care in some settings

Monitor quality of care and services provided

Lack of coordination between mental health professionals and primary care physicians

Collaborate with mental health professionals when possible; document names and agencies

Economic

Poverty, lack of health insurance, unemployment

Connect patients with needed social services when possible; be aware of economic barriers

Homelessness

Consider medication storage needs; limit the use of sedating medications

Lack of transportation

Be aware of external barriers that may affect adherence to the care plan

Communication

Cognitive impairment

Recognize the risk of deficits in memory, recall, and understanding; encourage caretaker participation, if appropriate

Fear that the physician will not take symptoms seriously

Take patient concerns seriously, especially because these patients are more likely to delay care

Physician stereotypes of patients with mental illness

Treat patients respectfully; include patient in medical care decision making

Difficulty expressing urgency

Provide options for urgent visits

Psychiatric

Psychiatric symptoms

Recognize symptoms that interfere with care; understand that patients may not have control over depression, anxiety, avolition, or delusions

Increased risk of suicide

Screen appropriately; know the risk factors for suicide (e.g., recent attempts, anxiety disorders, depression, hopelessness, suicide plan)

Table 1   Strategies for Addressing Potential Barriers to Adequate Primary Care in Persons with Serious Mental Illness

View Table

Table 1

Strategies for Addressing Potential Barriers to Adequate Primary Care in Persons with Serious Mental Illness

Barriers Strategies

Medical

High rate of chronic disease

Screen regularly

Medication adverse effects

Monitor medications and laboratory testing results

High rate of tobacco use

Urge tobacco cessation as a key health intervention

Unhealthy behaviors (e.g., poor diet, lack of exercise, lack of safe sexual practices)

Offer preventive care to all patients

Medical visits typically occur only for acute care instead of for chronic conditions

Encourage follow-up appointments for chronic disease and preventive care

Disparities in care in some settings

Monitor quality of care and services provided

Lack of coordination between mental health professionals and primary care physicians

Collaborate with mental health professionals when possible; document names and agencies

Economic

Poverty, lack of health insurance, unemployment

Connect patients with needed social services when possible; be aware of economic barriers

Homelessness

Consider medication storage needs; limit the use of sedating medications

Lack of transportation

Be aware of external barriers that may affect adherence to the care plan

Communication

Cognitive impairment

Recognize the risk of deficits in memory, recall, and understanding; encourage caretaker participation, if appropriate

Fear that the physician will not take symptoms seriously

Take patient concerns seriously, especially because these patients are more likely to delay care

Physician stereotypes of patients with mental illness

Treat patients respectfully; include patient in medical care decision making

Difficulty expressing urgency

Provide options for urgent visits

Psychiatric

Psychiatric symptoms

Recognize symptoms that interfere with care; understand that patients may not have control over depression, anxiety, avolition, or delusions

Increased risk of suicide

Screen appropriately; know the risk factors for suicide (e.g., recent attempts, anxiety disorders, depression, hopelessness, suicide plan)

Address correspondence to Katherine J. Gold, MD, MSW, MS, at ktgold@umich.edu. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Kiraly B, Gunning K, Leiser J. Primary care issues in patients with mental illness. Am Fam Physician. 2008;78(3):355–362.

2. Chafetz L, White MC, Collins-Bride G, Nickens J, Cooper BA. Predictors of physical functioning among adults with severe mental illness. Psychiatr Serv. 2006;57(2):225–231.

3. Parks J, Svendsen D, Singer P, Foti ME, eds. Morbidity and mortality in people with serious mental illness. 13th technical report. Alexandria, Va.: National Association of State Mental Health Program Directors Medical Directors Council; 2006.

4. Martínez-Arán A, Vieta E, Reinares M, et al. Cognitive function across manic or hypomanic, depressed, and euthymic states in bipolar disorder. Am J Psychiatry. 2004;161(2):262–270.

5. Diamond RJ. What primary care physicians need to know about people with schizophrenia. WMJ. 2004;103(6):29–33.

6. U.S. Department of Health and Human Services, National Institute of Mental Health. Mental health: a report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services; 1999.

7. Cook JA. Employment barriers for persons with psychiatric disabilities: update of a report for the president's commission. Psychiatr Serv. 2006;57(10):1391–1405.

8. Dean K, Walsh E, Moran P, et al. Violence in women with psychosis in the community: prospective study. Br J Psychiatry. 2006;188:264–270.

9. Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Aff. 2006;25(3):659–669.

10. Daumit GL, Pratt LA, Crum RM, Powe NR, Ford DE. Characteristics of primary care visits for individuals with severe mental illness in a national sample. Gen Hosp Psychiatry. 2002;24(6):391–395.

11. Hahm HC, Segal SP. Failure to seek health care among the mentally ill. Am J Orthopsychiatry. 2005;75(1):54–62.

12. Decoux M. Acute versus primary care: the health care decision making process for individuals with severe mental illness. Issues Ment Health Nurs. 2005;26(9):935–951.

13. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician. 2006;74(7):1132–1138.

14. Lehman AF, Lieberman JA, Dixon LB, et al., for the American Psychiatric Association Steering Committee on Practice Guidelines. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004;161(2 suppl):1–56.



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