Am Fam Physician. 2008;78(3):314-315
Author disclosure: Nothing to disclose.
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.3–5 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.5–9 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.
| 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) |