NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Bradford DW, Slubicki MN, McDuffie J, et al. Effects of Care Models to Improve General Medical Outcomes for Individuals With Serious Mental Illness [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011 Sep.
Effects of Care Models to Improve General Medical Outcomes for Individuals With Serious Mental Illness [Internet].
Show detailsIndividuals with serious mental illness (SMI) have shortened life expectancies relative to the general population1,2 to an extent that is not explained by unnatural causes such as suicide or accidents. Epidemiological studies have estimated the life expectancy of individuals with schizophrenia to be 10 to 25 years less than the general population.3–6 Increased morbidity of both chronic and acute illnesses in individuals with SMI also reduces quality of life and increases the overall burden of disability beyond that of the SMI itself. SMIs have an overwhelming economic impact, as measured by direct and indirect costs, including health care costs, disability payments, lost productivity, and law enforcement costs. For example, one study estimated annual costs due to schizophrenia to be $62.7 billion annually in the U.S.,7 and patients with bipolar disorder are estimated to have the highest total health care costs of any mental illness8,9 with up to 70 percent of these costs in non–mental health (e.g., primary care) settings.10,11 Given these issues, methods to improve general medical services for individuals with SMI is a pressing priority.
BACKGROUND
The issues that influence general medical outcomes for individuals with SMI are complex and overlapping and likely vary by disease state. Relevant factors can be categorized to include population characteristics, contextual and system factors, provider factors, and community resources. Interventions aimed at improving general medical outcomes in this population could be directed at any one, or several, of these factors.
The populations of individuals with SMI have consistently shown higher rates of illnesses, such as infectious disease,12 diabetes,13–15 respiratory illness,16 and cardiovascular disease,17,18 than the general population. Modifiablerisk factors for poor health, such as smoking,19 obesity,20,21 alcohol and substance abuse,22 and lack of exercise,23 are highly prevalent in individuals with SMI—as are obstacles to optimal health care such as poverty,24 homelessness,25 and social isolation.26
Multiple studies show diminished guideline concordance of general medical care provided to individuals with SMI, as evidenced by reduced receipt of preventive medical services27,28 and lower quality of chronic disease management for illnesses such as diabetes29,30 and cardiovascular disease31 as well as acute illnesses such as myocardial infarction.32 In addition, psychiatric medications can be risk factors for poor health given the association with some pharmacological treatments and medical outcomes such as increased risk of sudden death,33 hyperglycemia,34 hyperlipidemia,35 and weight gain.36
Effectiveness of Health Care Providers
The effectiveness of health care providers in optimizing general medical outcomes in individuals with SMI depends on multiple factors, including the type and level of training for working with this complex population, attitudes and beliefs about individuals with SMI, and knowledge of specific issues affecting individuals with SMI. The range of professionals involved with providing psychiatric care to patients with SMI includes disciplines with little or no training in medical issues. Among physician mental health providers (i.e., psychiatrists), general medical training is typically limited to less than 6 months of direct service in internal medicine settings. Further, general medical providers usually have limited experience working with patients with SMI. Although combined training programs, such as those in psychiatry and internal medicine, produce physicians who are well trained to address both medical and psychiatric problems, there are relatively few of these programs—only 17 in the U.S.37—so graduates of such programs represent a small minority of those who provide general medical services along with SMI care.
Settings of Care
The characteristics of various sites of care where individuals with SMI receive general medical services affect the general medical outcomes of this population. Individuals with SMI may receive psychiatric and general medical care at sites separated by geography, organization, financing, and/or culture.38 While integration of mental health and primary care services has been implemented in some settings for depressive and anxiety disorders, general medical and psychiatric services typically are received at different sites for individuals with SMI. Payment structures may not incentivize collaboration of care among medical and psychiatric care providers, making the increased time challenging for this important element of care. Even in integrated systems with single payers, medical and psychiatric care systems may be held accountable for outcomes that sometimes lead to conflicting medical decisions (e.g., psychotropic medication choice may lead to improved psychiatric symptom control while worsening metabolic indices).
Supportive Services
A further impact to general medical outcomes in persons with SMI may be the availability of various types of supportive services that facilitate overall well-being and access to care. While it has not been systematically studied to this point, the availability of housing, intensive case management services, and employment support would be expected to positively influence adherence to recommendations and the ability of persons with SMI to access general medical care.
Integration of Care
In this evidence synthesis, we sought to elucidate the best ways to integrate medical and mental health care to improve general medical outcomes in individuals with SMI. We were interested in understanding methods of integration of care for those whose psychiatric disability causes the greatest barriers to general medical care and for whom the site of greatest interaction with health care is the psychiatric setting. The term “serious mental illness” has been defined multiple ways and includes groupings of diagnoses and ratings of functional impairment, such as the Global Assessment of Functioning. Because the rating of illness severity—particularly those elements (e.g., cognitive functioning, communication abilities) that are most likely to have an impact on the quality of general medical healthcare received—is rarely reported in studies of general medical care in persons with SMI, we used reported psychiatric diagnoses as the best available proxy.
For this review, we chose to focus on the mental disorders of schizophrenia, schizoaffective disorder, and bipolar disorder as representative of the more serious mental illnesses. Lending support to this decision are the results of an analysis of a nationally representative survey39 showing that individuals with psychotic disorders and bipolar disorder, but not major depression, were less likely than the general population to have a primary care provider even after controlling for demographics, income, and insurance status. Another factor in this choice was the large body of literature40,41 and subsequent reviews42,43 that have described efforts to integrate primary and mental health care for individuals with unipolar depression and anxiety disorders.
Throughout health care systems, including the Veterans Health Administration (VHA), there is increasing emphasis on the patient-centered medical home (PCMH);44,45 however, the ways this model will be implemented in the care of individuals with SMI remain unclear. The organization of service delivery for individuals with SMI may be the most modifiable of the many factors that impact general medical outcomes in this population. In addition, components may be added to the delivery of care to enhance medical outcomes, such as patient self-management interventions, decision support, and shared medical records. In this review, we sought to evaluate models of care designed to improve general medical outcomes among individuals with SMI.
- INTRODUCTION - Effects of Care Models to Improve General Medical Outcomes for In...INTRODUCTION - Effects of Care Models to Improve General Medical Outcomes for Individuals With Serious Mental Illness
Your browsing activity is empty.
Activity recording is turned off.
See more...