Rx: Treating chronic medical vulnerability in the mentally ill

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹