Mentally Ill Die Young From Chronic Disease. Can Psychiatrists Fill a Medical Gap?

In the general population, it can be hard to get those with diabetes or obesity to stick with medication, quit smoking, or to follow a diet and exercise plan.

Add a serious mental illness to the mix, and the challenge escalates — so much so that those with diagnoses like schizophrenia die 15 to 20 years earlier than others with similar cardiovascular conditions, according Joseph P. McEvoy, MD, of the Medical College of Georgia at Georgia Regents University.

Dr McEvoy’s presentation, “Managing Modifiable Risk Factors for Cardiovascular Disease and Cancer in Individuals with Serious Mental Illness,” offered both a reality check and intriguing solutions to addressing chronic conditions among the mentally ill: Can psychiatrists provide basic primary care for high blood pressure, weight control, or smoking cessation, until they can get their patients to a clinic or a specialist?

“My hope is that some subset of mental health prescribers will be willing to take this on,” Dr McEvoy said, speaking Monday at the US Psychiatric and Mental Health Congress in Orlando, Florida.

As he explained, it’s not easy for healthy patients to engage the medical system, let alone a person with a serious mental illness. Even those who have insurance might not have transportation, and they might not trust a new provider. Cognitive deficits make it hard for some mentally ill patients to understand or follow instructions. While the medical system is becoming easier to navigate with the rise of care coordinators, it’s still imposing for those with serious mental illness, Dr McEvoy said.

So, trying to address high blood pressure, alcohol abuse, risky sex, or heavy smoking among this group will require solutions that “do not depend on them,” he said.

“We know exactly what is causing this accelerated mortality,” Dr McEvoy said. “There are no mysteries here.”

Among his recommendations:

• Psychiatrists, or at least some of them, must reorganize their practices to provide basic primary care services where patients already feel comfortable and safe.
• The use of nurse care managers is essential to help connect patients with services and stay in touch with family members who will aid in transportation and care.
• Psychiatrists must connect their patients with smoking cessation services and counsel them about reducing sun exposure.
• Psychiatrists must rethink the use of certain medications that cause weight gain and increase cardiometabolic risk unless those therapies are absolutely necessary.

One questioner asked about an obstacle to Dr McEvoy’s approach: Will payers fund this? Can nurses with bachelor’s degrees run smoking cessation groups, or act as navigators? Is a master’s necessary? Dr McEvoy agreed that reimbursement can be a challenge, and that he hopes payers see that it makes sense to use masters-educated personnel for higher-level tasks, such as coordinating with primary care physicians.

One key is understanding that some mentally ill suffer serious cognitive impairment, which Dr McEvoy said may be “up to 1.5 standard deviations to the left” from a healthy control. This makes taking instructions for exercise and especially diet exceedingly hard, and requires strong support from family members or others in the patient’s circle. But that is complicated, too. Persons with serious mental illness tend to have problems forming attachments to others, and Dr McEvoy said studies show this is a strong predictor to how well patients do with diabetes care.

A reason that the “team” approach for diabetes intervention works, he said, is that 60% to 70% of patients will respond when they know a group is invested in their health. For those with serious mental illness, the numbers are reversed.

“The slightest hiccup will cause them to drop out,” he said. “They don’t play well on the team, even if the purpose of that team is to keep them alive.”

However, integrating medical care with mental health services has shown some success. The closer the medical services were to the mental health services, the more likely patients were to use them, according to a Veterans’ Administration study. “Even a short journey to a free clinic was associated with less use compared with bringing the primary care service to the mental health clinic,” Dr McEvoy said.¹

If a small group of psychiatrists was willing to develop a competency in treating diabetes, hypertension, and obesity, Dr McEvoy said, it could allow the healthcare system to focus medical efforts on those mentally ill patients with more complex medical issues. Psychiatrists, he said, should not try to treat those with inadequate renal function or reproductive problems. He gave some examples of basic prescribing protocols for common medical problems:

Elevated low-density lipoprotein-cholesterol. For those <130 mg/dL, excluding women of child-bearing potential not on birth control. Prescribe simvastatin, starting at 10 mg QHS and increase at monthly intervals until patient at target; maximum dose 40 mg. Monitor for small risk of liver damage or muscle breakdown.

Hypertension. Exclude those with chronic kidney disease > stage 1; glomerular filtration rate <90mL/min. Target systolic blood pressure < 140 mmHg. Start with HCTZ 12.5 mg QHS, increase to maximum dose 25mg QHS at monthly intervals or until target reached. Amlodipin 5mg QHS, increased 2.5 mg increments to maximum dose of 10 mg QHS or until target reached.

Non-insulin dependent type 2 diabetes. Exclude those with renal impairment (serum creatinine > 1.5 mg/dL men; > 1.4 mg/dL women) or acidosis (serum bicarbonate <23 mEg/L). Start metformin 250 mg twice daily, increase dose to 500 twice daily (with meals). Recheck glycated hemoglobin (A1C) after 2 months.

Reference

1. Druss BG, Rohrbaugh Rm, Levinson, CM, Rosenheck, RA. Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry. 2001;58(9):861-868.