Psychiatry’s Role in Improving the Physical Health of Patients With Serious Mental Illness: A Report From the American Psychiatric Association

Although advances in treatment have greatly improved medical outcomes in the general population, individuals with mental illness have lagged behind. This has resulted in a widening disparity in life span, with pooled relative risk for all-cause mortality significantly elevated among those with any mental disorder, particularly those with serious mental illness (1). More than a decade has passed since data published by the National Association of State Mental Health Program Directors showed that people with serious mental illness treated in the public mental health system were dying, on average, 25 years earlier than the general population (2). However, little progress has been made in rectifying this disparity, and recent data indicate that the mortality gap for those with serious mental illness remains substantial.

In 2016–2017, the Integrated Care Workgroup of the American Psychiatric Association (APA) convened an expert panel charged with addressing the role of psychiatry in improving the physical health of persons with serious mental illness. The group conducted a systematic review of the peer-reviewed and gray literature, including recent policy developments on the topic, and developed a set of recommendations grounded in this review. This column summarizes the primary findings and recommendations from that panel. The full report is available on the APA Web site (www.psychiatry.org/File%20Library/Psychiatrists/Advocacy/psychiatrys-role-in-improving-the-physical-health-of-patients-with-serious-mental-illness.pdf).

General Medical Comorbidity

Strong evidence has emerged in the past two decades of the importance of general medical illness in driving the poor health and early mortality of patients with serious mental illnesses. Rates of general medical illness among those with serious mental illness exceed rates in the general population in every disease category, and those with serious mental illness experience higher standardized mortality ratios, compared with the general population, for cardiovascular, respiratory, and infectious diseases (3). About two-thirds of deaths among people with mental illness are attributable to natural causes (1).

The relationship between mental illness, general medical comorbidity, and premature mortality is complex and multifactorial. Adverse health behaviors contribute heavily. Four modifiable risk behaviors—tobacco use, substance use, poor diet, and lack of physical activity—are the cause of much of the morbidity and early mortality related to chronic diseases. Patients with serious mental illness engage in these behaviors at higher rates than the general population, placing them at risk of chronic general medical conditions and poorer outcomes. Adverse social determinants of health, including the effects of economic disadvantage and chronic stress, likely also play a part. Side effects of medications prescribed for patients with serious mental illness also contribute significantly, with weight gain and glucose dysregulation noted most prominently with antipsychotic drugs. Finally, those with mental illness are at risk of receiving poor-quality medical care, which is likely a significant determinant of adverse health outcomes in this population. They may underuse primary care services and overuse emergency and general medical inpatient care, resulting in fragmented and irregular services and lower rates of preventive care. Individuals with serious mental illness are also less likely to receive adequate, standard-of-care treatment for general medical conditions, compared with age-matched persons in control groups. Factors underlying the lack of high-quality medical care for persons with serious mental illness include lack of insurance and the cost of care; the effects of stigma on patient-provider interactions; and the symptoms of mental illness, which impose challenges to accessing care and adhering to recommended treatments.

Targeting Risk Factors and Improving Care

Over the past decade, studies have provided substantial evidence of the effectiveness of both pharmacologic and behavioral interventions to target cardiovascular risk factors among persons with serious mental illness. In particular, effective interventions are available to support smoking cessation and to promote weight loss, addressing the two leading causes of preventable mortality in the United States. Behavioral and pharmacologic interventions have demonstrated effectiveness among individuals with serious mental illness, and the magnitude of the effects appears to be comparable to that seen in general population studies. In addition, trials and demonstration projects support strategies to improve care for individuals with serious mental illness through systematic coordination and collaboration among treating providers (4).

Much work remains to be done to identify and develop best practices to improve general medical care and health outcomes among persons with serious mental illness and to increase access to evidence-based care (5). Future studies should test long-term interventions for cardiovascular risk factors and health-risk behaviors and evaluate the impact of interventions on all-cause mortality. Studies are also needed to evaluate strategies to more widely disseminate effective interventions in real-world settings. In many instances, significant resources might need to be dedicated to enhance engagement in care, and the most feasible and appropriate settings for intervention may not be clinical settings. Family support interventions and innovative collaborations with other disciplines and community partners may address some of the social determinants that increase risk factors and limit service engagement and that are among the most challenging barriers to reducing premature mortality in this vulnerable population.

Given the high burden of chronic general medical conditions such as hypertension and diabetes, interventions are needed to specifically target the treatment of these disorders. Studies should explore how to optimize the roles of a diverse multidisciplinary workforce, including peer support specialists, to match intensive services to high-need individuals. Technological innovations to support service delivery and care coordination should also be leveraged to integrate behavioral and general medical care for this population.

Psychiatrists can provide a range of services to address the poor health of patients with serious mental illness. These activities can include screening for general medical conditions; counseling patients to reduce cardiovascular risk factors; treating adverse health behaviors, including smoking; limiting side effects from psychotropic medications; coordinating with general medical care providers; and providing general medical services for patients who do not currently have primary medical providers (6). Psychiatrists in leadership roles can also play an important role in promoting better physical health for patients. Medical directors of community mental health centers or behavioral health homes should establish protocols and monitor outcomes for their medical staff.

Legislation and Policy Developments

The past decade has seen the passage of landmark federal legislation improving insurance coverage and testing new models of care delivery that could have an important positive impact on the lives of people with serious mental illnesses. The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) was a first step toward improving access to health insurance and reducing financial burden for patients with serious mental illnesses. The Affordable Care Act of 2010 (ACA) built on the MHPAEA to expand health insurance coverage for patients with mental illnesses. Section 2703 of the ACA provides funding for states to design health homes to provide comprehensive care coordination for Medicaid beneficiaries with chronic conditions, including mental illnesses. Most recently, the 21st Century Cures Act, signed into law in 2016, authorizes funding for several programs delivering evidence-based prevention and treatment services for individuals with serious mental illnesses and supporting the improvement of integrated care models for primary care and behavioral health care (7).

Several recent policy developments could have significant implications for addressing the physical health of people with serious mental illness. Repeal of the ACA could eliminate federal matching for Medicaid expansion and subsidies for insurance exchanges, remove essential health benefit requirements, curtail funding for demonstration projects addressing care coordination, and reduce funding for the public health and social safety net. The coming years will likely see greater autonomy for states in determining the scope and structure of Medicaid benefits and social services (8).

APA Report Summary and Recommendations

On the basis of findings from a literature and policy review, the APA expert panel developed the following recommendations for psychiatrists to address the health, well-being, and longevity of people with serious mental illnesses.

Clinical care.

Psychiatrists’ medical training makes them uniquely positioned to support the delivery of high-quality, coordinated general medical treatment, prevention, and mental health care to their patients with serious mental illness. To achieve this goal, it is essential to provide training programs in outpatient general medical care during internships, psychiatry residency, and combined medical/psychiatry residency programs; CME programs for practicing psychiatrists; and cross-training opportunities for psychiatrists in working collaboratively with general medical, substance use, and social services providers. Quality improvement initiatives should be implemented across the full range of settings in which patients with serious mental illness are treated, including community-based mental health clinics, primary care clinics, and emergency rooms.

Health care organizations.

Psychiatrists can play critical leadership roles in mental health and primary care delivery systems that treat patients with serious mental illness. In these roles, they can help to implement population models and integrated payment systems that foster communication, use of patient registries, and delivery of evidence-based interventions.

Research.

Although a robust body of literature supports the practice of primary care–based behavioral health integration, fewer studies have examined models to improve the physical health of people with serious mental illness. Further research is needed to inform initiatives addressing the physical health of this group, as well as to understand the optimal role of psychiatrists in these models.

Payers.

Current fee-for-service reimbursement, especially in the Medicaid program, does not adequately reimburse for care management, some peer and wellness services, and many components of team-based interventions. Psychiatrists should advocate for new payment structures, such as the monthly case rate supported in 2703 Health Homes, the new monthly CPT code for the collaborative care model, and for enhanced Medicaid rates similar to those in federally qualified health centers. Prospective payment models, such as certified community behavioral health clinics, should be expanded.

State policy.

With the increasing role of state policy makers in shaping health and mental health care, psychiatry can play a key role in advocating for states to improve the physical health of people with serious mental illness and provide input on program design and reform efforts. Advocacy efforts should include Medicaid directors, state mental health authorities, and other state agencies (for example, departments of corrections).

Federal health policy.

Even as states assume greater responsibility for setting policies, the federal government must continue to provide vital functions for patients with serious mental illness. Psychiatry should advocate for these key functions, including developing and implementing surveillance and monitoring efforts to track the health of people with serious mental illness and providing regulatory oversight and enforcement of existing policies to ensure insurance coverage, access, and quality of care for these patients.

Public health policy.

Premature mortality in populations with serious mental illness is ultimately a public health problem, which will require addressing prevention and treatment of general medical problems, mental and substance use disorders, health behaviors (smoking, diet, and physical activity), and social factors (poverty and stigma). Psychiatrists should advocate for a robust public health infrastructure that ensures prevention and treatment of ill health among individuals with serious mental illness and that addresses the community and social risk factors underlying poor outcomes in this vulnerable population.