Deadly consequences: why we need to integrate health and mental health
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Roger Craig was 38 when he died. His age and his weight doubled from the time he had his first psychotic break when still in high school. His illness was later diagnosed as bipolar disorder and he struggled with it until he died of a sudden cardiac attack one evening in 2007 in his parents' home. But it was not his bipolar illness or suicide -- which we often consider the cause of death in people with a serious mental illness (SMI) -- that killed him. It was heart disease, the greatest killer of all (in the USA). Except it took his life a good 30 or more years earlier than someone who does not have SMI.
At 6'4" Roger could almost carry the additional 150 pounds he gained. That is, carry it on his large and formerly athletic frame. But his arteries, heart and lungs (which had trouble breathing at night, a condition called sleep apnea that is highly related to weight) could not stand the strain. His loss is like too many others who suffer SMI and die too young of the chronic diseases that afflict us all.
Alarming evidence has emerged in recent years, from studies of people treated in the public mental health care system, that adults with serious mental illness die on average 25 years earlier than the general population. For a decade or two before their demise they suffer from early onset diabetes, high blood pressure, heart and lung disease and cancer. Why? Their habits place them at great risk for these conditions. They eat poorly, are sedentary and don't have a primary care doctor -- or if they do they don't go and get preventive and ongoing physical healthcare. They smoke heavily, with more than three out of four being nicotine dependent (see my previous blog on this issue here).
The psychiatric medications many receive for their mental illnesses increase the likelihood of weight gain, diabetes and cardiovascular disease. Mental health professionals have discovered what the Craig family painfully learned: physical disability and early death add to the burden of mental illness for those affected and their families. The burden does not stop there since our health care system, already groaning from the weight of the consequences of American habit disorders, shoulders the extraordinary health costs of this high need population.
What can be done? A lot.
We have to start early. Mental illness itself starts early, with half of all mental disorders appearing by age 14 and three-quarters by 24 (these are the ages when the illnesses begin, though it is typically many years before the problem behaviors are understood, diagnosed and treated).
We have to diagnose before we can treat. In 2006, the American Academy of Pediatrics (AAP) released a practice toolkit for doctors called Feelings Need Check Ups Too. Last year, AAP released a report defining what pediatric primary care physicians need to know about mental health care since most children with mental illness are seen in pediatric primary care, not in specialty mental health settings. Once diagnosed these children require early intervention with treatment programs that stress education and work as the goals of care, and skill-building to achieve those ends and prevent disability. This is the mental health side of the equation.
From the health side for youth, it is easier to prevent weight gain and nicotine dependence than it is to rid ourselves of these conditions after they have already damaged the body's metabolism and polluted the lungs with carcinogens. Activity, nutrition and smoking prevention, thus, need to become essential elements of integrated medical and mental health care. Finally, we now know that in as few as 12 weeks that second generation antipsychotic medications (olanzapine in particular) can produce unhealthy changes in lipid levels and the functioning of insulin in young bodies putting them at risk for the chronic diseases that can erode the quality of their lives and kill them prematurely. All medications have benefits and risks; this is not a call for not using medications but a call for using them judiciously: psychiatric medication prescribing must follow principles of no more than one drug (if possible), at the minimally effective dose and only for as long as needed.
Adults with SMI typically lack what our health care system now aspires to achieve: a medical home. Their primary site for treatment of their principal medical condition, namely a mental illness, is a mental health clinic, where medical care, even medical attention to basics like smoking, blood pressure and weight, has traditionally been someone else's business. Primary care settings that welcome people with SMI, and effectively engage them in smoking cessation, diet and exercise as well as proper care of any physical health condition are really hard to find. The answer, easy to say but very difficult to achieve, is the integration of health and mental health. What is needed are integrated health and mental health medical homes.
The critical principles of a medical home include: ready access to care, an ongoing relationship with a personal (primary care) physician, attention to the whole person, a team approach to care, a commitment to measuring and improving quality, and coordinated and/or integrated care. In an effective medical home, the primary care physician coordinates the work of a team of clinicians. For most adults, and almost all youth, with mental illnesses like depression, ADHD, and anxiety disorders, their "point of care" is the primary care, or family, practitioner. But people with a SMI (illnesses like bipolar disorder, schizophrenia, and severe forms of anxiety disorders like PTSD and OCD) will need something different. Their primary attachment is a mental health clinic which, through its psychiatrists and other clinicians, will need to take on basic tasks of measuring health indicators, providing wellness and prevention services, coordinating care and working closely with primary care practitioners to ensure that patients get what they need.
The New York State Office of Mental Health (of which I am medical director) early last year implemented health monitoring in all its 66 statewide outpatient clinics. Adults are monitored every three months for blood pressure, BMI and smoking -- and youth for BMI, smoking, activity and alcohol and drug use. We have developed wellness programs to offer solutions to individuals who make health a part of their recovery.
Innovators exist who are integrating health and mental health. Some are doing so with the primary site being medical and some where the primary site is mental health: we need both. Maimonides Hospital in Brooklyn has co-located a primary care clinic with a state mental health outpatient clinic and has a Federal grant to develop a model and standards for mental health medical homes. Group Health of Puget Sound has been a leader in integrating primary care with mental health, especially in the diagnosis and treatment of depression. Intermountain Healthcare in Salt Lake City has what it calls Mental Health Integration where both health and mental health are provided in the same site, to the satisfaction of patients and providers. Six chronic disease demonstration projects are underway in New York State where partnerships between mental health and health providers (led by the former!) will work with individuals with serious mental illness and chronic physical disorders towards stabilizing their conditions, improving their health and diminishing their taxpayer burden since these recipients all are on Medicaid.
But we are just getting started. Health reform will open paths for integration, and we would do well to search for and travel them. Imagine if Roger Craig had been treated differently from the time he was an adolescent. He might be alive today. While it is sadly too late for the Craig family, I know they would have some solace in knowing that integrating health and mental health will allow others to not suffer the same fate that he did.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Lloyd I Sederer, MD
www.askdrlloyd.com
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OF COURSE we want to first target diet, nutrition, allergies, exercise and other lifestyle strategies.
But when those fail or when ADHD symptoms interfere in pursuing them, as they often do, stimulant medications can be literal lifesavers and health-givers.
Untreated ADHD is associated with higher rates of substance abuse, traffic accidents, on-the-job accidents, obesity and other eating disorders, sleep apnea, and restless-legs syndrome -- and those are just the ones that have been studied.
Anecdotal reports from my 600-member online support group for the partners of adults with ADHD point to problems with diabetes and hypertension in apparent greater-than-average numbers. And that makes sense, given the physiological phenomenon and common lifestyle factors associated with unrecognized/untreated ADHD.
Gina Pera, author
Is It You, Me, or Adult A.D.D.?
MICHELLE OBAMA HAS MADE IT CLEAR THAT SHE WANTS OUR NATION'S CHILDREN TO EXERCISE. THE ONES WHO NEED IT MOST ARE THE ONES THAT ARE TAKING CRUDE BUT EFFECTIVE DRUGS SUCH AS RISPERIDONE, OLANZAPINE, ETC. MICHELLE OBAMA HAS THE RIGHT IDEA FOR OUR NATION'S CHILDREN; PERHAPS THE ADULTS COULD STEP UP TO THE PLATE AND EXERCISE AND BE GOOD EXAMPLES THE WAY THE OBAMA'S DO.
Yes, a fundamentally different approach is needed. But if doctors can't even pull together and get aggressive about treating sicknesses that are solely of the body, how are they ever going to integrate mental health treatment with what they already do?
All of your symptoms point to a food allergy...which should be a no-brainer for ANY MD.
Over one third of diagnosed schizophrenics tested - test positive for gluten intolerance.
over one third.
Thanks JD and JZ for posting so I could see others who are going through the same thing. I don't feel so alone now.
And, in many ways, we have insurance-industry reimbursement policy to thank. Medical-school students facing tuition pay-off often decide to turn away from being a GP, despite that being their motivation for becoming a physician, simply because specialties pay better.
We need to try to prevent mental illness if we can.
One way would be to really promote safety for the brain. As a primary care physician (retired) I saw many patients whose symptoms of mental illness appeared after traumatic brain injury. Frontal lobe trauma does cause psychiatric symptoms.
Another way would be to seriously promote reduction of child abuse. All health professionals have had patients whose mental illness refers back to abuse.
My recommendation would be clear family planning teaching in junior and senior high schools so that individuals understand when and how to have a child that they can keep safe: especially from abuse and brain injury. We need to plan far into the future.
Note: Many mentally ill patients smoke heavily because nicotine does indeed reduce symptoms of mental illness: depression, anxiety, hallucinations, delusions, paranoia, flashbacks.
And then we witness a family on overwhelm, not knowing what to do. Unable to negotiate the quagmire the patient is left out in the cold...to gain the 150 lbs, to eventually die of cardiac arrest.
Unconscionable treatment, or lack of it is inhumane and would be considered Barbaric practices one hundred years from now.
Wake-up and view this mess now. You suggest one pill, lowest dosage'. One pills side affects leads to the second pill, then the next; each with their debilitation. No quick fix; public awareness helps- Dr. Sederer, thank you for bringing this travesty to light.
I have severe bipolar disorder and was very fortunate to find an internist through my psychologist, but was in a world of hurt when he retired and I endeavored to find a new primary doctor.
Every doctor I called wished to know what medications I take, and not one called back. I was only able to find an internist (whom I had consulted when a friend was dying and we worked together on the case) who did not know my medical history but had had a positive experience with me in a very difficult situation. I'm very lucky he took me on, as he was no longer accepting new patients.
I hope these mental health "homes" will take root so we mentally ill will finally receive quality care from unbiased providers whose mission is to provide help to those who have been frustrated at every move to get it. We won't have parity until that happens.
A good book discussing separation of physical and mental illness and consequences:
A Dose of Sanity, Mind, Medicine, and Misdiagnosis, by neurologist/psychiatrist Dr. Sydney Walker.
Many "physical" diseases cause psychological/psychiatric changes; psychiatric disease can make doctors dismiss all physical complaints. Unfortunately (as the book illuminates) a big barrier to integrating mind and body is the ingrained tendency of many medical professionals to use mental illness as an excuse or trashcan for the limits of medicine or even for professional failures. It's not going to be so easy to substantially integrate physical and mental health, because it will involve a whole different professional mindset about solving complex diseases.
Patients with complex, difficult-to-diagnose physical problems are in a real vise: if they aren't initially depressed, they are likely to become so as their physical problems are dismissed as "depression" (thus both physical and mental problems go unaddressed); if they are initially depressed, depression will be latched onto as the source of complaints, and again, their physical problems go unaddressed. Patients with complex "physical" medical problems usually don't succeed in getting help unless they are somewhat savvy and persistent in the face of what can be incredibly degrading encounters -- unlikely traits for someone with mental illness.
Solving the problem of this separation will involve changing a whole paradigm of problem solving, something I think is unlikely given natural inertia and the extreme control of physician judgment and decisionmaking imposed on our system by insurers.