Colorado’s Community Mental Health System
People with serious mental illness lose 25 years of life expectancy as compared to the general population, and a new research report attributes this loss primarily to an increased risk of premature cardiovascular disease (CVD). The new report draws attention to thousands of Colorado’s citizens at risk. The report appears in the October 17, 2007 edition of the Journal of American Medicine (JAMA). The alarming numbers demand better communication between mental-health specialists and cardiologists, the authors argue. Colorado’s community mental health system is taking the research to heart.
“These statistics are a wake-up call for all healthcare providers and policymakers. Thousands of Coloradans are at risk,” said George DelGrosso, Executive Director of the Colorado Behavioral Healthcare Council. “While the state is working to reform healthcare coverage and delivery, we must take into account the mental health treatment needs of thousands of people and we must connect services with primary healthcare. Of course, this also means that primary healthcare providers need to connect their clients to appropriate mental health services.”
Many of Colorado’s community mental health centers already have wellness programs for clients to help them with their overall health, including dietary guidance and smoking cessation. Other centers are actively working with physicians through co-location and integration. As DelGrosso emphasized, this new report should help us eliminate barriers to further cooperation, communication, and innovation by all healthcare providers.
Drs. John W. Newcomer, Washington University, St Louis, and Charles H. Hennekens Florida Atlantic University, Boca Raton conducted the study. As they write in the October 17, 2007 issue of the Journal of the American Medical Association:
“Most psychiatrists tend to not be surprised that there’s a shortened lifespan, but they also tend to assume that this is suicide—a leading cause of death in this population—when in fact it’s really premature cardiovascular disease,” Newcomer said. “It’s also very important that we get this message out beyond the psychiatric community to those primary-care physicians and specialists who would see patients with diabetes mellitus or CVD who also happen to have a mental-health condition. Because historically what we’re seeing is that those patients are not getting appropriate access to either primary or secondary CVD prevention.”
Recent research has illuminated the relationship between depression and cardiovascular disease, but the impact of other mental illnesses on cardiovascular health is poorly understood. As the authors note in their paper, 50-80 percent of patients with diagnosable mental illness are smokers, as compared with approximately 25 percent of the US population as a whole. People with severe mental illness are also up to two times more likely to have diabetes, dyslipidemia, hypertension, obesity, and/or metabolic syndrome, yet they are significantly less likely to receive CVD risk-lowering drugs, including aspirin, beta blockers, and ACE inhibitors. The mentally ill are less likely to undergo revascularization procedures, and they are more likely to die following an MI.
Part of the problem is the way mental-health patients are handled in the US medical system, Newcomer explains. Historically, people with serious psychological disorders such as schizophrenia, bipolar disorder, and depression have been treated through outpatient mental-health centers, which are kept geographically remote from hospitals or more generalized medical facilities. While this may have worked well for targeting mental-health issues, it has allowed CVD risk factors to go largely unchecked.
“Just the simple act of referring a patient to one of your colleagues in another specialty often, for the patient, involves driving across town. And this is a patient group where the act of organizing one’s life to schedule the appointment, drive across town, arrange follow-up, and get to the lab has much less success.”
In their paper, Newcomer and Hennekens describe possible solutions, including physical co-location of medical facilities or having a primary-care physician or cardiologist on staff at the mental-health centers to perform the risk-factor screening that would improve primary and secondary CVD prevention efforts. But there are also professional barriers to overcome, Newcomer acknowledged. In some cases, there may be the misconception that psychiatric issues need to be resolved before other health problems can be addressed.
“Clinicians may think, well, I can’t really engage this patient in a discussion of risk-reduction approaches because they have schizophrenia, and I can tell that they have some active symptoms. But, in fact, if the clinician talks to the patient’s psychiatrist, the psychiatrist might say that this patient is actually as stable as he or she is going to get. And although the patient may speak of some delusional material at some point in the conversation, in fact they’re very good at listening to and understanding instructions about diet or smoking.”
In contrast, psychiatrists may feel that CVD prevention is not part of their scope of practice. “Everyone is thinking it’s someone else’s job,” Newcomer said.
While system-wide changes to how serious mental illnesses are handled in the medical system will take time, Newcomer stressed that cardiologists can take steps now to improve outcomes in this vulnerable population. “I think it’s important that the cardiovascular physician understand that this is very much an at-risk patient population, that they often have not been receiving appropriate screening in primary prevention, and that they have a high prevalence of smoking and poor dietary habits,” he said. “And there are psychiatrists who are potential partners in trying to work to lower risk in these patients.”
Even after prescribing medications, a cardiologist or general practitioner should know that a psychiatrist or case manager is likely available to help make sure the patient follows through on cardiovascular tests or medication.
A second area for collaboration or consultation is in choice of drugs targeting the particular mental illness, says Newcomer. “Many times psychiatrists struggle with decisions regarding prescription of certain psychotropic medications, and across the range of drugs that are available, there are some agents or some combinations of agents that would make weight reduction for a given patient very difficult. So we want to encourage communication between the psychiatry provider and the cardiologist so that both are pulling in the same direction. If the cardiologist thinks that it’s very important that a patient be on a medication that treats their psychiatric disorder but does not create an undue burden in terms of weight loss, then they should say that.”
Serious mental health issues affect about one out of every four families in Colorado at any given time and more than 60 million Americans. It will impact about half of us during our lifetimes. In addition:
- Mental illness is more common than cancer and diabetes.
- Mental illness costs the U.S. economy more than $80 billion annually.
- About 25 percent of all hospital admissions involve a mental-health or substance- abuse issue.
- About 90 percent of those treated with a combination of medication and therapy experience a partial to full recovery.
The Colorado Behavioral Healthcare Council (CBHC) is a nonprofit membership organization that represents Colorado’s statewide network of community behavioral healthcare providers, including 17 community mental health centers, two specialty clinics, and five behavioral health organizations. CBHC members contract with the State of Colorado and work together to provide comprehensive, community-based behavioral and psychiatric services to more than 80,000 people across the state.