Patients with chronic mental illness experience disproportionate rates of obesity, metabolic syndrome, diabetes, and hypertension, leading to higher mortality and worse health outcomes compared to the general population. Causes include factors related to disease, patients, and health care providers. Due to a variety of reasons, psychiatrists and other mental health practitioners have until recently played only a limited role in the physical health of their patients. In the last few years, however, psychiatrists have been increasingly called upon to play a larger role in screening for, as well as monitoring and managing, common medical conditions. However, issues related to physician comfort, training, and competence deter progress in this area.
Mortality in People Who Suffer from Chronic Mental Disorders
Patients with severe mental illness experience significantly higher rates of medical disorders and lower life expectancy than the general population.1,2 Hypertension, obesity, and hyperlipidemia are all more prevalent in people who have chronic mental disorders,3 leading to higher rates of diabetes. Evidence suggests that people with schizophrenia have a 2- to 3-fold increased risk of dying as compared with the population at large.4 Although suicide contributes to this elevated mortality rate, cardiovascular disease is the predominant cause, along with hypertension, diabetes, and infectious diseases.4–6 Similarly, the mortality rate of those with bipolar disorder is 2 times that of the general population.7 Quality of medical care has been identified as a key contributing cause.8 Improving patients' medical care holds potential for optimizing health outcomes and reducing mortality in people with serious mental illness.
Barriers to Medical Care
Lack of access to care may partially explain the excess burden of disease in people with severe mental disorders. Many patients are impoverished and cannot afford transportation to appointments or copayments for medical visits and medications.9 Cognitive problems due to mental illness can lead to difficulty planning for and following up with appointments, further disrupting continuity of care. Care managers and assertive community treatment programs may help to offset these challenges and improve access to care. Nevertheless, evidence suggests that this patient population is less likely to have quality primary and preventive health care. Studies demonstrate a lower likelihood of regularly seeing a primary care physician,10 receiving appropriate diabetic screening,11 or being prescribed appropriate medications to treat cardiac conditions.12 They often receive less preventive screening and thus are underdiagnosed for common medical conditions.8,13,14 One study revealed that even when medical disorders, such as hyperlipidemia, hypertension, and diabetes, were identified in patients with schizophrenia, treatment rates for these conditions were low.15 For example, 88% of patients with schizophrenia did not receive any treatment for dyslipidemia.15 Additionally, patients with psychiatric disorders may receive lower rates of coronary reperfusion interventions after myocardial infarction.13
Psychiatric Disorders and Treatment-Related Factors
Several other factors contribute to increased medical comorbidity in people who have mental disorders. Schizophrenia itself has been associated with obesity and glucose derangements, even before starting therapy with antipsychotic medication.16 Risk of diabetes mellitus has been linked to increased duration of psychosis.17 Furthermore, second-generation antipsychotics (SGAs) increase the risk of weight gain and metabolic disorders. In a meta-analysis of 80 schizophrenia trials, 10 weeks of treatment with clozapine was associated with an average weight gain of 4.5 kg, whereas olanzapine, risperidone, haloperidol, and fluphenazine were associated with a weight gain of 4.2 kg, 2.1 kg, 1 kg, and 0.4 kg, respectively.18 Nevertheless, some studies have demonstrated reduced mortality associated with antipsychotic use. Negative symptoms of schizophrenia such as apathy and avolition may be associated with sedentary lifestyle, poor dietary choices, and reduced adherence to medications and medical advice, thereby leading to unfavorable medical outcomes.19 For instance, studies of people with chronic mental disorders demonstrate lower rates of low- and high-intensity exercise, lower consumption of fruits and vegetables, and diets high in fast food.20,21 High rates of tobacco and substance use also contribute to elevated rates of lung and heart disease.6
The Role of Psychiatrists in the Physical Health of Their Patients
One of the first guidelines to suggest that psychiatrists participate in their patients' medical care came from a joint statement of the American Diabetes Association and the American Psychiatric Association (APA) published in 2004.22 This document outlines screening guidelines for cardiovascular risk factors in adults taking SGAs. Specifically, the statement recommends that prescribers of SGAs obtain weight, waist circumference, and blood pressure as well as laboratory tests for fasting blood glucose and a lipid panel. Since then, routine monitoring of these risk factors has been the standard of care for psychiatrists,23 although adherence to the guidelines remains low.24 One oft-cited reason for this is that psychiatrists do not feel comfortable managing abnormal medical findings should they be detected.
In 2015, the Association of Medicine and Psychiatry (AMP) and the APA approved a joint position statement, co-written by an author of this article (J. T. R.), supporting a role for psychiatrists in decreasing physical health disparities for patients with mental disorders.25 This document provides support for psychiatrists to expand, when appropriate, the scope of their practice to the prevention and management of common medical conditions. Specifically, it supports the psychiatrist's role in screening for common medical conditions and counseling on risk factor reduction. Psychiatrists should identify patients who may be receiving suboptimal primary care and intervene as necessary, based on available local resources, patient preference, and their own competencies. The statement calls for increased primary care training for psychiatrists and clear practice guidelines for management of medical problems by psychiatrists. Expanded training opportunities should occur in residency, fellowship, and through physician continuing medical education (CME). Further recommendations include greater advocacy for the general health of their patients, increased collaboration with primary care, and the development of integrated systems of care. Psychiatrists, given their medical training, are unique among mental health practitioners. Some argue they should make optimum use of their medical background to address this area of unmet need.
When Is It Appropriate to Intervene?
One barrier to increasing the psychiatrist's role has been the lack of consensus in the field regarding when it is clinically appropriate to treat medical illness. Vanderlip et al.23 proposed an algorithm to help guide psychiatrists in deciding when to proceed with managing common medical conditions, or alternatively referring to primary care or the emergency department. It proposes that psychiatrists consider medical management of physical health problems after reflecting on various factors: the nature and severity of the illness, the patient's access to primary care services, the training and comfort of the psychiatrist, the system resources available to the psychiatrist for management and follow up, and patient preference. This theoretical framework provides a systematic and practical approach to physical health management in psychiatric practice.
Indeed, it may be warranted for psychiatrists to extend their scope of practice under the right circumstances. When psychiatrists are confronted with patients having medical comorbidities, they must decide whether the medical condition is routine, urgent, or emergent. This will dictate whether the next most-appropriate step is referral, consultation, or management.23 Treatment of routine, common conditions such as hypertension or screening for chronic conditions like diabetes come with a low relative risk but high long-term benefit. Another example of this is screening for hyperlipidemia with a lipid panel and calculation of 10-year atherosclerotic cardiovascular disease risk, leading to prescription of a statin medication. Such interventions would require appropriate system capacity of the psychiatric practice or mental health organization, including availability of routine laboratory monitoring and the ability to track outcomes.
Urgent and emergent problems may pose a higher immediate risk of mortality and morbidity, and referral to appropriate medical care is generally indicated. However, in certain urgent medical situations, specifically if the patient does not have access to primary care, and depending on comfort level and system support, management by a psychiatrist may be warranted, possibly in consultation with primary care. In these scenarios, the role of the psychiatrist is not to completely take on the independent role of a primary care provider. That would require a higher level of training than is currently available in psychiatric residency or in specialized CME.
The Role of Care Setting and Patient Preference
Patient preference may ultimately determine where a patient receives treatment. If a patient wishes to pursue medical treatment with a primary care provider, the psychiatrist's expansion of scope may not be warranted. However, some people choose not to go to primary care even when it is available, instead opting to keep all care with their psychiatric provider. Some reasons cited for low engagement with primary care services are low health literacy, lack of insight about illnesses, paranoia, anxiety, and reclusiveness.3,23 Psychiatrists may advocate for improved engagement in primary care on behalf of their patients through involvement of care managers to help navigate barriers,1,23 or by collaborating directly with primary care physicians.
If difficulties in accessing or engaging in primary care services remain, despite efforts to overcome them, extension of the scope of practice might be warranted. This will depend on the nature of the medical illness and the training background of the provider. For many patients with chronic psychiatric disorders, the only interface with the health care system is through their mental health provider. Indeed, the psychiatrist may be the most consistent and frequent provider for the patient. People may feel more comfortable in the community mental health clinic that they have known for years. This scenario might occur more frequently in patients who suffer from chronic mental illness such as schizophrenia, schizoaffective disorder, bipolar disorder, or substance use disorders. In cases in which patients lack access to quality primary care or when they feel most comfortable and safe in the mental health setting, a psychiatrist with the appropriate training should consider management of medical conditions.
Some psychiatrists have concerns about managing medical conditions in their practice settings because of the effect on the therapeutic relationship. It is a departure from the traditional frame of treatment that may frown upon any physical contact with the patient. A psychoanalyst, for example, may prefer minimal deviation from the psychotherapeutic relationship, deferring blood pressure monitoring and management to a nonpsychiatric provider. Depending on the medical intervention, the therapeutic alliance and the psychotherapy treatment could become compromised. It is important to remember that expansion of the psychiatrist's role should occur in the appropriate clinical context. As such, certain psychotherapeutic settings may not be appropriate for a mental health provider to participate in a patient's medical care.
Experience and Knowledge in Management of Common Medical Conditions
With increasing emphasis being placed on the role of mental health providers in the physical health of their patients, many psychiatrists may feel that they lack the comfort, knowledge, or training to manage medical conditions unless there is collaboration or consultation with primary care physicians. Consensus panels comprised of both internists and psychiatrists have concluded that psychiatrists with primary care training can manage many common medical conditions with on-site supervision by an internist.26 Increasingly available to psychiatrists are options for general primary care education to address deficiencies in medical knowledge. For instance, the APA has been offering primary care skills courses for psychiatrists for several years at their annual meetings and at the Institute for Psychiatric Services. A similar online course has been offered since 2016. Textbooks have been published that specifically focus on teaching basic medical evaluation and treatment to psychiatrists.27 If psychiatrists do engage in managing medical illnesses, it is crucial that they maintain awareness of limitations in medical knowledge and pursue opportunities for CME. The aforementioned APA-AMP joint position statement encourages ongoing CME and training opportunities in basic primary care for practicing psychiatrists. Gaining more knowledge and training may also reduce psychiatrists' concerns about medico-legal liability. The APA-AMP position statement, which should become an accepted standard of care in our view, may help mitigate these concerns.
The organization of physical and mental health care has been traditionally separated with psychiatry viewed as distinct from other medical specialties. Psychiatry residents' time spent in medical internships has been reduced from a full year in the past to the current 4 months. These rotations frequently take place on inpatient medical units that do not align with the outpatient practice where most psychiatrists could manage general health conditions. Furthermore, the goals and objectives of these experiences are not clearly defined. Lastly, there is no structure to maintain this medical skill set throughout the duration of residency. Only a handful of psychiatry residency programs have general medicine training experiences.28 Many of these are either in medical-psychiatric inpatient units or integrated outpatient settings. There are no specific Accreditation Council for Graduate Medical Education or American Board of Psychiatry and Neurology goals for competency in general medical practice for psychiatrists in training.29
Physicians trained in both internal medicine/family medicine and psychiatry as well as leaders in resident education have proposed longitudinal curricula designed to increase general medical training.28,30 Goals of the curriculum described by Annamalai et al.28 include learning to identify medical emergencies, diagnose and manage or co-manage common medical conditions, and collaborate effectively with general medicine colleagues in outpatient settings. They also recommend that clinical sites should expand beyond general medical units and emergency departments to include community health centers and outpatient collaborative care clinics where supervision is available from primary care practitioners. Medical training should be extended throughout the trajectory of residency training rather than concentrated in the intern year, and should include didactics tailored to psychiatry residents. Similarly, the Integrated Medicine and Psychiatry curriculum focuses on longitudinal experiences in integrated care settings and targeted preventive care in patients with comorbid psychiatric conditions. Clinical settings for integrated experiences include the Veterans Administration and Federally Qualified Health Centers and involve collaborative care, telemedicine, outpatient primary care consultation, and inpatient or outpatient medical-psychiatric experiences.30 This is accompanied by a longitudinal lecture series whose goals are to teach preventive medicine strategies, models of integrated care, and use of brief psychotherapies to enhance treatment in medical settings.
Experience in Psychosomatic Medicine Fellowship
As a current psychosomatic medicine fellow, one of the authors (G. R.) has been able to use the decision algorithm in an outpatient integrated care setting—a primary care clinic with integrated psychiatric care. The fellow's role is primarily to perform psychiatric evaluations and provide treatment in collaboration with primary care providers. Additionally, the robust clinic resources facilitate diagnosis and management of common medical conditions under the supervision of the other author (J. T. R.), who is dual-boarded in internal medicine and psychiatry. Managing physical illness with supervision from an internist and reviewing relevant medical literature have provided the fellow with increased comfort and confidence in her practice. The co-location of psychiatry and medicine allows for greater ease of communication and collaboration with primary care providers. G. R. observed positive outcomes for a 34-year-old man with severe heart failure and panic attacks, who frequently presented with shortness of breath. This occurred through close collaboration with the patient's primary care provider and optimizing both psychiatric and physical aspects of his care.
However, the fellow has also been confronted with challenges when attempting to manage medical comorbidities in an integrated setting. The patients are referred from a tertiary care hospital and often experience a high burden of medical disorders, in addition to having complex psychiatric histories. Receiving referrals directly from the inpatient medical units after medical hospitalization, the fellow frequently encountered patients with relatively high medical acuity. At times, the medical acuity warranted a higher level of care. For example, a patient with diverticulitis complicated by perforation and recent history of multiple abdominal surgeries presented to her psychiatric appointment with subjective weakness, chills, and abdominal pain. After referral to the emergency department, she ultimately was admitted for management of sepsis due to infection at her ostomy site.
Time constraints may also be a valid concern for many psychiatrists. In the circumscribed time allotted for complex psychiatric evaluations, additional medical interventions may not be possible. Efficiently managing stable medical conditions during the typical appointment time may be especially challenging for psychiatrists when there are limitations in knowledge and training in screening, diagnosis, and evidence-based treatment. Increased basic medical training during psychiatry residency, for example, in integrated clinical settings, might better prepare psychiatrists in providing more comprehensive care for patients when needed. It could also be a venue to learn preventive medicine practices such as age-appropriate screening and use of adjunctive medications to treat or prevent common metabolic disorders.
The position statement approved by the AMP and APA aims to engage psychiatrists in reducing medical morbidity and mortality in people with mental disorders. Psychiatrists may feel supported in this role through the increased availability of general medicine educational opportunities, evidence-based treatment guidelines, and implementation of integrated health care models. Consideration should also be given to level of comfort and medical training background, concerns about medico-legal liability, and the effect on the more traditional psychiatrist-patient relationship. More research and real-world experience is needed to understand the perspectives of psychiatrists and their patients. With the push for increased involvement of psychiatrists in medical care, there lies hope of bridging the mortality gap in those with chronic mental illness.
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