In the general population, it can be hard to get anyone with diabetes or obesity to stick with taking medication, to 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 persons with both diabetes or obesity and a serious mental illness, such as schizophrenia, die 15 to 20 years earlier than those without mental illness, or it’s comorbid medical conditions, according to Joseph P. McEvoy, MD, of the Medical College of Georgia at Georgia Regents University.
McEvoy’s stark assessment came during his presentation, “Managing Modifiable Risk Factors for Cardiovascular Disease and Cancer in Individuals With Serious Mental Illness,” which was part of the US Psychiatric and Mental Health Congress held September 20-23, 2014, in Orlando, Florida.
However, McEvoy’s reality check came with an intriguing solution for treating 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,” McEvoy said.
Those who don’t have mental health issues can find the medical system in the United States difficult to engage; it’s especially imposing on those who suffer depression or cognitive deficits that come with serious mental illnesses. Individuals covered by insurance may not have transportation to reach a provider, and they may not trust a new provider. Additionally, complications associated with mental illness make it harder for patients to understand or follow instructions.
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,” McEvoy said. “We know exactly what is causing this accelerated mortality. There are no mysteries here.” Among his recommendations:
• Psychiatrists, 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 can 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.
A conference attendee pointed out several obstacles to 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 degree necessary? McEvoy agreed that reimbursement can be a challenge, and that he hopes payers see that it makes sense to use master’s-educated personnel for higher-level tasks, such as coordinating with primary care physicians.
One key is understanding that some of the mentally ill suffer serious cognitive impairment, which 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 social circle. But that is complicated, too. Persons with serious mental illness tend to have problems forming attachments to others, and McEvoy said studies show this is a strong predictor of 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,” McEvoy said.1
He believes that if a small group of psychiatrists were willing to develop a competency in treating diabetes, hypertension, and obesity, it could allow the healthcare system to focus medical efforts on those mentally ill patients with more complex medical issues. However, he cautioned that psychiatrists should not try to treat those with inadequate renal function or reproductive problems. He then provided some examples of basic prescribing protocols for common medical problems:
Elevated low-density lipoproteincholesterol.
• For those with LDL cholesterol greater than 130 mg/dL, excluding women of child-bearing potential not on birth control. Prescribe simvastatin, starting at 10 mg every night at bedtime (QHS) and increase at monthly intervals until the patient is at target, with a maximum dose of 40 mg. Patients should be monitored for a small risk of liver damage or muscle breakdown.
• Exclude those with chronic kidney disease that has progressed beyond stage 1; glomerular filtration rate less than 90 mL/min. The target systolic blood pressure is less than 140 mm Hg. Start with hydrochlorothiazide 12.5 mg QHS; the dose can be increased to a maximum dose of 25 mg QHS at monthly intervals or until the target is reached. Doctors can prescribe amlodipine, starting at 5 mg QHS and increasing in 2.5-mg increments to a maximum dose of 10 mg QHS or until the target is reached.
Non—insulin-dependent type 2 diabetes mellitus.
• Exclude those with renal impairment (serum creatinine greater than 1.5 mg/dL for men; greater than 1.4 mg/dL for women) or acidosis (serum bicarbonate less than 23 mEq/L). Start metformin 250 mg twice daily, and then increase dose to 500 mg twice daily (with meals). Recheck glycated hemoglobin 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.