By LINDA ROSENBERG, MSW
As a healthcare specialty, behavioral health-care has an obligation to foster not just healthy minds, but healthy lives too. After all, our struggle to help people with mental illnesses and addictions recover would be futile if their very lives were endangered due to unattended chronic medical conditions. Yet today we are confronted with a national tragedy that has assumed alarming proportions—the premature deaths of persons with serious mental illness.
While we have known for years that persons with serious mental illness die younger than the general population, recent studies have revealed that the rate of morbidity and mortality has accelerated. Persons with serious mental illness are now at risk of dying 25 years younger than the general population, compared with 10 to 15 years younger just two decades ago.
This tragic finding most recently was featured in Morbidity and Mortality in People with Serious Mental Illness, a technical report from the National Association of State Mental Health Program Directors (NASMHPD). The report looks at state studies comparing the mortality of consumers of public mental health services with the mortality of the states’ general population using age-adjusted death rates, standardized mortality ratios, and years of potential life lost. The findings corroborate what we have been hearing anecdotally from those working directly with the vulnerable population with serious mental illness.
The NASMHPD report reviews the causes of the increased morbidity and mortality—cardiovascular disease, diabetes, respiratory disease, and infectious diseases, including HIV/AIDS—and points out that many more persons with severe mental illness are dying of general medical conditions than are dying of suicide. The medical conditions are largely due to lifestyle issues, such as less physical activity and a high prevalence of addictive disorders like smoking, that persons with mental illness always have had greater difficulties in addressing. The medical conditions also are partly due to a lack of focus on managing the metabolic side effects of psychiatric medications.
The NASMHPD report recommends strategic approaches to reducing illness and premature death among the population with serious mental illness. The report's recommendations are focused on community services directly run by state mental health authorities. The report is a national call to action, reiterating the need for a better connection between general health and behavioral health emphasized by former Surgeon General David Satcher, the Bazelon Center for Mental Health Law, the President's New Freedom Commission on Mental Health, and the Institute of Medicine.
In a conversation with the National Council for Community Behavioral Healthcare, Joseph Parks, MD, chair of NASMHPD's Medical Directors Council and a coauthor of the report, emphasized that community providers must adopt multiple approaches to address this national tragedy. They must focus on overall wellness, incorporate tips for a healthy lifestyle into treatment plans, prioritize adherence to general medical care as much as adherence to mental health treatments, and draw from evidence-based practices to keep the people they serve alive to enjoy their recovery.
Despite enormous constraints, and with little support from government, many community providers have cobbled together innovative clinical and financing models to provide comprehensive care. Collaboration has taken many forms: colocated mental health and primary care services, contracting arrangements, enhanced referral processes, sharing of patient information, and cross-training of mental health and primary care staff.
With adequate funding and support, community mental health centers across the country are eager to replicate proven coordinated care models and provide the comprehensive care their patients need to stay alive and fully well. Therefore, we need to encourage a strong national dialogue about the resources that all behavioral healthcare agencies need to ensure that people with serious mental illness and addiction disorders are adequately screened and triaged for physical illnesses.
Most of the national attention and activity has focused on primary care sites. Acknowledging that mental health is integral to overall health, the Health Resources and Services Administration (HRSA) has underwritten mental health expansion initiatives in community health centers. As a result, the percentage of community health centers providing mental health services has grown from 53.8% in 1999 to 72.2% in 2004, representing 139.8% growth in the number of persons served and 75.9% growth in mental health visits, according to the National Association of Community Health Centers.
Sadly, general healthcare for people with serious psychiatric illnesses and addiction disorders being served in community-based behavioral health organizations has had far less attention and no additional funding support. And funding is needed to right this wrong. Funding will enable organizations to pay skilled staff, to allocate adequate space, and to buy basic equipment. Just as screening and evaluation for behavioral health disorders is appropriate in primary care settings, screening and evaluation for general health problems should be available to individuals in behavioral health settings.
The fragmented healthcare system is difficult to navigate, especially for those with mental illness, who can be cognitively impaired. They are often too debilitated to seek care from multiple providers. To ensure that they have access to proper care, community mental health organizations must be clearly defined as their allowable medical homes. This will help to prioritize continuity of care because it will allow such persons to continue to seek care from providers they know and trust. Persons with mental illness need providers knowledgeable about their behavioral, medical, and social needs. Often, the medical and social needs are directly related to symptoms of the mental illness and are specific to the individual. Community mental health providers are best suited to understand and meet this spectrum of needs.
Given concerns about rising healthcare costs, states must find ways to make the mental health system more efficient. States have an excellent opportunity to lay the foundation for coordinated care. By acknowledging community mental health organizations as medical homes and encouraging them to create and sustain relationships with primary care and other specialty providers, the healthcare system will be able to better serve persons with mental illness.
System transformation must include giving individuals with serious mental illnesses a chance for a full and long life. The federal government (specifically, the Substance Abuse and Mental Health Services Administration and HRSA) should set standards to ensure that funding is available so that every provider of public behavioral health services can assess the health status of all individuals receiving antipsychotic medications and has specific protocols in place for medically monitoring such individuals. An integral part of services should be to ensure that each person is connected to primary care, that there are specific mechanisms between behavioral health and primary care providers for coordination of services, and that there is the option to bring primary care into behavioral health settings.
If we want to build a better future for adults and children with mental illnesses and addiction disorders, we need to start by saving lives.
Linda Rosenberg, MSW, is President and CEO of the National Council for Community Behavioral Healthcare. She is also a member of Behavioral Healthcare's Editorial Board.
The National Council is aggressively pursuing a legislative agenda to create a new federal grant program to colocate primary care services within behavioral healthcare organizations.
The National Council is conducting a Behavioral Health/Primary Care Coordination survey to fully catalog members’ efforts and assess opportunities and barriers to collaboration.
A National Council pilot project is under way to increase primary care clinics’ ability to screen for mental health disorders and to effectively connect with community mental health organizations.
A National Council educational initiative currently in design will help mental health and addictions treatment administrators and practitioners understand the prevalence of physical illnesses among the individuals they treat, assess risk factors, provide patient education and lifestyle management, and facilitate collaboration with physical medicine.
The 37th Annual National Council Conference in Las Vegas, March 26–28, 2007, will give members, policy makers, researchers, and consumers a forum to explore the NASMHPD report's implications and commit to an action agenda.