Health care for patients with serious mental illness: family medicine's role

Abstract

Numerous studies document disproportionate physical morbidity and premature death among people with serious mental illness. Although suicide remains an important cause of mortality for this population, cardiovascular disease is the leading cause of death. Cardiovascular death among those with serious mental illness is 2 to 3 times that of the general population. This vulnerability is commonly attributed to underlying mental illness and behavior. Some excess disease and deaths result from poor access to and use of quality health care. Negative cardiometabolic effects of newer psychotropic medications augment these trends by increasing rates of obesity, diabetes, and hyperlipidemia among those treated. Researchers have developed innovative care models aimed at minimizing the disparate health outcomes of patients with serious mental illness. Most strive to enhance access to primary care, but publications on this topic appear almost exclusively in the psychiatric literature. A focus on primary care for the prevention of excess cardiometabolic morbidity and mortality in this population is appropriate, but depends on primary care physicians' understanding of the problem, involvement in the solutions, and collaboration with psychiatrists. We review health outcomes of the seriously mentally ill and models designed to improve these outcomes. We propose specific strategies for Family Medicine clinicians and researchers to address this problem.

Figure 1. Distribution of adjusted HRR-level percentage of patients with diabetes aged 65 years or older in Medicare Part D and the VA using brand-name drugs (and insulin analogues)

Each dot is 1 HRR, and all HRR percentages are adjusted for sociodemographic and health status variables. “Statins” refers to 3-hydroxy-3-methyl coenzyme A reductase inhibitors. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; HRR = hospital referral region; VA = Veterans Affairs.

Figure 2. Absolute difference, within each HRR, in adjusted percentage of patients with diabetes aged 65 years or older in Medicare Part D and the VA using brand-name drugs

Each dot is 1 HRR, and all HRR percentages are adjusted for sociodemographic and health status variables. More positive differences indicate higher rates of brand-name use in Medicare compared with the VA in a given HRR. “Statins” refer to 3-hydroxy-3-methyl coenzyme A reductase inhibitors. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; HRR = hospital referral region; VA = Veterans Affairs.

Figure 3. Prescription spending and projected spending if use of brand-name drugs would change, in each of 4 drug groups among diabetes patients aged 65 years or older in Medicare Part D and the VA in 2008

“Medicare” refers to patients enrolled in fee-for-service Parts A and B and stand-alone Part D. “Statins” refers to 3-hydroxy-3-methyl coenzyme A reductase inhibitors. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; VA = Veterans Affairs.