Co-morbid psychiatric and medical disorders: challenges and strategies.

A very troubling health care disparity exists among persons with serious mental illness (SMI). Even among those receiving regular psychiatric care, many individuals experience co-occurring medical conditions that go unidentified and/or untreated, significantly shortening their life spans. About 15 years ago, it was established that 60 percent of individuals with mental illness develop serious medical co-morbidities that result in a lost life span of 15 to 20 years compared to the general population (Berren, Hill, Merkile, Gonzalez, & Santiago, 1994). Recently, even more alarming evidence indicates the risk for lost years of life has accelerated to 25 years earlier than the general population (Parks, Svendesen, Singer, Foti, & Mauer, 2006). Gill (2008) commented:

   What does it mean that the life expectancy of
   persons with serious mental illness in the
   United States is now shortening in the context
   of longer life expectancy among others in our
   society? It is evidence of the gravest form of
   disparity and discrimination. (p.7)

Rates of circulatory disease, metabolic conditions including diabetes, obesity, hyperlipidemia (elevation of lipids in the bloodstream), osteoporosis, chronic pulmonary disease, HIV-related illnesses, polydipsia (excessive thirst and water drinking), and epilepsy are found to be consistently elevated in individuals with psychiatric illness (Green, Canuso, Brenner, & Wojcik, 2003; Jeste, Gladsjo, Linamer, & Lacro, 1996; Lambert, Velakoulis, & Panelis, 2003). Among the most common medical co-morbidities is the set of disorders known as metabolic syndrome, which increases an individual's risk for diabetes mellitus and coronary heart disease (Kelly, Boggs, & Conley, 2007). These symptoms include abdominal obesity (increased waist circumference), elevated triglycerides, elevated high density lipoprotein cholesterol, hypertension, and elevated fasting glucose (Grundy et al., 2005, as cited in Kelly et al., 2007). This medical co-morbidity, in combination with the vast health care disparities and service fragmentation among the mental health and medical service delivery systems, are associated with increased barriers to goal attainment, significantly reduced quality of life, and early mortality.

Early Mortality due to High Co-morbidity of Medical Conditions

According to the National Association of State Mental Health Program Directors, a multi-state mortality study revealed that the average years of life lost for people with mental illness were 25.2 (range = 13.5--29.3 in different states) and the average age at death was 56.8 (range = 48.9--76.7; Parks et al., 2006). Among individuals with schizophrenia, suicide and injury accounted for 30-40% of early deaths, but 60 % of early mortality was due to so called "natural causes" including cardiovascular disease, diabetes, respiratory diseases, and infectious diseases. In this group, individuals die from cardiovascular disease at more than double the rate of the general population and about triple the rate for diabetes, respiratory diseases, and infectious diseases (Parks et al.).

Among the general population in the United States, approximately 22% of adults have the metabolic syndrome. In comparison, among people with SMI the prevalence rate of the metabolic syndrome ranges from 30% to 60%. In one large study, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), 43% of the subjects enrolled had the metabolic syndrome, and of this group up to 83% received little or no treatment for this condition (Kelly et al., 2007). The authors report:

   The metabolic syndrome has been found to be
   an independent predictor of all-cause mortality.
   Although each of the individual components
   may be a risk factor for cardiovascular
   morbidity, the existence of several of these
   abnormalities together poses a risk that may be
   synergistic. (p. 460)

Potential Contributing Factors

There is a substantial body of research that has emerged documenting how psychotropic medications prescribed to ameliorate the symptoms of mental illness induce a number of serious adverse health issues including the metabolic syndrome, insulin resistance, diabetes, hyperglycemia, dyslipidemia (a condition of excessive levels of lipids or fats in the bloodstream), obesity, osteoporosis, and sexual dysfunction (Enger Weatherby, Reynolds, Glasser, & Walker, 2004; Joukamaa et al., 2006; Lieberman et al., 2005; Meltzer, 2005; Parks et al., 2006). Results of the CATIE study indicate that these effects are greater among those taking newer, "atypical" anti-psychotics. For example, those taking olanzapine were at an increased risk for abnormal glucose and lipid metabolism compared to those taking conventional antipsychotics (Lieberman et al.). In addition, the prolonged use of psychotropic medications also causes a range of oral complications and side effects including tooth decay, periodontal diseases, and xerostomia or "dry mouth" which leads to other complications such as gum disease (Barnes et al., 1988; Friedlander & Liberman, 1991; Velasco & Bullon, 1999). The link between oral health and general health, particularly cardiovascular functioning, has been well established and makes this of additional concern (Almomani, Brown, & Williams, 2006). For example, increased plaque on teeth is correlated with increased plaque on artery walls and thus heart disease and stroke (Almomani et al.).

The high incidence of medical comorbidity and increased rates of mortality among people with psychiatric disabilities is attributable in part to unhealthy, high risk behaviors. These behaviors include substance abuse, smoking, lack of exercise and poor diet (Brown, Birtwistle, Roe, & Thompson, 1999). Among individuals with mental illness, approximately half also have a substance use disorder. Substance use increases the likelihood that an individual will engage in risky behaviors including: intravenous drug use, needle sharing, and unprotected sex. These activities are implicated in elevated rates of HIV and other blood-borne viral infections (Corrigan, Mueser, Bond, Drake, & Solomon, 2008). An even greater percentage of people with mental illness are nicotine dependent. The reported rates of nicotine dependence range from 60-80% (Corrigan et al.; Parks et al., 2006). In addition to the high rates of use, people with mental illness are heavier smokers causing them to experience more toxic exposure than the average smoker (Parks et al.). Smoking is a known risk factor for cancer, chronic respiratory diseases, and cardiovascular disease. It is, in fact, a modifiable risk factor and there are a number of best practices available for helping persons with psychiatric disorders successfully discontinue smoking (NASMHPD, 2007).

The prevalence of being overweight and having a sedentary lifestyle is also increased among people living with a mental illness as compared to individuals without a mental illness. Lack of knowledge of correct dietary principles, lower self-efficacy, limited social support, and psychiatric symptoms all have an influence on health-related behavior (Leas & McCabe, 2007). According to Dickerson and colleagues (2006), 50% of women and 41% of men with psychiatric diagnoses studied are obese as compared to 27% and 20%, respectively, among a comparison group. The potential reasons for this increased obesity and poor diet are varied and include side effects of psychotropic medications (Allison et al., 1999; Elman, Borsook, & Lukas, 2006; Kane et al., 2004; Newcomer, 2005), lack of education regarding healthy eating (Leas & McCabe, 2007; Meyer, 2002), unhealthy and sedentary lifestyle (Brown et al., 1999; Strassnig, Brar, & Ganguli, 2003a; 2003b), and difficulty accessing and affording healthy food (Holt et al., 2004). While individuals with mental illness are often overweight, at the same time they generally do not meet the United States Department of Agriculture's (USDA) recommended daily intake for fruits, vegetables, grains, and dairy and often eat fewer than the recommended number of meals per day (Kilbourne et al., 2007; Strassnig et al., 2003b). Additionally, it is speculated by the authors that in some cases restricted meal choice due to congregate living and the negative effects of unemployment may also contribute to the problem of obesity.

Inadequate Access to Healthcare

Often individuals with mental illness do not receive sufficient preventative and diagnostic care or high quality medical treatment. People with mental illness are less likely to receive primary care services, routine testing, cardiovascular procedures and dental care than others (Parks et al., 2006). According to the CATIE study, most individuals who develop complications from psychotropic medications are not treated for them or are treated inadequately (Nasrallah et al., 2006). Rates of non-treatment are 30.2% for diabetes, 62.4% for hypertension, and 88% for dyslipidemia. The explanations for this discrepancy in care include limited financial resources, transportation issues, and lack of medical insurance (Dickerson et al., 2003; Druss & Rosenheck, 1998). Another factor that impedes the diagnosis and treatment of medical conditions among people with SMI is a lack of education on the part of medical and mental health care providers. Currently, the education that many medical and mental health care staff receives does not adequately prepare them to work collaboratively with people with mental illness to help them reduce their comorbidities and prevent premature death (Swarbrick, Hutchinson, & Gill, 2008).

Interference with Rehabilitation Goals

In addition to the negative consequences of medical comorbidities described above, poor physical health is a barrier to achieving rehabilitation goals. Psychiatric symptoms can be exacerbated by medical problems with individuals experiencing more severe psychosis, increased depression, and elevated rates of suicide attempts (Corrigan et al., 2008). Additionally, functional outcomes including employment, independent living, utilization of support services, hospitalization and mental health service utilization are all negatively impacted by the occurrence of serious medical disease (McIntyre et al., 2006; Sullivan, Hart, Moore, & Kotria, 2006). According to Swarbrick (2006), the lack of optimal health is a powerful contributor to disability, isolation, and the lack of community participation that people with mental illness often experience.

Addressing the Problems--Assertive Care Coordinators

Ironically, there is actually an extensive body of literature on demonstration projects to improve integration of mental health and primary health care for individuals with mental disorders (Bazelon Center for Mental Health Law, 2004; Corrigan et al., 2008; Horvitz-Lennon, Kilbourne, & Pincus, 2006; Harmon, Carr, & Lewin, 2000; Parks et al., 2006; WHO, 2008). While several models have been described, no single approach is likely to be suitable for all situations or all occasions (Keks, Altson, Sacks, Hustig, & Tanaghow, 1998). A promising approach for promoting better overall health care for persons with SMI is the use of a coordinator, sometimes referred to as counselor or care manager, responsible for overseeing integration of services. The World Health Organization (WHO) described such coordinators as "crucial in steering programs around [these] challenges and driving forward the integration process" (WHO, 2008, pg. 54). The report cites examples of countries that have employed coordinators to better serve the mental health and medical care of its citizens (WHO). These countries include Argentina, India, Belize, Iran, Saudi Arabia, South Africa, and Australia.

In Australia, for example, an alternative approach to traditional "referral-only" systems of integrated care was implemented using a "counselor model" (Harmon et al., 2000). This approach involved the participation of mental health nurses. The nurses were part of a regional community mental health team working closely with general practitioners who performed a liaison function with general medical practitioners (GPs). Their role involved the facilitation of communication, coordination of treatment and bi-directional referral between GPs and mental health services or other health care agencies. The nurses also provided short-term counseling or psychotherapy for patients whose GPs were unwilling or unable to provide this form of care. Additionally, they provided case management in partnerships with GP's for patients with long-term relapsing psychotic disorders or other severe chronic mental illness (Harmon et al.).

The Bazelon Center for Mental Health Law (2004) highlighted states that are evaluating collaborative models of care that employ counselors or care managers. Four state Medicaid systems (Massachusetts, Michigan, Oregon and Oklahoma) have made special efforts to address the coordination of primary care and behavioral health for people with serious mental disorders. Strategies used to improve collaboration include special targeted programs, financial incentives, managed care contract requirements, and provider education. The Bazelon Center for Mental Health Law (2004) notes that:

   Integration of care is difficult when providers
   practice separately and have separate administrative
   structures, information systems and
   funding sources. This model requires numerous
   adjustments and special efforts to overcome
   each of the barriers to collaboration. On the
   other hand, this approach causes the least disruption
   to traditional practice. (Improving
   Collaboration between Separate Providers Section,
   para. 2)

The Executive Summary also addressed the importance of effective information flow given the usual difficulties in communication among various providers. One problem noted during site visits in several states from both behavioral health and primary care providers was the lack of feedback to the referring agency.

One strategy identified by the Bazelon Center to address the referral feedback concern is for a case manager or psychiatric nurse to accompany the consumer to the primary care appointment. The care manager would then be able to share key information with clinical staff at the mental health program or other service providers in the person's life.

The Hogg Foundation for Mental Health has also identified innovative programs in the integration of mental health and medical care by looking at the problems associated with the limited capacity of behavioral health centers to provide on-site primary care (Hogg Foundation for Mental Health, 2008). Specifically highlighted is the facilitated or enhanced referral model. This model employs a nurse who assists consumers with accessing primary medical care, facilitating communication between providers and systems and helping consumers follow through with medical treatment. In addition, the nurse may provide health education and advocacy to help consumers overcome barriers to accessing primary care, all of which improve methods for integration of mental health and medical care.

Williams and Dietrich (n.d.) summarized a trial project employing case managers that tested a systematic approach to depression management. Three components were identified that included "the primary care physician working in a prepared practice; a care manager; and a psychiatrist all working collaboratively with the patient to improve treatment and outcomes" (Williams & Dietrich, p. 1). In this project, the care manager was a nurse who facilitated collaboration between primary care and mental health providers. The care managers also conducted follow-up assessments either via the phone or face-to-face. "Care managers call patients at a specified time over three to twelve months to assess symptoms, treatment adherence, problems with treatment and to promote self-management" (Williams & Dietrich, p. 1). In addition to the care manager, this approach also utilized the consultation of a mental health expert who advised primary care physicians. "Early evaluations of similar collaborative care models are encouraging. Patients in care management systems were about twice as likely to experience a sizable reduction in depressive symptoms" (Williams & Dietrich, p.2).

A variety of other approaches to integrate primary and psychiatric care have also been developed. These include the use of co-location of services, formal affiliations, and adaptations of assertive community treatment (ACT).

Co-Location of Services

Co-location of mental health and physical health services is a best practice to improve the health status of persons with psychiatric disabilities (Bazelon Center for Mental Health Law, 2004a; Corrigan et al., 2008; Parks et al., 2006; Horvitz-Lennon et al., 2006) and there are several versions of this model. The first is primary care services embedded in a Community Mental Health Center or the placing of a health practitioner such as a nurse or physician assistant at an existing behavioral health care agency, which is considered the most effective strategy for persons with SMI (Bazelon Center for Mental Health Law, 2004a). It should be noted that this model presents significant challenges for financing of services and successful recruitment of nursing staff (Boardman, 2006); however, research suggests that co-located services improve both access to health care and health outcomes (Corrigan et al.). This model has been studied and successfully replicated in Veterans Administration services (Druss, Rohrbaugh, Levinson, & Rosenheck, 2001; Druss &von Esenwein, 2006).

The second model of co-located services are referred to as unified programs in which one organization combines mental health and physical health services and integrates "not only delivery of care but also administration and financing" (Bazelon Center for Mental Health Law, 2004b, p. 5). Unified programs are a combination of both medical and mental health services, where the organization has a clear responsibility for both services. An approach that creatively unifies service is an integrated Community Mental Health Center and Federally Qualified Health Center (Schuffman, 2008). This type of service provided several benefits: (1) overcomes the financing issue that can be problematic with two separate entities providing separate streams of service, (2) allows for the delivery of services that are clinically integrated, (3) and improves communication between medical and psychiatric service staff. A lack of clinical integration of services often contributes to the diminished access to health care and its poor quality (Horvitz-Lennon et al., 2006). Finally, this model offers a "no wrong door approach to all of health care [which is] more friendly, less stigmatizing and easier to access" (Bazelon Center for Mental Health Law, 2004b, p. 6).

A final model of integrated care is behavioral health specialists within primary health care sites. In this model, a therapist or case manager is placed within an existing physical health clinic. One such initiative added a master's prepared clinician to coordinate care and an Advanced Practice Nurse to provide psychiatric screenings and preventative care at primary care clinics (Schuffman, 2008). This model focuses more on individuals with less severe psychiatric disabilities as it assumes people are receiving medication prescribing services from primary care practitioners (Bazelon Center for Mental Health Law, 2004a) and will need few additional resources to manage their illness in the community.

While co-location of services has demonstrated promising results for improved access to care and health outcomes, there are relatively few examples of this model in practice (Horvitz-Lennon et al., 2006). Co-location of mental and physical health care can improve the quality and access of health care for persons with psychiatric disabilities; furthermore, the model has reduced health disparities, improved health outcomes, and met with positive user satisfaction. Avenues of funding services must be further developed to promote this model of practice, including financial and other policies that act as incentives for service integration (Horvitz-Lennon et al.).

Formal Affiliations

Formal agreements and collaborations for combined mental and physical health care have primarily been between health care centers or individual general practitioners and Community Mental Health Centers (CMHC; Horvitz-Lennon et al., 2006). However, there are examples of formal affiliations between CMHC's and colleges. Often such affiliations provide development and implementation support and training such as in the Missouri Integration Initiative (Schuffman, 2008). Alternately, colleges can utilize faculty and students who provide direct care, either mental health or physical health interventions, like the Center for Integrated Care, a collaboration between Thresholds Psychiatric Rehabilitation Center and the University of Chicago's College of Nursing have done (Bazelon Center for Mental Health Law, 2004a). Affiliations can also include government entities. For example, in North Carolina the Department of Health and Human Services, a nonprofit association representing mental health and substance use services, and the program that provides medical case management for Medicaid enrollees initiated four pilot sites to provide integrated care (Overstreet, 2006).

Combining ACT with Advanced Psychiatric Nurses and Peer Providers

Traditional mental health services have not been designed to address physical health issues. One creative program has adapted Assertive Community Treatment (ACT) to include a greater emphasis on health promotion. ACT services can provide screening and assessment of health, basic nursing assistance, coordination of services, scheduling of medical visits and reproductive health education (Morse & McKasson, 2005; Phillips et al., 2001). While nurses are members on ACT teams, they are not typically utilized to focus on the improvement of health outcomes (Horvitz-Lennon et al., 2006). An experimental model of ACT, called Nurse Practitioner ACT (NPACT), included an advanced practice nurse and a peer provider to address modifiable health promoting behaviors (Kane & Blank, 2004). Interestingly, when NPACT was compared to traditional ACT services, NPACT showed improvements in areas other than the health behaviors. In particular, persons served in this manner found this approach to be more satisfying, demonstrated a reduction in psychiatric symptoms, and improved their community functioning. Further study is needed to understand the specific health promotion interventions that are most effective in helping to support healthier lifestyle change.

Promotion of Readiness for Lifestyle Changes

One area of health promotion best practice that is considered key in helping people move from considering a change to making a change is the concept of readiness. This concept assumes that all people can make changes to their health such as eating healthier, exercising more, going to the doctor or quitting smoking. The construct of readiness comes from Prochaska and DiClemente's Transtheoretical Model of Behavior Change, which identifies five stages of change: precontemplation, contemplation, preparation, action, and maintenance (Archie et al., 2007). The question for practitioners becomes: How can I support and motivate the person (i.e., service recipient) to take the steps necessary to change? To the extent that lifestyle is contributing to the poor health of persons with SMI, making changes such as healthier eating or increasing exercise can be very effective in promoting overall health.

Promoting readiness for change is a recommended principle in health promotion for persons with mental illness (Hutchinson et al., 2006). Interventions matched to the readiness stages have been proven successful in assisting with health changes across different types of health behaviors and with multiple behaviors concurrently in both the general population and among persons with psychiatric disabilities (Prochaska et al., 2004). If a practitioner understands the person's readiness to either change their behavior or accept an intervention, then the practitioner may be more successful in assisting the person (Emmons & Rollnick, 2001). The opposite is also true; if a practitioner does not consider which stage of readiness the person is in, the practitioner may actually reduce the likelihood of change. Addressing a person's need and readiness for change in their health behaviors is imperative since people with SMI often have difficulty engaging in interventions (Rogers et al., 2001).

Engaging people in services that address physical health are especially needed given the general health of persons with mental illness. Readiness based interventions are person-centered and do not require people to be prepared for active change, rather the opposite is true. For example, someone in the pre-contemplation stage of change toward a healthier lifestyle may benefit from motivational interviewing, which is designed to elicit personal goals while exploring the pros and cons of changes. However, a person in the contemplation stage may benefit from decisional balance exploration of changing vs. staying the same while someone in the action stage could benefit from learning positive self-reward strategies that will reinforce their changes (Archie et al., 2007).

Peer Coaching and Education

Peer-delivered health and wellness education curricula from the general population have been widely implemented for persons with chronic medical conditions. Kate Lorig (2000) and her associates at the Patient Education and Research Center in Palo Alto, CA have developed self-management programs for people living with chronic diseases, including arthritis, diabetes, and HIV/AIDS. Information about these programs can be accessed through their website (see Appendix for website information). Peer specialists act as coaches, helping to guide the person toward successful and durable behavioral change. The models are based on the premise that individuals can learn to promote their own health which contributes to the self-management of their illnesses.

Future Directions and Recommendations

It has been established that there are significant co-occurring medical conditions that negatively impact the lives of persons living with mental illness. This article has delineated some specific problems indicative of a true crisis and has offered some viable approaches to address various types of service limitations and challenges. Stakeholders include rehabilitation professionals, medical professionals, persons with serious mental illness and their families, researchers, as well as state and national level policy makers, and advocacy organizations. The Center for Mental Health Services (CMHS) has set a clear target which is to eliminate 10 years of the 25-year disparity in lifespan within the next 10 years (Manderscheid & del Vecchio, 2008).

Effective Practices

To accomplish the CMHS target of lengthening the lifespan and improving the quality of life for individuals with SMI, various strategies can be employed. For example, smoking cessation alone will lengthen life expectancy of this segment of the population as it has for the general public and best practices in this area are well known. NASMHPD (2007) has made an online a tobacco cessation toolkit available that has been adapted for people with mental illness (see Appendix for website information). In addition, known practices that are improving access to quality healthcare include assertive care coordination strategies, the addition of advanced practice nurses focused on holistic care to community mental health and assertive community treatment teams, specially trained peer advocates, the provision of psychiatric expertise to assist primary care providers, and the co-location of psychiatric and other healthcare services (Dickerson et al., 2003, Druss et al., 2001; Druss & Rosenheck, 1998).

Local and national mental health advocacy groups need to collaborate with national medical organizations to promote awareness of health needs among persons living with SMI and advocate for effective practices and services (Everett, Mahler, Biblin, Ganguli, & Mauer, 2008). Services delivered by mental and behavioral health professionals can be delivered from a holistic perspective. Mental and physical healthcare providers often assert they view people holistically; however, they seem to maintain a myopic view in terms of their domain of expertise. Providers must dispel the myth that the mind, body and spirit are separate entities. Professionals need to be ready to link individuals to needed services and resources, as well as teach self-advocacy skills so they can effectively assert their needs with healthcare providers and the complicated healthcare system.

Shared decision making (SDM) models are useful in assisting a person in developing and maintaining healthy habits that support wellness. SDM is a process by which consumers and practitioners consider treatment options, outcomes and preferences in order to reach a health care decision based on mutual agreement (Schauer, Everett, & del Vecchio, 2007). The model presumes both the person and the practitioner have equally valuable perspectives that are brought to decisions in care (Makoul & Clayman, 2006). Together both parties come to a solution and then evaluate the effectiveness of this shared perspective.

Research has demonstrated that people do better, are more satisfied with services, have improved self-efficacy and a greater ability to cope when they participate in decisions affecting their lives (Linhorst & Eckert, 2003). Participatory decision-making contributes to the well-being of a person on different levels. SDM is seen as a means of promoting recovery by fostering consumer self-direction, empowerment, responsibility and effective trusting relationships with providers (Schauer et al., 2007).

'To have real choices in any decision process, one must know what options are available and have accurate information about the various choices. The application of SDM in health promotion may include practitioners supporting or teaching the skill of decision making, promoting a person's ability to become a better health advocate, or being a partner in the decision-making process. SDM is generally preferred by persons with mental illness and can lead to improved self-efficacy and encourage self-responsibility (Schauer et al.). Nevertheless, practitioners should explore with service recipients whether a SDM process is desired by the individual (Adams, Drake & Wolford, 2007). For example, Kaplan (2003) recommended that SDM should be reserved for decisions that are especially problematic or life-threatening and not for all less important decisions.

Effective Policy

There are clear opportunities to change policies and practices in terms of funding, service coordination and delivery. Funding constraints that impede the implementation of the integrated models and care coordination will require that all stakeholders organize and create an advocacy agenda that forges policy changes to assure both service coordination and appropriate reimbursement. Everett and associates (2008) outline three categories of recommendations for effective policy reform: (1) immediate initiatives with limited additional resources; (2) substantial organizational changes and local leadership; (3) substantial national leadership. An example of an immediate initiative includes expanding Wellness Recovery Action Plans (WRAP) and other plans that address consumer generated goals for well-being and include physical activity, nutrition and primary care. An initiative that requires substantial organization change and leadership efforts would be the development of a consumer-run educational training module with consumers serving as peer health or wellness coaches (Everett et al.; Swarbrick et al., 2008). Peer wellness coaches can link peers to primary health care and health promotion activities thereby creating a new role that addresses health and wellness needs from a self-management perspective (Swarbrick et al.).

Requiring that Medicare and Medicaid partner to improve access to care, data analysis and implement strategies that will be effective with the population served by the mental health system (Everett et al.) is an example of a substantial national leadership type change. Since there are not any available data sets that combine psychiatric diagnosis, health risk behaviors, medical co-morbidity, medical and mental health service use, and quality of care; federal and state entities need to coordinate to establish sound and consistent methods for data collection (Manderscheid & del Vecchio, 2008). Federal and state authorities, as well as local mental and physical health service organizations, should be expected to gather, track and use data prudently to inform practice and policy. Local advocacy efforts can demand data collection surveillance on relevant indicators.

Workforce Development

Changes in services and policies cannot be implemented without a qualified workforce. Curriculum and training reform in each relevant discipline and modifying educational standards in both pre-professional training and continuing education is needed. Academic programs need to be redesigned to prepare practitioners who recognize health risk factors and can promote wellness. Professionals will need to develop a fuller understanding of wellness (Swarbrick, 1997; 2006; Copeland, 1997) and social determinants of health which include income and social status; social support networks; education and literacy (i.e., health literacy); employment, working conditions, social environments and physical environments; personal health practices and coping skills; child development; genetic factors; access to health services; gender and culture (Wilkinson & Marmot, 2003). A public health approach is required in this area. That is, initiatives are needed to prevent or reduce exposure of persons with SMI to risk factors that negatively affect their health status. The workforce needs to be versed in health promotion principles (Hutchinson, 2006), self management models, and responsibly design, deliver and evaluate such approaches.

Providers must take on new roles as both health educators and lifestyle coaches promoting knowledge and self-care skills that will foster optimal health. To do this, professionals need to be versed in the concept of health literacy. The Institute of Medicine (2006) defines health literacy as the ability to find, understand and use health information and services to make appropriate health decisions. Professionals need to understand the complex skills involved in health literacy including reading, listening, comprehending, problem-solving and analyzing (Costa, 2008). Furthermore, practitioners need to develop lifestyle coaching skills so they can teach individuals to find their own solutions by asking questions that give them insight into their situation. As a coach, practitioners help people be accountable to their agreed upon plan to achieve their goals.

Conclusion

The medical co-morbidities of people with SMI diminish the quality of their lives, cause needless suffering and shorten their life span. In addition, the pursuit of personal goals in interpersonal relationships, higher education, independent living, and employment are all hindered by medical complications. Numerous interventions are available but not widely utilized. It is incumbent upon rehabilitation professionals serving persons with SMI to learn and implement interventions that improve their overall health and promote a wellness lifestyle.

Appendix

1. Lorig and associates (2000) have developed self-management programs for people living with chronic diseases, including arthritis, diabetes, and HIV/AIDS. For more information on the see the website: http://patienteducation.stanford.edu.

2. NASMHPD (2007) has made an online tobacco cessation toolkit available that has been adapted for people with mental illness. See the website for more information: http://www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdat- ed90707.pdf.

Note

Support for Drs. Swarbrick's and Gill's effort on this article is in part from the National Institute of Disability and Rehabilitation Research Grant #H133P050006.

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Kenneth J. Gill

University of Medicine and Dentistry of New Jersey

Ann A. Murphy

University of Medicine and Dentistry of New Jersey

Michelle R. Zechner

University of Medicine and Dentistry of New Jersey

Margaret Swarbrick

University of Medicine and Dentistry of New Jersey

Amy B. Spagnolo

University of Medicine and Dentistry of New Jersey

Kenneth J. Gill, Ph.D., CPRP, Department of Psychiatric Rehabilitation and Counseling Professions, University of Medicine and Dentistry of New Jersey (UMDNJ), 1776 Raritan Road, Scotch Plains, NJ 07076. Email: [e-mail]