Promoting physical health among mentally Ill.
If, however, the two rings represented the typical models of care for physical and mental illness in this country, the intersection would be minimal at best.
Certainly, impaired physical health can be a consequence of mental illness and physical illness can negatively influence mental well-being. But rarely does consideration of one make its way into treatment of the other. This lack of coordination in care has grave repercussions, which are discussed in "Morbidity and Mortality in People With Serious Mental Illness," the report released last fall by the National Association of State Mental Health Program Directors.
According to the report, people with serious mental illness die, on average, 25 years earlier than the general population and about 60% of these premature deaths are linked to natural causes, such as cardiovascular and pulmonary disease ("Better Coordination of Mental, Physical Health Care Urged," CLINICAL PSYCHIATRY NEWS, February 2007, p. 1).
Research has long identified lifestyle factors that contribute to the increased health risks in this population. Individuals with severe and persistent mental illness smoke more cigarettes, drink more alcohol, and exercise less than does the general population. They are more likely to have poor dietary habits and are more prone to being overweight. In addition, those who take psychotropic medications are at increased risk for metabolic disturbances.
The sobering statistics have led to calls for more comprehensive strategies for managing mental illness. "There has to be a shift in thinking to meet the unique challenges presented by patients at the intersection of severe mental illness and medical conditions," said Dr. P. Michael Ho, a cardiologist at the University of Colorado at Denver.
In a recent publication discussing the increased risk of coronary heart disease among patients with severe mental illness, Dr. Ho and his colleagues proposed adopting interdisciplinary disease management care models that extend care delivery beyond traditional boundaries, whereby "providers from different specialties would collaborate to ensure that both psychiatric and general medical conditions are treated" (Lancet 2006; 367:1469-71).
Through such a model, for example, "patients could be encouraged to quit smoking through behavioral and pharmacologic interventions, and antipsychotics could be adjusted to help ameliorate the anticipated increase in symptoms," according to the authors. Furthermore, diabetes, hypertension, and hyperlipidemia "could be treated with careful attention to drug-drug interactions and medication adherence, and progress toward treatment goals could be followed up by nurse case-managers, home monitoring, or both," they wrote.
It is time, Dr. Ho explained in an interview, "to move beyond simply describing the link between severe mental illness and [physical] disease, and work toward reducing the risk in such patients."
Moving beyond an awareness of this link toward breaking the link requires targeted health education and promotion through the development and implementation of structured health interventions, according to Dori S. Hutchinson, Sc.D., director of services at the center for psychiatric rehabilitation at Boston University. Many traditional outpatient services focus mainly on mental illness management and do not include skill-based opportunities for people to learn how to live well in their communities, she said.
"Groups are needed that address physical activity, health literacy, nutrition, spirituality, and lifestyle choices to help people with serious mental illness attain the information and skills they need and want to live healthier lives."
Toward this end, the center for psychiatric rehabilitation developed a service initiative called Hope and Health for integrating health promotion and psychiatric rehabilitation for people with serious mental illness. Currently offered through the center's Recovery Education Program, the initiative includes classes built around evidence-based practice modules, including skills such as physical activity, food education, health education, illness management, and recovery education.
The program was piloted as a day treatment model of service provision, whereby participants received 16 weeks of on-site education, support, and skill instruction, and then an additional 16 weeks of coaching and case management to help people connect with health promotion services in their communities, Dr. Hutchinson said. Since its introduction, "4-day treatment sites in Massachusetts have inserted the program model into their more traditional environments," she said.
Each component of the Hope and Health curriculum offers practical tools that clients can use every day, Dr. Hutchinson said.
The efficacy of these and all health promotion interventions "is largely dependent on behavior change and individuals' ability to establish and maintain new habits," said William Collinge, Ph.D., a health care consultant in Kittery, Maine. "These challenges demand ego strength, self-direction, and motivation--qualities that can be difficult even for people without mental illness."
Such interventions are more likely to succeed if they include social support and social reinforcement for change, said Dr. Collinge, a researcher in the area of integrative medicine who has written extensively on mind/body medicine. 'Anything that involves group identity and group support has a better chance of success in the long term," he said.
Mental health clinicians looking to provide health support to their patients with serious mental illness--something the National Association of State Mental Health Program Directors' report strongly advocates--may use several behavioral education programs that are available. One such intervention, called the Solutions for Wellness Personalized Program, created by the Patient Marketing Group Inc. and sponsored by Eli Lilly & Co., is a 6-month program that provides individualized education on nutrition, exercise, stress management, and sleep improvement to patients diagnosed with a serious mental illness.
A study of more than 7,000 individuals enrolled in the program showed that, at 6 months, patients who finished the intervention reported positive changes in all four criteria. Most important were significant changes in body mass index among the participants--83% of whom were either obese or overweight at enrollment.
Participants reported an average BMI reduction of nearly 1 point--a weight loss of about 6 or 7 pounds. Most participants reported confidence in their ability to maintain the lifestyle changes they had made (J. Clin. Psychiatry 2005;66:1576-9).
The issue of tobacco use among people with serious mental illness is also a huge concern. The rates of cigarette smoking among the general public have been on the decline for several years, but the rates among people with psychiatric disorders have remained mostly stable and are significantly higher than those seen in the general population, according to Dr. Tony P. George, chair of addiction psychiatry at the University of Toronto.
Among the smoking cessation strategies that have been evaluated, those that combine medication and behavior modification appear particularly promising, Dr. George said. For example, atomoxetine (Strattera) has been shown to help smokers with schizophrenia cut back on cigarettes, as has bupropion (Zyban) combined with behavioral therapy.
The implementation of wellness initiatives among people with mental illness may seem like a tall order; it is not only possible, it is absolutely necessary, Dr. Hutchinson said.
"People with serious mental illnesses must have opportunities to obtain optimal health," he added. "We as a system are charged with helping people recover, and must begin to provide health promotion services."
By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at firstname.lastname@example.org.