Sunday, March 20, 2011

Collaborative Care: Fix It And Fix Mortality




I briefly scanned the Robert Wood Johnson synthesis report on mental and medical co-morbidity so I thought I'd summarize the highlights for the blog. If you'd rather watch the recorded web seminar you can hear it here.

The report relied on systemic literature review to look at the relative risk and mortality associated with co-morbid medical and mental health conditions. The looked at studies using structure clinical interviews, self-report, screening instruments and health care utilization data (diagnostic codes reported to Medicaid).

This is what they found:

  • 68 percent of adults with a mental disorder had at least one general medical condition, and 29 percent of those with a medical disorder had a comorbid mental health condition
  • These findings support the conclusion that there should be strong integration of medical and mental health care
  • Psychiatric disorders were the most expensive conditions to treat among Medicaid beneficiaries, but also the most common when combined with cardiovascular disease
  • Medical conditions and psychiatric conditions have a reciprocal risk relationship: having one disorder increases the risk for having the other
  • Both medical and mental disorders are associated with low income, poor education, early childhood trauma and chronic stress
  • Four modifiable risk factors are responsible for high rates of co-morbidity: alcohol and drugs, tobacco, poor nutrition and lack of exercise
  • The treatments themselves may worsen co-morbidity (somatic meds cause psychiatric side effects, psychiatric meds may cause or worsen medical conditions)
  • Public mental health clients die 25 years earlier than the average life expectancy (see Figure 4 above for the relative risk of six common psychiatric conditions)
  • Multidisciplinary team approach to treatment is most effective: fully integrated medical, mental health and substance abuse services
So instead of having a public health care system that is fragmented between freestanding clinics, we should have integrated clinics that follow a collaborative care model and that provide a broad range of services. For me this means that we can no longer afford to have disjunction of care between state agencies: correctional facilities and public clinics need to coordinate care for both medical and mental health conditions. This study describes my typical clinic population: poor, poorly educated, sick, traumatized and under chronic stress. They are at greater risk of dying and the most costly to care for.

6 comments:

moviedoc said...

If we could just influence the mentally ill to quit smoking imagine the impact, but your post also raises a question on the other side of the sporkiatry debate (psychiatrist providing psychotherapy and med management): Should psychiatrists assume a primary care role, do physical exams. Psychoanalytic mythology pushed this basic medical procedure out of the psychiatrist's toolkit. Is it time to bring it back?

Anonymous said...

A primary care doc talks to his patient. The study argues for greater integration between psychotherapy and use of medication, that is, "sporkiatry," not the opposite.

moviedoc said...

Anon: The last bullet point is: "Multidisciplinary team approach to treatment is most effective." I interpret that to mean separate providers who are collaborating, not working in isolation from one another, but not one jack-of-all-trades doing everything. But you're right, a PCP should talk with (not just TO) her patients, in fact so should ALL health care providers.

insurance quotes. said...

If we could just influence the mentally ill to quit smoking imagine the impact, but your post also raises a question on the other side of the sporkiatry debate (psychiatrist providing psychotherapy and med management):

Anonymous said...

It's difficult as a patient to know what to do about psychiatric medications, because so many of them can cause significant weight gain. And with many of the top causes of death (heart disease, diabetes, stroke, etc) being strongly correlated with obesity, it's not surprising psych patients would have a decreased life span.

After gaining weight on psych meds, I stopped them and refused any further drugs that had a significant risk of weight gain. This certainly limited my options, but the risk of obesity for me wasn't worth it. Gaining weight only exacerbated my depression. I felt more fatigued and even less inclined to exercise the more weight that piled on.

Off the meds I was able to return to my pre-psych med healthy weight.

I think this is where patients really have to weigh (no pun intended) what they're willing to risk. Some believe the risk of weight gain is worth it, and others don't.

Leslie

C said...

..."Medical conditions and psychiatric conditions have a reciprocal risk relationship: having one disorder increases the risk for having the other..."

This is certainly true with cardiovascular disease and depression. Dr. Susmita Mallik of Emory University School of Medicine reported in the Archives of Internal Medicine that women under the age of 60 are three times more likely to become depressed than male patients. She added:

“Both doctors and patients should be aware that depression is an important risk factor for adverse outcomes for cardiac event survivors.”

More on this at "Depressing News About Depression and Women's Heart Disease" at:
http://myheartsisters.org/2009/07/03/depression/