Psychiatric–Medical ComorbidityImproving general medical care for persons with mental and addictive disorders: systematic review☆
Introduction
An extensive literature has documented that individuals with mental and addictive disorders are at elevated risk for a wide range of medical comorbid conditions [1], [2], [3], [4], [5], [6], [7], [8], [9] and premature mortality [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. It has been estimated that life expectancy is reduced 6.3 years among persons with depression, 7.2 years for schizophrenia and 13.8 years for individuals with a substance use disorder [21].
What is the cause of this excess morbidity and mortality? The pathways are likely complex and multifactorial [22]; contributing risk factors include toxic effects of substances [7], [23], iatrogenic effects of medications [24], [25], [26], neurohumoral dysregulation [25], [27], [28], [29] and behavioral risk factors such as inactivity and smoking [30], [31], [32], [33], [34], [35], [36].
There is increasing evidence that these problems may also be accompanied by an added risk, poor quality of general medical care [37], [38], [39], [40], [41], [42], [43]. Elevated rates of poverty, unemployment and uninsurance may hinder these individuals' access to basic medical services [44], [45], [46]. Even when these patients are enrolled in primary care, they are at risk for poor compliance with prescribed treatments [47], [48]. General medical providers are often not comfortable in caring for these patients, regarding them as difficult and time-consuming to treat [49], [50]. Finally, the geographic, financial and ideological separation between the general medical and specialty behavioral systems present a range of challenges to coordinating care across the boundaries that divide them [51], [52], [53], [54]. Poor quality of medical care may explain a substantial portion of these patients' excess mortality [55].
The combination of high medical need combined with poor quality of medical care is the hallmark of medically vulnerable populations, groups for whom the gap between health needs and available services is greatest [56]. Primary medical care has been shown to be particularly important for, and efficacious in, improving health in populations who have problems in obtaining appropriate services due to demographic, geographic or economic barriers [57], [58].
To what extent can interventions targeted at improving care for persons with behavioral disorders produce similar benefits? This article seeks to address this question by systematically reviewing the studies of these interventions and their association with primary care linkage, quality, outcomes and costs.
Section snippets
Search strategy
An a priori search strategy was developed to identify all studies examining interventions to improve quality of primary medical care in persons with addictive (alcohol and illicit substance use) and/or mental conditions. We included both addictive and mental disorders given their high rates of co-occurrence, the fact that that both are associated with increased morbidity and mortality, and the fact that both are commonly treated in settings that are separated from general medical care.
A
Study sample and interventions
A total of six studies met the preestablished criteria for inclusion in the systematic review. Four focused on populations with addictive disorders [66], [67], [68], [69] and two on patients with serious mental disorders [70], [71]. All were randomized trials.
All six studies met criteria for adequate quality of randomized clinical trials [64]. As is the case in any organizational or practice-based intervention, fully blinded approaches were not possible in any of the studies, since both
Discussion
The studies covered in this review suggest the potential for improving linkage to, and quality of, primary medical care, in persons with mental and addictive disorders, at a relatively modest cost. At the same time, the paucity of studies on the topic suggests a need for greater research on the topic. Great strides have been made in the development and testing of models to improve the diagnosis and treatment of mental and addictive disorders in primary care [74], [75], [76], [77]. Now, similar
Acknowledgment
We thank Jeffrey Samet and Constance Weisner for comments on an earlier draft.
References (97)
Medical consequences of substance abuse
Psychiatr Clin North Am
(1999)Iowa record-linkage study: death rates in psychiatric patients
J Affect Disord
(1998)- et al.
Alcohol and public health
Lancet
(2005) - et al.
Life expectancies for individuals with psychiatric diagnoses
Public Health
(2001) Clinical and health services relationships between major depression, depressive symptoms, and general medical illness
Biol Psychiatry
(2003)- et al.
Depression and cancer: mechanisms and disease progression
Biol Psychiatry
(2003) - et al.
Does clinical case management improve outpatient addiction treatment
Drug Alcohol Depend
(1999) - et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?
Control Clin Trials
(1996) - et al.
Physical diseases in schizophrenia and affective disorder
J Clin Psychiatry
(1983) - et al.
Medical comorbidity in schizophrenia
Schizophr Bull
(1996)
Burden of medical illness in drug- and alcohol-dependent persons without primary care
Am J Addict
Burden of general medical conditions among individuals with bipolar disorder
Bipolar Disord
Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services
J Nerv Ment Dis
Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness
Psychiatr Serv
Comorbid medical illness in psychiatric patients
Curr Psychiatry Rep
Medical morbidity, mental illness, and substance use disorders
Psychiatr Serv
Mortality in patients with schizophrenia, mania, depression and surgical conditions. A comparison with general population mortality
Br J Psychiatry
Excess mortality in schizophrenia and affective disorders. Do suicides and accidental deaths solely account for this excess?
Arch Gen Psychiatry
Depression following myocardial infarction. Impact on 6-month survival
JAMA
Mortality rates and predictors of mortality among late-middle aged and older substance abuse patients
Alcohol Clin Exp Res
Mortality and medical comorbidity among psychiatric patients: a review
Psychiatr Serv
Minor and major depression and the risk of death in older persons
Arch Gen Psychiatry
Excess mortality of mental disorder
Br J Psychiatry
Life expectancy and causes of death in a population treated for serious mental illness
Psychiatr Serv
Mortality among patients with mental disease
Medical disorders of alcoholism
N Engl J Med
Antipsychotic drugs: prolonged QTc interval, torsade de pointes, and sudden death
Am J Psychiatry
Incidence of newly diagnosed diabetes attributable to atypical antipsychotic medications
Am J Psychiatry
Considerations for the use of antidepressants in patients with cardiovascular disease
Am Heart J
Influence of serotonin-transporter-linked promoter region polymorphism on platelet activation in geriatric depression
Am J Psychiatry
Medical comorbidity and schizophrenia
Schizophr Bull
Smoking characteristics of methadone patients
JAMA
Cigarette smoking: implications for psychiatric illness
Am J Psychiatry
Dietary intake of schizophrenic patients in Nithsdale, Scotland: case-control study
BMJ
The unhealthy lifestyle of people with schizophrenia
Psychol Med
Smoking and mental illness: a population-based prevalence study
JAMA
Tobacco use and quit attempts among methadone maintenance clients
Am J Public Health
Prevalence and correlates of obesity in a community sample of individuals with severe and persistent mental illness
J Nerv Ment Dis
Medical evaluation of psychiatric patients. I. Results in a state mental health system
Arch Gen Psychiatry
Health care utilization by persons with severe and persistent mental illness
Psychiatr Serv
Use of general medical services by VA patients with psychiatric disorders
Psychiatr Serv
Mental disorders and quality of diabetes care in the veterans health administration
Am J Psychiatry
Somatic healthcare utilization among adults with serious mental illness who are receiving community psychiatric services
Med Care
Physical health monitoring of patients with schizophrenia
Am J Psychiatry
Morbidity and rate of undiagnosed physical illness in a psychiatric clinic population
Arch Gen Psychiatry
Alcohol, drug abuse, and mental health care for uninsured and insured adults
Health Serv Res
Linkage with primary medical care in a prospective cohort of adults with addictions in inpatient detoxification: room for improvement
Health Serv Res
Mental disorders and access to medical care in the United States
Am J Psychiatry
Cited by (142)
Screening for more with less: Validation of the Global Appraisal of Individual Needs Quick v3 (GAIN-Q3) screeners
2021, Journal of Substance Abuse TreatmentA statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants
2019, Journal of Substance Abuse TreatmentCitation Excerpt :These models have been found to increase treatment participation and retention (Sutter et al., 2017), improve birth weight among other birth outcomes, and increase the likelihood of mothers retaining custody of their children (Buckley et al., 2013; Sutter et al., 2017). Consistent with this approach, the maternity medical home (MMH) model, which applies key principles of the patient-centered medical home to perinatal care (Rakover, 2016), has demonstrated positive outcomes in behavioral health, primary care, and child welfare settings through early engagement in prenatal care, enhanced access, care coordination, and patient-centered care which empowers women to make healthcare decisions (Druss & von Esenwein, 2006; Marsh, Smith, & Bruni, 2011; Rakover, 2016). To address the needs of pregnant women with OUD, a two-year state-led quality improvement (QI) effort was initiated in 2014 with the goal of increasing access to effective treatment, improving maternal and fetal health outcomes and family stability, and reducing costs of NAS for Ohio's Medicaid program.
Dealing With Discrimination in Physical Health Care Services: Strategies of People With Mental Health and Substance Use Conditions
2023, Journal of Patient Experience
- ☆
The study was supported by NIMH grant MH070437.