Psychiatry’s Role in Improving the Physical Health of Patients With Serious Mental Illness: A Report From the American Psychiatric Association

Strong evidence has emerged in the past two decades of the importance of general medical illness in driving the poor health and early mortality of patients with serious mental illnesses. Rates of general medical illness among those with serious mental illness exceed rates in the general population in every disease category, and those with serious mental illness experience higher standardized mortality ratios, compared with the general population, for cardiovascular, respiratory, and infectious diseases (3). About two-thirds of deaths among people with mental illness are attributable to natural causes (1).

The relationship between mental illness, general medical comorbidity, and premature mortality is complex and multifactorial. Adverse health behaviors contribute heavily. Four modifiable risk behaviors—tobacco use, substance use, poor diet, and lack of physical activity—are the cause of much of the morbidity and early mortality related to chronic diseases. Patients with serious mental illness engage in these behaviors at higher rates than the general population, placing them at risk of chronic general medical conditions and poorer outcomes. Adverse social determinants of health, including the effects of economic disadvantage and chronic stress, likely also play a part. Side effects of medications prescribed for patients with serious mental illness also contribute significantly, with weight gain and glucose dysregulation noted most prominently with antipsychotic drugs. Finally, those with mental illness are at risk of receiving poor-quality medical care, which is likely a significant determinant of adverse health outcomes in this population. They may underuse primary care services and overuse emergency and general medical inpatient care, resulting in fragmented and irregular services and lower rates of preventive care. Individuals with serious mental illness are also less likely to receive adequate, standard-of-care treatment for general medical conditions, compared with age-matched persons in control groups. Factors underlying the lack of high-quality medical care for persons with serious mental illness include lack of insurance and the cost of care; the effects of stigma on patient-provider interactions; and the symptoms of mental illness, which impose challenges to accessing care and adhering to recommended treatments.

Over the past decade, studies have provided substantial evidence of the effectiveness of both pharmacologic and behavioral interventions to target cardiovascular risk factors among persons with serious mental illness. In particular, effective interventions are available to support smoking cessation and to promote weight loss, addressing the two leading causes of preventable mortality in the United States. Behavioral and pharmacologic interventions have demonstrated effectiveness among individuals with serious mental illness, and the magnitude of the effects appears to be comparable to that seen in general population studies. In addition, trials and demonstration projects support strategies to improve care for individuals with serious mental illness through systematic coordination and collaboration among treating providers (4).

Much work remains to be done to identify and develop best practices to improve general medical care and health outcomes among persons with serious mental illness and to increase access to evidence-based care (5). Future studies should test long-term interventions for cardiovascular risk factors and health-risk behaviors and evaluate the impact of interventions on all-cause mortality. Studies are also needed to evaluate strategies to more widely disseminate effective interventions in real-world settings. In many instances, significant resources might need to be dedicated to enhance engagement in care, and the most feasible and appropriate settings for intervention may not be clinical settings. Family support interventions and innovative collaborations with other disciplines and community partners may address some of the social determinants that increase risk factors and limit service engagement and that are among the most challenging barriers to reducing premature mortality in this vulnerable population.

Given the high burden of chronic general medical conditions such as hypertension and diabetes, interventions are needed to specifically target the treatment of these disorders. Studies should explore how to optimize the roles of a diverse multidisciplinary workforce, including peer support specialists, to match intensive services to high-need individuals. Technological innovations to support service delivery and care coordination should also be leveraged to integrate behavioral and general medical care for this population.

Psychiatrists can provide a range of services to address the poor health of patients with serious mental illness. These activities can include screening for general medical conditions; counseling patients to reduce cardiovascular risk factors; treating adverse health behaviors, including smoking; limiting side effects from psychotropic medications; coordinating with general medical care providers; and providing general medical services for patients who do not currently have primary medical providers (6). Psychiatrists in leadership roles can also play an important role in promoting better physical health for patients. Medical directors of community mental health centers or behavioral health homes should establish protocols and monitor outcomes for their medical staff.

The past decade has seen the passage of landmark federal legislation improving insurance coverage and testing new models of care delivery that could have an important positive impact on the lives of people with serious mental illnesses. The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) was a first step toward improving access to health insurance and reducing financial burden for patients with serious mental illnesses. The Affordable Care Act of 2010 (ACA) built on the MHPAEA to expand health insurance coverage for patients with mental illnesses. Section 2703 of the ACA provides funding for states to design health homes to provide comprehensive care coordination for Medicaid beneficiaries with chronic conditions, including mental illnesses. Most recently, the 21st Century Cures Act, signed into law in 2016, authorizes funding for several programs delivering evidence-based prevention and treatment services for individuals with serious mental illnesses and supporting the improvement of integrated care models for primary care and behavioral health care (7).

Several recent policy developments could have significant implications for addressing the physical health of people with serious mental illness. Repeal of the ACA could eliminate federal matching for Medicaid expansion and subsidies for insurance exchanges, remove essential health benefit requirements, curtail funding for demonstration projects addressing care coordination, and reduce funding for the public health and social safety net. The coming years will likely see greater autonomy for states in determining the scope and structure of Medicaid benefits and social services (8).

On the basis of findings from a literature and policy review, the APA expert panel developed the following recommendations for psychiatrists to address the health, well-being, and longevity of people with serious mental illnesses.