The Health Literacy of Adults With Severe Mental Illness

Studies show that about 36% of U.S. adults have low health literacy, defined as “the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (1). Low health literacy is associated with a lower level of education, racial-ethnic minority status, age 65 years and older, male gender, poor health status, lack of private insurance, and risk of hospitalization (1,2). In psychiatric populations, health literacy is correlated with education and verbal, visual, and intellectual abilities (3). In addition, the presence of psychotic disorders is associated with an increased likelihood of limited health literacy (3). Previous studies have acknowledged the importance of including health literacy assessment in standard psychiatric evaluation protocols, because low health literacy has an impact on the effectiveness of current best-practice treatment approaches, which may require adequate literacy (3).

We examined factors related to the health literacy of 256 individuals with serious mental illness who were receiving services in an urban community mental health center (CMHC). The parent study was a randomized trial assessing the effects of a medical care management intervention for individuals treated at the CMHC (4). Participants were recruited on site and were required to have the ability to provide written informed consent before enrollment. We hypothesized that low health literacy would be associated with lack of health insurance, worse health status, the presence of a psychiatric diagnosis, more inpatient hospitalizations and emergency department visits, and lower use of preventive services.

We examined cross-sectional data related to participants' demographic characteristics, general health information, general medical and psychiatric diagnoses, and hospitalizations. Health literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM), a brief validated measure considered suitable for use in psychiatric populations (3,5). It measures a patient's ability to pronounce 66 commonly used medical words in an ascending order of difficulty. Scores of 0 to 60 indicate a third- to eighth-grade reading level; scores from 61 to 66 indicate a reading level of ninth grade and above (5).

The mean±SD age of the sample was 46.05±8.13 years, 207 participants (81%) were African American, 132 (52%) were male, 168 (66%) reported at least a 12th-grade education, and 106 (41%) were insured. Overall, 117 participants (46%) had low health literacy, and the mean REALM score was 55.18±15.60. In adjusted analyses, low health literacy was associated with increased odds of inpatient medical hospitalization when the analysis was controlled for education, race, gender, age, and schizophrenia diagnosis (odds ratio=3.71, 95% confidence interval=1.49–9.22, p=.005).

Low health literacy and cognitive or functional impairments may affect this population's abilities to effectively interpret health information or to meaningfully engage in psychiatric interventions, which may result in poor self-care management, increased disability and morbidity, and adverse health outcomes, such as hospitalization. Clinicians should consider integrating health literacy assessment and targeted patient education with standard psychiatric evaluation procedures, so that treatments are administered in a manner understandable by persons with low health literacy. Future studies should consider using more comprehensive health literacy and cognitive assessment tools and investigating the effectiveness of targeted patient education in improving health outcomes in psychiatric populations. In research environments, limited literacy may have a similar effect on participants' understanding of materials, such as informed consent documents, and it is important to ensure the readability of all written materials.