Most doctors are trained to locate the source of their patients’ ailments and to cure them using modern medical technology and pharmaceuticals, often without considering that bodily illness might be linked to mental illness. While primary care physicians write the majority of psychiatric medication prescriptions in the United States, many may not have the time or wherewithal to deeply examine their patients’ overall psychological wellness.
For example, a clinician might investigate and consider all types of somatic complaints for a patient presenting with primary stomach pain and diagnose a physical disease without examining possible psychological causes. Selective diagnostics creates serious problems for patients with serious mental health conditions, many of whom also have physical illness.
Schizophrenia mortality is a jarring example of the real need to integrate medical and behavioral health. Individuals with schizophrenia face myriad social challenges, mostly the result of stigma. In addition, their physical health is often compromised. Studies show that schizophrenia increases the risk of premature death, but the specific causes of schizophrenic-related mortality have only recently been uncovered. A retrospective longitudinal cohort study published in December looked at cause-specific mortality rates of more than 1 million people with schizophrenia. It found that they died of cardiovascular disease at 3.6 times the rate of the general population. The study results indicate that schizophrenia is indirectly associated with heart disease and death because people with schizophrenia are far more likely to engage in unhealthy behaviors, such as smoking and drug use. Additionally, antipsychotic medication aimed at managing schizophrenia increases the risk of obesity and cardiovascular disease. So addressing these risk factors as part of the spectrum of care for patients with schizophrenia is essential—and something that our current health system is ill equipped to accomplish.
People with schizophrenia are also at increased risk of having and dying from a substance use disorder. Research shows that as many as half of those diagnosed with schizophrenia may also suffer from some kind of substance use disorder. The Olfson and colleagues study cited above found that individuals with schizophrenia died as a result of drug abuse at 3.9 times the rate of the general population. Aggravating the problem are wide gaps between mental health care and addiction services. At both the federal and local level, separate agencies often handle mental health and substance abuse treatment. That makes little sense and leads to tragic results.
A holistic approach to delivering medicine that considers both physical and mental causes of ailments would greatly improve efficiency of the health care system and the experience of patients, especially those suffering from schizophrenia. There are provisions built into the Affordable Care Act that aim to create integrated care.
Medical and behavioral health care providers should approach their practice by using the biopsychosocial model, formally proposed and developed by George Engel. It provides a framework for conceptualizing all the systems that influence health – from molecules and cells to the whole individual, one’s family, community, and culture.
The most effective treatment plans would target improving patients’physical health through diet, exercise and smoking cessation—lifestyle changes that have the added benefit of then enhancing mental health. Assessing and referring individuals for substance abuse services as needed is critical. Patient-centered care - akin to VIP level care - whereby the patients’ values, preferences, and overall well-being are considered in making treatment decisions, is the right way forward for those suffering from mental illness.
The development of a new specialty of primary care provider, the primary care behaviorist (PCB), provides another possible solution. The primary care behaviorist would be a primary care physician with additional training and certification in diagnosing and treating behavioral health issues, bridging the gap between physical and mental health. But even standard primary care offices need to improve mental health screenings. Although studies have shown that depression screening does not substantially affect health (since simply discovering that a patient is depressed is of little help in a fragmented system of behavioral health care), a recent editorial in the Journal of the American Medical Association calls for regular depression screenings during primary care visits. Until a more efficient method of matching patients with effective types of treatment evolves, screening for depression can help clinicians better track their patients’ responses to treatment, nonadherence, and lack of symptom improvement during early stages of therapy.
Until we all realize that mental illness is simply illness—what a colleague has called “conceptual parity”—holistic mental health care will be difficult to achieve. Behavioral health and physical health are too closely intertwined to treat one and not the other.
Andrea Segal is research coordinator at the Scattergood Program for Applied Ethics of Behavioral Health Care and an MPH candidate at the University of Pennsylvania Perelman School of Medicine.
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