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Jamila Allen

Created on October 25, 2024

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Integrated Treatment for co-ocurring disorders

psychiatric and addictive disorder and chronic physical health conditions

Summary

Providing integrated treatment for people with co-ocurring behavioral and physical disorders has become a central goal of mental health policy reform.

Why integrated care for co-occuring disorders is so important

In part the answer is that the failure to provide effective integrated care drives up the cost of care. But the answer also is that the length and quality of life of people with serious, long-term mental disorders depends on addressing both behavioral and physical problems.

Here you can include a relevant data to highlight

Here you can include a relevant data to highlight

Premature Mortality

On average people with serious mental illness die considerably younger than the general population. It has become commonplace to claim that their life expectancy is reduced by about 25 years—roughly age 55 rather than 80. For the most part, the premature death of people with psychiatric disabilities reflects physical rather than mental causes. Yes, people with serious mental illnesses complete suicide far more often than those without, but that is not the greatest driver of low life expectancy. Obesity, which contributes to high blood pressure, diabetes, and heart disease, is probably a greater factor. Smoking, which provides emotional relief to many people and is very common among people with serious mental illness, also is a major contributor. Excessive use of alcohol and other drugs also contributes to poor health. And people with psychiatric disabilities often have periods of hard homelessness that exposes them to terrible health risks including assault and rape as well as exposure to dangerous extremes of weather and to contagious diseases such as AIDS, hepatitis, sexually transmitted diseases, and respiratory diseases.

Co-Occuring Substance Abuse

Many people with serious mental illness will have periods in their lives when they have co-occurring substance use disorders, which contribute to homelessness, incarceration in jails and prisons, and exposure to many other risks and barriers to achieving a satisfactory quality of life. For them the efforts of the mental health, substance abuse, and physical health care systems have been feeble and inadequate. Awareness of the problematic co-occurrence of mental and substance use disorders goes back to the very beginning of deinstitutionalization in the late 1960s and early 1970s. Over the years, there have been repeated announcements of efforts to integrate mental health and substance abuse services. Cross-training and inter-agency committees are old hat, and they’ve made some difference. But the schisms between the systems are still intact, driven by ideology, unwillingness to share power, competition for funds, and the inability to respond to clear data that integrated treatment is what’s needed.

Co-Occurring Depression and Serious Health Conditions

In addition to concerns about the unfortunate impact of physical illness on people with serious, long-term mental illness, awareness has grown in recent years about the impact of mental illness on people with serious chronic physical conditions such as heart disease. It is quite clear, for example, that people with depression and heart disease are more likely to suffer premature disability or death than are people with heart disease who are not depressed. In part this is a chicken and egg issue. Serious, chronic physical illness—especially if it is life threatening or results in reduced ability to perform basic life functions—often precipitates demoralization. Lack of hope contributes to resignation, lack of effort to recover, and ultimately to greater physical deterioration. But whatever the direction of causality, it is clear that addressing co-occurring mental issues is key to maximum recovery for people with serious physical conditions.

Opportunities for Early Identification and Treatment of Mental and Substance Use Disorders

Most people with diagnosable mental and/or substance use disorders go without diagnosis and treatment. One reason for this is the widespread reluctance of people suffering from emotional distress to seek treatment from mental health providers (we usually call this “stigma”) as well as the vast shortage of mental health providers in many parts of the country. But people who will not seek help from a “shrink” generally do go to primary health care providers, who have an opportunity to identify, and to provide rudimentary treatment for, people who might benefit from behavioral health services. Awareness of this fact has led to calls for increased behavioral health screening in primary care—especially screening for depression—and for meaningful responses to positive findings including professional diagnosis and treatment or referral to treatment. The problem, of course, is that most primary care physicians do not have the expertise to make sound diagnoses or to provide adequate treatment. According to the National Co-Morbidity Survey, more than 85% of people treated for mental disorders by primary care physicians do not get even “minimally adequate” treatment. Mental health providers are somewhat more likely to provide minimally adequate care, but about half of people referred to them do not follow up. It’s reasonably clear that primary care could do more to identify and treat behavioral disorders. Fortunately, there are some signs of improvement in the push for person-centered medical homes, which provide both behavioral and physical health services and require coordination of care if only through electronic medical records. And some medical practices now have behavioral health specialists on staff. Others—especially in areas with few behavioral health specialists—are using tele-psychiatry for consultative advice or even to see patients via Skype and the like. More sophisticated medical practices are using one form or another of coordinated care management, which follows patients after diagnosis, prescription, or referral to be sure that they get the treatment they need.

Suicide Prevention

Primary health care may also be a key place for suicide prevention. Now the 10th leading cause of death in the United States, suicide is gradually becoming a public health priority, though not fast enough to stop the rapid rise in suicides, which has spiked to over 40,000 deaths per year. Since the discovery that a large proportion of people who complete suicide see a primary care physician within the 30 days prior to their death (the current estimate is 45%), there has been a perception that doctors ought to be able to identify people at risk and to intervene to prevent suicide. This, of course, is far easier said than done. Very few people reveal their suicide intentions to doctors, who, in any event, are usually ill-prepared to respond appropriately when patients share their suicidal thoughts. As a result, there has been a widespread call for primary care practices to use one or another of the screening instruments that have been developed to flag depression, substance use, and other behavioral disorders. Recently, the Joint Commission has required the health care facilities that it accredits to screen specifically for suicide risk. This is highly controversial because according to the U.S. Preventive Services Task Force there is little evidence to support screening for suicide risk. They recommend screening for depression. Despite the controversy about what sort of screening to do, there is widespread consensus that primary care physicians need to pay far more attention to their patients’ emotional distress in the hopes of averting the suffering of mental disorders and of reducing the rising incidence of suicide.

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