Serious mental illness and the role of primary care

Psychiatry and Family Medicine Residents' Likelihood of Prescribing HIV Pre-exposure Prophylaxis to Patients With Mental Illness and HIV Vulnerability

BACKGROUND

People living with mental illness (PLMI) experience disproportionately high incidence of and vulnerability to HIV. Pre-exposure prophylaxis (PrEP) is an effective and safe HIV prevention method, but data regarding prescription to PLMI are lacking. Psychiatrists may serve as important points of access for PrEP prescription for PLMI.

METHODS

We conducted a vignette-based study of residents in psychiatry and family medicine (FM) to assess likelihood of prescribing PrEP and assumptions about the fictional patient. Participants were randomized to one of five vignettes in which the patients' psychiatric diagnosis was varied (schizophrenia on long-acting injectable or oral antipsychotic, bipolar disorder, major depression) or a control vignette without a psychiatric diagnosis.

RESULTS

A total of 439 residents participated. We found that high percentages of psychiatry (96.8%) and FM (97.4%) residents were aware of PrEP. High percentages of psychiatry (92.0%-98.1%) and FM (80.8%-100%) residents reported that PrEP was indicated for all patient conditions. Family medicine residents were more likely to prescribe PrEP to all experimental conditions than psychiatry residents. There was no difference in likelihood of prescribing to the control condition without a psychiatric diagnosis. The belief that PrEP prescription was out of scope of practice was greater among psychiatry residents.

CONCLUSIONS

A majority of psychiatry residents responded that PrEP was indicated for an array of patients with psychiatric diagnoses. However, psychiatry residents were broadly less likely to prescribe PrEP to patients with these diagnoses. The high percentage of psychiatry residents who reported that PrEP was indicated for all patients suggests that additional training is needed to facilitate PrEP prescription by psychiatrists.

A scoping review of cardiovascular risk factor screening rates in general or family practice attendees living with severe mental ill-health

BACKGROUND

Primary care is essential to address the unmet physical health needs of people with severe mental ill-health. Continued poor cardiovascular health demands improved screening and preventive care. No previous reviews have examined primary care cardiovascular screening rates for people living with severe mental ill-health; termed in the literature "severe mental illness".

METHODS

A scoping review following Joanna Briggs Institute methodology was conducted. Cardiovascular risk factor screening rates in adults with severe mental ill-health were examined in general or family practices (as the main delivery sites of primary care). Literature published between 2001 and 2023 was searched using electronic databases including Medline, Embase, Web of Science, PsychINFO and CINAHL. Two reviewers independently screened titles and abstracts and conducted a full-text review. The term "severe mental illness" was applied as the term applied in the literature over the past decades. Study information, participant details and cardiovascular risk factor screening rates for people with 'severe mental illness' were extracted and synthesised.

RESULTS

Thirteen studies were included. Nine studies were from the United Kingdom and one each from Canada, Spain, New Zealand and the Netherlands. The general and/or family practice cardiovascular disease screening rates varied considerably across studies, ranging from 0 % to 75 % for people grouped within the term "severe mental illness". Lipids and blood pressure were the most screened risk factors.

CONCLUSIONS

Cardiovascular disease screening rates in primary care settings for adults living with severe mental ill-health varied considerably. Tailored and targeted cardiovascular risk screening will enable more comprehensive preventive care to improve heart health outcomes and address this urgent health inequity.

Prevalence of suicide risk among a national sample of individuals referred from a primary care subpopulation, 2017-2020

Over the past decade, the age-adjusted suicide rate has increased by 35.2% in the United States. In primary care, practitioners often interact with patients at risk of dying by suicide, yet little is known about the prevalence of suicide risk in primary care populations. Patient data from 2017-2020, consisting of a national sample of patients referred from primary care and enrolled in collaborative care behavioral health services (n = 37 666), were analyzed. Controlling for demographic characteristics, logistic models were used to compare suicide risk prevalence by behavioral health diagnosis. An estimated 9.96% (95% confidence interval [CI]: 9.65-10.27)-or approximately 3751 individuals-of the total sample screened positively for suicide risk. Compared with individuals diagnosed with generalized anxiety disorder, individuals diagnosed with bipolar disorder had 8.21 times the odds (95% CI: 6.66-10.10) of screening for suicide risk. Practitioners and health care systems may benefit from adding suicide risk screeners as a standard practice for referred patients, which may lead to further development of clinical pathways and provider training. The high rate of suicide risk across the sample suggests that more research is needed to understand suicide risk prevalence across primary care and collaborative care populations.

Association of physician financial incentives with primary care enrolment of adults with serious mental illnesses in Ontario: a retrospective observational population-based study

BACKGROUND

Financial incentives may improve primary care access for adults with schizophrenia or bipolar disorder (serious mental illness [SMI]). We studied the association between receipt of the SMI financial premium paid to primary care physicians and rostering of adults with SMI in different patient enrolment models (PEMs), including enhanced fee-for-service and capitation-based models with and without interdisciplinary team-based care.

METHODS

We conducted a retrospective cohort study involving Ontario adults (≥18 yr) with SMI in PEM practices, in fiscal years 2016/17 and 2017/18. Using negative binomial models, we examined relations between rostering and the primary care model and the contribution of the incentive. Similar models were developed for adults with type 1 or 2 diabetes mellitus and the general population.

RESULTS

Among 9730 physicians in PEM practices, 4866 (50.0%) received a premium and 448 319 (88.4%) people with SMI in PEMs were rostered. Compared with enhanced fee for service, the likelihood of rostering people with SMI was 3.0% higher for patients in capitation with team-based care (adjusted relative risk [RR] 1.03, 95% confidence interval [CI] 1.02-1.04), with similar results for capitation without team-based care (adjusted RR 1.00 95% CI 0.99-1.01). Rostering for people with diabetes was similar in team-based care (adjusted RR 1.02, 95% CI 1.02-1.03) but higher in capitation without team-based care (adjusted RR 1.03, 95% CI 1.02-1.03) and slightly higher for the Ontario population (team-based care 1.04, 95% CI 1.04-1.05, capitation without team-based care 1.03, 95% CI 1.03-1.04).

INTERPRETATION

Rostering of people with SMI was lower than for the general population. Additional policy measures are needed to address persisting inequities and to promote rostering of this underserved population with complex needs.

Healthcare use in commercially insured youth with mental health disorders

BACKGROUND

The objective of this study is to describe age-related patterns of outpatient healthcare utilization in youth and young adults with mental health disorders.

METHOD

We used the IBM^® MarketScan^® Commercial Database to identify 359,413 youth and young adults (12-27 years) with a mental health disorder continuously enrolled in private health insurance in 2018. Exploratory analysis was used to describe patterns of outpatient healthcare use (e.g., primary, reproductive, mental health care) and therapeutic management (e.g., medication prescriptions, psychotherapy) by age. Period prevalence and median number of visits are reported. Additional analysis explored utilization patterns by mental health disorder.

RESULTS

The prevalence of outpatient mental health care and primary care decreased with age, with a larger drop in primary care utilization. While 74.0-78.4% of those aged 12-17 years used both outpatient mental health care and primary care, 53.1-59.7% of those aged 18-27 years did. Most 18-19-year-olds had a visit with an internal medicine or family medicine specialist, a minority had a pediatrician visit. The prevalence of medication management increased with age, while the prevalence of psychotherapy decreased.

CONCLUSIONS

Taken together, this descriptive study illustrates age-related differences in outpatient healthcare utilization among those with mental health disorders. Additionally, those with the most severe mental health disorders seem to be least connected to outpatient care. This knowledge can inform efforts to improve utilization of healthcare across the transition to adulthood.

A systematic review of mental health professionals, patients and carers' perceived barriers and enablers to supporting smoking cessation in mental health settings

Introduction

Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited.

Aims and Methods

We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the theoretical domains framework, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance.

Results

Of 31 included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms).

Conclusions

The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted.

Implications

Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients.

Effectiveness of Family- and Individual-Led Peer Support for People With Serious Mental Illness: A Meta-Analysis

Peer support has received increasing attention in the field of mental rehabilitation for serious mental illness (SMI), but meta-analyses are rare, especially in terms of family-led peer support. The current meta-analysis was conducted using PubMed, Embase, Cochrane, and Medline databases, and manual retrieval was performed. Randomized controlled trials of peer support interventions were included. Subgroup meta-analyses were performed separately for family-led and individual-led peer support. A total of 28 articles (five on family-led peer support and 23 on individual-led peer support) were included. For family-led peer support, there were no significant differences between intervention and control groups in family functioning or burden, and there seemed to be positive effects on use of health services, patient functioning, psychotic symptoms, rehospitalization, and duration. Individual-led peer support may have positive effects on well-being, medication adherence, finances, and loneliness; however, it seemed to be less effective in terms of self-efficacy, quality of life, recovery, hope, and activation. There were no significant differences between peer support groups and control groups in social support, functioning, psychotic symptom improvement, self-esteem, alcohol use, drug use, legal charges, building relationships, empowerment, satisfaction, and use of health care. Peer support, whether it is individualled or family-led, can be further developed for rehabilitation of individuals with SMI. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Primary care reform and funding equity for mental health disorders in Ontario: a retrospective observational population-based study

BACKGROUND

Mental health disorders are associated with high morbidity and reduced life expectancy, and are largely managed in primary care. We sought to assess the equity of distribution of new alternative payment models and teams introduced under primary care reform in Ontario for patients with mental health disorders.

METHODS

We conducted a retrospective observational study using population-level administrative data for insured Ontario adults (age ≥ 18 yr) to identify all primary care payments to physicians that were allocated to individual patients in 2002/03 and 2011/12. We identified patients with mental health disorders using validated algorithms, and modelled the relations between per capita primary care costs and mental health disorders over time, stratified by type of mental health or substance use disorder and type of primary care payment. In an adjusted model, we adjusted for age, sex, rurality, neighbourhood income quintile, immigrant status, comorbidity and primary care model. For comparative purposes, we also examined the distribution of primary care payments for people with diabetes mellitus.

RESULTS

Total per capita primary care payments increased more slowly over the study period for patients with mental health disorders (62.0%) than for the general population (88.3%). Total payments for patients with substance use disorders increased by 142.7%, largely owing to urine drug testing in opioid substitution clinics. Adjusted total payments for those with versus without mental health disorders decreased by 10% between 2002/03 and 2011/12, driven by lower alternative payments. Similar decreases, also driven by lower alternative payments, were found for all mental health disorder subgroups except substance use and for diabetes.

INTERPRETATION

Payment and team reforms were associated with inequitable resource allocation to people with mental health disorders. The findings suggest the need for monitoring reforms for their impact on high-needs populations and making appropriate adjustments.

Disparities in cancer screening in people with mental illness across the world versus the general population: prevalence and comparative meta-analysis including 4 717 839 people

BACKGROUND

Since people with mental illness are more likely to die from cancer, we assessed whether people with mental illness undergo less cancer screening compared with the general population.

METHODS

In this systematic review and meta-analysis, we searched PubMed and PsycINFO, without a language restriction, and hand-searched the reference lists of included studies and previous reviews for observational studies from database inception until May 5, 2019. We included all published studies focusing on any type of cancer screening in patients with mental illness; and studies that reported prevalence of cancer screening in patients, or comparative measures between patients and the general population. The primary outcome was odds ratio (OR) of cancer screening in people with mental illness versus the general population. The Newcastle-Ottawa Scale was used to assess study quality and I² to assess study heterogeneity. This study is registered with PROSPERO, CRD42018114781.

FINDINGS

47 publications provided data from 46 samples including 4 717 839 individuals (501 559 patients with mental illness, and 4 216 280 controls), of whom 69·85% were women, for screening for breast cancer (k=35; 296 699 individuals with mental illness, 1 023 288 in the general population), cervical cancer (k=29; 295 688 with mental illness, 3 540 408 in general population), colorectal cancer (k=12; 153 283 with mental illness, 2 228 966 in general population), lung and gastric cancer (both k=1; 420 with mental illness, none in general population), ovarian cancer (k=1; 37 with mental illness, none in general population), and prostate cancer (k=6; 52 803 with mental illness, 2 038 916 in general population). Median quality of the included studies was high at 7 (IQR 6-8). Screening was significantly less frequent in people with any mental disease compared with the general population for any cancer (k=37; OR 0·76 [95% CI 0·72-0·79]; I²=98·53% with publication bias of Egger's p value=0·025), breast cancer (k=27; 0·65 [0·60-0·71]; I²=97·58% and no publication bias), cervical cancer (k=23; 0·89 [0·84-0·95]; I²=98·47% and no publication bias), and prostate cancer (k=4; 0·78 [0·70-0·86]; I²=79·68% and no publication bias), but not for colorectal cancer (k=8; 1·02 [0·90-1·15]; I²=97·84% and no publication bias).

INTERPRETATION

Despite the increased mortality from cancer in people with mental illness, this population receives less cancer screening compared with that of the general population. Specific approaches should be developed to assist people with mental illness to undergo appropriate cancer screening, especially women with schizophrenia.

FUNDING

None.

Integrating Primary Care Into Community Mental Health Centres in Texas, USA: Results of a Case Study Investigation

Introduction

Despite evidence that people with serious mental illness benefit from receiving primary care within mental health care settings, there is little research on this type of integration. The objective of this study was to characterize how providers and patients experienced implementation of primary care into specialty mental health services.

Methods

During site visits, study team members interviewed staff and conducted focus groups with patients at 10 United States community mental health centres then beginning to integrate primary into their practices. One year later, follow up phone interviews with key centre staff informants validated and updated findings. Data analysis included thematic coding of results from staff interviews and patient focus groups.

Results

Findings included the importance of the scope of primary care services provided on site, given limited alternatives available to patients; rapid scale-up; overcoming challenges in provider recruitment and retention; and adaptations to engage patients as well as to improve communication between mental health and primary care providers.

Conclusion

Providers and patients perceived improvements through integrated care. However, the majority of patients were uninsured, and the funding was short term. The long-term viability of integrated care for community mental health centre patients may hinge on adequate, predictable public funding.

Community Mental Health Center Integrated Care Outcomes

Despite the compelling logic for integrating care for people with serious mental illness, there is also need for quantitative evidence of results. This retrospective analysis used 2013-2015 data from seven community mental health centers to measure clinical processes and health outcomes for patients receiving integrated primary care (n = 18,505), as well as hospital use for the 3943 patients with hospitalizations during the study period. Bivariate and regression analyses tested associations between integrated care and preventive screening rates, hemoglobin A1c levels, and hospital use. Screening rates for body-mass index, blood pressure, smoking, and hemoglobin A1c all increased very substantially during integrated care. More than half of patients with baseline hypertension had this controlled within 90 days of beginning integrated care. Among patients hospitalized at any point during the study period, the probability of hospitalization in the first year of integrated care decreased by 18 percentage points, after controlling for other factors such as patient severity, insurance status, and demographics (p < .001). The average length of stay was also 32% shorter compared to the year prior to integrated care (p < .001). Savings due to reduced hospitalization frequency alone exceeded $1000 per patient. Data limitations restricted this study to a pre-/post-study design. However, the magnitude and consistency of findings across different outcomes suggest that for people with serious mental illness, integrated care can make a significant difference in rates of preventive care, health, and cost-related outcomes.

Coordinating Mental and Physical Health Care in Rural Australia: An Integrated Model for Primary Care Settings

Introduction:

The ‘GP Clinic’ provides primary health care to people using community mental health services in a small town in Australia. This article examines the factors that have driven successful integration in this rural location.

Methods:

A multiple methods case study approach was used comprising service record data for a 24 month period and semi-structured interviews with sixteen staff members associated with the integrated rural service model.

Results:

Processes and structures for establishing integrated care evolved locally from nurturing supportive professional and organisational relationships. A booking system that maximised attendance and minimised the work of the general practice ensured that issues to do with remuneration and the capacity for the general practitioner to provide care to those with complex needs were addressed. Strong collaborative relationships led to the upskilling of local staff in physical and mental health conditions and treatments, and ensured significant barriers for people with mental illness accessing primary care in rural Australia were overcome.

Conclusions:

Integrated physical and mental health service models that focus on building local service provider relationships and are responsive to community needs and outcomes may be more beneficial in rural settings than top down approaches that focus on policies, formal structures, and governance.

Preparing the workforce for integrated healthcare: A systematic review

Integrated healthcare is recommended to deliver care to individuals with co-occurring medical and mental health conditions. This literature review was conducted to identify the knowledge and skills required for behavioral health consultants in integrated settings. A review from 1999 to 2015 identified 68 articles. Eligible studies examined care to the U.S. adult population at the highest level of integration. The results provide evidence of specific knowledge of medical and mental health diagnoses, screening instruments, and intervention skills in integrated primary care, specialty medical, and specialty mental health. Further research is required to identify methods to develop knowledge/skills in the workforce.

The effect of context in rural mental health care: Understanding integrated services in a small town

Unequal health care outcomes for those with mental illness mean that access to integrated models is critical to supporting good physical and mental health care. This is especially so in rural areas where geographic and structural issues constrain the provision of health services. Guided by a conceptual framework about rural and remote health, this study draws on interviews with health providers and other staff and examines the dynamics of integrated primary and community-based specialist care for people with severe and persistent mental illnesses living in rural Australia. Findings show that the facilitation of sustainable linkages between general practice and community mental health requires the skilful exercise of power, knowledge, and resources by partners in order to address the social and structural factors that influence local health situations. These findings suggest that incremental processes of integration that are responsive to patients' and stakeholders' needs and that build on success and increased trust may be more effective than those imposed from the 'top down' that pay insufficient attention to local contexts.

Making the journey with me: a qualitative study of experiences of a bespoke mental health smoking cessation intervention for service users with serious mental illness

BACKGROUND

Smoking is one of the major modifiable risk factors contributing to early mortality for people with serious mental illness. However, only a minority of service users access smoking cessation interventions and there are concerns about the appropriateness of generic stop-smoking services for this group. The SCIMITAR (Smoking Cessation Intervention for Severe Mental Ill-Health Trial) feasibility study explored the effectiveness of a bespoke smoking cessation intervention delivered by mental health workers. This paper reports on the nested qualitative study within the trial.

METHODS

Qualitative semi-structured interviews were conducted with 13 service users receiving the intervention and 3 of the MHSCPs (mental health smoking cessation practitioners) delivering the intervention. Topic guides explored the perceived acceptability of the intervention particularly in contrast to generic stop-smoking services, and perceptions of the implementation of the intervention in practice. Transcripts were analysed using the Constant Comparative Method.

RESULTS

Generic services were reported to be inappropriate for this group, due to concerns over stigma and a lack of support from health professionals. The bespoke intervention was perceived positively, with both practitioners and service users emphasising the benefits of flexibility and personalisation in delivery. The mental health background of the practitioners was considered valuable not only due to their increased understanding of the service users' illness but also due to the more collaborative relationship style they employed. Challenges involved delays in liaising with general practitioners and patient struggles with organisation and motivation, however the MHSCP was considered to be well placed to address these problems.

CONCLUSION

The bespoke smoking cessation intervention was acceptable to service users and the both service users and practitioners reported the value of a protected mental health worker role for delivering smoking cessation to this group. The results have wider implications for understanding how to achieve integrated and personalised care for this high-risk population and further underscore the need for sensitised smoking cessation support for people with serious mental illness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79497236 . Registered 3(rd) July 2009.