Factors associated with co-occurring medical conditions among adults with serious mental disorders

Early Health Impacts of a Primary Care Consultation Model for People Served by Assertive Community Treatment teams

The cardiometabolic health outcomes and life expectancy of people living with serious mental illness (SMI) continue to significantly flag behind that of the general population. This study explores the possibility of using the evidence-based Assertive Community Treatment (ACT) model and infrastructure to increase access to primary care and improve cardiometabolic outcomes of people with SMI. Four ACT teams in a large urban area received the services of a primary care consultant who was co-located at a Federally Qualified Health Center (FQHC), met regularly with ACT team clinicians to review a cardiometabolic registry of participants, and engaged participants in primary care services. Health screening rates, primary care utilization, and cardiometabolic outcomes-body mass index, blood pressure, hemoglobin A1c, cholesterol, and tobacco smoking status-were monitored over the course of a year. The efficacy of this integrated care model was also explored through focus groups with ACT team staff and participants. Significant improvements in screening rates were found for the ACT teams that received this integrated care intervention; however, only modest improvements in cardiometabolic outcomes were found. Future longitudinal, multi-site studies are needed to fully determine the impact of integrated care models on the physical health outcomes of this vulnerable population.

Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review

Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.

Relationship between severe mental illness and physical multimorbidity: a meta-analysis and call for action

BACKGROUND

People with severe mental illness (SMI) have a higher prevalence of several chronic physical health conditions, and the prevalence of physical multimorbidity is expected to rise. The aim of this study was to assess the strength of the association between SMI and physical multimorbidity.

STUDY SELECTION AND ANALYSIS

We systematically searched PubMed/Medline, Scopus, Embase, Web of Science, PsycINFO and the behavioural sciences collection databases, from inception to 31 January 2023, for studies that investigated the association between SMI and physical multimorbidity. Humans of any age either clinically diagnosed and/or currently receiving treatment for SMI, specified as schizophrenia (and related psychotic disorders), bipolar disorder and psychotic depression, were eligible. Data from studies selected for inclusion were converted into ORs, with a subsequent meta-analysis conducted.

FINDINGS

We included 19 studies with a total of 194 123 patients with SMI with different diagnoses and drawn from the general population. The pooled OR for physical multimorbidity in people with versus without SMI was 1.84 (95% CI 1.33 to 2.54), with the analysis indicating a high level of heterogeneity (98.38%). The other 15 studies included in the systematic review for which it was not possible to conduct a meta-analysis showed strong associations between SMI and physical multimorbidity.

CONCLUSIONS

The current evidence highlights the link between SMI and physical multimorbidity. A multidisciplinary approach is now urgent to develop the best models of services tailored to patients with SMI with physical multimorbidities to improve physical, mental and social outcomes. PROSPERO registration number CRD42023395165.

Predictors of Length of Hospitalization and Impact on Early Readmission for Mental Disorders

Length of hospitalization, if inappropriate to patient needs, may be associated with early readmission, reflecting sub-optimal hospital treatment, and translating difficulties to access outpatient care after discharge. This study identified predictors of brief-stay (1-6 days), mid-stay (7-30 days) or long-stay (≥31 days) hospitalization, and evaluated how lengths of hospital stay impacted on early readmission (within 30 days) among 3729 patients with mental disorders (MD) or substance-related disorders (SRD). This five-year cohort study used medical administrative databases and multinomial logistic regression. Compared to patients with brief-stay or mid-stay hospitalization, more long-stay patients were 65+ years old, had serious MD, and had a usual psychiatrist rather than a general practitioner (GP). Predictors of early readmission were brief-stay hospitalization, residence in more materially deprived areas, more diagnoses of MD/SRD or chronic physical illnesses, and having a usual psychiatrist with or without a GP. Patients with long-stay hospitalization (≥31 days) and early readmission had more complex conditions, especially more co-occurring chronic physical illnesses, and more serious MD, while they tended to have a usual psychiatrist with or without a GP. For patients with more complex conditions, programs such as assertive community treatment, intensive case management or home treatment would be advisable, particularly for those living in materially deprived areas.

Patient Service Utilization Among Individuals with Co-occurring Disorders: A Comparison of Two Models of Care Coordination

Healthcare systems have increasingly adopted integrated care models with demonstrated effectiveness. However, few studies examine integrated care for individuals with co-morbid mental illness and medical conditions. This quasi-experimental study compared service use for two integrated care models for patients with co-occurring conditions. We used hierarchical negative binomial and logistic regressions with random effects to test the relationship between integration and service use. Patients treated at co-located agencies had significantly higher odds of inpatient hospitalization compared to those in fully integrated settings. Additionally, some comorbidities had significantly different levels of service use. Patients at co-located agencies had more outpatient and emergency visits, but was not statistically significant. Our findings provide evidence that the model of care may impact service use for patients experiencing co-occurring conditions, however, variations in service use for specific co-morbid conditions highlight the need to examine the specific needs and characteristics of this population.

Primary care for people with severe mental illness and comorbid obstructive airways disease: a qualitative study of patient perspectives with integrated stakeholder feedback

OBJECTIVES

To explore patient and stakeholder perspectives on primary respiratory care for people with severe mental illness (SMI) and comorbid obstructive airways disease (OAD).

DESIGN

Qualitative, semistructured qualitative interviews were undertaken with a purposive sample of people with a diagnosis of SMI (bipolar illness, schizophrenia, affective disorder with psychosis) and comorbid asthma or chronic obstructive pulmonary disease. Transcribed data were analysed using an interpretive phenomenological approach. Study results were discussed with stakeholders.

SETTING

Eight UK general practices.

PARTICIPANTS

16 people aged 45-75 years, with SMI and comorbid asthma or chronic obstructive pulmonary disease, were interviewed. Twenty-one people, four with lived experience of SMI and seventeen health/social care/third sector practitioners, participated in discussion groups at a stakeholder event.

RESULTS

Participants described disability and isolation arising from the interplay of SMI and OAD symptoms. Social support determined ease of access to primary care. Self-management of respiratory health was not person-centred as practitioners failed to consider individual needs and health literacy. Participants perceived smoking cessation impossible without tailored support. Less than half of the practices facilitated personalised access to timely primary care and continuity. Overall, there was a reliance on urgent care if service adaptations and social support were lacking. The stakeholder group expressed concern about gaps in care, the short-term funding of community organisations and fear of loss of benefits. Potential solutions focused on supported navigation of care pathways, relational continuity, individual and community asset building and the evolving social prescriber role.

CONCLUSION

This study suggests that despite UK guidelines and incentives to optimise physical healthcare, primary care fails to consistently deliver integrated biopsychosocial care for patients with SMI and OAD. Collaborative, personalised care that builds social capital and tailors support for self-management is needed, alongside service-level interventions to enhance access to healthcare for patients with comorbid SMI and OAD.

The Health Improvement Profile for people with severe mental illness: Feasibility of a secondary analysis to make international comparisons

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Individuals with severe mental illness (SMI) have elevated risks for physical health problems and low screening rates. No previous studies have compared the physical health promotion needs of people with SMI using the same screening tool across different international settings. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: It appears feasible to use the HIP to profile and compare physical health-related risks in people with SMI across different international settings. The HIP tool identified significant differences in areas of risk across the four countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The HIP could be used to identify unique clusters of health promotion needs in different countries. Use of HIP health checks may support implementation of individualized interventions. ABSTRACT: Introduction To date, no studies have contrasted physical health profiles of people with severe mental illness (SMI) in different countries. Aim To evaluate feasibility of using the Health Improvement Profile (HIP) to compare and contrast physical health and health behaviours of people with SMI from four countries. Method An observational feasibility study using secondary analysis of pooled health state and lifestyle data. Physical health checks using modified versions of HIP were administered in four countries. Results Findings suggest feasibility of HIP screening to profile and compare physical health and health behaviours of people with SMI across international settings. High overall numbers of risk items (red flags) were identified in all but the Thailand sample. Despite some commonalities, there were important differences in health profiles across countries. Discussion This is the first study to demonstrate feasibility of the HIP to compare health risks in individuals with SMI across countries. Future multi-national HIP studies should recruit a fully powered stratified random sample of people with SMI that is representative of each setting. Implications for practice It appears feasible to utilize the HIP to identify specific areas of health risk in different countries, which may help to better focus nursing interventions and use of resources.

Unique cessation tools in the box: Quitline utilization and effectiveness trends among a large sample of tobacco users reporting mental health disorders

It is estimated that the prevalence of smoking among adults with MHDs ranges between 40-60%, as compared to about 17% among those without an MHD. In addition, smokers with MHDs smoke more cigarettes, are more nicotine dependent, and experience more difficulty quitting, compared to other smokers. The uniquely high smoking prevalence among the MHD population is a serious public health concern; unfortunately, a majority of individuals experiencing difficulty receive no treatment. The US Public Health Service guidelines, as well as the National Cancer Institute, strongly recommend quitlines as an evidence-based treatment strategy to reduce barriers to cessation treatment, especially among smokers with MHDs; however, the literature is sparse on quitline engagement trends and associated outcomes for quitline participants with MHDs. This study sought to contribute to this gap with the largest sample to-date of MHD-endorsing tobacco quitline (Oklahoma Tobacco Helpline, OTH) participants. From 2015 to 2020, ~65,000 registrants (45-50% of total registered participants) with the OTH identified as having one or more MHDs in addition to their tobacco use. This study tested for the presence of significant differences between groups with and without MHDs (as well as within the MHD-identified group) on program enrollment selections, the intensity of engagement with chosen services, NRT utilization, and quit rates. It also tested for the existence of differences and moderating effects of demographic variables associated with the comparison groups. Statistically significant differences were found between these two groups with regard to: sex, age, racial identity, education level, annual income and insurance status. Significant differences were also found with tobacco use patterns reported by individuals (e.g., timing and daily use amounts). Differences in quitline program selection were demonstrated, such that the MHD-endorsing sample were more likely to participate and agree to the most robust service available. Significantly higher rates of service intensity (number of services engaged) were demonstrated, and MHD individuals were also significantly more likely to receive NRT as a part of their treatment. This study suggests a simplistic "more is better" quitline services approach may suffer in effectiveness because it neglects barriers common to this population. Important information is provided on these unique variables associated with MHD-endorsing individuals trying to quit their tobacco use. These results can help tobacco quitlines conceptualize the unique difficulties experienced by individuals with MHDs and then tailor their approach to respond supportively and constructively to this high need group.

Mental Health of Parents and Primary Caregivers by Sex and Associated Child Health Indicators

Poor mental health among parents or primary caregivers is associated with poor mental and physical health in children; however, research often excludes the mental health of male caregivers including fathers. This analysis examines associations between caregiver mental health by caregiver sex and child health indicators (i.e., child's general health; child's history of diagnosed mental, behavioral, or developmental disorders (MBDDs)). Using parent-reported data on 97,728 US children aged 0-17 years from the National Survey of Children's Health (2016-2018), we estimated nationally representative, weighted proportions of children with parents or primary caregivers with poor mental health by caregiver sex, prevalence ratios (PR), and 95% confidence intervals (CI) for child health indicators by caregiver mental health and sex. Nationally, 7.2% of children had at least one caregiver with poor mental health; 2.8% had any male caregiver; and 5.1% had any female caregiver with poor mental health. Compared to children with all male caregivers with good mental health, children with any male caregiver with poor mental health were more likely to have poor general health (PR: 4.9, CI: 3.0-8.0) and have ≥1 diagnosed MBDDs (PR: 1.9, CI: 1.7-2.1); this remained significant when controlling for caregiver and household characteristics. Findings were similar when comparing children with any female caregiver with poor mental health to children with all female caregivers with good mental health. Our findings support previously published recommendations that promoting mental health among all types of caregivers by addressing gaps in research on fathers and male caregivers may further promote child health and wellness.

The impact of the COVID-19 pandemic on the mental health and daily life of adults with behavioral health disorders

People with behavioral health disorders may be particularly vulnerable to the impact of the COVID-19 pandemic, yet little is known about how they are faring. A mixed-methods, anonymous needs assessment was conducted to understand changes in the lives of adults with mental health and substance use disorders since the pandemic onset. A cross-sectional, online survey was completed by 272 adults in April and May 2020, recruited from statewide networks of community programs in New Jersey and New York. Measures included the Patient Health Questionnaire-2 and the Generalized Anxiety Disorder-2 to screen for depressive and anxiety disorders. Also assessed was the pandemic's impact on sleep and dietary patterns, exposure to COVID-19 infection, and access to health care and medications. Finally, respondents were asked to describe in their own words any changes in their lives since the pandemic began. Over one-third (35.1%) screened positive for generalized anxiety disorder and over one-quarter (29.6%) screened positive for major depressive disorder. The majority reported pandemic-related changes in eating and sleeping patterns and exposure to COVID-19 infection. Multivariable logistic regression analysis found that many changes attributed to the pandemic were positively and significantly associated with screening positive for anxiety and depressive disorders. Qualitative analysis confirmed these findings and identified participants' resilience stemming from social support, emotion management, and self-care. These results can inform the design of services that assist this population to bolster self-management skills and reestablish daily habits to improve their lives during and following the pandemic.

Impact of Co-occurring Mental Disorders and Chronic Physical Illnesses on Frequency of Emergency Department Use and Hospitalization for Mental Health Reasons

Background: Patients with mental disorders (MD) are at high risk for a wide range of chronic physical illnesses (CPI), often resulting in greater use of acute care services. This study estimated risk of emergency department (ED) use and hospitalization for mental health (MH) reasons among 678 patients with MD and CPI compared to 1,999 patients with MD only. Methods: Patients visiting one of six Quebec (Canada) ED for MH reasons and at onset of a MD in 2014-15 (index year) were included. Negative binomial models comparing the two groups estimated risk of ED use and hospitalization at 12-month follow-up to index ED visit, controlling for clinical, sociodemographic, and service use variables. Results: Patients with MD, more severe overall clinical conditions and those who received more intensive specialized MH care had higher risks of frequent ED use and hospitalization. Continuity of medical care protected against both ED use and hospitalization, while general practitioner (GP) consultations protected against hospitalization only. Patients aged 65+ had lower risk of ED use, whereas risk of hospitalization was higher for the 45-64- vs. 12-24-year age groups, and for men vs. women. Conclusion: Strategies including assertive community treatment, intensive case management, integrated co-occurring treatment, home treatment, and shared care may improve adequacy of care for patients with MD-CPI, as well as those with MD only whose clinical profiles were severe. Prevention and outreach strategies may also be promoted, especially among men and older age groups.

Factors associated with 30-day readmissions following medical hospitalizations among Medicaid beneficiaries with schizophrenia, bipolar disorder, and major depressive disorder

While evidence suggests that adults with serious mental illness have an elevated rate of 30-day readmissions after medical hospitalizations, most studies are of patients who are privately insured or Medicare beneficiaries, and little is known about the differential experiences of people with schizophrenia, bipolar disorder, and major depression. We used the Truven Health Analytics MarketScan® Medicaid Multi-State Database to study 43,817 Medicaid enrollees from 11 states, age 18-64, who were discharged from medical hospitalizations in 2011. Our outcome was unplanned all-cause readmissions within 30 days of discharge. In a multivariable analysis, compared to those with no SMI, people with schizophrenia had the highest odds of 30-day readmission (aOR: 1.46, 95% CI: 1.33-1.59), followed by those with bipolar disorder (aOR: 1.25, 95% CI: 1.14-1.38), and those with major depressive disorder (aOR: 1.18, 95% CI: 1.06-1.30). Readmissions also were more likely among those with substance use disorders, males, those with Medicaid eligibility due to disability, patients with longer index hospitalizations, and those with 2 or more medical co-morbidities. This is the first large-scale study to demonstrate the elevated risk of hospital readmission among low-income, working-age adults with schizophrenia. Given their greater psychological, social, and economic vulnerability, our findings can be used to design transition interventions and service delivery systems that address their complex needs.

Association of physical health multimorbidity with mortality in people with schizophrenia spectrum disorders: Using a novel semantic search system that captures physical diseases in electronic patient records

OBJECTIVE

Single physical comorbidities have been associated with the premature mortality in people with schizophrenia-spectrum disorders (SSD). We investigated the association of physical multimorbidity (≥two physical health conditions) with mortality in people with SSD.

METHODS

A retrospective cohort study between 2013 and 2017. All people with a diagnosis of SSD (ICD-10: F20-F29), who had contact with secondary mental healthcare within South London during 2011-2012 were included. A novel semantic search system captured conditions from electronic mental health records, and all-cause mortality were retrieved. Hazard ratios (HRs) and population attributable fractions (PAFs) were calculated for associations between physical multimorbidity and all-cause mortality.

RESULTS

Among the 9775 people with SSD (mean (SD) age, 45.9 (15.4); males, 59.3%), 6262 (64%) had physical multimorbidity, and 880 (9%) died during the 5-year follow-up. The top three physical multimorbidity combinations with highest mortality were cardiovascular-respiratory (HR: 2.23; 95% CI, 1.49-3.32), respiratory-skin (HR: 2.06; 95% CI, 1.31-3.24), and respiratory-digestive (HR: 1.88; 95% CI, 1.14-3.11), when adjusted for age, gender, and all other physical disease systems. Combinations of physical diseases with highest PAFs were cardiovascular-respiratory (PAF: 35.7%), neurologic-respiratory (PAF: 32.7%), as well as respiratory-skin (PAF: 29.8%).

CONCLUSIONS

Approximately 2/3 of patients with SSD had physical multimorbidity and the risk of mortality in these patients was further increased compared to those with none or single physical conditions. These findings suggest that in order to reduce the physical health burden and subsequent mortality in people with SSD, proactive coordinated prevention and management efforts are required and should extend beyond the current focus on single physical comorbidities.

Medical comorbid diagnoses among adult psychiatric inpatients

OBJECTIVE

Shortened life expectancy of people with mental disorders has been attributed to medical comorbidities, yet these conditions remain under-recognized and under-treated. This study characterizes the medical demands placed on inpatient psychiatric units to help guide medical assessment and management practices in these settings.

METHODS

Medicaid claims records and clinician data were linked with hospital and regional data for individuals with a principal diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. A modified Elixhauser Comorbidity Index (ECI) score was calculated for each unique individual (n = 14,458). Adjusted odds ratios (AORs) of having a medical comorbidity were calculated using logistic regression analyses.

RESULTS

74.9% of psychiatric inpatients had at least one medical comorbidity, including 57.5% of people ages 18-24. Higher rates of medical comorbidity were associated with older age, female gender, non-schizophrenia diagnoses, and engagement in care prior to hospitalization. Patients with medical comorbidities had lower odds (AOR 0.54; 99% CI 0.35-0.83) of being treated in hospitals with 100 or more total beds compared to smaller hospitals.

CONCLUSIONS

A high prevalence of common medical diagnoses among psychiatric inpatients underscores the importance of adequate detection and medical treatment of medical comorbidities in psychiatric inpatient settings.

Increased mortality from somatic multimorbidity in patients with schizophrenia: a Danish nationwide cohort study

OBJECTIVE

To investigate the association of single- and multimorbidity with mortality rates in patients with schizophrenia compared to the general population.

METHOD

A nationwide cohort study including residents in Denmark between 1995 and 2015. The cohort was dichotomously divided by a diagnosis of schizophrenia. Somatic diseases included infections, cancer, endocrine, neurologic, cardiovascular, respiratory, digestive, skin, musculoskeletal, and urogenital diseases. Hazard ratios (HRs) and population attributable fractions (PAFs) were calculated.

RESULTS

The cohort included 30 210 patients with schizophrenia [mean age (SD) = 32.6 (11.4), males = 57.2%], and 5 402 611 from the general population [mean age (SD) = 33.0 (14.5), males = 50.4%]. All number of somatic diseases were associated with an increased mortality in schizophrenia [HR = 16.3 (95% CI = 15.4-17.3) for 1 disease to 21.0 (95% CI = 19.1-23.0) for ≥5 diseases], using the general population with no somatic disease as reference. Across all somatic diseases, patients with schizophrenia showed a HR > 2, compared to the general population, and respiratory (PAF = 9.3%), digestive (PAF = 8.2%), and cardiovascular (PAF = 7.9%) diseases showed largest contributions to death.

CONCLUSIONS

Patients with schizophrenia showed higher mortality on all levels of multimorbidity, and a doubled mortality rate across all somatic diseases, compared to the general population. The findings suggest that the clusters and trajectories of symptoms associated with schizophrenia is the main driver of the excess mortality.

Factors associated with regular physical activity participation among people with severe mental ill health

PURPOSE

People with severe mental ill health (SMI) are less physically active and more sedentary than the general population. There is limited research investigating the correlates of physical activity (PA) in people with SMI impeding the development of successful interventions. This study aimed to assess the factors associated with regular participation of PA among a large sample of people with SMI.

METHODS

The data for this study were collected from the 'Closing the Gap: Lifestyle Health and Wellbeing' (HWB) cohort that collected data through self-administered questionnaire from participants with SMI. Self-reported participation in regular PA was the main outcome variable. Potential predictors of PA were grouped as demographic, biological, psychological and behavioural variables. Multivariable logistic regressions were conducted considering PA participation as the dependent variable adjusted for possible correlated predictors.

RESULTS

In total, 3287 people with SMI [mean (SD) age 47.7 (14.58) years, 59% male] were included; 38% reported undertaking regular PA and 61% wanted to undertake more physical activity. Multivariable logistic regressions showed that the following factors were associated with undertaking more regular PA: being male, aged 18-65 years, having a body mass index between 18.5 and 30 kg/m², having better self-perceived general health condition, not having a health problem that limits activity, giving higher importance to maintain a healthy lifestyle, and eating more fruit and vegetables.

CONCLUSIONS

Having a better self-perceived general health and placing importance on maintaining a healthy lifestyle were important predictors of regular PA. Lifestyle interventions targeting increased PA among people with SMI should be shaped by their health perception and informed by their needs.

Analysis of Emergency Room Visits Reveals a Seriously Mentally Ill, Medically Fragile Population Requiring Strategic Management

OBJECTIVE: This practice improvement project evaluated the cost of health care services utilized by patients with comorbid mental and physical chronic conditions who were psychiatrically hospitalized but transported for health care services of physical symptoms that developed during their psychiatric hospitalization. METHOD: A retrospective review of invoices to a regional psychiatric hospital for non-psychiatric health services utilized by inpatients revealed high costs of emergency room (ER) visits from July 2016 to June 2017. Medical records for these seriously mentally ill inpatients who visited the ER for evaluation of sudden emergent physical symptoms were reviewed. The collected data were analyzed. RESULTS: ER invoices revealed that 41 visits had been made by 28 patients with a total cost of $308,466.67, of which $258,668.15 was judged to be for the treatment of patients with symptoms of preventable side effect syndromes. This chart review and analysis suggest a need for improved strategic medication management in an integrated model of care. CONCLUSIONS: Polypharmacy was found to be responsible for increased debilitating physical symptoms requiring ER visits for this seriously mentally ill, medically fragile population. An integration of care services for comorbid conditions by advanced practice registered nurses with protocols specifically designed for this population was recommended.

Patterns of chronic physical multimorbidity in psychiatric and general population

OBJECTIVE

A growing body of evidence has demonstrated the high prevalence and complexity of chronic physical multimorbidity defined as ≥2 chronic physical illness in people with psychiatric disorders. The present study aimed to assess differences in the prevalence and patterns of self-reported chronic physical illness and multimorbidity in the general and psychiatric populations.

METHODS

We performed a latent class analysis of 15 self-reported chronic physical illnesses on a sample of 1060 psychiatric patients and 837 participants from the general population.

RESULTS

Self-reported chronic physical illness and multimorbidity were significantly more prevalent in the population of psychiatric patients than in the general population (P < .001). Psychiatric patients had 27% (CI_95% 24% - 30%) higher age-standardized relative risk for chronic physical illness and a 31% (CI_95% 28% - 34%) higher for multimorbidity (P < .001). The number of chronic physical illnesses combinations was 52% higher in the psychiatric than in general population (255 vs 161 combinations respectively; P < .001). We identified four distinct latent classes: "Relatively healthy", "Musculoskeletal", "Hypertension and obesity", and "Complex multimorbidity" with no significant differences in the nature of multimorbidity latent classes patterns. The class "Relatively healthy" was significantly less (ARI = -25% (CI_95% -30% -21%), and the class "Hypertension and obesity" was significantly more prevalent in the population of psychiatric patients (ARI = 20% (CI_95% 17% - 23%).

CONCLUSIONS

These findings indicate that mental disorders are associated with an increased risk of a wide range of chronic physical illnesses and multimorbidity. There is an urgent need for the development of the guidelines regarding the physical healthcare of all individuals with mental disorders with multimorbidity in focus.

Primary Care for Mentally Ill Adults in Acute Residential Treatment Facilities

Psychiatric bed capacity has decreased nationally with an impact on the number and the types of patients admitted to acute in-patient units. Acute residential programs provide alternatives to hospitals for patients with problems that do not meet criteria for admission. However, these settings may not have resources to respond to the medical co-morbidities associated with severe mental illness. To understand the medical needs of patients in these settings, this research examined data from a nurse-managed primary care outreach service. Prevalent problems included acute issues and chronic disorders associated with severe mental illness. In multivariate analyses, demographic and substance related factors contributed to all chronic illness. However, age was the over-riding predictor of cardio-metabolic disorders. Drug abuse consistently predicted HIV/AIDS and HCV risk. Findings demonstrate that patients diverted to alternative forms of acute psychiatric care are no less in need of medical services than those admitted to hospitals. This underscores the importance of primary care that is provided at the site of acute residential treatment and integrated with overall care.

Improving care planning and coordination for service users with medical co-morbidity transitioning between tertiary medical and primary care services

WHAT IS KNOWN ON THE SUBJECT?: Mental health service users with medical co-morbidity frequently experience difficulties accessing and receiving appropriate treatment in emergency departments. Service users frequently experience fragmented care planning and coordinating between tertiary medical and primary care services. Little is known about mental health nurses' perspectives about how to address these problems. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Emergency department clinicians' poor communication and negative attitudes have adverse effects on service users and the quality of care they receive. The findings contribute to the international evidence about mental health nurses' perspectives of service users feeling confused and frustrated in this situation, and improving coordination and continuity of care, facilitating transitions and increasing family and caregiver participation. Intervention studies are needed to evaluate if adoption of these measures leads to sustainable improvements in care planning and coordination, and how service users with medical co-morbidity are treated in emergency departments in particular. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Effective planning and coordination of care are essential to enable smooth transitions between tertiary medical (emergency departments in particular) and primary care services for service users with medical co-morbidity. Ongoing professional development education and support is needed for emergency department clinicians. There is also a need to develop an organized and systemic approach to improving service users' experience in emergency departments.

ABSTRACT

Introduction Mental health service users with medical co-morbidity frequently experience difficulties accessing appropriate treatment in medical hospitals, and often there is poor collaboration within and between services. Little is known about mental health nurses' perspectives on how to address these problems. Aim To explore mental health nurses' perspectives of the experience of service users with medical co-morbidity in tertiary medical services, and to identify how to improve care planning and coordination for service users transitioning between tertiary medical and primary care services. Method Embedded within an experience-based co-design study, focus group discussions were conducted with 17 emergency department nurses and other clinicians, in Melbourne, Australia. Results Three main themes were abstracted from the data: feeling confused and frustrated, enhancing service users' transition and experience and involving families and caregivers. Participants perceived the service user experience to be characterized by fear, confusion and a sense of not being listened to. They highlighted that service users' transition and experience could be enhanced by facilitating transitions and improving coordination and continuity of care. They also emphasized the need to increase family and caregiver participation. Conclusion Our findings contribute to knowledge about improving the way service users are treated in emergency departments and improving care planning and coordination; in particular, facilitating transitions, improving coordination and continuity of care and increasing family and caregiver participation.

Medical Co-morbidities Among Patients with Severe Mental Illnesses in a Community Health Facility in Nigeria

To examine prevalence of medical comorbidity (MCM) in schizophrenia (n = 1310) and in bipolar disorder (n = 1307) and the association of high burden of MCM (≥3 MCM) with duration of untreated illness, number of episodes, functioning, poly-medication and lifetime hospitalization for the mental disorder. Participants were recruited from a private psychiatric facility in Ibadan, Nigeria between 2004 and 2013 and enquiry made about the lifetime occurrence of 20 common chronic diseases including common tropical diseases. Psychiatric diagnosis was made using the Structured Clinical Interview for DSM IV Axis I disorder (SCID). Except for nutritional anemia, dermatitis and intestinal Helminthiasis, patients with schizophrenia were not at higher odds of reporting MCM than those with bipolar disorder. DUI ≥2 years, episodes of illness ≥3, being on multiple neuroleptics and history of previous hospitalization were significantly associated with high burden of MCM in schizophrenia and episodes of illness ≥3, reduced functioning and history of previous hospitalization with bipolar disorder. Schizophrenia and bipolar disorder are associated with high rates of medical comorbidity. Treatment of this medical comorbidity is essential in order to improve the outcomes for patients with bipolar disorder and schizophrenia.

Has the income of the residential area impact on the use of intensive care?

BACKGROUND

The socioeconomic factors have an impact on case mix and outcome in critical illness, but how these factors affect the use of intensive care is not studied. The aim of this study was to evaluate the incidence of intensive care unit (ICU) admissions in patients from residential areas with different annual incomes.

METHODS

Single-center, retrospective study in Northern Finland. All the non-trauma-related emergency admissions from the hospital district area were included. The postal codes were used to categorize the residential areas according to each area's annual median income: the low-income area, €18,979 to €28,841 per year; the middle-income area, €28,879 to €33,856 per year; and the high-income area, €34,221 to €53,864 per year.

RESULTS

A total of 735 non-trauma-related admissions were included. The unemployment or retirement, psychiatric comorbidities and chronic alcohol abuse were common in this population. The highest incidence, 5.5 (4.6-6.7)/1000/year, was in population aged more than 65 years living in high-income areas. In working-aged population, the incidence was lowest in high-income areas (1.5 (1.3-1.8/1000/year) compared to middle-income areas (2.2 (1.9-2.6)/1000/year, P = 0.001) and low-income areas (2.0 (1.7-2.4)/1000/, P = 0.009). Poisonings were more common in low-income areas. There were no differences in outcome.

CONCLUSION

The incidence of ICU admission in working-aged population was 25% higher in those areas where the annual median income was below the median annual income of €38,775 per inhabitant per year in Finland.

Correlates of Current Smoking Among Adults Served by the Public Mental Health System

OBJECTIVE

As part of a study of health status among 457 adults with diagnostically heterogeneous serious mental illnesses served by the public mental health system in four U.S. states, we assessed predictors of current cigarette smoking.

METHODS

We examined bivariate relationships between smoking status and risks for drug and alcohol use disorders, residential setting, parental status, and employment. Finally, we used multivariable logistic regression to predict current smoking, controlling for significant confounds.

RESULTS

Of the total sample, 44% of participants reported that they currently smoked and most (62%) were moderately to severely nicotine-dependent. Those at high risk for drug use disorders were more than three times as likely and those at high risk for alcohol use disorders were more than twice as likely to smoke, compared to their counterparts with little or no drug or alcohol use disorder risk. Controlling for all other model variables including drug and alcohol disorder risk, current smokers were less likely to be parents and more likely to reside in supervised settings than nonsmokers. Younger people and those without a college degree were more likely to smoke, controlling for all other model variables.

CONCLUSIONS

Given the high degree of comorbidity of smoking, alcohol disorders, and drug use disorders, the authors highlight the need for integrated interventions that address these issues simultaneously.

Medicaid Expenditures for Fee-for-Service Enrollees with Behavioral Diagnoses: Findings from a 50 State Claims Analysis

Medicaid is an important funder of care for individuals with behavioral (psychiatric and/or substance use) diagnoses, and expenditures will likely increase with expansion of services under the Affordable Care Act. This study provides national estimates of Medicaid expenditures using a comprehensive sample of fee-for-service Medicaid enrollees with behavioral diagnoses. Data for analysis came from 2003 to 2004 Medicaid Analytic eXtract (MAX) files for 50 states and the District of Columbia. Individuals with behavioral diagnoses had high rates of chronic medical comorbidities, and expenditures for medical (non-behavioral) diagnoses accounted for 74 % of their health care expenditures. Total Medicaid expenditure was approximately 15 billion dollars (equivalent to 18.91 billion in 2016 dollars) for individuals with any behavioral diagnosis. Medicaid fee-for-service beneficiaries with behavioral diagnoses have a high treated prevalence of individual medical comorbid conditions, and the majority of health care expenditures in these individuals are for medical, rather than behavioral health, services.

Improving mental health service users' with medical co-morbidity transition between tertiary medical hospital and primary care services: a qualitative study

Background

Mental health service users have high rates of medical co-morbidity but frequently experience problems accessing and transitioning between tertiary medical and primary care services. The aim of this study was to identify ways to improve service users’ with medical co-morbidity care and experience during their transition between tertiary medical hospitals and primary care services.

Method

Experience-based co-design (EBCD) qualitative study incorporating a focus group discussion. The study took place in a large tertiary medical service, incorporating three medical hospitals, and primary care services, in Melbourne, Australia. A purposive sample of service users and their caregivers and tertiary medical and primary care clinicians participated in the focus group discussion, in August 2014. A semi-structured interview guide was used to inform data collection. A thematic analysis of the data was undertaken.

Results

Thirteen participants took part in the focus group interview, comprising 5 service users, 2 caregivers and 6 clinicians. Five themes were abstracted from the data, illustrating participants’ perspectives about factors that facilitated (clinicians’ expertise, engagement and accessibility enhancing transition) and presented as barriers (improving access pathways; enhancing communication and continuity of care; improving clinicians’ attitudes; and increasing caregiver participation) to service users’ progress through tertiary medical and primary care services. A sixth theme, enhancing service users’ transition, incorporated three strategies to enhance their transition through tertiary medical and primary care services.

Conclusion

EBCD is a useful approach to collaboratively develop strategies to improve service users’ with medical co-morbidity and their caregivers’ transition between tertiary medical and primary care services. A whole-of-service approach, incorporating policy development and implementation, change of practice philosophy, professional development education and support for clinicians, and acceptance of the need for caregiver participation, is required to improve service users’ transition.

Associations Between Gender and Obesity Among Adults with Mental Illnesses in a Community Health Screening Study

The prevalence of obesity and its associations with gender, clinical factors, and medical co-morbidities were examined among 457 adults attending public mental health programs in 4 U.S. states. BMI was measured directly and other information was gathered by interview. Over half (59%, n = 270) were obese including 18% (n = 83) who were morbidly obese. In hierarchical ordinary least squares regression analysis controlling for demographic, psychiatric, medical, smoking, and health insurance statuses, women were significantly more likely to be obese than men. Obesity also was more likely among those who were younger and not high school graduates, those with diabetes or hypertension, and those who did not smoke tobacco. Interaction effects were found between gender and diabetes, hypertension, tobacco smoking, education, race, and age. The high prevalence of obesity among women, coupled with interactions between gender and other factors, suggest that targeted approaches are needed to promote optimal physical health in this population.

A Preliminary Analysis of Individuals With Serious Mental Illness and Comorbid Diabetes

OBJECTIVE

To understand factors related to managing illness in older individuals with serious mental illness (SMI).

METHODS

Baseline data from 200 individuals with SMI and diabetes enrolled in a study were used to compare characteristics between older (age >55) vs. younger (age ≤55) individuals.

RESULTS

Older individuals had better diabetes control compared to younger individuals, those with major depressive disorder had diabetes for a longer duration, worse diabetic control, and more emergency department encounters.

CONCLUSIONS

Helping younger individuals with SMI learn to manage their mental and physical health early-on might minimize the negative and cumulative effect of diabetes.

Cancer Screening Among Peer-Led Community Wellness Center Enrollees

Growing evidence suggests health disparities exist in services for individuals with mental disorders served by the public mental health system. The current study assessed the use of cancer screening services among New Jersey residents in publicly funded mental health programs. Self-administered written surveys were completed by 148 adults using peer-led community wellness centers throughout New Jersey. Information was collected on (a) the use of breast, cervical, and colorectal cancer screening services; (b) barriers to receiving preventive services; and (c) perceptions of overall health. More males than females participated in the study, with equal participation among White and African American individuals. Schizophrenia spectrum disorders were the most common self-reported psychiatric condition. Colorectal cancers had lower screening levels compared to those of the general population. Physicians not advising patients to complete tests emerged as a main cause of low screening rates. Wellness initiatives designed by peers collaborating with health care providers may improve adherence to preventive cancer screening measures.

Health risks and changes in self-efficacy following community health screening of adults with serious mental illnesses

Physical health screenings were conducted by researchers and peer wellness specialists for adults attending publicly-funded community mental health programs. A total of 457 adults with serious mental illnesses attended health fairs in 4 U.S. states and were screened for 8 common medical co-morbidities and health risk factors. Also assessed were self-reported health competencies, medical conditions, and health service utilization. Compared to non-institutionalized U.S. adults, markedly higher proportions screened positive for obesity (60%), hypertension (32%), diabetes (14%), smoking (44%), nicotine dependence (62%), alcohol abuse (17%), drug abuse (11%), and coronary heart disease (10%). A lower proportion screened positive for hyperlipidemia (7%). Multivariable random regression analysis found significant pre- to post-screening increases in participants’ self-rated abilities for health practices, competence for health maintenance, and health locus of control. Screening identified 82 instances of undiagnosed diabetes, hypertension or hyperlipidemia, and 76 instances where these disorders were treated but uncontrolled. These results are discussed in the context of how this global public health approach holds promise for furthering the goal of integrating health and mental health care.