You are here

Position Statement 16: Health and Wellness for People with Serious Mental Illnesses

Policy Position

Mental Health America (MHA) calls for dedication of significant state and federal resources to reduce the alarmingly high rates of overall health problems (morbidity) and premature death (mortality) among people with serious mental illnesses. Recent studies demonstrate that with the addition of surveillance and treatment services, overall healthcare costs can actually be reduced, both in the near and long-term. When appropriate physical and behavioral services, including rehabilitation-recovery services, are provided in a coordinated system, overall costs are reduced through:

  • reduction in inappropriate emergency room use;
  • reduced hospital stays, both for acute physical and mental health interventions; and
  • elimination of prescription duplication and an increase in medication adherence. 1

For mental health consumers to have a fair chance to live healthy and long lives, medical practice, health policy and public dialogue must reflect the fact that overall health and mental health are inextricably intertwined.

A seminal 2006 study by the National Association of State Mental Health Program Directors (NASMHPD) 2   found that the rates of mortality and morbidity among people with severe mental illnesses are alarmingly high in comparison to the rest of the population. A 2003 NASMHPD comparison of sixteen states found that these rates have increased at least in part due to the increased use of newer generations of psychotropic medications. 3   The reports both found that many of the factors contributing to this disparity are preventable, such as smoking, substance abuse, infectious diseases and suicide. Some additional factors, such as obesity and diabetes, are often side effects of the very medications used to treat these mental illnesses.

The promotion of seamless, effective and culturally and linguistically appropriate healthcare services and supports for people with severe mental illnesses is fundamental to MHA’s mission. MHA supports the implementation of the recommendations proposed by NASMHPD so that individuals with severe mental illnesses can recover and lead meaningful lives in the community. The key recommendations remain:

  1. To prioritize the public health problem of morbidity and mortality among people with serious mental illnesses.
  2. To track and monitor morbidity and mortality in populations served by public mental health systems (surveillance).
  3. To implement established standards of care (i.e. evidence-based and evidence-informed practices) for prevention, screening, assessment, and treatment.
  4. To improve access and integration with general medical care services.

In addition, every person with a mental illness should have either a Primary Healthcare Home or a Behavioral Healthcare Home, a place where primary healthcare services are coordinated and integrated with specialty services, especially psychiatric and behavioral health supports. 4

Background

In October 2006, the National Association of State Mental Health Program Directors (NASMHPD) released a report entitled Morbidity and Mortality in People with Serious Mental Illness, cited above. Among the report's findings, and those of subsequent studies, were the following devastating outcomes for people with serious mental illnesses:

  • People with serious mental illnesses are now dying at least 25 years earlier than the general population.
    • 88% of the deaths and 83% of premature years of life lost in people with serious mental illness are due to “natural causes:”
      • Cardiovascular disease
      • Diabetes
      • Respiratory diseases
      • Infectious diseases
  • Increased morbidity and mortality are largely due to treatable medical conditions that are caused by modifiable risk factors such as smoking, obesity, substance abuse, and inadequate access to medical care.
    • People with Depression are 1.2 to 1.8 times more likely than the general public to be obese. 5
    • People with Bipolar Disorder are 1.5 to 2.3 times more likely than the general public to be obese. 6
    • People with Schizophrenia are 3.5 times more likely than the general public to be obese. 7
    • 56 to 88% of people with schizophrenia smoke compared to 25% of the general public. 8
      • People with schizophrenia who smoke have a higher toxic exposure than other smokers.
        • They smoke more cigarettes and consume more of each cigarette.
      • Smoking is associated with increased insulin resistance.
  • 44% of all cigarettes smoked in the U.S. are consumed by people with a mental illness. 9
  • Antipsychotic medications have become more highly associated with weight gain, diabetes, dyslipidemia, insulin resistance and the metabolic syndrome.
  • Access to adequate healthcare for individuals with serious mental illnesses is often impaired by numerous factors, including:
    • Over-use of emergency and medical acute inpatient care
    • Lack of a primary care relationship (a Healthcare Home)
    • Lower rates of routine testing
    • Very poor dental care 10
    • Lack of integration of primary and behavioral health care
  • People with mental illness frequently get lower quality care for medical interventions 11
    • Following myocardial infarction, due to lower quality of care, Medicare patients with mental illness were:
      • 19% more likely to die if they had any mental disorder
      • 34% more likely to die if they had schizophrenia
    • People with serious mental illness are:
      • Less likely to be screened or treated for dyslipidemia, hyperglycemia, hypertension
      • Less likely to receive angioplasty or CABG
      • Less likely to receive drug therapies of proven benefit (thrombolytics, aspirin, beta-blockers, ACE inhibitors) post-myocardial infarction
    • The large CATIE study of adults with schizophrenia 12 found:
      • 88.0% of subjects who had dyslipidemia (high cholesterol) were not receiving treatment
      • 62.4 % of subjects who had hypertension (high blood pressure) were not receiving treatment
      • 30.2% of subjects who had diabetes were not receiving treatment
  • These data were updated in 2010 by Wood, W.G., 13 with no improvement shown.

Call to Action

Mental Health America envisions a healthcare system that fully integrates general medical health and mental wellness by ensuring accessible, high-quality care for all people regardless of treatment setting, disability, racial or ethnic background, and income. In order to eliminate the disparities in overall health and wellness for people with serious mental illnesses, MHA supports the following strategies:

Increase Outreach and Surveillance

It is urgent that surveillance and outreach be dramatically increased, now that the scope of this problem has been understood. Federal designation of people with serious mental illness as a distinct at-risk health disparities population is a first step, followed by development of tools for wellness promotion and prevention of illness in this vulnerable population. Effective response to this problem requires, at a minimum:

  • Expand national surveillance activities to incorporate information about health status in all appropriate records concerning people with severe mental illness.
  • Engage at the national and state levels in developing the National Health Information Infrastructure (NHII) to assure that electronic health records and personal health record templates include the data elements needed to manage and coordinate both general medical health and mental health care. 14 Privacy and confidentiality protections for information concerning minors, chemical dependency diagnoses, and sensitive background information, should be assured in the design and implementation of health information exchanges.
  • Assure at the state and federal levels that the impacts of healthcare reform changes are monitored and corrected as needed to promote integration of care.
  • Share information widely about general medical health risks in persons with severe mental illness to encourage awareness and advocacy. Educate the healthcare community. Encourage persons served and family members to advocate for wellness approaches as part of recovery, especially through Healthcare Homes.
  • Promote the recommendations in the NASMHPD Technical Reports on polypharmacy, 15 smoking and diet and implement policies and programs addressing these risk factors.
  • Expand recovery programs to add tools to address wellness goals. 16
  • Apply a public health approach and population-based interventions. Work with recovery- oriented clubhouses and other programs to develop a wellness culture among consumers.
  • Improve access to general medical health care and the development of Primary Healthcare and Behavioral Healthcare Homes.
  • Fund, require, regulate, and lead the public behavioral healthcare system to ensure prevention, screening, and treatment of general health care issues.

Address Funding

  • Assure financing methods for service improvements, including reimbursement for coordination activities, community case management, 17 transportation and other supports to ensure access to general healthcare services. Total healthcare costs are actually reduced, both in the near and long-term when appropriate physical and behavioral services, including rehabilitation-recovery services, are provided in a coordinated healthcare system.
  • As a healthcare purchaser, Medicaid should:
    • Provide coverage for health education and prevention services (primary prevention) that will reduce or slow the impact of disease for people with severe mental illnesses.
    • Establish reimbursement rates adequate to assure access to primary care by persons with serious mental illnesses.
    • Cover smoking cessation and weight reduction treatments.
    • Use community case management to improve engagement with and access to preventive and primary care, especially as an extension of Primary Healthcare and Behavioral Healthcare Homes.
    • Adopt payment codes that permit payment for behavioral health consultation as part of primary healthcare.
  • Establish system accountability for the mental health, substance use disorder and corrections systems to assure quality integrated behavioral and general healthcare.
  • Join the Medicaid and public health agencies at the state level to develop a quality improvement (QI) plan to support appropriate screening, treatment and access to healthcare for people being served by the public mental health and substance use disorder systems, whether Medicaid-eligible or uninsured.
  • Assure that all initiatives to address morbidity and mortality have concrete goals, timeframes and specific steps. Gather performance measurement data and use them to manage overall systems performance.
  • Use regulatory, policy and other programming opportunities to promote personal responsibility for making healthy choices by changing the locus of control from the systems of care (program rules, regulations, staff) to the individuals being served (self-control and management).

Effective Period

This policy was approved by the Mental Health America Board of Directors on June 9, 2012. It is reviewed as required by the Public Policy Committee.

Expiration: December 31, 2017

  1. Parks, J.J. et al., “Mental Health Community Case Management and its Effect on Healthcare Expenditures,” Psychiatric Annals 40-8:415-419 (2010).
  2. Parks, J., Svendsen, D., Singer, P. & Foti, M.E., Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors, Medical Directors Council ( 2006), monograph available at http://www.dsamh.utah.gov/docs/mortality-morbidity_nasmhpd.pdf power point available at http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&ved=0CEcQ...
  3. Lutterman,T., Ganju, V., Schacht, L., Monihan, K., et.al., Sixteen State Study on Mental Health Performance Measures, DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (2003), monograph available at http://webcache.googleusercontent.com/search?q=cache:6O2wW8_yq6UJ:www.nr....
  4. Mauer, B., National Council for Community Behavioral Healthcare: Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home (2009), monograph available at http://www.thenationalcouncil.org/galleries/resources services%20files/Integration%20and%20Healthcare%20Home.pdf (Password Required)
  5. Simon, G.E., Von Korff, M., Saunders, K., Miglioretti, D.L., Crane, P.K., van Belle, G. & Kessler, R.C., “Association Between Obesity and Psychiatric Disorders in the US Adult Population,” Arch Gen Psychiatry 63(7):824-30 (2006); Petry, N.M., Barry, D., Pietrzak, R.H. &Wagner, .JA., “Overweight and Obesity are Associated with Psychiatric Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions,” Psychosom Med 70(3):288-97 (2008).
  6. Id.
  7. Coodin, et al., “Body Mass Index in Persons with Schizophrenia,” Can J Psychiatry 46:549–55 (2001).
  8. George, T.P., et al., “Nicotine and Tobacco Use in Schizophrenia, in: Meyer, J.M., Nasrallah, H.A., eds., Medical Illness and Schizophrenia (American Psychiatric Publishing, Inc. 2003); Ziedonis, D., Williams, J.M. & Smelson, D., “Serious Mental Illness and Tobacco Addiction: A Model Program to Address this Common but Neglected Issue,” Am J Med Sci. 326(4):223-330 (2003).
  9. Lasser, K et al., “Smoking and Mental Illness: A Population-Based Prevalence Study,” JAMA 284(20):2606-2610, doi: 10.1001/jama.284.20.2606 (2000).
  10. Kilbourne A.M., et al., “Oral Health in Veterans Affairs Patients Diagnosed with Serious Mental Illness,” J Public Health Dentistry 67(1):42-8 (2007).
  11. Newcomer, J. & Hennekens, C.H., “Severe Mental Illness and Risk of Cardiovascular Disease,” JAMA 298(15):1794-1796 (2007); Druss, B.G., Bradford, W.D., Rosenheck, R.A., et al., “Mental Disorders and Access to Medical Care in the United States,“ Arch Gen Psychiatry. 58:565-572 (2001).
  12. Lieberman, J.A., Stroup, T.S., McEvoy, J.P., Swartz, M.S., Rosenheck, R.A., Perkins, D.O., et al., for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators, “Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia” N Engl J Med 353:1209-23 (2005); Nasrallah, H.A., Meyer, J.M., Goff, D.C., McEvoy, J.P., Davis, S.M., Stroup, T.S. & Lieberman, J.A., “Low Rates of Treatment for Hypertension, Dyslipidemia and Diabetes in Schizophrenia: Data from the CATIE Schizophrenia Trial Sample at Baseline,” Schizophr Res. 86:15-22(2006); Lefkowitz, P.M., National Council of Community Behavioral Healthcare, 2009 Behavioral Health/Human Services Information Systems Survey, monograph at http://www.thenationalcouncil.org/cs/hit_funding_fails_to_address_mental...
  13. Wood, W.G., Mental Illness and the Medical Home, power point available at http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCQQ...
  14. http://www.cms.gov/EHRIncentivePrograms/01_Overview.asp
  15. NASMHPD Medical Directors’ Technical Report on Psychiatric Polypharmacy, National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council (2001), monograph available at http://www.nasmhpd.org/general_files/publications/med_directors_pubs/Pol...
  16. In 2009, MHA launched a website called “Live Your Life Well,” intended to promote mental wellness through ten straightforward steps:
    • Connect with Others. People who feel connected are happier and healthier--and may even live longer.
    • Stay Positive. People who regularly focus on the positive in their lives are less upset by painful memories.
    • Get Physically Active. Exercise can help relieve insomnia and reduce depression.
    • Help Others. People who consistently help others experience less depression, greater calm and fewer pains.
    • Get Enough Sleep. Not getting enough rest increases risks of weight gain, accidents, reduced memory and heart problems.
    • Create Joy and Satisfaction. Positive emotions can boost your ability to bounce back from stress.
    • Eat Well. Eating healthy food and regular meals can increase your energy, lower the risk of developing certain diseases and influence your mood.
    • Take Care of Your Spirit. People who have strong spiritual lives may be healthier and live longer. Spirituality seems to cut the stress that can contribute to disease.
    • Deal Better with Hard Times. People who can tackle problems or get support in a tough situation tend to feel less depressed.
    • Get Professional Help if You Need It. More than 80 percent of people who are treated for depression improve.
    These steps, and concrete suggestions for achieving mental wellness, are summarized on the MHA wellness website, http://www.liveyourlifewell.org/go/you-can-live-life-well-more. ADD: Fricks citation, WHAM program, etc
  17. Parks, J.J. et al., op. cit.

2000 N. Beauregard Street,
6th Floor Alexandria, VA 22311

Phone (703) 684.7722

Toll Free (800) 969.6642

Fax (703) 684.5968

Text Resize

-A +A

The links on this page may contain document data that requires additional software to open: