Why We Fail Patients with Comorbid Mental and Physical Illness

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In an age of "affordable care" and "health care transformation," we have devoted resources for many, yet we have not cared particularly well for those patients who suffer from severe and persistent mental illness alongside comorbid chronic physical health conditions.

In The Largest Health Disparity We Don't Talk About, physician and researcher Dhruv Khullar wrote, "Americans with depression, bipolar disorder, or other serious mental illnesses die 15 to 30 years younger than those without mental illness—a disparity larger than for race, ethnicity, geography or socioeconomic status." Dr. Khullar wrote that this is a gap that has grown despite leaps in human life expectancy since the middle of the 20th century. Individuals with serious and persistent mental illness have higher rates of chronic physical illness. He worried, "Nearly half don't receive treatment, and for those who do, there's often a long delay."

Joseph Firth, a research fellow at the University of Manchester and chairman of the Lancet Psychiatry Commission, led a research team that analyzed nearly 100 studies. Dr. Firth and colleagues found that around 17 percent of unnatural deaths of mentally ill individuals are attributed to suicide. But the most striking finding? Most people with mental illness die early because of poor physical health that could be largely preventable.

People with severe mental illness die early due to pharmaceutical drug-induced obesity, diabetes, and heart disease; smoking; the hazards of poverty and homelessness; poor medical care; poor diet and inadequate exercise; and suicide.

Integrated Care: An Aside

Across the U.S., we have invested heavily in health care integration efforts. We have invested significant efforts and resources in these four dominant models for the integration of behavioral health and primary care:

1. Primary care behavioral health—behavioral health providers embedded within primary care clinic milieus, providing consultation, warm hand-offs, brief intervention, and psychotherapy.
2. Collaborative Care Management—a psychiatric health care management approach centering around psychiatric medication management, primarily focused on depression.
3. SBIRT (Screening, Brief Intervention, and Referral to Treatment)—a primary care approach that provides a methodological pathway for identifying addiction-related need and linking to assessment and treatment services.
4. Medication-assisted treatment—an approach to integrating medication-assisted treatment of opioid and alcohol use disorders into primary care and specialty mental health care treatment milieus.

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Each of these versions of integrated care has at least one thing in common: they aim to identify and serve patients in primary care who may be suffering from a behavioral health condition.

This is worthwhile. According to the National Comorbidity Survey Replication, around 29 percent of patients with a medical disorder had a comorbid mental health condition.

Yet even more striking, more than 68 percent of adults with a diagnosed mental disorder reported having at least one general medical disorder. Still, "reverse integration," in which primary care providers are embedded in behavioral health facilities, remains extremely rare.

Comorbid patients are the least likely to receive preventative services such as immunizations, cancer screenings, and smoking cessation counseling, and receive worse quality of care across a range of services, according to the Robert Wood Johnson Foundation's Synthesis Project.

Patients with anxiety or depression who have a comorbid medical condition cost $700-800 more, on average, in monthly health care expenditures to the system of care than those without anxiety or depression. That's on average. These patients are more likely to utilize emergency room services unnecessarily, and those emergency room services make up the bulk of the additional cost. Otherwise, you might think that the additional expense is well placed for patients with more complex conditions. Not when you understand that there is no evidence these patients are being treated effectively.

Where Next?

We should have significantly more focus on innovating practice models for “reverse integration," in which primary care and other medical providers are embedded within the behavioral health milieu.

The Affordable Care Act created an optional Medicaid State Plan benefit for states to establish Health Homes, which coordinate care for Medicaid members who have multiple chronic conditions. The Centers for Medicare and Medicaid Services expects health home providers to operate under a "whole-person" philosophy, integrating and coordinating all primary, acute, behavioral health, and long-term services and supports.

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Health homes are designed to be a person-centered, integrated care model that coordinates medical care, behavioral health services, as well as community and social supports. They offer one model for integrated care for those with significant chronic conditions and comorbidities.

However, according to the Urban Institute, health homes have faced significant difficulties in the provision of an integrated model, from building an effective team-based approach, lack of infrastructure to support the model, continual health care culture change, and complexities in processes necessary to address required health home services. Even more, health homes have faced substantial systemic challenges to broadening care management functions needed to scaffold mental health treatment and increasing connections to nonclinical supports and services.

Health Essential Reads

Stemming the Ripple Effect of Untreated Mental Illness

The Connection Between Love, Happiness, and Good Health

It remains clear that disparities and barriers remain. There is no formula from which to apply a solution, yet as a society we have responsibility to do better. We have our work cut out for us.