Medical Management Of Individuals With Severe Mental Illness

Patients with severe mental illness have worse medical outcomes than their unaffected counterparts. Psychiatric patients generally have a poor appreciation of their medical conditions and are both less aware of their physical condition and less likely to have or seek adequate medical care. The treatment of mentally ill patients is often more difficult and time consuming for providers than for those without mental illness. Because they are a more difficult population to treat, providers are hesitant to accept them as patients, and they are at higher risk for being discharged from care. Psychiatric patients also have decreased ability to participate in their care because of cognitive and emotional limitations. They often fail to appreciate benefits of treatment that are not immediately apparent and are focused concretely on the here and now. Patients with apathy and low mood may feel that treatment is pointless or feel that they just don't have the energy to participate. Decreased concentration and memory in many conditions may cause patients to forget medications and appointments.

HIV and medical screening of psychiatric patients is inadequate in psychiatric and medical settings. Patients with severe, chronic mental illness may receive limited medical attention in general and therefore are at risk for sequelae of undiagnosed disorders, such as neurosyphilis and chronic pelvic inflammatory disease. Women with chronic psychiatric illnesses are less likely to receive prenatal care during pregnancy (Turner et al., 1996) and thus are more likely to spread infection to their offspring. Individuals with chronic mental illness are less likely to have access to medical care and are more likely to be without insurance, homeless, and unemployed (Folsom et al., 2005; Meade and Sikkema, 2005). Unsurprisingly, outcomes are worse for individuals with severe mental illness (Goldman, 2000; Cournos et al., 2005).

It is therefore necessary to aggressively screen individuals with mental illness for both HIV and other medical illnesses, such as diabetes, hepatitis, hypertension, and heart disease. It is helpful for both patients and providers to centralize care as much as possible, making all providers aware of all medical problems as well as the current treatment plan to provide a consistent message (Treisman and Angelino, 2004). Frequent pregnancy testing and on-site prenatal care may improve outcomes for pregnant women with HIV. It is important to incorporate preventative medicine whenever possible, including smoking cessation, weight management, and risk reduction; this counseling has been often overlooked in patients with multiple medical problems and with HIV, but is even more crucial now that HIV/AIDS has become a chronic illness. We emphasize that psychiatric providers should be vigilant about screening for medical illnesses, even using a standard medical review questionnaire for the periodic assessment of a patient's medical status. Patients with altered mental status in particular need special attention and careful physical examinations because they may be less likely or able to report symptoms. In addition, we urge medical providers in clinics to take extra care in examining the chronically mentally ill, because often their illnesses, or the stigma attached to them, prevent open lines of communication.

In medicine, physicians often seek to educate patients about risks to their health and benefits of treatment and health maintenance in an effort to influence patients' behavior toward compliance and improved quality of life. Providers treating people with chronic mental illness, however, have to take a different approach to therapy. In this population increasing knowledge does not usually affect behavior; thus patients with severe psychiatric illnesses require assistance with behavior modification. As discussed above, chronically mentally ill individuals with HIV who engage in risky behaviors are often better educated about risks than their HIV-positive counterparts who are not mentally ill (Chuang and Atkinson, 1996, McKinnon et al., 1996), perhaps because of their providers' efforts to motivate them to change through increased education about HIV risk. This suggests that education alone may be successful in increasing knowledge in this population, but not in changing behavior. Cognitive behavioral therapy can be useful in this regard; identifying harmful attitudes, ideas, and behaviors and creating a framework of new, healthy attitudes and behaviors is helpful for patients who struggle to modify their behavior. Interventions in which patients actively practice health hygiene, behavior modification, safesex negotiation, and positive interactions with others help patients to realize their own ability to retrain patterns of harmful behaviors.

Many individuals with mental illness are unstable extroverts who are reward focused and somewhat indifferent to risk. Furthermore, physician education often focuses on risks and negative outcomes that result from failing to be compliant with treatment. We suggest that providers focus strongly on the benefits of treatment, such as improved energy, a more stable living situation due to substance abstinence, better relationships with others, improvement in lab values as a result of good treatment adherence, and decreased time spent in the hospital (Treisman and Angelino, 2004). Although education is essential, and negative outcomes must be discussed with patients, an optimistic, behavior-focused plan for patients is more helpful than general discussion of health risks. We encourage providers to take small steps in behavior modification, setting one or two concrete goals at each visit and following their progress, praising success and exploring the cause of failures. These steps also help patients to build rapport with providers and build confidence in patients as well as providers, who tend to get discouraged with negative outcomes of mentally ill patients.

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