JOURNAL TRANSCRIPT
Treating Severe Mental Illnesses and Comorbid Medical Conditions in the Primary Care Setting: An Idea Whose Time has Come Carol Blixen PhD, Associate Professor of Medicine, Center for Health Care Research and Policy. Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio Adam Perzynski PhD, Center for Health Care Research and Policy. Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio Martha Sajatovic MD, Professor of Psychiatry, Neurology, Biostatistics and Epidemiology, Case Western Reserve University School of Medicine and Neurologic Institute, University Hospitals Case Medical Center, Cleveland, Ohio Neal V. Dawson, MD, Professor of Medicine, Epidemiology and Biostatistics Center for Health Care Research and Policy. Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio Study Sponsor: This study was supported by a Bridge Funds grant from Case Western Reserve University (CWRU) School of Medicine and the Department of Psychiatry, University Hospitals Case Medical Center and by CWRU CTSA grant number UL1RR024989. Keywords: primary care, serious mental illness, diabetes mellitus, self-management, comorbidity
Abstract. The mortality of patients with comorbid serious mental illness (SMI) and diabetes (DM) is high. In this pilot study in patients with SMI and DM, the effect of group work using the strategy of “targeted training in illness management” with nurse educators and peer educators was examined. The results indicated that improvements in the outcome of both the serious mental illness and the diabetes might be achieved with this approach.
Introduction Individuals with serious mental illness (SMI), (schizophrenia/schizoaffective disorder, bipolar disorder or major depressive disorder), die earlier than individuals in the general population, losing on average, 9-32 years of life (1,2). Much of the premature mortality among persons with SMI is due to medical comorbidities, such as diabetes (DM), which has achieved epidemic proportions (3), complicates both psychiatric and medical health outcomes and inflates costs (4-6). SMI patients often rely on primary care settings for the treatment of comorbid medical conditions, yet studies conducted on management of psychiatric care and medical care in SMI patients have generally focused on patients recruited from mental health care sites (7-9). We developed and tested a psychosocial group-format treatment targeted for SMI participants with DM, and adapted it to the primary care setting. The treatment blended psycho-education, problem identification, goal-setting, and behavioral modeling/reinforcement. A key feature of this 16-week intervention, Targeted Training in Illness Management (TTIM), was the use of a Nurse Educator, as well as a Peer Educator with both SMI and DM, to teach and model self-management for these concurrent conditions. After 12 group sessions were completed in the pilot, individuals participated in a 4-week maintenance period consisting of 2 telephone sessions (spaced about 2 weeks apart) with the SMI Peer Educator and 2 telephone sessions (spaced about 2 weeks apart) with the Nurse Educator. In this pilot trial (N=12), TTIM was associated with significant improvement (P10 years) or insulin therapy was associated with a particularly higher risk of CVD mortality after multivariate adjustment (RRs, 3.22 and 4.90, respectively). Clearly, the coexistence of these conditions puts individuals at particularly high risk for premature mortality.
Implications for Primary Care Practice The primary care medical clinic setting offers a logical venue for teaching skills necessary to manage both mental health and medical care, and for facilitating the linkage of mental health and medical care for complex comorbid SMI patients. Primary care sites offer an opportunity to identify and work with patients with a mental disorder who may not be willing to seek mental health care. DM management is most often handled separately from other health counseling in primary care clinics, often with DM educators on staff. Training DM educators to work specifically with SMI individuals with comorbid DM utilizes existing clinic resources and facilitates better care of patients who may be most at risk for negative outcomes. In conclusion, comorbid SMI and DM cause extensive suffering and premature mortality. Psychosocial interventions that empower individuals and allow them to self-manage their mental and medical comorbid disorders better can be readily and successfully implemented in primary care settings using existing staff. Larger and controlled trials are needed to confirm the positive findings from this pilot work.
GP comment What have I learned from this paper? 1. Comorbid diabetes and severe mental illness can reduce life expectancy far more than either condition on its own. 2. Although this was a pilot study in a different culture, the results are very encouraging in suggesting that intervention by a nurse educator and peer educator might improve management of both the diabetes and the mental illness. 3. If these results are borne out by further large studies, they could have considerable implications for general practice, although the best way of organising the appropriate ‘targeted training in illness management’ in our setting would need to be determined. Tom Inskip, GP, Bedford
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