Sunday, March 20, 2011

Collaborative Care: Fix It And Fix Mortality




I briefly scanned the Robert Wood Johnson synthesis report on mental and medical co-morbidity so I thought I'd summarize the highlights for the blog. If you'd rather watch the recorded web seminar you can hear it here.

The report relied on systemic literature review to look at the relative risk and mortality associated with co-morbid medical and mental health conditions. The looked at studies using structure clinical interviews, self-report, screening instruments and health care utilization data (diagnostic codes reported to Medicaid).

This is what they found:

  • 68 percent of adults with a mental disorder had at least one general medical condition, and 29 percent of those with a medical disorder had a comorbid mental health condition
  • These findings support the conclusion that there should be strong integration of medical and mental health care
  • Psychiatric disorders were the most expensive conditions to treat among Medicaid beneficiaries, but also the most common when combined with cardiovascular disease
  • Medical conditions and psychiatric conditions have a reciprocal risk relationship: having one disorder increases the risk for having the other
  • Both medical and mental disorders are associated with low income, poor education, early childhood trauma and chronic stress
  • Four modifiable risk factors are responsible for high rates of co-morbidity: alcohol and drugs, tobacco, poor nutrition and lack of exercise
  • The treatments themselves may worsen co-morbidity (somatic meds cause psychiatric side effects, psychiatric meds may cause or worsen medical conditions)
  • Public mental health clients die 25 years earlier than the average life expectancy (see Figure 4 above for the relative risk of six common psychiatric conditions)
  • Multidisciplinary team approach to treatment is most effective: fully integrated medical, mental health and substance abuse services
So instead of having a public health care system that is fragmented between freestanding clinics, we should have integrated clinics that follow a collaborative care model and that provide a broad range of services. For me this means that we can no longer afford to have disjunction of care between state agencies: correctional facilities and public clinics need to coordinate care for both medical and mental health conditions. This study describes my typical clinic population: poor, poorly educated, sick, traumatized and under chronic stress. They are at greater risk of dying and the most costly to care for.