One in five US adults lives with a mental illness, and over 5% of the adult population suffers from a serious mental illness (SMI), which results in severe functional impairment that limits one or more major life activities (activities of daily living, social functioning, thinking, concentration and judgment, and adaptation to stress).1 Those with an SMI, such as bipolar disorder, depression, schizophrenia, and psychosis, have more medical comorbidities, higher premature mortality, and die on average 10 to 20 years earlier than the general population, primarily due to general medical disorders.1-3 Adults with any mental illness (AMI) account for over 14% of deaths worldwide, or approximately 8 million deaths each year, mortality 2.22 times higher than those without mental illness.4 AMI and SMI rank among the most significant causes of death worldwide. Interestingly, 67.3% of deaths among individuals with AMI are related to potentially preventable natural causes (heart disease, cancer, chronic diseases, diabetes, infections, other causes).4
Persons with SMI are at higher risk for physical health problems, contributing to chronic medical conditions.3,5 This discrepancy in the physical health of this population is multifactorial: healthcare system fragmentation, homelessness, poverty, provider bias, unhealthy lifestyle, and adverse reactions from psychotropic medications that contribute to higher incidence rates of diabetes, metabolic syndrome, and infectious diseases.6-8 Unfortunately, many physical illnesses are often unrecognized, untreated, or poorly treated by clinicians but are amenable to successful intervention.9 Patients with SMI may be considered less desirable in clinical practices due to inadequate insurance coverage and the need for greater resources for successful treatment (for example, longer visits and collaboration for follow-through).6 Perspective from patients with SMI included provider not listening, making assumptions about their illness, talking down to them, being judgmental in responses, expressing doubt about their physical symptoms, and underinforming them about their medical care.6,9 There is a need for NPs to improve medical care for this population and integrate mental health and primary care services.
Most persons with SMI report at least one chronic health condition (such as, diabetes, hypertension, and pulmonary disease).10 The types and severity of physical health problems among this population vary by race and gender, with higher rates of cardiovascular disease, diabetes, and obesity than the general population.11 Individuals with SMI are less likely to access and utilize physical healthcare.6,7,12 Similar to the general population, racial and gender health disparities exist among people with SMI with higher prevalence in females and Black individuals.11 Lower access and healthcare service utilization in racial and ethnic minorities are compounded in the SMI population, who generally struggle socioeconomically. The objective of this article is to discuss some of the foremost medical issues in patients with SMI and provide strategies for NPs to monitor and treat.
Metabolic syndrome
Metabolic syndrome comprises weight gain (particularly abdominal obesity), increased blood glucose, dyslipidemia, and high BP.13 Persons with SMI are three times more likely to have metabolic syndrome than the general population, with obesity rates of 70% compared with 42% in the general population.11,14 Women with SMI are more likely than men to have obesity, with higher body mass index (BMI) seen in Black women than White women.11
A possible mechanism for the increased risk of metabolic syndrome includes adverse reactions of antipsychotic medications used to treat SMI, such as appetite stimulation via hypothalamic eating centers in the brain and antimuscarinic effects on pancreatic beta cells leading to insulin resistance.13 Clozapine and olanzapine carry the highest risk of metabolic syndrome, while aripiprazole and ziprasidone have among the lowest risk in this classification.13
Diabetes prevalence is twice as high among patients with SMI, but metabolic screening remains low.15 Because patients with SMI have difficulty engaging in care, they struggle with adhering to national recommendations for treating diabetes or metabolic issues.11 In 2004, the American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity came together as a panel to develop metabolic screening guidelines for patients taking second-generation antipsychotics (SGAs).16 The panel recommended that several known risk factors for the development of metabolic syndrome be monitored prior to initiation of and throughout treatment with an SGA: personal and family history of related conditions (such as diabetes), BMI (monitor at baseline then at 4, 8, and 12 weeks after initiation of an SGA, and quarterly), BP (monitor at baseline, 12 weeks, then annually), fasting plasma glucose (monitor at baseline, 12 weeks, then annually), and fasting lipid panel (monitor at baseline, 12 weeks, then every 5 years).16 Additionally, the panel recommended monitoring waist circumference at baseline and annually; however, other guidelines recommend measuring it more often - at least quarterly.16,17 The authors also recommend monitoring hemoglobin A1C at baseline and then annually.
Concerns persist that many healthcare providers do not monitor the metabolic health of patients with SMI adequately, which places patients taking SGAs at increased risk for cardiovascular disease, diabetes, obesity, and early death.18 One recent study noted that individuals taking atypical antipsychotics received routine baseline monitoring at the following rates: lipid profile 49%, blood glucose 55%, systolic BP 69%, and BMI 43%.19 A year later, rates of routine monitoring decreased to lipid profile 19%, blood glucose 24%, systolic BP 44%, and BMI 22%.19
With the majority of healthcare moving to the electronic medical record (EMR), practice alert systems may lead to improvement in the ordering of metabolic monitoring.20 For example, for patients taking an SGA, the EMR could send an alert to the provider with the recommended screenings for that particular visit. These alerts could be set to follow the monitoring standards discussed earlier for patients taking SGAs.
In addition to SGAs, many antidepressants and mood stabilizers are associated with weight gain and warrant monitoring.13 Unfortunately, some patients will request to stop their psychotropic medication when they experience weight gain.21 It can be tricky to maintain a therapeutic relationship while encouraging patients to stay on their medications to prevent relapse while being truthful about medication adverse reactions.
Treatment recommendations
* Follow the metabolic monitoring guidelines for all patients taking SGAs.16,17
* Measure waist circumference at least quarterly. Waist circumference greater than or equal to 35 in (88.9 cm) for women or greater than or equal to 40 in (101.6 cm) for men warrants intervention.17
* Unless a patient is underweight (BMI < 18.5), a weight gain of one BMI unit indicates a need for intervention.17
* Discuss patient successes and challenges. Weight neutrality or 1-lb weight loss is an opportunity to reinforce patient efforts and provide guidance.
* Engage patients in behavior change talk. Ask questions about dietary intake and exercise. Empower patients to make small, impactful dietary and exercise changes over time.
* On-site lab work with same-day appointments and a primary support person to accompany the patient improves adherence.10
* Consider adjunctive treatment to reduce patient weight. Studies on the use of medication for antipsychotic-related weight gain have found metformin to be effective for weight loss with diet and exercise changes, although it is not a labeled indication.22
* Collaborate with the patient and their mental health provider to potentially switch to psychotropic medications with lower metabolic risks.
Cardiovascular disease
The majority of excess preventable deaths in people with SMI are due to cardiovascular disease.23 People with SMI have more than two times higher cardiovascular mortality than the general population and an increased prevalence of all cardiovascular disease risk factors, including sedentary behavior, diabetes, tobacco smoking, obesity, dyslipidemia, elevated hemoglobin A1C levels, and hypertension.11,23-25
Treatment recommendations
* Start with a broad physical activity prescription (for example, sitting less, standing, and walking during TV commercials) throughout the day.24
* Individualize recommendations to encourage a slight but regular increase from the patients' current activity level.26
* Encourage the use of a buddy system to promote movement and dietary change.
* If self-management does not work (physical activity and diet), move to a manualized approach under the supervision of a nonspecialist (for example, a nurse).24
* Consider switching antipsychotic medications to drugs with fewer metabolic adverse reactions.
* Be aware that smoking cessation may initially lead to weight gain.27
* Utilize motivational interviewing principles to help the patient move toward change.28
Smoking
The prevalence of tobacco smoking among people with SMI is three times higher than in the general population, and may be the most vital modifiable cause of premature mortality in persons with SMI.26,29,30 People with SMI who smoke tend to smoke more and inhale more deeply (increasing nicotine exposure) than others who smoke.30 SMI tobacco use is associated with lower quality of life, poorer mental health, worse cognitive and overall functioning, and increased suicide risk.29,31,32 Historically, mental health professionals viewed smoking as a secondary concern compared with psychiatric symptoms, believed smoking was therapeutic, and feared that quitting might worsen psychiatric symptoms.32,33 These inaccurate beliefs have perpetuated tobacco use among people with SMI by depriving them of evidence-based interventions.
Persons with SMI have the same desire to reduce or quit smoking as individuals without SMI and are able to do so when interventions are incorporated into their mental health treatment.34,35 However, smoking cessation rates have been far lower for people with SMI compared with those without SMI.36 Current smoking cessation guidelines for people with SMI advise that both pharmacologic and psychosocial smoking cessation treatments should be provided, and a combination of these approaches is more effective than either of these treatments alone.35
Treatment recommendations
* Utilize the "5 As" screening and intervention model (ask, advise, assess, assist, and arrange).35
* Combine pharmacologic (varenicline, bupropion XL, or nicotine-replacement therapy [NRT]) and nonpharmacologic interventions (for example, cognitive-behavioral therapy, motivational interviewing, acceptance and commitment therapy, contingency management/reinforcement, brief motivational and educational interventions, quitlines, and technology interventions like web-based and phone applications).32
* Monitor all patients with SMI taking varenicline, bupropion, or NRT for psychiatric symptom worsening (for example, agitation, depression, suicidal ideation).
* Gather a list of local allied health professionals who can provide effective nonpharmacologic interventions.
Immunizations
Vaccinations are a cost-effective way to prevent communicable diseases.37 Adult vaccination rates in the US are less than optimal, and tend to be lower among adults with SMI.37,38 Barriers to immunizations in this population include lack of awareness and knowledge, accessibility, and lack of recommendations from primary care providers.38 Depending on age, prior vaccination status, health conditions, and lifestyle, the CDC recommends multiple vaccines for adults, including annual influenza; pneumococcal; tetanus, diphtheria, and pertussis; zoster; hepatitis A; hepatitis B; measles, mumps, and rubella; human papillomavirus; and COVID-19.39
Usually, pneumococcal vaccination is recommended for persons age 65 or older and persons 19 to 64 years old with risk factors such as certain chronic medical conditions, alcoholism, or cigarette smoking.39 There is a higher prevalence of chronic medical conditions and higher smoking rates among adults with SMI than the general population.38 Consequently, NPs should recommend the pneumococcal vaccine to their younger at-risk patients with SMI.
A large majority (94%) of people with SMI are receptive to education and desire to receive future immunizations if they are easily accessible.38 Removing barriers to adult immunizations in this population by offering vaccines at medical appointments or in sites that are frequented by those with SMI, such as Clubhouse International facilities (which provide psychosocial rehabilitation), can improve vaccination rates.38
Persons with SMI often struggle with cognitive impairment which makes it challenging to remember personal immunization history, and many do not have hard copies of their records.40 The majority of US states utilize immunization information systems (IIS) to confidentially store individual immunization records.40 Accessing your state's IIS is a no-cost method to record and track personal immunization histories.
Treatment recommendations
* Assess individual adult immunization status and provide education and rationale of benefits for CDC-recommended vaccinations.39
* Provide vaccinations on-site or help the patient create a plan to access.
* Encourage pneumococcal vaccination if the patient smokes cigarettes or has a chronic medical condition.
* Utilize a state-managed IIS for accurate documentation.
Drug-drug interactions
It is essential for NPs to carefully monitor for potential drug-drug interactions when treating the medical needs of individuals with SMI. Drug-drug interactions with psychotropic medications can increase an individual's risk for hospitalizations, treatment failure, and avoidable medical complications. NPs need to be familiar with potential drug-drug interactions that can cause lithium toxicity, serotonin syndrome, and ventricular arrhythmia (see Interactions between psychotropic and nonpsychotropic medications).
Lithium is a psychotropic medication commonly used to treat mood instability and suicidal ideation.13 Lithium is a renally excreted salt with a very narrow therapeutic blood level. Medications that impact electrolyte balance or renal elimination can negatively impact lithium levels.13
Serotonin syndrome is primarily caused by overstimulation of the serotonin 5-HT2A receptors, though stimulation of other serotonin receptors also contributes.41 In addition to treating depression and anxiety, serotonergic medications are utilized to treat neuropathic pain, migraines, insomnia, nausea, cough, and Parkinson disease.43 It is important to be aware of these medications (see Examples of serotonergic medications used for nonpsychiatric conditions) and minimize coadministration.46
QT intervals above 500 milliseconds are positively correlated with the development of torsades de pointes, a potentially fatal ventricular arrhythmia.43 Identifying medications that cause QT prolongation (see Antidepressants and antipsychotics with potential for QT prolongation) and assessing patient risk factors for this condition are vital.48
Treatment recommendations
Due to the complexity of drug-drug interactions, we recommend that NPs utilize drug interaction databases to identify potential interactions. Medscape, http://Drugs.com, and Epocrates are three open-access programs, and Clinical Pharmacology, Lexicomp, and Micromedex are three subscription-based programs. It is essential to recognize the limitations of these resources. Drug interaction database programs do not account for patient age, comorbid medical conditions, or lab values. There is also only a 67% agreement between databases regarding psychiatric drug-drug interactions.12,49,50 Utilizing multiple drug interaction databases and consulting pharmacists is recommended when caring for patients with complex psychiatric and medical comorbidities.49,50
Collaboration
An NP and psychiatric specialist working as a team to improve a patient's care is best practice. There are several ways to improve access to mental health services through primary care. The Veterans Health Administration has developed a model in which mental health specialists, primary care practitioners, and nursing care managers trained in mental health are colocated in clinics together.51 This model has increased mental health visits and primary care visits.51 It also uses the expertise of nursing-care managers to assist patients in meeting their physical and mental health needs and addressing social issues that may play a part in their overall health.
With increased telehealth services, mental health video consultations are also an option for use in primary care offices.52 Use of this model would not require the mental health specialist to be physically present during the consultation and therapy or medical management sessions. This may be an excellent option for primary care practices in rural areas where it is difficult to find specialized mental health providers.
Dually certified primary care and psychiatric NPs may offer another solution to improve care for patients with high needs by providing whole-person care that is high-quality, cost-effective, and patient-centered.53 A dually certified family and psychiatric-mental health NP could integrate medical and mental health care. The NP would also be an excellent resource to other primary care providers when treating patients with complex needs.
Conclusion
Patients with SMI have additional barriers to receiving timely and appropriate physical health services, which causes health disparities. Clinicians are well-positioned to reduce such disparities by implementing processes to monitor and address physical health needs. Improved physical health treatment could lead to positive lifestyle changes and enhanced monitoring that could reduce mortality and morbidity among people with AMI and SMI. Complete assessment and monitoring of physical health concerns and high-quality integrated behavioral and medical care should be the standard of care. NPs can play a significant role in eliminating health disparities in persons with SMI.
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