Silke A. von Esenwein

Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey.

BackgroundAlthough growing concern has been expressed about premature medical mortality in persons with mental illness, limited data are available quantifying the extent and correlates of this problem using population-based, nationally representative samples. MethodsThe study used data from the 1989 National Health Interview Survey mental health supplement, with mortality data through 2006 linked through the National Death Index (80,850 participants, 16,435 deaths). Multivariable models adjusting for demographic factors assessed the increased hazard of mortality adding socioeconomic status, healthcare variables, clinical factors first separately, and then together. ResultsPersons with mental disorders died an average of 8.2 years younger than the rest of the population (P < 0.001). Adjusting for demographic factors, presence of a mental illness was associated with a significant risk of excess mortality, (hazard ratio=2.06, 95% confidence interval=1.71-2.40), with 95.4% of deaths owing to medical rather than unnatural causes. Adding socioeconomic variables to the model, the hazard ratio was 1.77 (P < 0.001); adding health system factors, it was 1.80 (P < 0.001)); adding baseline clinical characteristics, the hazard ratio was 1.32 (P < 0.001). After adding all the 3 groups of variables simultaneously, the association was reduced by 82% from baseline and became statistically nonsignificant (hazard ratio=1.19, P=0.053). ConclusionsThe results of the study underscore the complex causes and high burden of medical mortality among persons with mental disorders in the United States. Efforts to address this public health problem will need to address the socioeconomic, healthcare, and clinical risk factors that underlie it.

A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study

OBJECTIVE Poor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings. METHOD A total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care. RESULTS At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% [versus a 1.1% decline in the usual care group]) and a nonsignificant improvement on the SF-36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%). CONCLUSIONS Medical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.

The Health and Recovery Peer (HARP) Program: A peer-led intervention to improve medical self-management for persons with serious mental illness

OBJECTIVES Persons with serious mental illnesses (SMI) have elevated rates of comorbid medical conditions, but may also face challenges in effectively managing those conditions. METHODS The study team developed and pilot-tested the Health and Recovery Program (HARP), an adaptation of the Chronic Disease Self-Management Program (CDSMP) for mental health consumers. A manualized, six-session intervention, delivered by mental health peer leaders, helps participants become more effective managers of their chronic illnesses. A pilot trial randomized 80 consumers with one or more chronic medical illness to either the HARP program or usual care. RESULTS At six month follow-up, participants in the HARP program had a significantly greater improvement in patient activation than those in usual care (7.7% relative improvement vs. 5.7% decline, p=0.03 for group *time interaction), and in rates of having one or more primary care visit (68.4% vs. 51.9% with one or more visit, p=0.046 for group *time interaction). Intervention advantages were observed for physical health related quality of life (HRQOL), physical activity, medication adherence, and, and though not statistically significant, had similar effect sizes as those seen for the CDSMP in general medical populations. Improvements in HRQOL were largest among medically and socially vulnerable subpopulations. CONCLUSIONS This peer-led, medical self-management program was feasible and showed promise for improving a range of health outcomes among mental health consumers with chronic medical comorbidities. The HARP intervention may provide a vehicle for the mental health peer workforce to actively engage in efforts to reduce morbidity and mortality among mental health consumers.

Viral Vector-Mediated Overexpression of Estrogen Receptor-α in Striatum Enhances the Estradiol-Induced Motor Activity in Female Rats and Estradiol-Modulated GABA Release

Classical estrogen receptor-signaling mechanisms involve estradiol binding to intracellular nuclear receptors [estrogen receptor-α (ERα) and estrogen receptor-β (ERβ)] to promote changes in protein expression. Estradiol can also exert effects within seconds to minutes, however, a timescale incongruent with genomic signaling. In the brain, estradiol rapidly potentiates stimulated dopamine release in the striatum of female rats and enhances spontaneous rotational behavior. Furthermore, estradiol rapidly attenuates the K+-evoked increase of GABA in dialysate. We hypothesize that these rapid effects of estradiol in the striatum are mediated by ERα located on the membrane of medium spiny GABAergic neurons. This experiment examined whether overexpression of ERα in the striatum would enhance the effect of estradiol on rotational behavior and the K+-evoked increase in GABA in dialysate. Ovariectomized female rats were tested for rotational behavior or underwent microdialysis experiments after unilateral intrastriatal injections of a recombinant adeno-associated virus (AAV) containing the human ERα cDNA (AAV.ERα) into the striatum; controls received either the same vector into areas outside the striatum or an AAV containing the human alkaline phosphatase gene into the striatum (AAV.ALP). Animals that received AAV.ERα in the striatum exhibited significantly greater estradiol-induced contralateral rotations compared with controls and exhibited behavioral sensitization of contralateral rotations induced by a low-dose of amphetamine. ERα overexpression also enhanced the inhibitory effect of estradiol on K+-evoked GABA release suggesting that disinhibition of dopamine release from terminals in the striatum resulted in the enhanced rotational behavior.

Integrating Wellness, Recovery, and Self-management for Mental Health Consumers

Three distinct, yet interrelated, terms—wellness, recovery, and self-management—have received increasing attention in the research, consumer, and provider communities. This article traces the origins of these terms, seeking to understand how they apply, individually and in conjunction with one another to mental health consumers. Each shares a common perspective that is health-centered rather than disease-centered and that emphasizes the role of consumers as opposed to professional providers as the central determinants of health and well-being. Developing approaches combining elements of each construct may hold promise for improving the overall health and well-being of persons with serious mental disorders.

Randomized Trial of an Electronic Personal Health Record for Patients With Serious Mental Illnesses

OBJECTIVE The authors evaluated the effect of an electronic personal health record on the quality of medical care in a community mental health setting. METHOD A total of 170 individuals with a serious mental disorder and a comorbid medical condition treated in a community mental health center were randomly assigned to either a personal health record or usual care. One-year outcomes assessed quality of medical care, patient activation, service use, and health-related quality of life. RESULTS Patients used the personal health record a mean of 42.1 times during the 1-year intervention period. In the personal health record group, the total proportion of eligible preventive services received increased from 24% at baseline to 40% at the 12-month follow-up, whereas it declined in the usual care group, from 25% to 18%. In the subset of patients with one or more cardiometabolic conditions (N=118), the total proportion of eligible services received improved by 2 percentage points in the personal health record group and declined by 11 percentage points in the usual care group, resulting in a significant difference in change between the two groups. There was an increase in the number of outpatient medical visits, which appeared to explain many of the significant differences in the quality of medical care. CONCLUSIONS Having a personal health record resulted in significantly improved quality of medical care and increased use of medical services among patients. Personal health records could provide a relatively low-cost scalable strategy for improving medical care for patients with comorbid medical and serious mental illnesses.

Budget impact and sustainability of medical care management for persons with serious mental illnesses

OBJECTIVE The authors assessed the 2-year outcomes, costs, and financial sustainability of a medical care management intervention for community mental health settings. METHOD A total of 407 psychiatric outpatients with serious mental illnesses were randomly assigned to usual care or to a medical care manager who provided care coordination and education. Two-year follow-up chart reviews and interviews assessed quality and outcomes of care, as well as costs from both the health system and managerial perspectives. RESULTS Sustained improvements were observed in the intervention group in quality of primary care preventive services, quality of cardiometabolic care, and mental health-related quality of life. From a health system perspective, by year 2, the mean per-patient total costs for the intervention group were

Randomized Trial of an Integrated Behavioral Health Home: The Health Outcomes Management and Evaluation (HOME) Study

932 (95% CI=-1,973 to 102) less than for the usual care group, with a 92.3% probability that the program was associated with lower costs than usual care. From the community mental health center perspective, the program would break even (i.e., revenues would cover setup costs) if 58% or more of clients had Medicaid or another form of insurance. Given that only 40.5% of clients in this study had Medicaid, the program was not sustainable after grant funding ended. CONCLUSIONS The positive long-term outcomes and favorable cost profile provide evidence of the potential value of this model. However, the discrepancy between health system and managerial cost perspectives limited the programs financial sustainability. With anticipated insurance expansions under health reform, there is likely to be a stronger business case for safety net organizations considering implementing evidence-based interventions such as the one examined in this study.

A Day in the Life of Women With a Serious Mental Illness: A Qualitative Investigation

OBJECTIVE Behavioral health homes provide primary care health services to patients with serious mental illness treated in community mental health settings. The objective of this study was to compare quality and outcomes of care between an integrated behavioral health home and usual care. METHOD The study was a randomized trial of a behavioral health home developed as a partnership between a community mental health center and a Federally Qualified Health Center. A total of 447 patients with a serious mental illness and one or more cardiometabolic risk factors were randomly assigned to either the behavioral health home or usual care for 12 months. Participants in the behavioral health home received integrated medical care on-site from a nurse practitioner and a full-time nurse care manager subcontracted through the health center. RESULTS Compared with usual care, the behavioral health home was associated with significant improvements in quality of cardiometabolic care, concordance of treatment with the chronic care model, and use of preventive services. For most cardiometabolic and general medical outcomes, both groups demonstrated improvement, although there were no statistically significant differences between the two groups over time. CONCLUSIONS The results suggest that it is possible, even under challenging real-world conditions, to improve quality of care for patients with serious mental illness and cardiovascular risk factors. Improving quality of medical care may be necessary, but not sufficient, to improve the full range of medical outcomes in this vulnerable population.

Using electronic health records to improve the physical healthcare of people with serious mental illnesses: A view from the front lines

PURPOSE Few studies have taken a holistic perspective to the lives of women with a serious mental illness (SMI). This qualitative study of women with an SMI describes and interprets womens experiences and provides a new understanding about the nature and needs of these women. METHODS A convenience sample of 30 poor, urban, predominantly African-American women with a diagnosis of an SMI was recruited from an ongoing National Institutes of Mental Health study. Data collection involved face-to-face, in-depth interviews. The interviews were audio-recorded and transcribed verbatim. Data analysis occurred concurrently with data collection using a modified constant comparative method. RESULTS The majority of the women self-identified as African American, single, having completed high school, and at the time of the interview were either unemployed or on disability. The most common SMI was major depression. A common topic in the womens reflections on their lives was that of social disadvantage both before being diagnosed as well as after to their diagnosis with an SMI. Salient themes of their stories included social isolation, experiencing loss, and having a lack of control over ones own life decisions. CONCLUSION The findings from this study revealed varied experiences among these women as well as the complexity of their situation. The enhanced understanding of womens situation will allow mental health professionals to improve the quality of life for women with an SMI by taking a contextual approach to the treatment of their mental illness.