Health, Wellness and Health, Wellness and Recovery; Getting There Recovery; Getting There

from Herefrom Here

William G Wood, MD, PhD, FAPAWilliam G Wood, MD, PhD, FAPA

August 21, 2009August 21, 2009

ObjectivesObjectives

Definition of Recovery Definition of Recovery Progress in RecoveryProgress in Recovery Major Gap in Recovery FocusMajor Gap in Recovery Focus Problems in Current ConceptsProblems in Current Concepts Directions and Solutions Directions and Solutions

National Consensus Statement on National Consensus Statement on Mental Health RecoveryMental Health Recovery

Mental health recovery is a journey of healing Mental health recovery is a journey of healing and transformation for a person with a mental and transformation for a person with a mental health problem to be able to live a meaningful health problem to be able to live a meaningful life in a community of his or her choice while life in a community of his or her choice while striving to achieve maximum human potential.striving to achieve maximum human potential.

The President’s New Freedom The President’s New Freedom Commission on Mental HealthCommission on Mental Health

“After a year of study, and after reviewing research and testimony, the Commission findsthat recovery from mental illness is now a real possibility. The promise of the New Freedom Initiative—a life in the community for everyone—can be realized.”

Excerpt from the letter to the President byMichael F. Hogan, Ph.D.Chairman, President’s New Freedom Commission on Mental Health

Progress in RecoveryProgress in Recovery

Recognition of possibility of Recovery from Recognition of possibility of Recovery from Mental Illness disabilityMental Illness disability

Programs developed to focus on recoveryPrograms developed to focus on recovery Seeing the person, not the disease Seeing the person, not the disease Moving beyond the treatment of symptomsMoving beyond the treatment of symptoms Decrease in Stigma associated with Decrease in Stigma associated with

Mental Illness-ex. US Air Force PolicyMental Illness-ex. US Air Force Policy

““The significant The significant problems that we face problems that we face cannot be solved at cannot be solved at the same level of the same level of thinking we were at thinking we were at when they were when they were created.”created.”

Albert EinsteinAlbert Einstein

What is the problem???What is the problem???

Family??? The Consumer???

The system??? The doctors???

Pharmaceutical companies???

Insurance companies???Stigma???

The Illness?

What Is Missing?????What Is Missing?????What is Missing?????

Overview- THE PROBLEMOverview- THE PROBLEM

Increased Morbidity and Mortality Associated with Increased Morbidity and Mortality Associated with Serious Mental Illness (SMI)Serious Mental Illness (SMI)

Increased Morbidity and Mortality Largely Due to Increased Morbidity and Mortality Largely Due to Preventable Medical Conditions Preventable Medical Conditions

• Metabolic Disorders, Cardiovascular Disease, Diabetes MellitusMetabolic Disorders, Cardiovascular Disease, Diabetes Mellitus• High Prevalence of Modifiable Risk Factors (Obesity, Smoking)High Prevalence of Modifiable Risk Factors (Obesity, Smoking)• Epidemics within Epidemics (e.g., Diabetes, Obesity)Epidemics within Epidemics (e.g., Diabetes, Obesity)

Some Psychiatric Medications Contribute to RiskSome Psychiatric Medications Contribute to Risk

Established Monitoring and Treatment Guidelines to Established Monitoring and Treatment Guidelines to Lower Risk Are Underutilized in SMI PopulationsLower Risk Are Underutilized in SMI Populations

Why Should we be Concerned About Why Should we be Concerned About Morbidity and Mortality?Morbidity and Mortality?

Recent data from several states have Recent data from several states have found that found that people with serious mental people with serious mental illness served by our public mental illness served by our public mental health systems die, on average, at least health systems die, on average, at least 25 years earlier than the general 25 years earlier than the general populationpopulation. .

• National Association of State Mental Health Program DirectorsNational Association of State Mental Health Program Directors• Medical Directors CouncilMedical Directors Council

• July 2006July 2006

Public Health Impact:Public Health Impact:Early Mortality in Individuals with Early Mortality in Individuals with

Major Mental Illness (MMI)Major Mental Illness (MMI)

0

5

10

15

20

25

30

35

Average Arizona Missouri Oklahoma RhodeIsland

Texas Utah

Ye

ars

of

Po

ten

tia

l Lif

e L

os

t

Adapted from Colton and Manderscheid, 2006, Prev Chronic Dis

• Data from outpatient and inpatient clientsdiagnosed with MMI

• Average age at time of death : 56 years

• Increased likelihood of dying from suicide

• Medical co-morbidities

What are the Causes of Morbidity and What are the Causes of Morbidity and Mortality in People with Serious Mortality in People with Serious Mental Illness?Mental Illness?

While suicide and injury account for about 30-While suicide and injury account for about 30-40% of excess mortality, about 60% of 40% of excess mortality, about 60% of premature deaths in persons with schizophrenia premature deaths in persons with schizophrenia are due to “natural causes”are due to “natural causes” Cardiovascular diseaseCardiovascular disease DiabetesDiabetes Respiratory diseasesRespiratory diseases Infectious diseasesInfectious diseases

Osby U et al. Schizophr Res. 2000;45:21-28.

Schizophrenia: Schizophrenia:

Natural Causes of DeathNatural Causes of Death Higher standardized mortality rates than the general Higher standardized mortality rates than the general

population from:population from: Diabetes Diabetes 2.7x2.7x Cardiovascular diseaseCardiovascular disease 2.3x2.3x Respiratory diseaseRespiratory disease 3.2x3.2x Infectious diseases Infectious diseases 3.4x3.4x

Cardiovascular disease associated with the largest Cardiovascular disease associated with the largest number of deaths number of deaths

2.3 X the largest cause of death in the general population 2.3 X the largest cause of death in the general population

Allison DB et al. J Clin Psychiatry. 1999;60:215-220.

Pe

r ce

nt

Pe

rce

nt

< 18.518.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34

0

10

20

30

No schizophrenia

Schizophrenia

Obese Overweight Acceptable Under-weight

BMI RangeBMI Range

BMI Distributions for General Population BMI Distributions for General Population and Those With Schizophrenia (1989)and Those With Schizophrenia (1989)

Mental Disorders and SmokingMental Disorders and Smoking• Higher prevalence (56-88% for patients Higher prevalence (56-88% for patients

with schizophrenia) of cigarette smoking with schizophrenia) of cigarette smoking (overall U.S. prevalence 25%)(overall U.S. prevalence 25%)

• More toxic exposure for patients who More toxic exposure for patients who smoke (more cigarettes, larger portion smoke (more cigarettes, larger portion consumed)consumed)

• Smoking is associated with increased Smoking is associated with increased insulin resistanceinsulin resistance

• Similar prevalence in bipolar disorderSimilar prevalence in bipolar disorderGeorge TP et al. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003; Ziedonis D, Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4):223-330

50-59 y60-69 y

70-74 y

0

5

10

15

20

25

30

Diagnosed Diabetes, General Population

Diagnosed Diabetes, Schizophrenic Patients

Harris et al. Diabetes Care. 1998; 21:518.Mukherjee et al. Compr Psychiatry. 1996; 37(1):68-73.

Schizophrenic:General: 50-59 y

60-74 y75+ y

Percent of

population

Prevalence of Diagnosed Diabetes in General Population Versus Schizophrenic Population

How Does This Relate to What is How Does This Relate to What is Happening in the General Population?Happening in the General Population?

There is an “epidemic” of obesity and diabetes, There is an “epidemic” of obesity and diabetes, increasing risk of multiple medical conditions increasing risk of multiple medical conditions and cardiovascular disease.and cardiovascular disease. Obesity Obesity Diabetes Diabetes Metabolic SyndromeMetabolic Syndrome Cardiovascular DiseaseCardiovascular Disease

Identification of the Metabolic SyndromeIdentification of the Metabolic Syndrome

≥≥3 Risk Factors Required for Diagnosis3 Risk Factors Required for Diagnosis

Risk FactorRisk Factor Defining LevelDefining Level

Abdominal obesity Abdominal obesity Men Men Women Women

Waist circumference Waist circumference >40 in (>102 cm) >40 in (>102 cm) >35 in (>88 cm) >35 in (>88 cm)

TriglyceridesTriglycerides 150 mg/dL 150 mg/dL (1.69mmol/L)(1.69mmol/L)

HDL cholesterol HDL cholesterol Men Men Women Women

<40 mg/dL <40 mg/dL (1.03mmol/L) <50 (1.03mmol/L) <50

mg/dL (1.29mmol/L)mg/dL (1.29mmol/L)

Blood pressureBlood pressure 130/85 mm Hg130/85 mm Hg

Fasting blood glucoseFasting blood glucose 110 mg/dL 110 mg/dL (6.1mmol/L)(6.1mmol/L)

HDL = high-density lipoprotein.NCEP III. Circulation. 2002;106:3143-3421.

CHD Risk Increases with Increasing CHD Risk Increases with Increasing Number of Metabolic Syndrome Risk Number of Metabolic Syndrome Risk

Factors Factors

Sattar et al, Circulation, 2003;108:414-419Whyte et al, American Diabetes Association, 2001Adapted from Ridker, Circulation 2003;107:393-397Adapted from Ridker, Circulation 2003;107:393-397

00.5

11.5

22.5

33.5

44.5

55.5

66.5

7

one two three four

Rel

ativ

e R

isk

Direct and indirect components of the economic burden of serious mental disorders, excluding incarceration, homelessness, comorbid conditions and early mortality. ($ in billions)

1992 2002

Health Care Expenditures $62.91 $100.12

Loss of earning $76.71 $193.23

Disability (SSI + SSDI) $16.41 $24.34

Totals $156.0 B $317.6 B

Resources Matched with Public Health Need

Insel, Am J Psychiatry, 2008

Prevalence of Behavioral Health Prevalence of Behavioral Health DisordersDisorders

26.2% of US adults 18 and over have a 26.2% of US adults 18 and over have a diagnosable Behavioral Health disorderdiagnosable Behavioral Health disorder 19% have Mental Disorders19% have Mental Disorders 3% have both Mental and Addictive Disorders3% have both Mental and Addictive Disorders 6 % have Addictive Disorders alone6 % have Addictive Disorders alone

Leading Cause of Disability in US and Canada Leading Cause of Disability in US and Canada for Ages 15-44for Ages 15-44

20.9% of Children and Adolescents have a 20.9% of Children and Adolescents have a mental disorder that causes some functional mental disorder that causes some functional impairmentimpairment

Psychiatrically Disabled Psychiatrically Disabled AdultsAdults

Co-morbid Medical ConditionsCo-morbid Medical Conditions 36% Male, 64% Female36% Male, 64% Female 17.08% of population (25,202)17.08% of population (25,202)

4.81% have Psych High [Schizophrenia]4.81% have Psych High [Schizophrenia] 2.58% have Psych Medium [Bipolar affective 2.58% have Psych Medium [Bipolar affective

disorder]disorder] 9.69% have Psych Low [Other depression, panic 9.69% have Psych Low [Other depression, panic

disorder, ADD, ADHD]disorder, ADD, ADHD]

Most Frequent ComorbiditiesMost Frequent Comorbidities

Cardiac Extra LowCardiac Extra Low 63026302 25.01%25.01%

CNS LowCNS Low 60126012 23.86%23.86%

Pulmonary LowPulmonary Low 55385538 21.97%21.97%

GI LowGI Low 53195319 21.11%21.11%

Diabetes 2 LowDiabetes 2 Low 35823582 14.21%14.21%

Skeletal Extra LowSkeletal Extra Low 33883388 13.44%13.44%

Psychiatrically Disabled AdultsPsychiatrically Disabled AdultsIncidence of Co-morbidityIncidence of Co-morbidity

      # Behavioral Conditions# Behavioral Conditions   

      11 22 TotalTotal

# Ph

ysical Co

nd

ition

s# P

hysical C

on

ditio

ns

00 59655965 711711 66766676

11 36713671 530530 42014201

22 34943494 585585 40794079

33 28442844 554554 33983398

44 20382038 462462 25002500

55 14521452 391391 18431843

66 896896 252252 11481148

77 499499 153153 652652

88 262262 105105 367367

99 125125 5959 184184

1010 6161 2727 8888

   TotalTotal 2135221352 38503850 2520225202

Components of recoveryComponents of recovery

Responsibility

Respect

Peer support

Strengths-Based

Non-linear

Holistic

Empowerment

IndividualizedPerson-centered

Self direction

Hope

Resources

Source: www.samhsa.gov: National consensus statement on mental health recovery

Components of recoveryComponents of recovery

Responsibility

Respect

Peer support

Strengths-Based

Non-linear

Holistic

Empowerment

IndividualizedPerson-centered

Self direction

Hope

Resources

Source: www.samhsa.gov: National consensus statement on mental health recovery

Components of recoveryComponents of recovery

Responsibility

Respect

Peer support

Strengths-Based

Non-linear

Holistic

Empowerment

IndividualizedPerson-centered

Self direction

Hope

Resources

Source: www.samhsa.gov: National consensus statement on mental health recovery

Physical Health

Components of recoveryComponents of recovery

Responsibility

Respect

Peer support

Strengths-Based

Non-linear

Holistic

Empowerment

IndividualizedPerson-centered

Self direction

Hope

Resources

Source: www.samhsa.gov: National consensus statement on mental health recovery

Physical Health Wellness

Prevention

Physical HealthPhysical Health

Recovery only partial with continuing Recovery only partial with continuing medical illnessmedical illness

Barriers to Good Health and Wellness Barriers to Good Health and Wellness concept-Integrated Careconcept-Integrated Care Availability of providers of medical careAvailability of providers of medical care Willingness to treatWillingness to treat Consumer resistance to physical health focusConsumer resistance to physical health focus Lifestyle choicesLifestyle choices Lifestyle limitationsLifestyle limitations

Problem: Problem: SMI and Reduced Use of Medical ServicesSMI and Reduced Use of Medical Services

Fewer routine preventive services (Druss Fewer routine preventive services (Druss 2002)2002)

Worse diabetes care (Desai 2002, Frayne Worse diabetes care (Desai 2002, Frayne 2006)2006)

Lower rates of cardiovascular procedures Lower rates of cardiovascular procedures (Druss 2000)(Druss 2000)

Access and Quality of CareAccess and Quality of Care

SMI may be a health risk factor because of:SMI may be a health risk factor because of:

Patient factorsPatient factors, e.g.: amotivation, fearfulness, , e.g.: amotivation, fearfulness, homelessness, victimization/trauma, resources, homelessness, victimization/trauma, resources, advocacy, unemployment, incarceration, social advocacy, unemployment, incarceration, social instability, IV drug use, etcinstability, IV drug use, etc

Provider factorsProvider factors: Comfort level and attitude of : Comfort level and attitude of healthcare providers, coordination between mental healthcare providers, coordination between mental health and general health care, stigma,health and general health care, stigma,

System factorsSystem factors: Funding, fragmentation: Funding, fragmentation

Challenges in a Holistic ApproachChallenges in a Holistic Approachto Recovery in Mental Illnessto Recovery in Mental Illness

Lack of Physical Health Focus Lack of Physical Health Focus Presence of Co-occurring IllnessesPresence of Co-occurring Illnesses Lack of Coordination of CareLack of Coordination of Care Obtaining True Healthcare IntegrationObtaining True Healthcare Integration Developing Focus on Early Detection and Developing Focus on Early Detection and

Treatment of Physical and Mental IllnessesTreatment of Physical and Mental Illnesses Development and Education of Support SystemsDevelopment and Education of Support Systems Developing an Integrated Care Model such as Developing an Integrated Care Model such as

the Medical Homethe Medical Home

Coordination of CareCoordination of Care

Primary Care in BH SettingPrimary Care in BH Setting BH care in Primary Care SettingBH care in Primary Care Setting Communication between providers of careCommunication between providers of care

BH providers sharing with Medical Providers BH providers sharing with Medical Providers and vice versaand vice versa

Inpatient sharing with outpatient providersInpatient sharing with outpatient providers

Overview - PROPOSED SOLUTIONSOverview - PROPOSED SOLUTIONS

Prioritize the Public Health Problem• Target Providers, Families and Clients• Focus on Prevention and Wellness

Track Morbidity and Mortality in Public Mental Health Populations

Implement Established Standards of Care

• Prevention, Screening and Treatment

Improve Access to and Integration of Physical Health and Mental Health Care

National Association of State Mental Health Program DirectorsNational Association of State Mental Health Program Directors

Recommendations Recommendations NATIONAL LEVEL

1. Seek federal designation of people with SMI as a distinct at-risk health disparities population. Establish coordinated mental health and general health care as a national healthcare priority.

2. Establish a committee at the federal level to recommend changes to national surveillance activities that will incorporate information about health status in the population with SMI.

Consider representation from SAMHSA, Medicaid, the Centers for Disease Control and Prevention, state MH authorities/NASMHPD, and experts This may include the IOM project and other national surveys.

National Association of State Mental Health Program DirectorsNational Association of State Mental Health Program Directors

RecommendationsRecommendations NATIONAL LEVEL

3. Share information widely about physical health risks in persons with SMI to encourage awareness and advocacy. Educate the health care community. Encourage consumers and family members to advocate for wellness approaches as part of recovery.

Recommendations Recommendations STATE LEVEL

1. Seek state designation of people with SMI as BOTH an at-risk and a health disparities population.

2. Establish coordinated mental health and general health care as a state healthcare priority.

3. Education and advocacy

policy makers

funders

providers

individuals, family, community

RecommendationsRecommendations STATE LEVEL

4. Require, regulate and lead Behavioral Health provider systems to screen, assess and treat both mental health and general health care issues. Provide for

staffing time

record keeping reimbursement

linkage with physical healthcare providers

5.5. Funding Funding

6. Promote co-ordinated and integrated mental health and physical health care for persons with SMI.

See 11th NASMHPD Technical Paper: Integrating Mental Health and Primary Care.

It has been a long journeyIt has been a long journey

Next Steps?Next Steps?