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Health,Wellnessand Recovery082109 Presentation
 

Health,Wellnessand Recovery082109 Presentation

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Middle TN Mental Health Recovery and Resiliency Symposium

Middle TN Mental Health Recovery and Resiliency Symposium
Dr William Wood

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    Health,Wellnessand Recovery082109 Presentation Health,Wellnessand Recovery082109 Presentation Presentation Transcript

    • Health, Wellness and Recovery; Getting There from Here William G Wood, MD, PhD, FAPA August 21, 2009
    • Objectives
      • Definition of Recovery
      • Progress in Recovery
      • Major Gap in Recovery Focus
      • Problems in Current Concepts
      • Directions and Solutions
    • National Consensus Statement on Mental Health Recovery
      • Mental health recovery is a journey of healing and transformation for a person with a mental health problem to be able to live a meaningful life in a community of his or her choice while striving to achieve maximum human potential.
    • The President’s New Freedom Commission on Mental Health “ After a year of study, and after reviewing research and testimony, the Commission finds that 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 by Michael F. Hogan, Ph.D. Chairman, President’s New Freedom Commission on Mental Health
    • Progress in Recovery
      • Recognition of possibility of Recovery from Mental Illness disability
      • Programs developed to focus on recovery
      • Seeing the person, not the disease
      • Moving beyond the treatment of symptoms
      • Decrease in Stigma associated with Mental Illness-ex. US Air Force Policy
      • “ The significant problems that we face cannot be solved at the same level of thinking we were at when they were created.”
      • Albert Einstein
    • What is the problem??? Family??? The Consumer??? The system??? The doctors??? Pharmaceutical companies??? Insurance companies??? Stigma??? The Illness?
    • What Is Missing????? Social Support? Physical Health?? Coordination of Care?? What Else Should We Be Focused On???? What is Missing????? Prevention?? Physical Illnesses????
    • Overview- THE PROBLEM
      • Increased Morbidity and Mortality Associated with Serious Mental Illness (SMI)
      • Increased Morbidity and Mortality Largely Due to Preventable Medical Conditions
          • Metabolic Disorders, Cardiovascular Disease, Diabetes Mellitus
          • High Prevalence of Modifiable Risk Factors (Obesity, Smoking)
          • Epidemics within Epidemics (e.g., Diabetes, Obesity)
      • Some Psychiatric Medications Contribute to Risk
      • Established Monitoring and Treatment Guidelines to Lower Risk Are Underutilized in SMI Populations
    • Why Should we be Concerned About Morbidity and Mortality?
      • Recent data from several states have found that people with serious mental illness served by our public mental health systems die, on average, at least 25 years earlier than the general population .
          • National Association of State Mental Health Program Directors
          • Medical Directors Council
          • July 2006
    • Public Health Impact: Early Mortality in Individuals with Major Mental Illness (MMI) Adapted from Colton and Manderscheid, 2006, Prev Chronic Dis
      • Data from outpatient
      • and inpatient clients
      • diagnosed 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 Mortality in People with Serious Mental Illness?
      • While suicide and injury account for about 30-40% of excess mortality, about 60% of premature deaths in persons with schizophrenia are due to “natural causes”
        • Cardiovascular disease
        • Diabetes
        • Respiratory diseases
        • Infectious diseases
    • Schizophrenia: Natural Causes of Death
      • Higher standardized mortality rates than the general population from:
        • Diabetes 2.7x
        • Cardiovascular disease 2.3x
        • Respiratory disease 3.2x
        • Infectious diseases 3.4x
      • Cardiovascular disease associated with the largest number of deaths
        • 2.3 X the largest cause of death in the general population
      Osby U et al. Schizophr Res . 2000;45:21-28.
    • BMI Distributions for General Population and Those With Schizophrenia (1989) Allison DB et al. J Clin Psychiatry . 1999;60:215-220. Percent < 18.5 18.5-20 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 Range
    • Mental Disorders and Smoking
      • Higher prevalence (56-88% for patients with schizophrenia) of cigarette smoking (overall U.S. prevalence 25%)
      • More toxic exposure for patients who smoke (more cigarettes, larger portion consumed)
      • Smoking is associated with increased insulin resistance
      • Similar prevalence in bipolar disorder
      George 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
    • 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 y 75+ y Percent of population Prevalence of Diagnosed Diabetes in General Population Versus Schizophrenic Population
    • How Does This Relate to What is Happening in the General Population?
      • There is an “epidemic” of obesity and diabetes, increasing risk of multiple medical conditions and cardiovascular disease.
        • Obesity
        • Diabetes
        • Metabolic Syndrome
        • Cardiovascular Disease
    • Identification of the Metabolic Syndrome HDL = high-density lipoprotein. NCEP III. Circulation. 2002;106:3143-3421. ≥ 3 Risk Factors Required for Diagnosis Risk Factor Defining Level Abdominal obesity Men Women Waist circumference >40 in (>102 cm) >35 in (>88 cm) Triglycerides  150 mg/dL (1.69mmol/L) HDL cholesterol Men Women <40 mg/dL (1.03mmol/L) <50 mg/dL (1.29mmol/L) Blood pressure  130/85 mm Hg Fasting blood glucose  110 mg/dL (6.1mmol/L)
    • CHD Risk Increases with Increasing Number of Metabolic Syndrome Risk Factors Sattar et al, Circulation, 2003;108:414-419 Whyte et al, American Diabetes Association, 2001 Adapted from Ridker, Circulation 2003;107:393-397
    • 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 Disorders
      • 26.2% of US adults 18 and over have a diagnosable Behavioral Health disorder
        • 19% have Mental Disorders
        • 3% have both Mental and Addictive Disorders
        • 6 % have Addictive Disorders alone
      • Leading Cause of Disability in US and Canada for Ages 15-44
      • 20.9% of Children and Adolescents have a mental disorder that causes some functional impairment
    • Psychiatrically Disabled Adults Co-morbid Medical Conditions
      • 36% Male, 64% Female
      • 17.08% of population (25,202)
        • 4.81% have Psych High [Schizophrenia]
        • 2.58% have Psych Medium [Bipolar affective disorder]
        • 9.69% have Psych Low [Other depression, panic disorder, ADD, ADHD]
      Most Frequent Comorbidities Cardiac Extra Low 6302 25.01% CNS Low 6012 23.86% Pulmonary Low 5538 21.97% GI Low 5319 21.11% Diabetes 2 Low 3582 14.21% Skeletal Extra Low 3388 13.44%
    • Psychiatrically Disabled Adults Incidence of Co-morbidity     # Behavioral Conditions       1 2 Total # Physical Conditions 0 5965 711 6676 1 3671 530 4201 2 3494 585 4079 3 2844 554 3398 4 2038 462 2500 5 1452 391 1843 6 896 252 1148 7 499 153 652 8 262 105 367 9 125 59 184 10 61 27 88   Total 21352 3850 25202
    • Components of recovery Source: www.samhsa.gov : National consensus statement on mental health recovery Responsibility Respect Peer support Strengths- Based Non-linear Holistic Empowerment Individualized Person- centered Self direction Hope Resources
    • Components of recovery Source: www.samhsa.gov : National consensus statement on mental health recovery Responsibility Respect Peer support Strengths- Based Non-linear Holistic Empowermen t Individualized Person- centered Self direction Hope Resources
    • Components of recovery Source: www.samhsa.gov : National consensus statement on mental health recovery Physical Health Responsibility Respect Peer support Strengths- Based Non-linear Holistic Empowerment Individualized Person- centered Self direction Hope Resources
    • Components of recovery Source: www.samhsa.gov : National consensus statement on mental health recovery Physical Health Wellness Prevention Responsibility Respect Peer support Strengths- Based Non-linear Holistic Empowerment Individualized Person- centered Self direction Hope Resources
    • Physical Health
      • Recovery only partial with continuing medical illness
      • Barriers to Good Health and Wellness concept-Integrated Care
        • Availability of providers of medical care
        • Willingness to treat
        • Consumer resistance to physical health focus
        • Lifestyle choices
        • Lifestyle limitations
    • Problem: SMI and Reduced Use of Medical Services
      • Fewer routine preventive services (Druss 2002)
      • Worse diabetes care (Desai 2002, Frayne 2006)
      • Lower rates of cardiovascular procedures (Druss 2000)
    • Access and Quality of Care
      • SMI may be a health risk factor because of:
        • Patient factors , e.g.: amotivation, fearfulness, homelessness, victimization/trauma, resources, advocacy, unemployment, incarceration, social instability, IV drug use, etc
        • Provider factors : Comfort level and attitude of healthcare providers, coordination between mental health and general health care, stigma,
        • System factors : Funding, fragmentation
    • Challenges in a Holistic Approach to Recovery in Mental Illness
      • Lack of Physical Health Focus
      • Presence of Co-occurring Illnesses
      • Lack of Coordination of Care
      • Obtaining True Healthcare Integration
      • Developing Focus on Early Detection and Treatment of Physical and Mental Illnesses
      • Development and Education of Support Systems
      • Developing an Integrated Care Model such as the Medical Home
    • Coordination of Care
      • Primary Care in BH Setting
      • BH care in Primary Care Setting
      • Communication between providers of care
        • BH providers sharing with Medical Providers and vice versa
      • Inpatient sharing with outpatient providers
    • Overview - 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 Directors
    • Recommendations NATIONAL LEVEL
      • 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.
      • 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 Directors
    • Recommendations NATIONAL LEVEL
      • 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 STATE LEVEL
      • Seek state designation of people with SMI as BOTH an at-risk and a health disparities population.
      • Establish coordinated mental health and general health care as a state healthcare priority.
      • Education and advocacy
      • policy makers
      • funders
      • providers
      • individuals, family, community
    • Recommendations STATE LEVEL
      • 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
      • Funding
      • 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 journey
    • Next Steps?