Hello and welcome. I'm Amy Cohen, a member of the clinical expert team with SMI Advisor and an Associate Research Professor in UCLA's Department of Psychiatry and Biobehavioral Science. I'm pleased that you're joining us for today's SMI Advisor webinar, Addressing the Public Health Epidemic of Premature Mortality in People with SMI, Evolving Roles for Mental Health Clinicians. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Benjamin Druss. Benjamin Druss is Professor and Rosalind Carter Chair in Mental Health in the Department of Health Policy and Management at Rollins School of Public Health at Emory University. As one of only a handful of psychiatrists in the country based in the School of Public Health, Dr. Druss is working to integrate mental health, physical health, and public health. His research is focused on understanding and improving access, quality, and outcomes of care for populations with serious mental illnesses and medical comorbidity. This work has included epidemiological studies, intervention trials, and health policy and public health research. Dr. Druss serves on the editorial boards of JAMA Psychiatry and the American Journal of Psychiatry and was a member of the NIMH National Advisory Mental Health Council from 2014 through 2019. In 2018, Dr. Druss was awarded the American Public Health Association's Carl Taub Award for lifetime contribution to the field of mental health. Ben, thank you for leading today's webinar. Thank you so much, Amy. It's great to be here. I have no relationships or conflicts of interest related to the subject matter. So as Amy said today, I'm going to be talking very broadly about the problem of poor health and early mortality of people with serious mental illness. This is a major public health concern, and it's one that really ultimately is a public health problem that warrants a public health approach to addressing it. So what I want to do to start is to talk a little bit about what is public mental health. As Amy mentioned, I'm a psychiatrist, but I've been sitting here in the School of Public Health for the last 16 years, and that really shapes how I understand addressing mental health in general, and in particular, addressing the health and early mortality of people with serious mental illnesses. So what is public mental health? There are kind of two ways of thinking of it, both of which add up to a full picture. So the first is ensuring that mental health is a part of public health initiatives and research and in education. So it's recognizing the importance of mental health, putting it on the broader public health radar screen. The second, which is particularly relevant to what we're talking about today, is using public health approaches to improve whole person outcomes in populations with mental illness. It's seeing a population with mental illness, particularly a population, say, with serious mental illness, as a group, as a vulnerable population who share a lot of common challenges and for whom there are opportunities to improve those challenges collectively. So this is the cover of the book of what is probably the most famous public health burden study. It's called the Global Burden of Disease Study, and it was commissioned by the World Bank in 1990 and conducted by a couple of health economists. And what the study set out to do was to understand the burden of disease, both in different parts of the world and across different kinds of conditions. So when you're thinking about public mental health, it's a very useful starting point to think about. And this is a recent ranking of different kinds of health conditions within the United States using the global burden of disease methods. Those methods combine two pieces. The first piece is the degree of disability associated with the condition. That means how impaired your life is while you're alive from having a condition, different kinds of conditions. And what you see when you look at this disability metric is that three out of the top 10 conditions posing the most burden are all mental conditions. Those are major depressive disorder, anxiety disorders, and opioid use disorders. And for depression and anxiety in particular, the reason that there is such a high burden of these diseases from a public health perspective is three pieces. First is they're highly prevalent. So mental disorders affect something like 20% of the population in the United States at any given time. The second is they start young. So in contrast, say, to cardiovascular disease, which actually isn't on this list of disabilities, mental disorders tend to begin in childhood and adolescence or early adulthood. And the third factor is that mental disorders are by definition disabling. So the bright line between having a mental disorder and not having a mental disorder is that they're impairing some domain of function. Often in contrast, say, to low back pain, they're affecting higher order functions such as ability to hold a job or to interact socially. So this is the disability piece. And this is what really put mental disorders on the public health map beginning in 1990, the fact that there's such a high disability burden associated with them. The piece, though, that isn't typically included in these public health burden rankings is the piece that I'm going to be talking about today, and that's mortality. So public health burden is a combination of how disabling a condition is while you're alive, and then how likely it is to cause early mortality. So if you look across all different kinds of mental disorders, this was a large meta-analysis that we did very broadly across the studies that have been done, you find about a 10-year shortening of lifespan. And if you multiply that by the very high prevalence of mental disorders, it results in something like eight million annual deaths due to mental disorders worldwide. So the burden at a population level is very high for conditions like depression and anxiety because they're so prevalent. But when you look at serious mental illness, which is going to be the focus of what we're talking about today, what you see is, although they're less prevalent, there's something like 5% of the population as opposed to 20% of the population, you see much more dramatic problems in physical health status and early mortality. So you see something, if you look at a general population, say with schizophrenia, something like a 15-year shortening of lifespan. And then if you look at people treated in the public mental health sector, so places like state hospitals or community mental health centers, it starts to look more like about a 25-year shortening of lifespan. So this is a huge burden. It's largely underappreciated or under-reported in public health burden estimates. And part of the reason that that is under-reported is because people with mental disorders, from a public health perspective, are most commonly dying of general medical conditions. So from what historically the field focused on for many years, probably since these studies were first reported beginning in the 19th century through the 1990s, was unnatural deaths. And the reason for that is that when you look at a problem like suicide, it's the worst possible outcome that a mental health clinician can see that is directly resulting from a mental disorder. But when you kind of flip it and look from a population perspective, what you realize is because of the high base prevalence of conditions like cardiovascular disease, diabetes, and cancer, is that most of the deaths at a population level, again, if you're looking at people with serious illness as a population, the majority of deaths are due to general medical conditions. It's the same conditions that the general population is dying from. They're just dying at rates of something like two-fold higher than the general population. And interestingly, if you look even at other countries or other time periods, you see the same pattern. So in developing countries, what those natural deaths look like are infectious diseases, the same conditions that other people are dying from in that country. But in the United States, those deaths are cardiovascular disease, again, cancer, or lung disease. So that's the problem. So if we're taking this as a public health problem, then addressing it requires a public health framework. That's going to be the remainder of my talk of what I'm going to be talking about today. The World Health Organization has begun recently to engage with this issue. In 2017, they published a multi-level framework for addressing the problem of early mortality and poor physical health of people with serious mental illness. And the three levels that I'm going to be talking about that fit within that framework are individual level. So that is the issues that we commonly think of around improving lifestyle, like smoking, reducing smoking and other risk factors, improving physical activity and diet, and getting people good medical treatment. But those individual treatments are happening within health systems. And the only way to ensure that they're delivered are to redesign health systems in ways that allow them to be effectively delivered. So those include service integration and efforts to better coordinate care between medical and mental health providers, and then also implementation of guidelines. And then finally, those health systems are sitting within communities and patients spend most of their lives outside of health systems in those communities. And within those communities, you have policies that are setting the rules and the reimbursement systems for health systems. And then also you have patients who are needing to effectively manage their illnesses. So I'm going to talk about each of these levels and what the evidence, the current evidence shows. So first, individual interventions. First, as I mentioned, there's a need to address lifestyle factors. It's been estimated in general populations that something like 40% of preventable mortality is related to lifestyle factors rather than where most of our resources go, which is in formal medical care. And populations with serious mental illness have drastically worse lifestyles, the worst of which is smoking, in which it's been estimated that something like 60 or 70% of people with schizophrenia continue to smoke. They also have worse diets and lower rates of physical activity. So in addition to lifestyle factors, people with serious mental illness are at risk for receiving, having worse access to medical services, and then receiving lower quality of medical services. So it's important that they get effective treatment for medical conditions. And here, in a way, the problem is relatively straightforward. There's a very good body of literature that documents how to provide effective medical care, and that should be the default for people with serious mental illness. If you have a treatment proven effective in a general population, that should be a starting point for treatment of people with serious mental illness. And that's sort of the message that was the bottom line of the second set of World Health Organization guidelines that were just released last fall, which said that interventions delivered in general populations should also apply to populations with serious mental illness, although typically there needs to be some degree of tailoring. And it needs to be tailored for the factors specific, the cognitive and other kinds of symptoms related to mental disorders, and also the fact that people tend to be poorer and that they're treated in systems that may be more fragmented. So it should default to high quality medical care appropriate to general populations, but with tailoring for populations with serious mental illness. So the second level is system-level interventions, and these are helping systems to facilitate those individual level, either lifestyle or medical treatments. And they typically use either people, so people like care managers or information technology to help ensure that the systems that are in which populations with serious mental illness are found and are treated can effectively deliver those individual level treatments. In the U.S., these are typically delivered in public sector community mental health settings, like community mental health centers or inpatient state hospitals and psychiatric facilities. Interestingly, in other countries that can look quite different, say in the U.K., much of both the mental health and medical care for populations with serious mental illness is actually happening in primary care, and therefore that requires different kinds of system-level interventions to allow people to get good medical care and health behavior interventions. So there has been some research on system-level interventions. There's obviously a lot less on them because they're more specific to providing care specific to populations with serious mental illness in contrast to the individual-level interventions, which can be drawn just from general populations. But what they've generally found is that it is feasible and possible to improve medical care for populations with serious mental illness, and that it's possible to deliver high-quality medical care to them through these interventions. But alone, these system-level interventions, you tend to see kind of a voltage drop where there are smaller effects on downstream physical health outcomes, such as cardiovascular health and overall measures of physical health status. Interestingly, these interventions may have benefits for mental health symptoms and recovery outcomes, so that many of these interventions, although they're designed to improve patients' physical health status, actually may improve their patients' mental health well-being as well as the broader recovery functional kinds of outcomes. So I'm going to give you one example of a community-level intervention that we've been involved in. But first, just want to kind of highlight why this is important. The time that patients spend outside of doctors' offices is typically much greater than the time that they spend in doctors' offices. That applies to all of us. But even those folks with chronic illnesses or with serious mental illness, the vast amount of time that people spend is referred to as the other 5,000 hours. It's all those waking hours that people need to learn to be better self-managers. They need to be able to manage their health behaviors as well as become effective advocates for themselves in the time that they're spending during their doctor visits. The other factor that is hugely important. When you're thinking, when you're taking this public health lens, thinking about populations with serious mental illness as a population, you need to understand the importance of the social determinants of health in these populations. People with serious mental illness typically are poor, often resulting from their mental illness, but also poverty can then further exacerbate mental illness as well as their physical health illness. It's a common risk factor, both for mental illness and chronic medical conditions. It can also then make it more difficult to manage conditions. So it can, poverty and stigma and social isolation can make it more difficult to be able to stay on medications as well as to access high quality healthcare, to get nutritious food, to engage in physical activity. So these are really important factors to be thinking about. I'm gonna give you one example of a study that we did addressing this. It's called the Health and Recovery Peer Program. And this was a medical disease self-management program that was originally developed for general medical populations, but that we adapted to be led by people with, who are users of mental health services, but then also for people who are users of mental health services, typically those who have treated the public mental health sector with more serious conditions. This was a six-session group format. And really, if you looked under the hood at what made it work, it was focused around helping people with serious mental illness become more self-managed, effective self-managers by goal-setting. And this is really, if you look at most health behavior programs, what really allows them to work. And again, this applies again, both to the populations that we treat, but also to any of us in our own lives. The way that health behavior change happens is through setting small, achievable goals that a person feels confident in their ability to be able to achieve. And then each week, that process of goal-setting allows them both to kind of feel good about themselves, improve what's called activation or self-efficacy, but then also to, through these little steps, in this longer journey, towards better health. So that's really, it's what we used in our intervention, but really what any of us should be thinking about when we're working either with ourselves or with our patients in terms of wanting to change a health behavior like smoking, physical activity, or adherence and engagement with formal medical services. And again, this is, I think, my only data slide in the presentation, but it's a, what we felt was interesting outcome that we felt really good about. The intervention only lasts three months. So what you see here is that by three months, you begin to see an improvement in the intervention, the self-management intervention, relative to usual care, but you see a continuing improvement and difference between the intervention and usual care between three months and six months. And that does suggest the possibility that these kind of self-management interventions can kind of help set people on a course towards better health that may actually improve and be sustained over time. Okay, so what I want to end with is to think with you about what you, what we all as mental health clinicians can do to address this problem of poor physical health and early mortality. So the first piece to think about, this is a statue of Hippocrates, who of course famously said, first, do no harm. And this is what medical students and really all clinicians learn about when we are trained, which is let's at least not make problems worse. And we have to recognize that part of the problem of poor health and early mortality in people with serious mental illness is actually iatrogenic. It's the inevitable consequence of the fact that any of our treatments, medications in particular, often can lead to obesity, to adverse metabolic consequences. So here, what you want to be thinking about is if you're trying to minimize these effects, is a few things. There are a few options. So first is, if possible, people who are already on medications, to always be reviewing both whether they need to continue to be on them and whether they are on the minimum effective dose. Many of the metabolic effects of psychotropic medications and in particularly, probably the worst offenders, which are second generation psychotic, antipsychotic medications appear to be dose dependent. So try to have people on the minimum possible dose of medications and always be reevaluating this over time to be adjusting down. The second is where possible, particularly when patients do need to be on these medications long term to consider switching medications. There've been a number of studies that show that switching from antipsychotics with high potential for metabolic side effects to ones with more favorable profiles does not appear to result in worsening of psychiatric symptoms. So it can be done safely, but does improve patients' metabolic profiles, which in turn can have downstream beneficial effects for people's health. And yeah, I mean, the high risk groups in terms of people at risk for developing these metabolic problems are both people who are on high doses of the medications, people who are on polypharmacy. So that's something to try to avoid if possible. And then also to keep a particular eye on potentially vulnerable subgroups. So young people, people, first episode psychosis, and then also older elderly populations. So the second strategy that we clinicians should be thinking about is screening for common problems. Screening alone isn't enough to address poor health, but it's the first step. It's necessary, even if it's not sufficient. And this is becoming more common practice in mental health settings, places like community mental health centers, certainly more common practice than it was when I was in training. But screening rates are still variable. Screening rates are still variable. And it appears that while they tend to be pretty good for things like blood pressure, they're more variable for glucose and lipids. This is a monitoring protocol that was done based on a meta-analysis for individuals with schizophrenia. It, you see things like medical history, weight, waste, body mass index, blood pressure, glucose, lipids, lifestyle advice. I should say that although this specifies fasting glucose and fasting lipids, that research that has come out more recently suggests that it may not be necessary to do these fasting. And certainly, you know, fasting can be a lot harder to get fasting bloods in busy public mental health settings. So it's probably adequate just to get non-fasting if that's what's available. And these particularly need, you need more frequent measurements initially after starting medications. So counseling is also important and something that mental health clinicians should really be thinking about. We are presumably experts in understanding how to change behaviors. And we can put those ones that we learned originally in the service of changing things like how people think and behave socially to things like how they behave on the medical side as well. And as I mentioned, the sorts of strategies like goal setting and motivational interviewing where you're trying to really engage patients rather than kind of telling them what they should be doing, trying to understand from their perspective what's in it for them around something like quitting smoking. You know, how is it gonna positively affect their life if they're able to quit tobacco in terms of expenses for cigarettes and kind of their freedom to be able to go to different places and not have to worry about finding a place to, where they can smoke outside. And then finally, treating common conditions. So this is a somewhat complicated question that I wanna spend a little bit more time walking you through it. You know, often people, this is sort of the piece of the issue that makes people the most anxious. You know, are we gonna suddenly be expected to be treating really complicated medical conditions or unstable medical conditions in our patients? And really the answer is that this is, the answer of when and how and whether to treat common medical conditions really depends on the context that you're working in. So this is a framework that we worked on that sort of walked through some of those different scenarios and I think might be useful for you to be thinking about. The first is the nature of the problem. So no one is expecting psychiatrists or other mental health providers to be dealing with someone who is having unstable angina or some potentially, you know, an acute GI bleed. You know, if there is an immersion problem, they need to be referred, you know, to be walked over to an emergency room or have 911 called. But if problems are more routine, then you can begin to think of, you know, it's still in the realm of possibility that you may be considering treating them. The second question is, you know, do they already have a primary care provider? You know, probably if someone already has a primary care provider and has a reasonable relationship and is engaged in that treatment, you know, your main role as a mental health provider is really effectively coordinating with that provider rather than either shifting all of the care to the mental health setting or to trying to, you know, provide parallel treatment with the primary care provider. So the third thing to think about is your own level of training. Now that is something that of course can change and one of the things that you really should be thinking about is kind of dusting off some of your medical know-how and skills. But, you know, what you do in terms of treating people should reflect what your current level of competency is in treating. And it also depends on where you're working. You know, do you have a medical director who supports this kind of work? Do you have an organization that has the things that would be needed? Does it have, you know, capacity to provide on-site testing? Does it have a pharmacy on-site that can dispense medical, you know, statins or other common medical treatments? So those are the kinds of system level issues that you want to be thinking about. And the more that there's a system in place that's supportive of providing medical care, the more it becomes feasible and safe and desirable to provide that care. And then finally, we really need to think about the issue of patient preference. You know, ask your patients. I mean, there may be, you know, there are some patients who may really want to get their medical care in a primary care setting, particularly if they've had good experiences there. But there may be others who really feel like their home base is a medical, is a mental health setting, is a community mental health center. And in those cases, and if all of those other pieces are in place, that really may be the place where they're most likely to get, to accept and feel happy with the medical services that they're receiving. So really, when all of those pieces are in place, that's when you really can think about managing a, you know, what is typically a problem, say like high, you know, a stable problem, like high cholesterol or high blood pressure in a mental health setting. And this says psychiatrists, but really this would apply to other prescribing clinicians like nurse practitioners or physician assistants. So I just want to end by zooming out a bit to think about, you know, based on all of that, what really then are the roles for mental health clinicians? And here, I really do want to include not only psychiatrists but other kinds of mental health clinicians as well. So I'm guessing on the call today, we have probably psychiatrists, but also nurses and social workers and perhaps peer providers as well. And really their roles for mental health providers of all types in the health system. So the first is, regardless of what you're doing, regardless of whether, you know, your patients are getting their care from a, you know, all of their medical services in primary care setting, or whether you're providing some of them on site at a mental health facility, all mental health clinicians should be literate in basic medical diagnoses and treatments. So you should know, you know, what's the threshold? And it may change over time for what's high blood pressure. What is a high hemoglobin A1C? What's a high cholesterol? What's, you know, this is basic medical literacy that will help you to interpret when you see a result, a lab result, or a medical chart. It'll let you understand, you know, what are the most, you know, common medical conditions? What are they? What do they look like? And again, it's important not all, whether you're actually, whether your facility is actually providing medical services or whether you're just trying to help coordinate services between your setting and a primary care setting. Second is, you know, this issue of coordination, you're never gonna be able to get, it's always gonna be central. Even if you're a facility that's providing some medical services onsite, routine medical services, like a behavioral health home, if you're a, you know, there may be some grantees, SAMHSA grantees from these integrated clinics. There's still gonna be more complicated cases or emergent cases that need to be referred out. So you're always gonna need to really be attuned to the idea of effectively coordinating between the mental health care that you're providing and the medical services that are provided elsewhere. And here on the coordination side, you know, it's really where there's this vital role for care managers of different kinds of training, nurses or peers or social workers who are really serving as that connector to other, between mental health settings and other systems. And finally, I just wanna say that there are many opportunities for you to develop and enhance these skills or rediscover these skills that you may have had at one point, but that have kind of atrophied a bit as we've moved away from our internships and med school. So the American Psychiatric System, the American Psychiatric Association provides online and in-person trainings for psychiatrists to develop their primary care skills. I know for instance, at the upcoming APA meeting, there is a track for improving primary care skills for psychiatrists. And these are great skills again to burnish whether or not you're directly providing primary care. And it's fun to both to relearn what you may have once known and then also to learn what's new on the horizon in terms of managing some of these common medical conditions so I strongly recommend you to do, to engage in these learning opportunities. So that's what I have to say. Thank you.

premature mortality

serious mental illness

public health approach

integrating mental health

physical health

lifestyle factors

care coordination

peer-led medical disease self-management program