Integrated Care and Psychiatrists

Abstract

The world of health care in the United States is changing fairly rapidly, especially with regard to how care is delivered. Providers, patients, and payers need to adapt to the changing healthcare environment to maximize their effectiveness and to avoid being made irrelevant by this cataclysm of system transformation, particularly the specialized interface between primary care (PC) and behavioral health (BH) (which includes mental health and substance use disorders and the patients/services/providers associated with such conditions). It is abundantly clear that delivery system redesign is essential to improve health of the population, improve patient experiences with the delivery of healthcare services, and reduce per capita costs for such services.

Appendices

Appendix A: Comprehensive Preventive Health Screening for Adults with Serious Mental Illnesses

This appendix is designed to assist community psychiatrists in providing preventive disease services currently recommended for the general population, based on age, gender, smoking, and pregnancy status, with additional recommendations for screening services and/or medications for persons with SMI.

Recommended Universal Screening

Universal preventive health recommendations (USPSTF) based on gender, age, smoking, and pregnancy status are accessible at http://epss.ahrq.gov/ePSS/search.jsp, including a printable version. The USPSTF list is a reasonable baseline set of recommendations. Further services may be indicated based on personal history, family history, other known risk factors for preventable diseases, or individual patient characteristics.

Immunizations

A convenient and user-friendly guide for recommended adult vaccine schedules, assuming patients are up to date on recommended childhood vaccinations, is accessible at: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm. Of particular note for persons seen in BH settings, where there is a high incidence of tobacco use, especially smoking, adults who smoke are considered to have chronic underlying lung disease and should be offered a pneumococcal (polysaccharide) vaccine once before the age of 65, and again at the age of 65 in addition to yearly influenza vaccinations.

Additional Preventive Services for Persons with Serious Mental Illnesses

Communicable Diseases

People should be offered screening at intake and annually for the following if risk factors exist or persist (De Hert et al. 2011): syphilis; tuberculosis, hepatitis B, and hepatitis C; HIV.

Cardiovascular Disease

Basic screening should occur similarly to the general American adult population, with additional screening as guided by individual risk factors (i.e., high-risk medications, smoking cessation, etc.).

High-Risk Medications

Some common medication classes and specific medications to consider in screening and monitoring for this population:

• Second generation antipsychotics (American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists and North American Association for the Study of Obesity 2004):

  

• Lithium: Renal, thyroid, pregnancy, fluid status, urinalysis, and complete blood count.

• Valproic acid: Liver function tests (baseline and throughout), complete blood count with platelets, serum drug levels; prothrombin time/partial thromboplastin time, especially prior to surgery; serum ammonia if the person is lethargic or with mental status changes.

• Tricyclic antidepressants: Blood pressure, pulse, weight, electocardiogram in older adults and those with previous history of heart disease.

• First generation antipsychotics: AIMS every 6 months, some with EKG.

Metabolic, Nutritional, and Endocrinologic Deficiencies

Monitor for these deficiencies with the following screening tests/questions: complete blood count (anemia may present as depression); thyroid (may mask signs of depression, may be affected by some treatments); liver function tests (may be at elevated risk for nonalcoholic hepatitis, hepatitis, or alcoholism) (De Hert et al. 2011); vitamin B12 and folate (poor dietary intake); vitamin D (limited sunlight exposure or dietary intake); dexa scan: especially in those at equal risk to women above 65 years of age; questions about constipation and oral health (De Hert et al. 2011).

Endocrinological or Metabolic Disorders

These disorders may be addressed with the following treatments: multivitamin; folate (dosage: 400–800 μg/day), especially in women of childbearing age; thiamine (dose: 100 mg/day): there is a high co-occurrence in alcohol misuse disorders; vitamin D (dosage: 400 IU daily); and calcium (dosage: 1,000 mg elemental daily); omega-3 fatty acids that may help with depression and schizophrenia (no dosage range has been identified, doses above 3,000 mg/day should be used cautiously; Akter et al. 2011).

Intrapartum and Postpartum Period

Neonatal urine drug screen/meconium drugs of abuse on neonates born to mothers with serious mental illnesses or depression (De Hert et al. 2011); postpartum depression screening instrument; increased frequency of visits, higher monitoring of high-risk medications and exacerbation of symptoms.

Co-occurring Conditions

Alcohol and substance misuse; tobacco use. Adults with SMI should be offered counseling routinely, in addition to pharmacological/replacement therapies to assist in cessation (Allen et al. 2011).

Injury/Violence

Suicide risk; intimate partner violence; seatbelt use; helmet use.

Appendix B: Indications for Referral to PCP

Elevated Blood Sugar

Fasting blood sugar (serum) above100 mg/dL, two non-fasting (random) serum blood sugars above 200 mg/dL, or Hemoglobin A1C (non-fasting) above 6.5%.

Dyslipidemia

Fasting LDL above 130 mg/dL, total cholesterol above 240 mg/dL; HDL below 40 mg/dL. Triglycerides (fasting) above 150 mg/dL. The following website provides a useful step-by-step guide for screening, diagnosing, and treating dyslipidemias: http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.htm.

Hypertension

Two blood pressures above 140 mmHg systolic or above 90 mmHg diastolic greater than 1 week apart.

Metabolic Syndrome

Any three of the following:

Risk factor	Defining level
Abdominal obesity	Waist circumference
Men	>102 cm (>40 in.)
Women	>88 cm (>35 in.)
Triglycerides	≥150 mg/dL
HDL cholesterol
Men	<40 mg/dL
Women	<50 mg/dL
Blood pressure	≥130/≥85 mmHg
Fasting glucose	≥110 mg/dL

Obesity is associated with insulin resistance and metabolic syndrome. The presence of abdominal obesity is more highly correlated with metabolic risk factors than an elevated body mass index (BMI). Therefore, the measurement of waist circumference is recommended to identify the body weight component of the metabolic syndrome. Some male patients develop multiple metabolic risk factors when waist circumference is only marginally increased, e.g., 94–102 cm (37–39 in.). They may have a strong genetic contribution to insulin resistance and should benefit from changes in life habits, similar to men with categorical increases in waist circumference.