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August 17, 2009

Double Trouble — Managing Medical and Mental Illness
By Lisa Esposito
For The Record
Vol. 21 No. 16 P. 24

The inability to share patient information across provider settings is just one drawback to better care for patients suffering from both physical and mental health problems.

Adrienne Fitts, 46, is a disabled Navy veteran living in Chicago who learned in 1998 that she had a mental illness. The psychiatric drugs she was prescribed as a result caused her weight to balloon to 265 pounds and, in 2001, she developed diabetes. In addition, she has hypertension and is now recovering from a stroke and a bout with encephalitis.

Gloria, a 56-year-old legislative advocacy worker, also deals with both a major mental and a medical condition. Gloria, who asked to be identified by first name only, has long-term clinical depression, neurological problems, and partial kidney failure.

“Multiple conditions are not rare, and they become even more common as people get older,” says Dennis Freeman, PhD, CEO of Cherokee Health Systems in Tennessee. “Twenty-five percent of people in a primary care practice have a psychiatric illness,” adds Wayne Katon, MD, vice chair of the department of psychiatry and behavioral science at the University of Washington School of Public Health.

Children are vulnerable, too. “Kids with asthma are more likely to have every kind of anxiety and depressive disorder,” Katon says. “This makes more of an impact on school performance and the ability to make and keep friends. Parents and schools have to be especially watchful for the additive effects of having two conditions.”

For many people, physical conditions can contribute to issues with their mental health—problems that are often ignored and untreated. Research has shown that emotional health and physical health affect each other. Here’s what the public should know.

The Stakes Are High
When recovering from a heart attack, it’s natural to be focused on your physical recovery rather than your state of mind, but the two are intertwined, says Eric Goplerud, PhD. “A heart attack produces large amounts of cortisol that precipitates depression,” explains Goplerud, the director of the Center for Integrated Behavioral Health Policy at George Washington University Medical Center. “At least 20% [of people] with heart attacks have severe depression, and these people are three times more likely to die if the depression is not dealt with promptly. People who have mental problems often have other health problems, and they come together in legion.”

To make matters more complicated, sometimes drugs that help your mind can harm your body. In a sort of healthcare catch-22, the same drugs that help people manage bipolar disorder, schizophrenia, and depression can have serious physical side effects. As part of her treatment, Fitts has received some heavy-duty drugs, including olanzapine. “Clozapine and olanzapine are the two antipsychotic drugs that the American Diabetes Association found have the highest risk of causing weight gain and poor lipid control,” Goplerud says. As for drugs to combat depression, “Some SSRIs [selective serotonin reuptake inhibitors] are associated with weight gain and may contribute to diabetes. So you may be developing life-threatening illnesses from appropriate treatment of your mental illness,” he explains.

The dilemma works both ways, says Goplerud. “Sometimes the treatment we prescribe for in medical care ends up causing mental health problems,” he notes. For example, “People who have been legitimately prescribed powerful pain meds can become addicted.” Patients who are prescribed antidepressants or given medication to help them sleep often need to fine-tune their dosages or try several drugs before finding one that works. Although primary care practitioners or clinic doctors can prescribe these drugs, follow-up can fall through the cracks. Patients should let someone know if their treatment isn’t helping because they have options, says Goplerud. “Talk to your physician about other medicines that might be used,” he adds.

Speak Up
Stigma; no insurance; lifestyle behaviors; a lack of psychiatric providers; poor access to psychologists, clinical social workers, or counselors; and shaky communication between doctors all contribute to extra complications for people dealing with more than one condition at a time. Fear of the stigma of mental illness can keep patients from speaking up, says Chris Koyanagi, policy director of the Bazelon Center for Mental Health Law. Some “are reluctant to tell primary care doctors about their psychiatric medicines: ‘I just don’t want my regular doctor to know,’” he says.

Recalls Gloria: “As a teenager I had aches and pains, and my parents took me to the Mayo Clinic. They wanted me to see a psychiatrist. My father said fine, as long as they could come with me. The psychiatrist asked, ‘Are you depressed?’ Dad answered, ‘No, she’s not.’” Meanwhile, physical conditions arose that could not be brushed aside. It was only years later—when she had an emotional collapse on the job—that Gloria began treatment for depression.

“Health systems are fragmented, [and] people are integrated,” says Freeman. As a result, consumers are often forced to work with an array of healthcare providers. “It’s daunting to go to three different clinics; it’s hard for anyone,” Katon says. “Fragmentation is even worse for people with mental health issues.”

Scattered Healthcare Information
Dangerous drug interactions are possible when no single health professional has a handle on all the medications patients are receiving. The consequences can be serious. For example, a patient could receive heart pills from one doctor and an antidepressant from another physician without either being aware of what the other prescribes. “At the least, one single person or entity needs to know all the medications you take and all the diagnoses you have,” Koyanagi says. “This can be your primary care physician, your mental health practitioner, your pharmacist.”

Katon, who brings his psychiatric expertise to a medical practice one day per week, says, “It’s ideal if psychiatric care can be merged into medical care.”

Koyangi agrees: “We found that mental health care programs with primary care on site—sometimes provided by a nurse practitioner or a physician assistant who can perform regular and effective screening—that can link people to community services [work best].” Federally qualified health centers, such as Freeman’s Cherokee Health System, provide a full range of services from professionals who communicate daily with one another and have access to a single, unified medical record for each patient.

Unfortunately, it can be hard to find mental health care at all, much less integrated medical-mental care. “Half of the counties in the United States don’t have mental health providers,” Freeman says. In those areas, “You probably go to a primary care physician. They will do the very best they can. They’re not psychotherapists or behaviorists, but psychiatrists are in short supply every place, even among insured,” he says. “So you go to see your primary care physician, talk to your minister, [and] if you’re in school, it may be your teacher and guidance counselor.”

Everyone’s Vulnerable
Just as there are ups and downs when it comes to physical health, everyone also deals with challenges that affect our moods and stability. It helps to know your baseline: What’s your usual mental state? How do you know when things are out of control? “We all have times when we’re not as resilient and not managing as well,” Freeman says. “That’s when the team needs to support you, help you through the rough times.”

People may need additional support, not only from mental health professionals but also others in their lives. Sharing confidences and concerns with trusted friends and family or joining a support group can help restore mental balance. Fitts has found and given support through the Depression and Bipolar Support Alliance, a peer group for people with mood disorders. Earlier, when she developed substance abuse issues (which often go along with mental illness and can complicate medical treatment), she looked outside herself for help. “I just made some decisions. It’s a process,” she says. “I use a 12-step approach. I have a group in my church. It’s helped me to get my thoughts together.”

For those who have been diagnosed with a medical illness and don’t feel right emotionally, Goplerud recommends talking to a trusted physician or nurse. “Misery is not necessary,” he says. “You don’t have to live with feeling physically miserable or mentally miserable.”

— Source: Center for Advancing Health


Looking for Support?
• Cleveland Clinic includes the patient information sheet “Chronic Illness and Depression” on its Web site at http://my.clevelandclinic.org/disorders/Depression/ hic_Chronic_Illness_and_Depression.aspx.

• The Depression and Bipolar Support Alliance aims to improve the life of people with mood disorders. Visit www.dbsalliance.org for more information.

• Medline Plus, which is a service of the U.S. National Library of Medicine and the National Institutes of Health, offers a comprehensive list of resources on mental health at www.nlm.nih.gov/medlineplus/mentalhealth.html.

• Mental Health America has the fact sheet “Staying Well When You Have a Mental Illness.” See the PDF at the end of the list of resources at www.mentalhealthamerica.net/go/co-occurring-disorders.

• The U.S. Health Resources and Services Administration has a tool to locate federally qualified health centers at http://findahealthcenter.hrsa.gov.