Heart Disease a Common Challenge For the Mentally-Ill

HHC psychiatrists and clinicians coordinate medical and mental health services to care for the whole person and help reduce risk of heart disease and other chronic conditions.

	Lincoln Hospital's Dr. Fisher and Patient Navigator Melissa Rivera.

Patients with severe mental illnesses such as schizophrenia and bipolar disorder die 25 years earlier than the general population, and up to 60% of early deaths are as a result of heart disease and such contributing conditions as hypertension and diabetes.

But with a growing focus on integrating care for all mental and physical health, the city’s public hospitals are removing hurdles to care and helping patients with severe mental health conditions beat heart disease and other common chronic conditions. At two HHC hospitals, mental health patients receive primary health care - including health screenings, and counseling for nutrition, exercise and smoking cessation - in the same clinics where they receive therapy and medication for psychiatric issues.

At HHC’s Woodhull Hospital Center, internists and psychiatrists in the Center for Integrated Health huddle each morning and afternoon to coordinate treatment for about 135 psychiatric patients. They discuss the medications that patients have been prescribed for psychiatric illness and their side effects, as well as medications the internist may have prescribed to control other conditions like high blood pressure, a major risk factor for cardiovascular disease.

Leonel Urcuyo, M.D., chief of psychiatry at Woodhull, said that while research has not yet proved all the links between mental illness and heart disease, there are some common behaviors that put psychiatric patients particularly at risk.

“Patients with severe mental illness tend not to follow doctor’s recommendations and often neglect themselves. Sixty to 80% of patients don’t keep their appointments for medical conditions like diabetes when they are discharged. And many don’t take their medications or simply drop off from care altogether,” he said.

A study released in Feb. 2013 by the American Journal of Human Genetics stated schizophrenics die from heart and blood vessel disorders at twice the rate of others without the mental disorder. Depression and bipolar disorder also have been linked to heart disease, but it isn’t yet clear whether the mood disorders create elevated heart risk or vice versa, researchers say.

“The challenge to treat these individuals is immense. Thank goodness for the movement to integrated care. We are finally beyond the 'you take care of the soul and I will take care of the psyche' approach, and are focusing on the whole person,” Dr. Urcuyo said. “We are seeing promising results. Our appointment cancellation rates are 20-30% lower in the integrated health center than they are in the primary care clinic.”

While behavior among the mentally-ill continues to be considered a common driver of the risk factors for heart disease and other chronic ailments, in the case of schizophrenia, recent research suggests there may be common genetic causes of both heart disease and mental illness. Also, people with schizophrenia are often prescribed antipsychotic medications that can have side effects of weight gain and elevated blood sugar, which are risk factors for cardiovascular disease. Antipsychotic medications also may disrupt normal heart rhythms in some patients. And there is 45-50% higher incidence of obesity among people with schizophrenia compared to people without the disease.

With this in mind, the same coordinated care approach at HHC’s Lincoln Medical Center has set goals to get patients with mental health conditions more exercise to improve heart health.

The hospital’s Integrated Wellness Center, co-located within the Behavioral Health Clinic, has 95 patients in program and expects to care for as many as 360 in the next year.

“One of the things we are trying to do is to arrange low impact exercise for the patients, simple things they can do at home to increase their heart rate,” said Akinola Fisher, M.D., chief of ambulatory care at Lincoln, where they also coach patients on how to improve their eating habits.

“We encourage them to set a goal for themselves that they think they can meet. For instance, if they drink a bottle of Coke a day, we ask if there is a specific amount they can reduce consumption by, like to cut that in half,” Dr. Fisher said.

“Our program is not yet a year old, and we’ve seen a 20% reduction in patient cholesterol levels without use of medication,” said Dr. Fisher.

At Woodhull, Dr. Urcuyo recalled a patient with a serious mental health condition who was able to drop 30 pounds over a period of six to eight months thanks to dietary guidance and counseling by internists and others at the center who worked with the patient to develop a menu that was both healthy and culturally sensitive.

“We are very, very vigilant about patients gaining weight because of the medication and we target support with their diet,” he added.

The coordination of physical and mental health services is a growing priority for HHC even in the absence of a formal integrated wellness center. All of HHC’s primary care clinics, which are designated Patient-Centered Medical Homes, have primary care doctors working along a team of expert healthcare providers, including nurses, social workers, mental health providers and others, to manage patients’ healthcare needs. Learn more about HHC’s Behavioral Health Services and Patient-Centered Medical Homes.

February 2014