Almost 1 billion people worldwide and over 25% of US adults suffer from a mental illness.¹ Those with mental illness have higher rates of death, disability, medical illness, incarceration, homelessness, unemployment, poverty, and violation of their human rights. Exposure to humanitarian crises, natural disasters, violence, poverty, and chronic illness increase the likelihood of mental illness.

Lack of access to mental illness care is very common—treatment rates range from 13% to 33% in high-income countries, and from 5% to 13% in low- and middle-income countries.² When mental illness co-occurs with other medical conditions, it complicates treatment of both conditions. Unfortunately, even with access to care, medical disorders in people with severe mental illnesses (SMIs) often go undiagnosed and untreated, and conversely, mental disorders in people with medical conditions often go undiagnosed and untreated. Overall, medical costs are higher for people with mental illness.^3,4 For example, people with diabetes and comorbid depression have health-care costs that are 4.5 times higher than those without depression.⁴

Since the majority of people with mental illnesses are served in primary care, this chapter is dedicated to helping primary care providers improve the medical care received by this vulnerable population.⁵ First, we review common medical comorbidities of people with SMIs and suggest guideline-concordant screening and treatment strategies. Second, we discuss the psychiatric comorbidities commonly afflicting people with medical conditions, and suggest screening tools to identify these illnesses. Third, since many people with HIV are treated in primary care, we have a special section dedicated to psychiatric comorbidities among people living with HIV. Finally, we discuss models for integration of mental and physical health that can assist administrators of health-care systems serving these patients. Although we concentrate on the US population, many of the issues we raise have relevance globally as well.

In 2012, the prevalence of SMI (e.g., schizophrenia, schizoaffective disorder, bipolar disorder) was approximately 4% of the US population, or 9.6 million people nationwide.⁶ Although the majority of these patients are cared for in specialty mental health-care settings, primary care physicians—particularly those serving safety-net populations—often provide care to these patients.^5,7

Primary care providers may be unaware that people with SMI are among the most vulnerable groups in society (Box 33-1). For example, people with SMI die, on average, 25 years earlier than the general population, most often from cardiovascular disease (CVD).⁸ Although the causes of this premature death are multifactorial, some of the responsibility rests on the shoulders of medical providers—since there are major gaps in screening and treatment of preventable disease.⁹ In fact, 87% of the years lost are from treatable medical conditions.⁸

These medical conditions are associated with modifiable risk factors including smoking, obesity, substance abuse, psychotropic medication side effects, and inadequate access to medical care. Considering that primary care physicians do provide care to people with SMI, it is essential that primary care providers have expertise in the common medical illnesses in this population and provide appropriate screening that impact long-term outcomes (Box 33-2).

CARDIOVASCULAR DISEASE, THE METABOLIC SYNDROME, AND DIABETES

People with SMI have higher rates of CVD and the metabolic syndrome than the general population.¹⁰ About 40% of all deaths of people with SMI are from CVD, which is higher than the general population (30%).⁸ In one large trial, the 10-year coronary heart disease risk was significantly higher among people with schizophrenia than among a general US population sample,¹¹ as was the prevalence of the metabolic syndrome.¹² Studies also indicate that the prevalence of diabetes among people with SMI is two to three times higher than the general population.¹³ In fact, a meta-analysis showed that people with SMI have a 70% increased risk of diabetes compared with the general population.¹⁴

Some second-generation antipsychotic (SGA) medications contribute to CVD by increasing risk of obesity, diabetes, hypertension, and dyslipidemia. Because the evidence for medication-related metabolic risk was so compelling and because SGAs are so widely used,¹⁵ the American Diabetes Association (ADA), the American Psychiatric Association (APA), and others recommended that annual metabolic screening be performed for anyone taking these medications, regardless of age or predisposing factors.¹⁶ Specifically, ADA/APA guidelines recommend quarterly weight/BMI measurements; and annual monitoring of blood pressure, fasting glucose, fasting lipids (if high risk), and waist circumference (Table 33-1).¹⁶ Unfortunately, 10 years after publication of these guidelines, up to 70% of those on antipsychotics remain unscreened or undermonitored for metabolic abnormalities.¹⁷

This lack of screening is particularly concerning for subpopulations that may be at greater risk of metabolic side effects of these medications, namely, children/adolescents, women, and minorities.^12,18 We recommend adherence to ADA/APA recommendations with annual metabolic screening of people with SMI taking antipsychotic medications, regardless of age (Table 33-2).

It is worth noting that even when diabetes or other metabolic risk factors are identified, people with comorbid diabetes and SMI are less likely to receive evidence-based diabetes care than people without SMI.¹⁹ In one Veteran’s Administration (VA) study, only 11% of people with comorbid diabetes and SMI received treatment.²⁰ In addition, evidence suggests that minorities with SMI and diabetes are less likely to be treated than their white counterparts.

NICOTINE DEPENDENCE

Smoking rates among people with SMI are extremely high: close to 59% of people with schizophrenia smoke compared with 18% in the general population.²¹ Smoking puts people with SMI at increased risk for CVD and influences recommendations for initiating oral medications for metabolic abnormalities.²² In a study of 1,213 people with schizophrenia-related psychotic disorders, the odds ratio of cardiac-related death among those aged 35–54 years was increased 12-fold in smokers relative to nonsmokers²² Unfortunately, smokers with type 2 diabetes and schizophrenia were significantly less likely to receive services and treatments known to improve cardiovascular outcomes (e.g., blood pressure exams, lipid profiles, treatment with angiotensin-converting enzyme inhibitor [ACE] inhibitors or statins) when compared to people with diabetes who did not have SMI regardless of smoking status.²³ Although the exact cause is unknown, this particular health disparity is highly concerning given the proven increased risk of CVD with smoking.

The Schizophrenia Patient Outcomes Research Team (PORT) recommends that people with schizophrenia who want to quit or reduce cigarette smoking be offered treatment with bupropion SR 150 mg twice daily for 10–12 weeks, with or without nicotine replacement therapy, to achieve short-term abstinence.²⁴ The pharmacological treatment should be accompanied by a smoking cessation education or support group.²⁴

SUBSTANCE ABUSE

Among people with SMI, the Substance Abuse and Mental Health Services Agency (SAMHSA) estimates that 27% have had a co-occurring substance use disorder in the previous year.⁶ Of the 2.6 million adults with both a SMI and a co-occurring substance use disorder, 35% received no treatment for either problem and only 20% received treatment for the substance abuse disorder.⁶

SAMHSA has put forth the SBIRT (screening, brief intervention, and referral to treatment) model as a comprehensive integrated public health strategy for dealing with substance abuse in the primary care setting.²⁵ It involves universal screening, 5–12 brief sessions (5–10 minutes each) targeting risky behaviors, and referral for more comprehensive treatment in patients with very high risk or when dependence criteria are met. The SBIRT model has demonstrated effectiveness for reducing risky alcohol behaviors and there is growing evidence that it is also effective in reducing risky drug use behaviors. Using the SBIRT model is consistent with the Schizophrenia PORT recommendation that people with schizophrenia and a comorbid alcohol or drug use disorder should be offered substance abuse treatment.²⁴

HUMAN IMMUNODEFICIENCY VIRUS

The prevalence of HIV infection among people with SMI is 6.0% (95% CI 4.3-8.3), which is significantly higher than in the general population (0.6%).²⁶ The increased prevalence is complex and multifactorial, including higher rates of HIV risk behaviors, lack of knowledge about HIV transmission and prevention, lack of motivation to engage in safer practices, lack of the behavioral skills to engage in prevention practices, and residing in neighborhoods or institutional settings (such as homeless shelters) where HIV is prevalent.²⁷ Additionally, some psychiatric disorders themselves cause symptoms (e.g., impulsivity, increased sexual activity, poor cognitive function) that contribute to higher HIV risk behaviors.^27,28

Despite this high prevalence, HIV testing among people with SMI is low.²⁹ Since African Americans and Latinos have the highest rates of HIV in the general population, this deficiency in HIV testing is likely to be particularly problematic for underserved racial minorities with SMI.³⁰

People with SMI should be tested annually for HIV (see Box 33-1) and if infected suppressing their viral load is an important treatment goal. In addition, roughly 25% of people living with HIV are coinfected with hepatitis C virus (HCV) and in those who are intravenous drug users, the coinfection rate is 75%.³¹ They should also be screened both for HCV and hepatitis B. If they have not been vaccinated for hepatitis B, they should be.

Regular screening for CVD and treatment of modifiable risk factors such as smoking, obesity, and the metabolic syndrome is also essential. It is important to note that people with HIV alone have high rates of CVD. This is partly due to HIV itself and the fact that traditional CVD risk factors (smoking, dyslipidemia) are highly prevalent in this population.³² CVD risk in those with HIV is additionally increased due to the side effects of protease inhibitors, the most common front line of treatment for HIV infection, which themselves promote dyslipidemias.³³

HEPATITIS C

The prevalence of HCV infection among people with SMI is 17.4% (95% CI 13.2-22.6), which is significantly higher than in the general population (1%).³⁴ Despite the serious health impacts of this disease and the high risk in this population, most patients with SMI are neither tested nor treated (Box 33-1).³⁵ It is possible that fear of HCV treatment–related psychiatric symptoms, as well as perceived low adherence, has resulted in providers’ reluctance to refer and treat people with SMI.³⁵

Studies have demonstrated similar adherence and response rates among populations with and without SMI, when done in concert with mental health treatment. Further, the risk of psychiatric symptom exacerbation (e.g., depression, psychosis) due to HCV treatment with interferon may be overstated.³⁶ That said, these potential exacerbations are important to include in discussions with patients.

Recently, the development of interferon-free, direct-acting antiviral agents is revolutionizing HCV treatment and offering the potential of cure.³⁷ However, the first such FDA-approved agent, sofosbuvir (Sovaldi) is extremely expensive (~$84,000–$120,000 per patient), which limits the availability of this agent to the general population. The appropriate use of these new agents in patients with SMI is unknown.

Although no screening tool exists specifically for the selection of HCV treatment for people with comorbid SMI, the Beck Depression Inventory (BDI) has been examined in samples of people with depression and suggest that people with baseline scores >10 are more likely to develop interferon-associated depression. For these patients, “pre-treatment” with an antidepressant should be considered and, if initiated, should be continued for the duration of HCV treatment.³⁸ All things being equal, the selective serotonin reuptake inhibitors (SSRIs), citalopram, and sertraline are good choices for HCV-related depression prevention and treatment due to their equivalent efficacy to other SSRIs, good tolerability, and low drug–drug interaction profiles (see later).³⁸ One-third of HIV specialists use or offer the option of prophylactic antidepressants to people with comorbid HCV and HIV with no past or current depression, with the number rising to more than two-thirds among people with a history of depression but no current symptoms.³⁹ Notably, this pretreatment with SSRIs should be avoided in a patient with bipolar disorder or schizoaffective disorder to avoid SSRI-induced mania.

It is advised that prior to initiating interferon-based HCV treatment, the client is at his or her baseline mental health level. Ideally, appropriate patients for treatment are ones who are not actively suicidal, can be closely monitored clinically (weekly or biweekly), and can successfully complete necessary serologic testing. Patient should be monitored at baseline and then monthly during treatment with a clinical interview and Patient Health Questionnaire 9 (PHQ9) screening tool. Since many clients will continue to experience depression despite use of an SSRI during HCV treatment, nonmedication treatments such as supportive therapy are also recommended.⁴⁰

Many psychiatric medications can impair liver function as can both the HCV itself and HCV treatments. Therefore, monitoring of liver enzymes is recommended at baseline, within 1 month of starting treatment, and every 2–3 months during treatment.

More than 80% of primary care patients who have co-occurring mental health disorders are either undertreated or receive no treatment for their mental illness at all.^41,42 This lack of treatment is due, in part, to underdiagnosis.⁴¹ Routine screening in primary care settings could enable earlier identification and treatment of mental health and substance use disorders (Box 33-3). In addition, the US public mental health-care system is designed primarily to treat those with SMIs (e.g., schizophrenia, bipolar disorder). This often leaves safety-net primary care providers holding the responsibility to care for those with less SMIs. This section aims to make recommendations on treatment of common medical conditions in primary care. More ideal models of primary care and behavioral health integration are described in the next section.

MAJOR DEPRESSIVE DISORDER

In primary care, the prevalence of major depressive disorder (MDD) ranges from 5% to 13% in adults and 6% to 9% in older adults.⁴³ Depression is associated with poorer outcomes among people with a variety of medical conditions, including coronary artery disease, diabetes, and stroke.⁴⁴ Treatment of depression may reduce mortality from these conditions, and help prevent suicide.⁴⁵ Accurate identification of depression is critical so that appropriate treatment can be initiated.

If clinical practices have systems in place to ensure accurate diagnosis, effective treatment, and follow-up, the US Preventive Services Task Force recommends screening adults for depression.⁴³ There is some evidence that asking two questions in the PHQ-2 may be as effective as the longer PQH-9.⁴⁶ Treatment with antidepressants, psychotherapy, or both decreases clinical morbidity and improves outcomes in adults with depression identified through screening in primary care settings.⁴³ For people with comorbid anxiety and depression, short-term use of long-acting benzodiazepines is widely accepted until SSRIs begin to exert their antidepressant effects.⁴⁷

ANXIETY DISORDERS

Anxiety disorders affect about 40 million American adults (~18%) annually.⁴⁸ They are commonly seen in primary care, affecting about 10% of patients.⁴⁹ There are a wide variety of anxiety disorders, including GAD, obsessive-compulsive disorder, panic disorder, PTSD, and social phobia. Unfortunately, people with anxiety disorders are often underdiagnosed and undertreated.⁴⁹

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both depending on the illness and patient preference.⁴⁸ SSRIs are considered first-line therapy in the treatment of various anxiety disorders because of their efficacy, good tolerability, and efficacy for comorbid depression.⁴⁷

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