Medical advance care planning for persons with serious mental illness

OBJECTIVE: This study examined preferences regarding medical advance care planning among persons with serious mental illness, specifically, experience, beliefs, values, and concerns about health care proxies and end-of-life issues. METHODS: A structured interview, the Health Care Preferences Questionnaire, was administered to a convenience sample of 150 adults with serious mental illness who were receiving community-based services from the Massachusetts Department of Mental Health. Clinical information and demographic data were also collected. RESULTS: A total of 142 participants completed the questionnaire. Although more than one-quarter had thought about their medical treatment preferences in the event that they became seriously medically ill, very few had discussed these preferences. A majority of respondents (72 percent) believed that someone should be designated to make medical health care decisions for a person who is too sick to make or communicate these decisions him- or herself. Common end-of-life concerns included financial and emotional burdens on family, pain and suffering, interpersonal issues such as saying "goodbye," spiritual issues, and funeral arrangements. Participants were most uneasy about the prolonging or stopping of life support by proxy decision makers. A total of 104 respondents (69 percent) expressed interest in formally selecting a health care proxy. CONCLUSIONS: Although persons with serious and persistent mental illness have little experience with medical advance care planning, they show substantial interest in it. Furthermore, they are able to consider and communicate their preferences. This study supports the feasibility, acceptability, and utility of a standardized approach to medical advance care planning with this population.     

Practitioner relationships and quality of care for low-income persons with serious mental illness

OBJECTIVE: Though central to experiences of mental health care for persons with serious mental illness, relationships with practitioners have been underemphasized in recent quality-of-care research. This qualitative study described concepts of good care in relationships with psychiatrists, therapists, and case managers from the perspectives of low-income persons with psychiatric disabilities. METHODS: In-person, semistructured interviews were conducted with 51 adult Medicaid enrollees with psychiatric disabilities and diagnoses of schizophrenia. Grounded theory techniques were used to analyze the data. RESULTS: Eight categories representing service users' priorities for care in practitioner relationships resulted from the analysis: getting "extra things," looking for common ground, feeling known, the importance of talk, feeling like "somebody," practitioner availability, practitioner flexibility, and opportunities for input into treatment. CONCLUSIONS: Quantitative and illness-centered formulations may miss much of what low-income service users with serious mental illness value in their relationships with practitioners. The opportunity to counter feelings of vulnerability and alienation with a sense of connection that is based on shared humanness may be a high priority for services for this group. Practitioner relationships that help service users feel cared about and connected to the social world address suffering in mental illness and are thus essential to the meaning of good care.     

Assessment of Medicaid managed behavioral health care for persons with serious mental illness

OBJECTIVES: This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness. METHODS: Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes. RESULTS: A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables. CONCLUSIONS: Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.     

HIV risk factors for persons with serious mental illness

HIV risk factors were assessed among 120 persons in treatment for serious mental illness. Although subjects had good general knowledge regarding HIV, many engaged in high risk behaviors. Condom use was infrequent among those who had multiple sexual partners, and sharing needles was common for those who used IV drugs. Clearly, factual knowledge about HIV was not sufficient to prevent risky behavior. Nearly half of the sample was categorized as at medium to high risk, and almost half of the participants, especially those at medium risk, underestimated their own level of risk. The results suggest that education and intervention strategies should focus on increasing the accuracy of the individual's risk assessment as well as changing attitudes towards condoms and improving skills in using condoms. Assessing personal risk and adopting risk-reduction strategies are the keys to successful AIDS prevention for persons with serious mental illness.Michael D. Knox is Professor and Chair of the Department of Community Mental Health at the University of South Florida's Florida Mental Health Institute. He also serves as Director of the USF Center for HIV Education and Research. Timothy L. Boaz is Associate Professor in the Department of Community Mental Health. Martha A. Friedrich is Assistant Professor in the Department of Community Mental Health and Associate Director of the USF Center for HIV Education and Research. Michael G. Dow is Associate Professor and Director of Research in the Department of Community Mental Health.This research was funded in part through contract #91MF57230401D with the National Institute of Mental Health. The support and guidance of Armand Checker and Juan Ramos, National Institute of Mental Health, is appreciated.     

Randomized trial of psychiatric care with representative payeeship for persons with serious mental illness

OBJECTIVES: This randomized clinical trial assessed whether a community-based representative payee program that was coordinated with psychiatric care from the Department of Veterans Affairs was more effective than customary treatment. METHODS: In the experimental condition representative payeeship was provided by a community agency that worked to enroll clients and coordinate payeeship with clinical care through communication with clinical staff. The control condition consisted of customary clinical care that included the typical availability of representative payeeship. Hypotheses were that, compared with the control group, the experimental group would experience greater enrollment in a representative payee program; improved residential status; improved quality of life, including fewer symptoms of mental illness; less substance abuse; and improved money management. Participants were interviewed at baseline and at six and 12 months. Outcomes were analyzed with analysis of covariance by using covariates from the baseline. RESULTS: A total of 184 participants were enrolled at baseline (94 in the experimental group and 90 in the control group). A total of 152 interviews were completed at six months, and 149 were completed at 12 months. At 12 months, 31 percent of patients in the experimental group and 14 percent of those in the control group were receiving representative payee services. At 12 months, significant positive effects were observed for the experimental group on enrollment in a representative payeeship, alcohol and drug use, quality of life, and money management. Residential status approached significance. CONCLUSIONS: Use of a coordinated representative payee program was found to be effective in improving outcomes at 12 months. Although this evidence supports the wider implementation of a coordinated representative payee program, only 31 percent of the experimental group had their money banked with a representative payee. Therefore, future studies should focus on achieving a better understanding of the causal components of the intervention.     

Unmet need for medical care among homeless adults with serious mental illness

OBJECTIVE: The objective of this study was to determine the rates and predictors of unmet medical needs among homeless adults with serious mental illness entering a community-based case management program and those of receipt of medical care in the subsequent 3-month period. METHODS: We analyzed baseline and follow-up data for 7213 homeless clients in the multisite Access to Community Care and Effective Services and Supports program. RESULTS: Overall, 43.6% of the sample reported having an unmet need for medical care at baseline; of these subjects, only 36.1% received medical services during the 3 months following program entry. Using multivariate logistic regression modeling, we found that, at baseline, independent correlates of an unmet medical need included lower educational level, increased depressive and psychotic symptoms and greater number of potentially competing needs. None of these variables, however, adversely affected the likelihood of receiving medical care during follow-up. Factors associated with receiving medical services in the 3 months following program entry included receiving outpatient psychiatric services and reporting stronger therapeutic alliance with one's case manager. CONCLUSIONS: Collaborative case management may play an important role in meeting mentally ill homeless persons' medical needs. Greater efforts are needed to identify and link at-risk clients with appropriate medical services.     

Improving general medical care for persons with mental and addictive disorders: systematic review

OBJECTIVE: To conduct a systematic review of studies of interventions designed to improve general medical care in persons with mental and addictive disorders. METHODS: Following Cochrane Collaboration guidelines, a comprehensive search through October 2005 was conducted in multiple bibliometric indexes using search terms related to primary medical care and mental health/addictive disorders. Two assessors independently extracted information on linkage, quality, outcomes and costs of care. RESULTS: Six randomized trials met the preestablished search criteria. The interventions spanned a continuum of approaches for improving treatment, ranging from on-site medical consultation, through team-based approaches, to models involving facilitated referrals to primary care. The studies demonstrated a substantial positive impact on linkage to and quality of medical care; there was evidence of health improvement and improved abstinence rates in patients with greater medical comorbidity. The three studies that assessed expenditures found the programs to be cost-neutral from a health-plan perspective. CONCLUSION: A small but growing body of research suggests that a range of models may hold potential for improving these patients' health and health care, at a relatively modest cost. Future work should continue to develop and test approaches to this problem that can be tailored to local system needs and capacities.     

Perceptions of discrimination among persons with serious mental illness

OBJECTIVES: The authors sought to gain further perspective on discrimination experienced by persons with mental illness by comparing self-reports of discrimination due to mental illness to self-reports of discrimination due to other group characteristics, such as race, gender, and sexual orientation. METHODS: A total of 1,824 persons with serious mental illness who participated in a baseline interview for a multistate study on consumer-operated services completed a two-part discrimination questionnaire. The first part of the questionnaire assessed participants' perceptions about discrimination due to mental illness as well as more than half a dozen other group characteristics. The second part of the questionnaire asked participants who reported some experience with discrimination to identify areas in which this discrimination occurred, such as employment, education, and housing. RESULTS: More than half of the study participants (949 participants, or 53 percent) reported some experience with discrimination. The most frequent sources of this discrimination were mental disability, race, sexual orientation, and physical disability. Areas in which discrimination frequently occurred included employment, housing, and interactions with law enforcement. Areas in which discrimination was experienced did not significantly differ among groups of study participants characterized by mental disability, race, gender, sexual orientation, or physical disability. CONCLUSIONS: Discrimination based on group characteristics other than mental illness does not diminish the impact of stigma associated with mental illness. Antistigma programs need to target not only discrimination related to mental illness but also that associated with other group characteristics, such as race, gender, sexual orientation, and physical disability.     

End-of-life treatment preferences of persons with serious mental illness

OBJECTIVE: The goal of this study was to ascertain preferences for end-of-life care among persons with serious mental illness. METHODS: The participants were 150 community-residing adults with serious mental illness. The Health Care Preferences Questionnaire was administered to obtain information about treatment preferences in response to hypothetical medical illness scenarios: use of pain medication in the case of incurable cancer and use of artificial life support in the case of irreversible coma. Participants were asked what their treatment preferences would be for an imaginary person in each scenario ("other") as well as their preferences for themselves ("self"). RESULTS: For the scenario involving pain medication for incurable cancer, most participants chose aggressive pain management even if cognition might be affected (64 percent of respondents under the "other" scenario and 66 percent under the "self" scenario). Few participants thought a doctor should provide patients with enough medication to end their life (34 percent for self and 24 percent for other). For the scenario involving irreversible coma, respondents were divided in their choice regarding life support. Approximately one-quarter said that they would prefer to immediately terminate life support (28 percent of respondents for other and 29 percent for self), and half said they would choose to turn it off after a defined period (48 percent for other and 45 percent for self). CONCLUSIONS: Persons with serious mental illness were able to designate treatment preferences in response to end-of-life health state scenarios. Future research is needed to test advance care planning methods, assess stability of choices over time, and ascertain the utility of scenario-based preferences to guide end-of-life care decisions in this population.     

Integrating physical activity into mental health services for persons with serious mental illness

This article reviews evidence supporting the need for interventions to promote physical activity among persons with serious mental illness. Principles of designing effective physical activity interventions are discussed along with ways to adapt such interventions for this population. Individuals with serious mental illness are at high risk of chronic diseases associated with sedentary behavior, including diabetes and cardiovascular disease. The effects of lifestyle modification on chronic disease outcomes are large and consistent across multiple studies. Evidence for the psychological benefits for clinical populations comes from two meta-analyses of outcomes of depressed patients that showed that effects of exercise were similar to those of psychotherapeutic interventions. Exercise can also alleviate secondary symptoms such as low self-esteem and social withdrawal. Although structured group programs can be effective for persons with serious mental illness, especially walking programs, lifestyle changes that focus on accumulation of moderate-intensity activity throughout the day may be most appropriate. Research suggests that exercise is well accepted by people with serious mental illness and is often considered one of the most valued components of treatment. Adherence to physical activity interventions appears comparable to that in the general population. Mental health service providers can provide effective, evidence-based physical activity interventions for individuals with serious mental illness.