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The public health
disgrace in Psychiatry
Clinical Senate
9th August; WA.
Prof Tim Lambert
Further resources:
http://www.ccchip.com.au
The ccCHiP motto
‣There is no physical health
‣There is no mental health
‣There is ...
‣Health!
The ccCHiP model (Central Sydney)
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training
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inpatients
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(HUB)
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LHD
CRGH
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Sections of
General
Practice
University and/or
Health Network
Research Programmes
and Institutes
'External' links
Life expectancy - living in the past
Australian population
Severe mental illness population
Sources: ABS Cat No. 3302.0; ABS Cat. No. 3105.0.65.001 (green
line); the age of death in schizophrenia imputed from literature (ibid)
No Reduction in Cardiovascular
Disease in Schizophrenia
1.4
Patients With Schizophrenia†
1.2
1
0.8
0.6
General Population‡
0.4
0.2
0
1976-79
1980-85
1986-89
1990-95
*Period of reference, 1976-1979.
†Controlling for age at first diagnosis & years of follow-up.
‡Standardized by gender & age distribution of the patients.
3.
Osby U, Correia N, Brandt L, Ekbom A, Sparen P. Mortality and causes of death in schizophrenia in Stockholm
county, Sweden. Schizophr Res. 2000;45:21-28.
The Service Manual: ccCHiP series
A Practical Guide
Sustainable metabolic interventions
for patients with mental illness
ccCHiP
CONCORD CENTRE FOR CARDIOMETABOLIC HEALTH IN PSYCHOSIS
Screening
Detection
Formulation
Intervention
Monitoring
Resources
Setting up a
new service
Services: the big picture
Public Health Awareness-Promotion
I
Screening
II
Detection/Evaluation
III
Treatment Initiation
Treatment Monitoring
IV
GP with
onsite
MH
support
GP with
CMH
liaison
Cardiometabolic
education centres
A Practical Guide
Sustainable metabolic interventions
for patients with mental illness
MH
general
interv. for
health
GP/MH
shared
site
MH site
specific
clinics
Specialist collaborative
clinics (e.g. ccCHiP)
ccCHiP
CONCORD CENTRE FOR CARDIOMETABOLIC HEALTH IN PSYCHOSIS
Health outcome improvement
Screening
Detection
Formulation
Intervention
Monitoring
Resources
Setting up a
new service
Services: Level IV, the rate-limiting step
Public Health Awareness-Promotion
IV
I
Screening
II
Detection/Evaluation
Treatment
Monitoring
III
Treatment Initiation
IV
GP with
CMH
liaison
Treatment Monitoring
GP with
onsiteGP with
MH onsite
MH
supportsupport
GP with
CMH
liaison
GP/MH
GP/MH
shared
shared
site
site
Cardiometabolic
education centres
A Practical Guide
Sustainable metabolic interventions
for patients with mental illness
MH
general
interv. for
health
MH
general
MH site
specific
interv.
for
clinics
health
MH site
specific
clinics
Specialist collaborative
clinics (e.g. ccCHiP)
ccCHiP
CONCORD CENTRE FOR CARDIOMETABOLIC HEALTH IN PSYCHOSIS
Health outcome improvement
Screening
Detection
Formulation
Intervention
Monitoring
Resources
Setting up a
new service
Psychosis & the GP: reasons for visits
Reasons for encounter
Rate per 100 psychosis
encounters
Prescriptions all*
Schizophrenia
Bipolar disorder
Other psychological symptom
General check up*
Depression*
Clarification/discussion
Sleep disturbance
Follow up unspecified
Charles et al (2006) Australian Family Physician. 35(3);88-89,
Based on beach data 1998 to 2005
33.2
18.0
5.5
4.8
4.2
4.2
3.3
2.9
2.6
Contingency planning in the Real World
GP with
CMH
liaison
GP with
onsite
MH
support
GP/MH
shared
site
MH
general
interv. for
health
MH site
specific
clinics
Optimal
Real-World
default service set point should be to provide
‣ The
complete health care (physical and mental) to at least
minimal standards
service progressively engages the patients in GP
‣ The
shared care (on a continuum regarding parameter
focus)
Barriers to
integrated medical
and psychiatric care
See: Lambert & Newcomer. MJA 2009; 190: S39–S42
Barriers to integrated care
Health care systems related
Guidelines for IMPHC* are perceived a threat to autonomy, are not wellknown, or are not clinically accepted
Non-psychiatric doctors are reticent to treat those with serious mental
illness despite relative deficits in the quality of care being linked to
increased mortality
Lack of continuity of treating doctor with subsequent failure for patient
to have his/her longitudinal history available
Treatment teams may have various levels of consensus over their
collective role for metabolic health screening
The move to community mental health places more onus on non-medical
case managers to provide a range of physical health services they may not
be trained in
Specific health promotion and public health interventions targeted
towards people with schizophrenia are generally insufficient
*IMPHC=integrated medical and psychiatric health care
Lambert & Newcomer. MJA 2009; 190: S39–S42
Barriers to integrated care
Health care systems related...
Perception by specialists/community mental health teams
that physical health matters should be the province of
referring or other doctors
Attention solely focused on presenting psychiatric problems
with subsequent infrequent physical examination of patients
Time and resources for physical/medical examinations not
available in current mental health service settings
Physical complaints are regarded as psychosomatic
symptoms
Separation of the medical and mental health systems of care
(geographic, financial, organizational, and cultural) rather than
integrated services
Lambert & Newcomer. MJA . 2009; 190: S39–S42
Barriers to integrated care
Illness and person
Difficulty comprehending health care advice and/or carrying out
required changes in lifestyle (such as exercise, diet, sleep) due to
cognitive deficits, negative/deficit symptoms, impoverished social
contacts, development of depression due to the rigors of life-style
curtailment, or lack of confidence
Physical symptoms are unreported/masked due to a reported high pain
tolerance, and a reduction in pain sensitivity due to the use of
antipsychotic drugs
Poor general treatment adherence (in all aspects)
Lack of adequate follow-up of psychiatric patients, due to itinerancy,
the effects of homelessness or lack of motivation on the part of the
patient
Unawareness of physical problems due to the cognitive deficits
associated with mental illness
Lambert & Newcomer. MJA 2009; 190: S39–S42
Barriers...
Illness and person...
Avoidance or neglect of contact with GPs or general
health care services
Difficulty communicating their physical needs and
problems in general due to social deficits and/or stigma
In some case, reluctance to discuss problems or
volunteer symptoms, and/or general uncooperativeness,
perhaps due to mistrust (inc. blood test refusal)
Migrant status and/or cultural and ethnic diversity
Lambert & Newcomer. MJA 2009; 190: S39–S42
Recommendations
4 Recommendations to address integrated health care in those with severe mental illnesses*
1
2
Issue
Obstacles to integrated care
Suggested policy recommendations
Reorganisation of mental health
service delivery
• Mental health staff do not routinely
provide screening or monitoring of
physical health and have little
knowledge of the general health plan.
• Mental health providers should attend to all health care
needs of patients with serious mental illness.
• Links between services (eg, colocation) are non-existent or are
ineffective in providing coordinated
care.
• Case-management policy directed specifically towards
physical health needs of patients should be developed.
• The potential of information
technology to improve care
coordination, safety and efficiency has
failed in general and mental health
settings.
• Federal and state departments of health should offer
incentives for the provision of functional clinical information
systems.
Promotion of patient-sanctioned
communication and
collaboration between providers
• Enhanced collaboration and communication with general
practitioners is essential.
• Consent to relay clinical information between sectors should
be enhanced bilaterally.
• Varying interpretations of privacy laws.
3
Preparation of the health care
workforce to provide
coordinated care
• The development and sustainability of
interdisciplinary skills essential to
integrated care are not well addressed
across mental health and general
health professional groups.
• Increase mental health staff competencies in physical health
screening and developing patient self-care skills.
• Increase GPs’ practical knowledge of severe mental illnesses.
• Stress interdisciplinary teamwork and provide appropriate
skills at a professional and postgraduate level.
• Alter professional licensing and certification procedures to
reflect the needs of integrated models of care.
4
• Mental health funding at present has
Elimination of policies and
little in the way of incentives to
practices that offer no incentives for,
promote integrated care.
or discourage, integrated care
5
Strengthening of the
accreditation process
6
Development of federally
sponsored coordination research
and demonstrations.
• Few formal accreditation standards
exist for integrated physical and
mental health care.
• Funding policies need to reflect that integrated care should
be written in to all agreements.
• Standards organisations (such as the Australian Council on
Healthcare Standards) should require coordinated and
integrated general heath metrics to be demonstrated.
• Evaluative research is required to assess feasibility and
effectiveness of programs implemented on the basis of
evidence-based medicine, and quality improvement
initiatives.
Recommendations: #1
Issue
Obstacles to integrated
care
• Mental health staff do
not routinely provide
screening or monitoring
of physical health and
have little knowledge of
the general health plan.
Reorganisation of • Links between services
(eg, co-location) are
mental health
non-existent or are
service delivery
ineffective in providing
coordinated care.
Suggested policy
recommendations
Mental health providers
health providers
•• Mental
should attend to all health
should attend to all health
care needs of patients with
care
needs
of patients
serious
mental
illness. with
serious mental illness.
• Enhanced collaboration
communication
with
Enhanced
collaboration
and
• and
general
practitioners
is
communication
with general
practitioners is essential.
essential.
• Case-management policy
specificallypolicy
Case-management
• directed
towards
physical health
directed specifically
towards
needs
patients
should
physicalofhealth
needs
of
be
developed.
patients
should be
developed.
Recommendations 3
Obstacles to
integrated care
• The development
and sustainability of
interdisciplinary skills
essential to
integrated care are
not well addressed
across mental health
Preparation of and general health
the health care
professional groups.
Issue
workforce to
provide
coordinated care
Suggested policy
recommendations
• Increase mental health staff
competencies in physical health
screening and developing
patient self-care skills.
Increase GPs’ practical
• Increase
GPs’ practical
• knowledge
of severe mental
knowledge of severe mental
illnesses.
illnesses.
• Stress interdisciplinary
teamwork
and provide
interdisciplinary
• Stress
appropriateand
skills
at a
teamwork
provide
professional and
appropriate
skillspostgraduate
at a
level.
professional
and postgraduate
Alter professional licensing and
• level.
certification procedures to
and
• Alter
reflectprofessional
the needs oflicensing
integrated
certification
procedures to
models of care.
reflect the needs of integrated
models of care.
Who should be involved?
Profession
Potential Activity
Dietitians
A critical role in educating staff, and carers, as well as patients on
healthy living
GP
Work in close liaison with public sector
Medical specialists
Consult on relevant difficult cases
Nurse
Organise ± perform blood taking; history of CMRs; coordinate
whole shooting match
OT ± EP
Working on activities that focus on self management of CMRs;
exercise; diet
Pharmacists
Advising team members of key hi-risk medications
Psychiatrist
Take the global responsibility to ensure the patient’s health needs
are met
Psychologist
Groups; motivational interviewing regarding smoking, alcohol, food
binging
Registrar
Practical role in assessing risks; help educate other staff, patients,
and fx; goferism
Social Workers
Work with families and patients regarding optimising healthy
lifestyle in situ /ex hospital
Who’s job is it anyway?
Alas, poor phYsical cardiOvasculaR
comorbidIty Care ...
Hammedup, Prince of Psych Services
Fear not, My Lord
The cavalry (GPs) will ride in and save us
Laertes
Developing Sustained Systematic
Interventions to manage cardiometabolic
risks for those with severe mental illness
Concord Centre for Cardiometabolic Health in Psychosis
Dr Jeff Snars
Clinical Director,
Concord Centre for Mental Health
Assoc Prof Roger Chen
Endocrinologist, Concord Hospital Dept of
Endocrinology & Metabolism
Dr Libby Dent
Clinical Research Fellow, ccCHIP
Vanessa Barter
Admin, Sleep ccCHIP
Angela Meaney
Clinical Nurse Consultant, ccCHIP
Thank you
Prof Tim Lambert
Director, ccCHIP:
University of Sydney
CCMH and BMRI