People with severe mental illness (e.g., schizophrenia, bipolar disorder) die 25 years earlier than the general population, with the most common cause of death being cardiovascular disease. This mortality gap is likely due to several complex risk factors, including increased smoking, sedentary lifestyle, poor eating habits, and substance abuse. However, another significant contributing factor is the use of antipsychotic medications, many of which are associated with metabolic complications (e.g., obesity, diabetes, and dyslipidemia), which increase risk of cardiovascular disease. These metabolic complications are likely even higher in racial and ethnic minority populations with severe mental illness given the traditionally poor access to care and higher rates of metabolic conditions within these vulnerable subpopulations. However, despite national metabolic screening guidelines, people with severe mental illness who take antipsychotic medications are still unlikely to receive screening for metabolic abnormalities.
Multiple patient, provider, and systemic factors must be overcome to improve metabolic screening and treatment. For example, the mental and physical health systems are separate (geographically, culturally, electronically, financially), making it difficult for this vulnerable population to access care in both systems. In prior studies, psychiatrists report that the metabolic screening guidelines go beyond their scope of practice as they lack the knowledge, comfort, time, or resources to address metabolic problems. Similarly, primary care physicians (PCPs) lack knowledge and comfort dealing with people with SMI.
Given the severity of psychiatric illness and the low rates of successful referral of people with severe mental illness from specialty mental health clinics to primary care, psychiatrists often serve as the first and often only line of care for this vulnerable population. This research team proposed a novel intervention to improve quality of care, called CRANIUM (Creating a culture change in community mental health clinics through having a Registry and reminders, Advice to get medical screening, peer Navigators, Identification of diseases, Umbrella of services, and initiating Medications). The main focus of CRANIUM is creating a culture shift where psychiatrists would be encouraged to take a more active role in preliminary treatment of metabolic abnormalities in community mental health clinics. In this proposed intervention model, psychiatrists would be encouraged to order guideline-recommended metabolic laboratory tests for those patients who are taking antipsychotic medications. Until the patient can be successfully linked with primary care, the psychiatrist would follow an algorithm for initiation of medications for uncomplicated metabolic abnormalities (e.g., metformin for early type II diabetes, atorvostatin for dyslipidemia, and amlodipine for hypertension). These psychiatrists would have electronic access to a consulting primary care doctor for any questions.
Although it is clear that a systemic intervention must be implemented to overcome this disparity in health care, it is unclear what key stakeholder groups would think of this culture change and, ultimately, the creation of a behavioral health home. To understand their thoughts about this novel intervention, we decided to convene focus groups of four key stakeholder groups: consumers with severe mental illness, psychiatrists, primary care providers, and public health administrators. By conducting these focus groups, we hope to determine acceptability of this novel intervention and modify the intervention based on unique barriers to metabolic screening previously unidentified through quantitative techniques. Since deficits in quality of health care greatly influence mortality rates in people with severe mental illness, these tailored modification of the intervention may increase early detection and treatment and, thereby, hopefully reduce this trend in excess cardiovascular mortality in this vulnerable population.
The CRANIUM study was funded by an NIH Career Development Award (K23MH093689) and the UCSF Hellman Fellows Award for Early-Career Faculty