Integrated care for physical health in severe mental illness

It is now widely recognised that people with mental health conditions experience significant inequalities in terms of health and wellbeing including lower life expectancy.

The reasons for this are complex and interlinked and include lifestyle factors (smoking cigarettes, poor diet, risky levels of alcohol consumption) as well as factors associated with mental health treatment (such as physical health consequences of antipsychotics including weight gain and type 2 diabetes).

In addition there are organisational and institutional barriers to promoting physical health care including lack of physical health expertise and screening in mental health services, diagnostic over-shadowing (that is, putting physical complaints such as fatigue down to the mental health issue) and general lack of joined up working between physical and mental health service provision at primary and secondary care levels.

With the recognition that people often have both physical and mental health needs, the direction of travel in health policy in the UK is towards “integrated care” (NHS 5 year forward view (PDF)).

This seems like a logical solution to the problems just highlighted, but in terms of implementation we don’t really know what integrated care should look like and whether new models and ways of working would be more effective in reducing health inequalities than the status quo. Therefore a rapid review was undertaken to inform our understanding of Integrated Care (Rodgers et al, 2016)

People with severe mental illness typically live 15-20 years younger than the national average, because of avoidable physical illnesses.

Aim

They sought to ask four questions:

What type of models currently exists for the provision of integrated care specifically to address the physical health needs of people with SMI when accessing mental healthcare services?
What are the perceived facilitators and barriers to implementation of these models?
How do models implemented in practice compare and contrast with those described in the literature?
Can we identify high-priority research areas for either further primary studies or a full evidence synthesis?

Methods

They took a pragmatic approach, using systematic and transparent methods to search for published evidence, as well as what is known as “grey literature” (anything in the public domain that isn’t a peer reviewed publication but could be a government report or local evaluation). The authors themselves recognise the limitations of a rapid review as opposed to a systematic review, but a strength of this project is that they complemented the review with expert advisors which included a range of stakeholders such as academics, clinicians, and people with lived experience and carers.

They developed an a priori protocol and searched in academic databases as well as the health department web pages in the UK, Australian, New Zealand, Canadian and USA. They also searched in Google; using the first 100 hits as potential sources of information. In addition they asked the advisory group for suggestions of documents relating to the topic.

Setting

Integration of services within healthcare settings (reports related to wider integration with non-health setting such as education, housing, social care were excluded).

Population

People with severe mental illness (SMI). This includes schizophrenia, schizotypal and delusional disorders, bipolar affective disorder or severe depressive episode(s) with or without psychotic episodes.

Intervention

Anything that brings together care from different disciplines and related to organisation and delivery of that care, rather than discreet interventions.

Outcomes

Any outcomes that relate to provision and implementation of integrated care.

Through the database and internet search they initially found 2,742 and rejected 2,672 based on initial screen of title and abstract. 70 full papers were checked against inclusion and finally 38 were included in the review. The expert group suggested 10 further items of which 7 were also including bringing the total to 45 studies (27 were evaluations of integrated care and 18 were descriptions only).

Analysis

They used a narrative synthesis to analyse the papers based on 9 principles of Integrated Care from the Mental Health Foundation.

This rapid review tried to unearth the most promising Integrated Care models to help people with severe mental illness improve their physical health.

Results

Summary of the review

The report is very detailed and extensively addresses what was learnt about Integrated Care so I urge you to download and read the full report for a deeper understanding of the findings.

It seems that whilst Integrated Care seems like an obvious solution, the organisation and implementation issues are fraught with complexity both in terms of attitude and culture as well as ethics and regulatory requirements. They found many different models of Integrated Care but often poorly described and using low level evaluation methods. What has been highlighted is that there are significant challenges to Integrated Care which will need to be overcome, as well as a need for higher quality studies that provide findings that can be relied on to inform innovation in the future.

Integrated Care is intended to bring different services together. For this to work there needs to be information sharing (14 papers). However, there are practical and legal barriers to this, for instance the Data Protection Act as well as incompatible IT systems and paper-work.
It’s also important to have a shared agreement about roles and responsibilities and the review found 10 papers that referred to shared protocols.
Co-location of services within another service (19 papers) is suggested as a way of integration but this requires effective multi-disciplinary working and communications for this to work.
There can be missed opportunities for integration as well; one service user described the fact that they attend a clozapine clinic and have health checks there but it’s very much focused on detecting any adverse effects of the clozapine rather than also using it as an opportunity to address broader health and lifestyle issues. The use of navigators as a single named person to help a person through the complex healthcare pathway, ensuring that things happen as they should and care is coordinated. The example of this is Care Programme Approach, however this tends to focus on mental health, social care and housing, and could be extended to also focus on coordinating of care related to physical health needs. However, in order to do this we need to address the issue of staff attitudes and skills related to physical health care within mental health services, and vice versa.
One final and important issue is that of stigma. There is a stigma related to mental health and no more so than in serious mental illness. Staff who are not trained to work in mental health may have negative perceptions of mental illness and may shy away from working with a group of people they perceive as complex and confusing. The system of operating physical health services from the appointments system itself and requirements for attendance or discharge may be a barrier to people with SMI who may have additional cognitive impairments to remembering appointments or feel anxious about attending a new service where they may feel that they are not fully understood or accepted for who they are.

The evidence base for Integrated Care remains quite thin, but should that prevent further efforts to make it work?

Conclusions

So in conclusion, where are we at?

Well it seems that there is no compelling research that demonstrates confidently that Integrated Care is more effective at improving health than standard (parallel) care.

In addition, various models of Integrated Care are presented and poorly described, which means it’s really challenging to know what is the best way (and in what setting) Integrated Care can be implemented. This feels like a familiar issue to me, having worked in the field of co-occurring substance use and mental health (known as dual diagnosis) where the debate focuses on whether care should be integrated by one team (or individual) or whether we can work effectively in parallel (as long as care is coordinated).

Integrated Care for physical health and mental health needs careful evaluation especially in terms of health economics. Often integrated care looks expensive but may provide significant cost savings in the long term. On the other hand, maybe we should focus our energies on making sure that usual care (parallel) care is improved by ensuring greater awareness of the link between mental health and physical health, and ensuring that across ALL health care settings that every opportunity for “making every contact count” is used.

The cost effectiveness of Integrated Care models is paramount to future success.

Summary

We need to address the health inequalities for people with serious mental illness
Whilst Integrated Care looks like a great solution, we need to be better informed before we start creating new (and possibly ineffective) models of care provision
We need clear typologies of Integrated Care and a better understanding of how these models work, in what context, for whom and why
We also need long-term evaluations that can measure the long-term outcomes of Integrated Care compared with usual care