A holistic approach to patient care in psychiatry

According to epidemiological data obtained from 2001 to 2003 by the National Comorbidity Survey Replication, approximately 25% of adults in any given year have a mental illness, with 68% of those having one or more general medical conditions.¹² Risk factors for both mental and medical conditions include exposure to early trauma and chronic stress as well as socioeconomic factors, such as low income and poor educational status.³⁴ Those with mental illness have higher rates of substance use (including tobacco, alcohol, and illicit substances), poor eating habits, and physical inactivity, thereby increasing the risk of chronic medical conditions.² Patients with mental disorders have also demonstrated lower adherence rates to medications (both psychotropic and non-psychotropic).² A meta-analysis found that patients with depression were three times as likely to be non-adherent to medical treatment recommendations than non-depressed patients.⁶ Rate of premature mortality is also increased in patients with mental disorders, which has been attributed to lower socioeconomic status, poor quality of care, medication adherence issues, and adverse health behaviors.⁷⁸ Additionally, those with mental disorders are less likely than those without mental disorders to receive preventative care services, which may also contribute to this increased mortality rate.⁹ Conversely, chronic medical conditions with high symptom burden, such as migraine headaches or back pain, increase the risk of major depression.²⁵ Medications used to treat mental illness, such as second generation antipsychotics, may induce metabolic abnormalities and lead to metabolic syndrome, while medications used to treat chronic medical conditions, such as steroids, can potentially exacerbate or destabilize a patient's mental illness.²

The DSM-5 has recognized the importance of an integrated approach to patient care by removing the multiaxial system of diagnosis and instead listing both medical and mental conditions together, highlighting the intricate relationship between the two and the need for coordinated care for appropriate management.¹⁰ Collaborative care models, which focus on integrating mental health and primary care services through the use of a multidisciplinary team to screen and monitor patients, have proven to be an effective approach to providing integrated care.²¹¹ The degree of integration can vary from fully integrated models, such as the VA in which all services, including both mental health and primary care, are housed in one location with an integrated electronic medical record, to limited or moderately integrated models, in which the primary care or mental health consultant is housed in a remote location.¹¹ A systematic review found that initiatives focused on integrating medical and mental health care were shown to improve preventative care in patients with mental illness, as demonstrated by higher rates of immunizations and screening tests provided to those receiving integrated care compared to patients receiving usual care.¹¹ The expansion of Medicaid services under the Affordable Healthcare Act is projected to provide coverage to an additional six million previously uninsured patients with mental illness, who may have accompanying chronic medical comorbidities, further supporting the need for integrated care models.¹² While additional research exploring clinical outcomes associated with integrated models are needed, the importance of addressing mental and medical comorbidities and the provision of preventative care in patients with mental illness cannot be overlooked.

The primary responsibilities of a psychiatric pharmacist include optimizing psychotropic therapy, preventing or minimizing side effects and drug interactions, providing medication education, and identifying and surmounting any barriers to medication adherence. One must also keep in mind the importance of a holistic approach to patient care, taking into consideration medical comorbidities when selecting psychotropic agents, to prevent potential worsening of the patient's medical conditions. Hypertension, smoking, heart disease, diabetes, obesity, and asthma are more prevalent in those with mental illness compared to those without mental illness.²⁸ Thus, it is imperative for psychiatric pharmacists to keep abreast of recent guideline updates in order to provide evidence-based medicine when treating common medical conditions affecting our patients. The May issue of the Mental Health Clinician is dedicated to updating the reader on recent guidelines regarding the identification and management of common conditions encountered in the primary care setting. A review of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guideline, published in December of 2013, will be provided as well as an overview of the American College of Cardiology and the American Heart Association guideline for the management of blood cholesterol to reduce atherosclerotic cardiovascular risk.¹³¹⁴ Highlights from the 2014 American Diabetes Association guideline will also be reviewed.¹⁵ Additionally, articles addressing the use of medications in patients with hepatic dysfunction, the management of depressive symptoms in patients with cancer, the management of medication-induced sexual dysfunction, the treatment of chronic respiratory illness, as well as an article discussing the treatment of pain in patients with comorbid substance use issues will be provided.