by Jack Carney*

Recently published studies have startled mental health professionals with the assertion that persons with serious mental illnesses in the United States can now expect to live, on average, 25 years less than everybody else. Those of us who work with persons with serious mental illnesses have long suspected their foreshortened life expectancy. Indeed, twenty years ago, persons with schizophrenia were believed to have an average life expectancy ten years less than members of the general population. Nonetheless, such a jump – or loss of life span – from ten to twenty five years less life expectancy over the course of only twenty years is dramatic. What accounts for it and what do we do about it?

Recent studies – the CATIE and National Association of State Mental Health Program Directors (NASMHPD) studies -- detail a hierarchy of inter-related, and presumably remediable, causative factors. They point to the “second generation” or “atypical” neuroleptic medications, which began appearing on treatment program formularies in the 1990’s, as linked to excessive weight gain and insulin resistance, and accounting for the emergence of a medical condition termed Metabolic Syndrome. This is comprised of a constellation of medical problems, including: obesity; elevated blood glucose; hypertension; elevated triglycerides; and, reduced HDL cholesterol. If left untreated, these problems can lead to Diabetes II, cardio-vascular diseases, and other systemic medical conditions.

Other “remediable” problems lead to shorter life expectancy, and they include life style choices, i.e., smoking, lack of exercise, poor nutrition, abuse of intoxicants; exposure to communicable diseases in shelters and mental health residences; and, most importantly, lack of access to appropriate and effective medical care.

Finding solutions
FEGS, a large mental health and social welfare program in New York City and neighboring Nassau and Suffok counties, currently employs 50 case managers, serving 720 clients with serious mental illnesses, in its New York City offices. After internal discussions with supervisory staff, case managers, program consumers, and senior administration, we decided to develop a pilot training program and demonstration project whose primary objective is to improve consumers’ access to necessary medical treatment. The immediate goal was to teach consumers and case managers how to collaborate with one another and, with consumers’ psychiatrists and primary care physicians, to detect and treat the signs and symptoms of Metabolic Syndrome. These include elevated body mass; blood pressure; blood sugar & trycglicerides. We also wanted them to learn the benefits of the Metabolic Syndrome Monitoring Protocol recommended by the American Diabetes Association and American Psychiatric Association.

We have termed our endeavor the Integrated Collaborative Case Management Demonstration Project (ICCM) to reflect our newly balanced emphasis on behavioral and physical health care and the collaboration between consumer, case manager and health care providers that will be required. We expect improved treatment access and coordination will reduce of emergency room medical care and in-patient hospitalization, and, ultimately, result in longer and healthier lives for consumers.

We launched a demonstration and training project on September 11, 2007, when 11 case managers, 11 consumers and four supervisors began a 14-hour training course. The case managers were selected because of their interest in participating in the eight-months project; and the consumers were chosen because they were being prescribed one of the atypical anti-psychotic medications – Olanzapine, Quetiapine, Riserpidone, Ziprasidone, Aripiprazole, Clozapine -- or because they suffered from a chronic physical illness.

We decided to train consumers and case managers together because we assumed that a true collaborative effort between the two will be required to overcome the barriers to health care personified by overtaxed and often intolerant health care providers.

As soon as the training was completed, each of the case managers who participated selected a second consumer with similar characteristics (i.e., prescribed one of the atypical anti-psychotic medications or with a chronic physical ailment). The case managers then shared with this second group the information that they had acquired in the previous formal training, teaching consumers about the side effects of these medications and the larger health consequences.

The entire cohort – case managers and both sets of consumers – then set out to operationalize our ICCM protocol, to initiate, review and communicate test results with the appropriate physician and arrange for recommended referral(s).

Preliminary results
All but one of the original participants (one consumer dropped out) completed the seven-session training program. Evaluation data, collected after each session and at the conclusion of training, substantiated the usefulness for both consumers and case managers: each group found each of the seven sessions informative as well as effective in achieving each session’s learning objectives; and each group, in pre- and post-training learning assessments, reported to have learned similar amounts of new information at virtually identical rates by the training’s conclusion. Anecdotal comments from consumers and case managers written after each session matched the evaluative data; and the consumers’ evident enthusiasm, which I witnessed first hand, appeared to animate the training and the trainers. One of the consumers characterized the training’s objective as teaching consumers and case managers to “ask questions and get answers.”

Three months after the initial training, evaluation data indicate consumers and case managers retained substantial amounts of information. The same can also be said for the second group of consumers, whose learning of fundamental concepts, e.g., Metabolic Syndrome, has progressed, although at a slower rate. We will collect final post-training evaluation data at the end of April when the demonstration project concludes.

Finally, project outcome data as well as anecdotal reports from consumers and case managers appear to indicate improved consumer access to health care, in general, and movement toward achievement of several of the project’s key objectives. Specifically, the data collected reveals the following, based on responses by 17 consumers:

1. Twelve have primary care physicians, most of them in hospital-based clinics, and all continue to see their psychiatrist regularly.

2. Thirteen, with the assistance of their case manager collaborators, have identified the presence of Metabolic Syndrome risk factors in themselves; have communicated their concerns to their treating physicians, usually psychiatrists; and, they have complied with the medical tests and medication prescribed them.

3. Eight reported chronic medical ailments, principally, Diabetes II, hypertension and obesity, with seven of them receiving ongoing care in hospital clinics for chronic medical ailments

4. Twelve reported satisfaction with their physicians’ response to their concerns; and eleven reported satisfaction with the health care they are receiving.

5. All but one reported that they had benefited from participating in the project

Jack Carney, Ph.D., is the senior director to FEGS Citywide & Brooklyn Blended Case Management Programs. An outline and summary of the training program is available at Jcarney@fegs.org