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THE RIGHT TO OPTIMAL HEALTH

July 01, 2006

Optimal health is something all people—people with and without disabilities—aspire to. Optimal health is a state of being we all struggle toward; it is a goal that most people aim for their entire lives. And when we reach optimal health, we appreciate the struggle to achieve it, as optimal health makes us feel alive, vibrant, and full of possibilities. Our health is our very own resource that allows us to believe in our future and make a commitment to a meaningful and productive life.

People who live with serious mental illnesses often do not experience optimal health. Health issues and medical comorbidities are extremely prevalent among people with psychiatric disabilities.1 Research reviews have documented that people with psychiatric disabilities have elevated rates of comorbid diseases and related mortality, with their risk of premature death estimated at 2.4 to 2.85 times higher than that of the general population.2,3 This translates into a life span reduced by 15 to 20 years.

People with mental illnesses often have difficulty achieving optimal health for a variety of reasons:

  • Adverse health consequences suggested to be associated with atypical antipsychotics include obesity, diabetes, metabolic syndrome, osteoporosis, periodontal disease, and sexual dysfunction.1,4

  • People with severe mental illnesses receive less primary and preventive healthcare than the general population and often rely on expensive emergency room services.5,6

  • People with serious mental illnesses may be afraid to seek necessary medical care because of the very real fear of coercive treatment or possible commitment to a psychiatric facility, even though they were seeking care for physical health problems.7

  • People with psychiatric disabilities are at much higher risk than the general public for developing substance abuse disorders and being infected with HIV and developing AIDS.8-10

Despite these immense challenges, research documents that health promotion practices can increase the health of people with serious mental illnesses.11 In fact, a recent Surgeon General statement supports this assertion, advocating for greater attention to and support for services promoting health for people with disabilities.12

Therefore, the mental health system's primary focus on ameliorating the negative consequences of severe mental illnesses (i.e., impairment, dysfunction, and disability) and promoting recovery must be complemented by an emphasis on improving people's physical health. Clearly, the lack of good health contributes powerfully to the disability experienced by a person diagnosed with a mental illness. It is difficult to work, go to school, and live independently when challenged by a serious mental illness and significant physical health issues. Assisting people to attain optimal health through health education and promotion and structured health interventions may lead to not only improved health outcomes, but to greater participation in community environments and desired roles, such as student, worker, parent, and citizen.

Many people with mental illnesses have not had the opportunity to achieve optimal health. They have lacked the resources and skills to improve and achieve a positive lifestyle that supports their physical health and recovery from mental illnesses. They also have faced the inaccurate belief that people with mental illness are incapable of achieving optimal health. This attitude is reflected in the low expectations or the lack of importance that systems of care place on the overall health of people with mental illnesses. Gloria Dickerson, who has received public mental healthcare for more than 30 years, speaks to this issue:

We wondered if the silence of our treaters when it came to our bodies was collusion with the lack of care of our bodies. Most of our psychiatrists just prescribed medications and did not ask about health issues, and left it up to me totally. I feel most lost when it came to being fully informed, so how could I ask the appropriate questions? No one seems to care what it is like living in our bodies with mind-altering drugs.

This mind-body duality has been the prevalent perspective in mental health centers, inhibiting the attainment of optimal health and full recovery.13 Many traditional outpatient services focus primarily on mental illness management and do not include skill-based opportunities for people to learn how to live well in their communities. Groups are needed that address physical activity, health literacy, nutrition, spirituality, and lifestyle choices to help people with serious mental illness attain the information and skills they need and want to live healthier lives.

Also consider how our government separates community-based healthcare services into community health centers and community mental health centers.

While it is certainly challenging to provide health promotion services in community mental health centers because of the need for staff training, funding and reimbursement barriers, scarce resources, and time constraints, it is not only possible but absolutely necessary. People with serious mental illnesses must have opportunities to obtain optimal health, and we as a system are charged with helping people recover and must begin to provide health promotion services.

Hope and Health

At the Center for Psychiatric Rehabilitation at Boston University, a new service initiative has begun to help people develop optimal health as a resource in their recovery. “Hope and Health” is a structured, intensive 16-week program with four evidence-based practice modules:

  • Supported physical activity focuses on walking and functional exercises to increase strength, balance, and flexibility.

  • Food education, derived from a diabetes prevention program, teaches people healthy eating/cooking habits to prevent or minimize disease, as well as provide social and emotional nourishment.

  • Health education helps people determine optimal health practices.

  • Illness management and recovery educates people about psychiatric illnesses and provides skills and strategies to live well while having mental illnesses.

Four days a week, people with serious psychiatric illnesses who take antipsychotics and have a medical disease attend these four groups, offered in an educational environment to begin the process of improving their health. Each curriculum offers practical tools for healthy everyday living, with people taught skills they can use in their communities and within financial constraints. The program's goal is to improve people's functional health so they may use it as a resource for their recovery and community integration. The Center for Psychiatric Rehabilitation is offering to teach this program to other agencies.

The Center for Psychiatric Rehabilitation also has been working with a large managed care corporation that funds day treatment services in Massachusetts to implement elements of the program. Four day treatment centers are working with the Center for Psychiatric Rehabilitation to receive training and support for the delivery of supported physical activity and food education. Staff are working together to implement these practices within the constraints of a day treatment environment and promote a culture of health management, rather than one of illness management.

The day treatment clients' responses have been so positive that one day treatment center is offering a complete “wellness tract” for clients. People can spend their entire time at this center participating in therapeutic groups focused on health promotion skills and lifestyle issues.

Conclusion

The fragmentation of healthcare in our society is magnified in the mental health system. The lack of financial resources and reimbursement strategies for health promotion services are formidable barriers, compounded by complex factors including socioeconomic status, medications, lifestyles, and attitudes. But imagine the difference in people's lives if we work toward reducing the barriers to optimal health as a tool for recovery. Imagine more people saying, as in Dickerson's words, “My body has paid the price, and now I am working toward the recovery of my body as home.”

Dori Hutchinson, ScD, is Director of Services of the Center for Psychiatric Rehabilitation at Boston University.

References

  1. Meyer JM, Nasrallah HA. Issues surrounding medical care for individuals with schizophrenia: The challenge of dual neglect by patients and the system. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. Arlington Va.:American Psychiatric Publishing, Inc.; 2003:1-11.
  2. Berren MR, Hill KR, Merikle E, et al. Serious mental illness and mortality rates. Hosp Community Psychiatry 1994; 45:604-5.
  3. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000; 177:212-17.
  4. Meltzer HY. The metabolic consequences of long-term treatment with olanzapine, quetiapine and risperidone: Are there differences? Int J Neuropsychopharmacol 2005; 8: 153-6.
  5. Folsom DP, McCahill M, Bartels SJ, et al. Medical comorbidity and receipt of medical care by older homeless people with schizophrenia and depression. Psychiatr Serv 2002; 53:1456-60.
  6. Goldberg RW, Seybolt DC, Lehman A. Reliable self-report of health service use by individuals with serious mental illness. Psychiatr Serv 2002; 53:879-81.
  7. Hahm HC, Segal SP. Failure to seek health care among the mentally ill. Am J Orthopsychiatry 2005; 75:54-62.
  8. Davidson S, Judd F, Jolley D, et al. Cardiovascular risk factors for people with mental illness. Aust N Z J Psychiatry 2001; 35:196-202.
  9. Klinkenberg WD, Caslyn RJ, Morse GA, et al. Prevalence of human immunodeficiency virus, hepatitis B, and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders. Compr Psychiatry 2003; 44:293-302.
  10. Razzano L. Issues in comorbidity and HIV/AIDS. In: Graham HL, Copello A, Birchwood MJ, Mueser KT, eds. Substance Misuse in Psychosis: Approaches to Treatment and Service Delivery. West Sussex England:John Wiley & Sons, Ltd.; 2003:333-46.
  11. Richardson CR, Faulkner G, McDevitt J, et al. Integrating physical activity into mental health services for persons with serious mental illness. Psychiatr Serv 2005; 56:324-31.
  12. U.S. Department of Health and Human Services. The Surgeon General's Call to Action to Improve the Health and Wellness of Persons with Disabilities. U.S. Department of Health and Human Services, Office of the Surgeon General, 2005. Available at: http://www.surgeongeneral.gov/library/disabilities/.
  13. Duckworth, K. The case for a wellness orientation: Understanding cardiovascular risk. Presentation at: A Colloquium: Health promotion for people with psychiatric disabilities. Boston: Center for Psychiatric Rehabilitation; October 4, 2004.
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