The Double, Triple, or Fourfle Whammy, Revisited

While we're on the subject of how we treat people with mental illnesses here in the Greatest Country on Earth, it's important to remember that people with severe mental illness are also disproportionately likely to suffer from other chronic and acute diseases. In the chronic category these include co-morbid substance abuse disorders, obesity and diabetes (which are side effects of anti-psychotic and sedative medications), ill-effects of tobacco use, and HIV infection. On the acute side they include injuries from trauma and exposure.

I happen to know a lot about HIV so I'll just throw out a few factoids. A study of middle aged and older persons living with HIV in New York City and Wisconsin found that 27% had thought about suicide in the prior week. A study of HIV seropositive women found that 38% reported needing mental health services in the prior six months. A study comparing HIV+ and HIV- homosexual men found that HIV+ men had significantly higher levels of psychiatric symptomatology and depression. Psychiatric morbidity is associated with significantly poorer health related quality of life for people living with HIV. In addition, psychiatric morbidity is known generally to be associated with poor medication adherence, particularly in affective disorders. A study conducted by somebody well known to this writer, for the City of Boston in 1997, found that, among Latino men and Latina women living with HIV in Boston, a history of mental illness and reported psychiatric symptomatology was associated with an extraordinarily high rate of a history of homelessness.

So, along comes the Compassionately Conservative President’s New Freedom Commission on Mental Health, which in 2003 noted the high prevalence of co-morbidity among people with mental illnesses and found that “While mental health and physical health are clearly connected, a chasm exists between the mental health care and general health care systems in financing and practice.” The report goes on to promise a new era of integrated, coordinated care, in which people's behavioral health and medical providers work together.

Well, here it is 2006 and we don't actually have any proposal whatsoever to do anything about this. People's docs still aren't talking to their shrinks and social workers (if they're lucky enough to have the latter two), and the people have to go to three or four different places, where they often have three or four different case managers, and keep track of nine different medications while they are sleeping in a shelter. Oh, wait. There is a new initiative at the Substance Abuse and Mental Health Services Administration (SAMHSA): they're trying to steer more funding to so-called faith based organizations. Maybe the folks can go down to the local church now and have their demons exorcised.

References: Kalichman SC, Heckman T, Kochman A, Sikkema K, Bergholte J. Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv 2000;51(7):903-7.
Schuman P, Ohmit SE, Moore J, Schoenbaum E, Boland R, Rompalo A, Solomon L. Perceived need for and use of mental health services by women living with or at risk of human immunodeficiency virus infection. J Am Med Womens Assoc 2001;56(1):4-8.
Dickey WC, Dew MA, Becker JT, Kingsley L. Combined effects of HIV-infection status and psychosocial vulnerability on mental health in homosexual men. Soc Psychiatry Psychiatr Epidemiol 1999;34(1):4-11.
Otto-Salaj LL, Heckman TG, Stevenson LY, Kelly JA. Patterns, predictors and gender differences in HIV risk among severely mentally ill men and women. Community Ment Helth J 1998;34(2):175-90.
Sullivan G, Koegel P, Kanouse DE, Cournos F, McKinnon K, Young AS, Bean D. HIV and people with serious mental illness: the public sector's role in reducing HIV risk and improving care. Psychiatr Serv 1999;50(5):648-52.
Sherbourne CD, hays RD, Fleishman JA, Vitiello B, Magruder KM, Bing EG, McCaffrey D, Burnam A, Longshore D, Eggan F, Bozzette SA, Shapiro MF. Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. Am J Psychiatry 2000;157(2):248-54.
Mehta S, Moore RD, Graham NMH. Potential factors affecting adherence with HIV therapy. AIDS 1997;11:1665-1670.