Patients with serious mental disorders will be best served when psychiatrists starting thinking like primary care physicians, and primary care physicians start thinking like psychiatrists, experts said at a forum on integrating physical and mental health care.

"There has always been this

disconnect between what we think of as physical illness and what we think of as mental illness," said Dr. J. Sloan Manning, a family physician at the University of North Carolina, Chapel Hill. "The reality is that there is no disconnect.... We, the medical community, are the ones who are divided."

This philosophical division has created a practical division as well, in which patients might receive therapy for their mental illness while their physical problems are ignored. This one-sided treatment can have serious repercussions--patients who are physically ill are less likely to be adherent to antipsychotic medications, fueling a vicious cycle of psychiatric crises.

"These patients require more than one clinician and more than one treatment approach," Dr. Manning said in an interview. "Only when clinicians collaborate and communicate will their patients get the full benefit of multiple modes of therapy."

Dr. Manning was speaking at the multidisciplinary forum cosponsored by the National Council for Community Behavioral Healthcare and Eli Lilly & Co.

It's not news that patients with mental illnesses carry a significantly increased risk for chronic physical disease, including diabetes and cardiovascular disease. Those with mental disorders also have significantly higher rates of modifiable risk factors for physical disease, such as smoking and poor diet and exercise habits. The result, said Dr. Joseph Parks, is that patients with serious mental illness typically lose more than 25 years from their normal lifespan, compared with the general U.S. population.

According to a 2006 study, compared with patients without mental disorders, discharged patients with mental illness were 10 times more likely to have abnormal physical findings in the clinic or in lab studies; 6 times more likely to die from pneumonia, influenza, or chronic respiratory disease; and 3 times more likely to die of heart disease or diabetes.

"While suicide and injury account for up to 40% of excess mortality in schizophrenia for example, about 60% of these premature deaths are attributable to "natural causes,' such as cardiovascular, respiratory, and infectious disease and diabetes," said Dr. Parks, chief clinical officer and director of comprehensive psychiatric services at the Missouri Department of Mental Health, Jefferson City.

Antipsychotic medications also play a role in comorbid illnesses--especially those related to excess weight--but the physical interplay of mind and body accounts for most of the problem, Dr. Manning said. Patients with bipolar disorder, for example, have dysregulation of the hypothalamic, pituitary, thyroid, and adrenal axes, predisposing them to diabetes as well as inflammation leading to atherosclerosis.

The chain of care begins when a psychiatrist makes physical health an equal part of the treatment plan, said Dr. Thomas E Liffick, a psychiatrist and medical director emeritus of the Southwestern Indiana Mental Health Center in Evansville. "We definitely should have a role in screening for health abnormalities and making recommendations for risk reduction and lifestyle modification in this population. We can catch patients earlier, refer them for appropriate treatment, and improve their physical and mental outcomes," since physically healthy patients are more likely to adhere to their medications.

Collaboration can be as simple as a personal connection with a primary care physician who will accept a mental health patient referral or as comprehensive as a large program specially designed to deliver integrated health services.

Formal programs are a successful option in some areas of the country, said Dr. Benjamin G. Druss of Emory University, Atlanta. Collaborative care clinics provide physical health care for patients with mental health disorders. One experimental program uses nurse practitioners.

Most successful programs start small and grow incrementally over time, Dr. Druss said in an interview. "Try something small and, if that doesn't work, try something else. But keep trying. Don't let the perfect be the enemy of the good."

BY MICHELE G. SULLIVAN

Mid-Atlantic Bureau