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Defining the link between primary and mental health care

Benjamin Druss and Silke Von Esenwein

Researchers have known since the late 1980s that people with a serious mental health disorder are generally sicker and die younger than those without such a disorder. The weak link between mental health care and primary or specialist care is one that Emory's Benjamin Druss and Silke von Esenwein have sought to better define. Both professors are part of the Center for Behavioral Health Policy Studies, founded in 2013 and housed at the Rollins School of Public Health.

They conducted a study in 2011 that looked at people with mental health disorders over a 17-year period. They found that people with mental disorders died an average of 8.2 years younger than the rest of the population. The average age of death was 66 years, compared with 74 years of age in the general population. Nearly all of the excess mortality was due to medical rather than mental health causes.

"In my work as a psychiatric resident at Yale, I saw how many of my patients' problems went beyond clinical issues, such as being on the right medication, and were in fact larger systems issues with getting access to decent care, particularly to primary medical care," says Druss. "At Emory, our work has increasingly expanded from a health services framework to a broader public health approach. This method looks at people with serious mental illnesses as a disadvantaged population for whom we must address formal health needs, health behaviors, and social and environmental issues if we are going to improve their health and longevity."

One idea that is gaining much attention nationally and from Druss and von Esenwein is that of an integrated health model, one that provides primary and mental health care in a coordinated fashion. When mental health care is integrated with primary care, often at the same location, mental health patients have greater access to primary and preventive care, and their health status significantly improves. For patients with a serious mental disorder, mental health clinics are often their first and only points of contact with the health care system. Moreover, when people with mental illness feel understood and trusted by their mental health provider, they tend to be more engaged with the health care system.

Von Esenwein is now focusing on evaluating integrated systems. She cautions that "integration" does not simply mean locating mental health and primary care in the same building.

"Patients should not have the sense that this hallway is for mental health appointments and this other hallway is for physical care; it should be a team practice," she says. "And if a practice is not sharing medical records, it's not integrated.

"Access to care is a long-term problem. There is a big research-to-practice lag in mental health care, even with other areas of physical medical care, such as cardiology. I think the population that we are working with is a difficult one, and the mental health system has a lot of catching up to do."

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