Managing Physical and Mental Health Conditions: Consumer Perspectives on Integrated Care

Abstract

Background:
Despite the growing trend of integrating primary care and mental health services, little research has documented how consumers with severe mental illnesses manage comorbid conditions or view integrated services.

Objectives:
We sought to better understand how consumers perceive and manage both mental and physical health conditions and their views of integrated services.

Methods:
We conducted semi-structured interviews with consumers receiving primary care services integrated in a community mental health setting.

Results:
Consumers described a range of strategies to deal with physical health conditions and generally viewed mental and physical health conditions as impacting one another. Consumers viewed integration of primary care and mental health services favorably, specifically its convenience, friendliness and knowledge of providers, and collaboration between providers.

Conclusions:
Although integration was viewed positively, consumers with SMI may need a myriad of strategies and supports to both initiate and sustain lifestyle changes that address common physical health problems.

Full text

Managing physical and mental health conditions: Consumer
perspectives on integrated care
Angela L. Rollins, PhD,
Richard L. Roudebush VAMC Center for Health Information and Communication, ACT Center of
Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis,
Indiana, USA
Jennifer Wright-Berryman, PhD,
School of Social Work, University of Cincinnati, Cincinnati, Ohio, USA
Nancy H. Henry, B.A.,
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Alicia M. Quash,
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Kyle Benbow,
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Kelsey A. Bonfils, M.S.,
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Heidi Hedrick, M.A.,
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Alex P. Miller, B.S.,
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Ruthie Firmin, M.S., and
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Michelle P. Salyers, Ph.D.
ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology
Department, Indianapolis, Indiana, USA
Corresponding address: Jennifer Wright-Berryman, PhD, University of Cincinnati, School of Social Work, PO Box 210108, French
Hall West, 1616, Cincinnati, OH 45221-0108, wrigh2jb@ucmail.uc.edu.
Authors disclose no conflicts of interest related to this research.
All authors wrote or contributed significant editing for the manuscript.
HHS Public Access
Author manuscript
Soc Work Ment Health
. Author manuscript; available in PMC 2018 January 04.
Published in final edited form as:
Soc Work Ment Health
. 2017 ; 15(1): 66–79. doi:10.1080/15332985.2016.1173160.
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Abstract
Background—Despite the growing trend of integrating primary care and mental health services,
little research has documented how consumers with severe mental illnesses manage comorbid
conditions or view integrated services.
Objectives—We sought to better understand how consumers perceive and manage both mental
and physical health conditions and their views of integrated services.
Methods—We conducted semi-structured interviews with consumers receiving primary care
services integrated in a community mental health setting.
Results—Consumers described a range of strategies to deal with physical health conditions and
generally viewed mental and physical health conditions as impacting one another. Consumers
viewed integration of primary care and mental health services favorably, specifically its
convenience, friendliness and knowledge of providers, and collaboration between providers.
Conclusions—Although integration was viewed positively, consumers with SMI may need a
myriad of strategies and supports to both initiate and sustain lifestyle changes that address
common physical health problems.
Keywords
Severe mental illness; integrated care; mental health services; primary care services
Introduction
People with a severe mental illness (SMI), such as schizophrenia, bipolar disorder, and
major depression, experience shortened lifespans compared to their peers without major
mental illnesses. Recent reviews document that people with SMI die 15–25 years earlier
than the general population, and the trend towards early mortality has accelerated in recent
years (Jones et al., 2004; Morden, Mistler, Weeks, & Bartels, 2009; Saha, Chant, &
McGrath, 2007). The causes of this unfortunate phenomenon are complex. Some research
attributes excess mortality to the high rates of physical comorbidities: 75% of adults with
SMI have one or more comorbid physical health conditions and 50% have at least two such
conditions (Jones et al., 2004; Morden et al., 2009). Other research suggests risky health
behaviors, such as smoking, poor diet, and sedentary lifestyles, contribute to a wide range of
these comorbid conditions, like cardiovascular disease, diabetes, cancer, and chronic
pulmonary illness. Prevalence rates for cardiovascular disease, for instance, are 22% for
people with SMI (Jones et al., 2004), compared to 11.5% for the US general population
adults (Centers for Disease Control and Prevention, 2012). Many of these factors can be
attributed to a metabolic syndrome associated with extended use of atypical antipsychotic
medications. Metabolic syndrome is described as a group of risk factors (such as weight
gain, hypertension and insulin resistance) that occur together to increase the risk for
cardiovascular disease, type II diabetes, and stroke (Deakin et al., 2010). For example, Casey
et al. (2004) reported that people with schizophrenia using antipsychotics such as olanzapine
and clozapine were six times as likely to have insulin resistance compared to the group using
conventional antipsychotics. Although metabolic syndrome has been associated with weight
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gain and subsequent insulin resistance, the exact causes of the syndrome are not fully
understood (De Hert, Schreurs, Vancampfort, & Van Winkel, 2009).
The mental health field has focused on the integration of primary care and behavioral health
services as one method of addressing the early mortality and physical comorbidity
challenges for people with SMI. A recent initiative by the Substance Abuse and Mental
Health Services Administration (SAMHSA) of the US Department of Health and Human
Services funded 100 demonstration projects for integrated primary care and behavioral
health. However, published data from these demonstrations have not included how
consumers experience comorbid mental and physical health conditions, or the integration of
their physical and mental healthcare services. The majority of studies in this area focus on
the benefits and challenges of providing mental health services within traditional primary
care settings (e.g., (Bailey, 1997; Bindman et al., 1997; Lester, Tritter, & Sorohan, 2005;
Rogers, 2001)). For example, Lester and colleagues (2005) asked consumers with SMI about
their experience of traditional primary care services. In this study, consumers reported that
quick access to primary care services, provider optimism, continuity of care, and listening
skills were more important than specific mental health knowledge from their primary care
provider (Lester et al., 2005). In the same study, primary care providers reported less
comfort with the specialized mental health care needs of persons with SMI and recognized
struggles in communicating with this patient population (Lester et al., 2005). To our
knowledge, there has been only one study focused on consumers’ perspectives of integrated
primary care services within specialty mental health contexts. In this study, consumers
endorsed their preference for consumer providers (over traditional clinician-delivered
services) and hands-on guidance on healthy lifestyle management (Cabassa et al., 2013). We
sought to better understand how consumers experience both mental health and physical
health conditions, how they attempt to manage these conditions, and how they perceive
integrated care in the context of a particular demonstration project focused on integrating
primary care services within a specialty mental health clinic. This information can contribute
to the limited but growing knowledge base on consumer perceptions and experiences of
integrated care, and can be used to create more consumer-centered services.
Methods
The community and academic partners involved in this study received a SAMHSA
integration grant in 2010 to implement a primary care clinic within a community mental
health center (CMHC) in a Midwestern city. The primary care clinic staff were employed by
a federally-qualified heath care center with whom the CMHC had a long-standing
partnership. The primary care provider (a nurse practitioner) and nurses met weekly with
CMHC staff (primarily nurses) to coordinate care and review clients’ charts. A nurse care
manager, employed by the CMHC, was also assigned full-time to the primary care clinic to
serve as another conduit for coordination of care. At the time of this particular study, the
program had enrolled over 300 individuals with SMI to receive their primary care services
within the new clinic.
We conducted semi-structured interviews with 39 consumers who were participating in a
larger study of physical health decision-making autonomy preferences in integrated care
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settings. Participants were all diagnosed with a major mental disorder, including
schizophrenia (n=19), major affective disorders (n=16), or other mental health disorders
(n=4). Using convenience sampling, research staff approached consumers and invited them
to participate as they arrived for their primary care appointment at the integrated health
clinic. Consumers who agreed to participate were asked to provide written informed consent
and were compensated $20 for their time. Most interviews took 30 minutes to complete. Of
the 47 consumers approached, 39 agreed to participate in the interview. Interviewers were
bachelor’s and master’s level research assistants who had received training in qualitative
interviewing techniques. None of the interviewers had clinical responsibilities for research
participants. Interview questions were designed to answer 4 key research questions: 1) What
health conditions do participants have and how do they manage them? 2) Are there
differences in how consumers manage their physical health versus their mental health? 3)
What do consumers think about relationship of mental and physical health? 4) What are
consumer perceptions of integrated care? Research protocol probes then included: What are
your thoughts about having your primary care clinic at the mental health center? What do
you like about getting your primary care services at your mental health center? Is there
anything that you would change about it? What condition(s) cause you to seek services here?
How are you managing those conditions? How do you think your mental health and your
physical health affect one another? Are there differences in what you do to take care of your
mental health versus your physical health? All study procedures were reviewed and
approved by the Indiana University Purdue University Indianapolis Institutional Review
Board.
Interviews were recorded, transcribed, and coded using a combination of content analysis
and an iterative, consensus-based approach to identify emergent themes (Charmaz, 2006).
Pairs of raters (eight total) divided the transcripts for coding. Two raters read each transcript
and independently extracted quotes that reflected answers to each of the four questions. The
two raters then compared notes and came to consensus on which quotes reflected the
particular domains. Then each team developed a summary for a particular question, reading
the quotes across participants within a domain and linking responses together, looking for
similarities and differences across participant responses. One person took primary
responsibility for the summary, and the second rater re-read the quotes and edited the
summary.
Results
What health conditions do participants have and how do they manage them?
Participants were asked to indicate if they have any of a list of specific health conditions
(diabetes, hypertension, COPD, heart disease, and cancer) or other health issue(s), and if so,
participants were asked how they manage that condition. Table 1 lists the frequency of
conditions disclosed by participants and methods of managing these conditions. Of the 39
participants interviewed, 37 (94%) reported having at least one chronic physical health
condition.
Most (68%) of participants reported having hypertension. Participants reported managing
their hypertension by taking medications as prescribed, getting exercise, and being
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conscientious of what they consume. Participant 1009 stated, “I take medicine, so I’m okay
every day as long as I take my medicine… And, I walk a lot. I’ve got a dog, so I walk at
least three times a day… And the apartment I live in has an indoor pool…It’s relaxing for
me and it kind of relieves stress for me”. Participant 1009 also addressed the importance of a
healthy diet saying, “I do eat fruits. I just need to work on the vegetables…. and cut back on
my [soft drinks]”.
Chronic obstructive pulmonary disease (COPD) was the second most prevalent health
condition reported amongst our participants (28%). Several others also mentioned difficulty
breathing at times. Using oxygen, inhalers or nebulizers, and/or quitting smoking were the
most commonly reported strategies for managing this condition. Participant 3001 reported
that attending support groups along with using the nicotine patch helped to reduce smoking:
“I’m trying real hard to quit smoking and that’ll help it a lot…I do pretty well. I tried several
methods to quit smoking. The patch works real well for me, and nicotine gum works well for
me and I, over the past year, I’ve probably not smoked more than I smoke [now], which does
affect COPD a lot. [It would help] to have the smoking cessation class come back. There
was, like, a get together group for people to support each [sic] and not smoke.” While it is
ideal to stop smoking, several continued to struggle with cessation, as participant 1011
shared: “It managed me… I smoked for 40 years. I didn’t manage it for 40 years.”
Diabetes was another commonly endorsed condition (16%). Monitoring blood sugar, taking
insulin, and being cautious about eating habits are a few ways participants reported dealing
with this physical health condition. Participant 2002 stated, “I test my blood at least once a
day. I take my insulin shots. I changed my diet once I knew I was diabetic. I cut out a lot of
sugar and sodium.”
Three participants reported having heart disease while four more reported a heart condition
including irregular heart rate and heart valve issues. These individuals reported managing
heart disease or related conditions in a variety of ways such as: taking medication,
exercising, quitting smoking, and having a healthy diet. Participant 2003 also discussed
getting support to lose weight and eat healthy, saying, “I’ve had people inspire me to do that,
and it’s given me that little bit of a push, [more] than I had before where I just had to make
up my own mind. It’s kind of hard to do that. And if you have somebody kind of give you a
little bit more inspiration and [sic] willing to do it with you or give you that ‘go for it’ kind
of attitude…That’s what makes me motivated to make it better.”
While some participants are succeeding in managing their particular health condition, there
is still room for improvement in obtaining resources and learning how to properly manage
these problems. As seen in Table 1, although many reported taking prescribed medication,
getting adequate exercise, and constructing healthy eating habits to maintain good health,
others were still struggling to manage their conditions. For example, several participants
(n=7) reported relying on medication alone. However, the majority of participants (n=26)
used two or more methods to manage their health, with diet and exercise being the most
frequently reported behavioral strategies.
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Are there differences in how consumers manage their physical health versus their mental
health?
Yes, there are differences—Of the 39 people who participated in the interviews, 21
people (54%) responded that they do, in fact, approach the management of their physical
health and mental health differently. For some, there appeared to be different levels of
perceived control. For example, Participant 1007 indicated that she had more control over
mental than physical health, without mention of medication as an intervention. “I try to coax
myself out of a mental slump if I’m in one. A physical slump—not—I can call a doctor or
do something about it, but basically I’m not too much in control of that. But, mentally, I try
to work on it and, and get in a better state of mind.” Similarly, Participant 1008 shared:
With mental health, I try, I sit and study, thinking about things that might help…do
self-help things, and sometimes it does help for the time being. As far as my
physical health, I mean I do the best I can. When my foot – I got this gout – and
when my foot hurts I stay off of it. Like, I’ve been in bed for about five days here.
Conversely, one participant (Participant 1021) offered an alternate perspective, believing he
had more control over physical health through exercise and weight loss, for example. When
asked about mental health management strategies, however, he simply replied, “I pray”
without much additional elaboration.
In addition to the theme of control, some participants explicitly described different
management strategies for mental vs. physical health. For example, Participant 1020 seemed
to equate mental health management strictly with pharmacologic intervention, but thought
physical health could be managed with general wellness strategies. “Mental is medication…
Physical, I eat more properly and exercise and stuff like that.” Another participant (1017)
reported that she takes preventative measures for physical health and relies on social support
for her mental well-being. “Well, my physical health—I just need to make sure that I drink
plenty of water because when I went into [health center] the first time I was dehydrated.”
She added in reference to her mental health, “I’m down here [the CMHC] and I have my
brother and sister-in-law to check up on me.” Participant 2005 also differentiated helpful
activities for mental vs. physical health, stating “I read a lot, which keeps your mind
occupied…Well, cooking relaxes me mentally; but physically, it ain’t going to do a dang
thing.”
It should be noted that three participants initially answered “No” when asked if there were
differences in the management of their mental and physical health needs, but went on in
their interviews to describe distinctly different ways in which they manage each area. As
such, these three responses were considered to manage their physical and mental health
differently.
There are no differences—Twelve participants (31%) reported no appreciable
differences in how they managed mental vs. physical health problems. Of those 12 people,
half of them specifically mentioned medication (either alone or along with other strategies)
as an intervention they use to manage both physical and mental health issues. For example,
when asked if there was a difference, P1014 said, “No. They both— pretty much I just take
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the pills.” P1029 elaborated a little more, “Well, I take medicine for both of them. So, I try
to relax. I can’t think, I try to just rest and try to relax. That’s basically what I do for both of
them, even if they’re independent or separate.” Some participants had multiple strategies for
both conditions. For example, P1002 reported, “See the doctor on a regular visit, take my
medicine, exercise, music and go to movies, entertain, have friends.” Interestingly, this same
participant also reported that he partakes in boxing as a health management technique. When
queried about whether boxing was for mental or physical health, he indicated that this
activity was effective in managing both areas: “Yeah, because you get your aggression out,
too.”
What do consumers think about the relationship between mental and physical health?
While one person indicated he found no relationship between mental and physical health and
others provided responses indicated uncertainty, 32 participants (82%) reported that they
believe there is some relationship between the two areas of health. Multiple themes emerged
in this area and are discussed below.
Mental health affects physical health—Thirteen participants (33%) indicated that their
mental health has an effect on their physical health. For example, Participant 1023 simply
stated: “if you’re depressed, you’re probably not going to feel good.” Several clients
reported that a decline in their mental health often resulted in lethargy. “Sometimes with my
mental health”, said Participant 1014, “I want to sit and sleep.” Participant 1026 made a
similar observation stating that feeling “lonely” leads to inactivity: “I get lazy, and I don’t
want to do nothing.” Participant 3000 had similar feelings about the link between depression
and activity level: “You’ll be depressed and don’t want to get out of bed.”
Only one participant (2001) discussed a link between the use of psychotropic medication
and physical health side effects from those medications. “I take [medication] and it makes
me a little dizzy and stuff.” When further queried by the researcher, this participant added:
“Like, you could be tired too much. You could be dizzy…. you could get a stomachache.
Your muscles could tense up.”
Physical health affects mental health—Of the 39 participants, 10 people (26%)
endorsed the belief that physical health has a unidirectional, mostly negative, effect on
mental health. As Participant 1007 stated, “… mostly if I don’t feel physically well,
sometimes it could drag me down.” Another participant had a similar response, stating
“whenever I’m physically ill or having symptoms more than usual, it affects my depression
and my anxiety.” (P1019).
A few participants cited physical injuries or conditions as triggers for mental health
problems. For instance, Participant 1024 reported that a back injury necessitated a job
change, which negatively impacted his income and thereby his mood: “my income was way
lower than what I was used to making. That was a big reason why I think depression kind of
set in.” Similarly, Participant 1025 reported that a knee injury limited physical activity,
which contributed to the onset of depressive symptoms: “And I know that the fact that I’m
less physically active is a concern for me and leads to depression.” Participant 1017 noted
specifically that menstruation took a toll on her mentally: “I was crying at the drop of a hat.”
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One participant expressed a more positive outlook, that taking preventative measures for
physical health such as exercise and proper diet can positively influence mental health as
well. “Yeah, it does affect the mental health also”, said Participant 3001. “It strengthens your
ability to, um, feel better.”
Mental health and physical health affect each other—Nine participants (23%)
reported the effects of each health dimension reciprocally influence the other. As Participant
1003 said, “If one is bad, the other one’s bad.” Participant 1002 concurred: “If, you know,
one’s out of whack, it’s going to cause the other to be.” Participant 3003 spoke eloquently
on this issue:
Well, if your mental is not working right, your physical’s not going to be right.
They work together. You know, you’ve got to have one to have the other. But,
mental affects your physical as well as the physical affects the mental, so you got to
have them working together. That’s why it’s so important, like I said, you got to be
able to exercise and sleep, and that way your physical is working for the mental.
You know, so it all goes together.
What are consumer perceptions of integrated care?
Convenience—The most common response when asked about the positives of integrated
care was convenience. Many participants liked that they could make only one trip for all
their physical and mental health needs. Participant 1015 stated, “I like that it’s easier to
interact with both doctors.” Another key point included location and travel, with many citing
how close the clinic was from where they were living. Many people also stated the
convenience of not having multiple appointments at multiple locations. Participant 1030
highlighted this saying, “you don’t have to worry about having to rush from place to place
and missing appointments or being late, so I think that’s really cool.”
Friendly and knowledgeable staff—The on-site staff members were also frequently
cited as positive aspects of integrated care. Many referred to staff as “really, really nice”,
“friendly”, and “personable.” Staff (including the front office workers, nurses, and doctors)
also helped participants feel comfortable. Participant 1003 spoke to this point saying, “I
appreciate [staff names] and I get along with them. I trust them and I just enjoy coming
here.” Similarly Participant 1009 said, “I like it here. I mean they treat me good…I don’t
have to wait long. And, if I do, they, they come and let me know. And, they take care of me.
I like my doctor and I like my therapist. … I like the people here, everybody here.”
Participant 1013 said “[Staff name] always has something funny to say to lighten people
up… The doctor is nice as well as his nursing staff. Everybody’s nice. They respect me, that
kind of thing.”
In addition to being personable, staff were considered knowledgeable. For example,
Participant 1016 stated, “I really like my doctor. I really think he knows his stuff. I like, too,
that they’re really also concerned about you psychologically. I like how it is holistic…”
Similarly, Participant 1022 spoke about this knowledge saying, “if I have a question they’ll
answer it…I haven’t gotten an ‘I don’t know’.”
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The overall environment of the setting was also considered a positive aspect of integrated
care. Participant 4010 praised the staff for making the environment more comfortable than
his previous experiences: “The feeling that it doesn’t feel like a mental health center. It
doesn’t feel like I’m in an institution. I know there are people here with more severe
situations than myself, but I think it feels very right at home.” The highest praise came from
participant 1011 who said the staff was professional, well-managed, and welcoming every
time they visited:
They’ve been very accommodating here…I can tell you those persons along with
the persons that work behind the counter out here make you feel mighty welcome
when you come here…And, they’re so good about keeping appointments, calling
you a day ahead of time, uh, you know, it’s just well managed here. And, the people
are professional…It’s – I mean, they’re very professional. I’ve come to rely on
them…I think highly of everyone here. I just really do.
Shared information and communication—Many consumers appreciated that mental
and physical health doctors could easily communicate and collaborate. Participant 1025
spoke to this point, saying, “I think it’s a good idea because then they can relate my physical
symptoms to my mental treatment and they’re there to know if it ties”. Participant 1027 was
more specific in explaining how the coordination between doctors can ensure that they are
taking the correct medication: “Because I’m not getting medicine from this doctor and that
doctor and then having to confer. They know exactly what I’m taking, when I’m taking it,
and how it’s supposed to be taken.” One participant (1028) had a very detailed response,
highlighting how the coordination and communication specifically helped her:
I think it’s a wonderful thing because not only can they communicate with each
other, they can communicate with me…One time when I was having a test and it
came out positive, my therapist that I was talking to went to see the doctor and
[could coordinate when to see her]. When they’re all working together, there’s not
such a big assumption that, ‘oh, it’s all in her head’…. So, if we’re all
communicating, we kind of can try to stay on the same page at least…And, also, if
I do get some of the diagnosis [and] I don’t know exactly how to react, or if they
worry me, then I can talk to my therapist [there] and say, you know, “I feel a little
worried”, that kind of thing. And, and, I don’t have to sign a release for another
place. I’ve already signed all that. And, it’s all coordinated. I like it.
Needed improvements—When asked about improvements to integrated care, 31
participants (79%) responded that they would not recommend any changes. Those who
thought improvements were needed pointed to a few minor changes. Two participants spoke
about missing equipment that was necessary for their treatment, including an X-ray machine
and materials needed for blood testing. Another consumer wanted more prompt return on
phone calls, while two participants mentioned that having more doctors would help their
treatment. For example, Participant 2003 suggested, “There should be more, maybe more
doctors or psychiatrists and stuff like that, to be available to maybe even give you a choice of
your own, to pick out somebody. Maybe more counselors besides psychiatrists or doctors
[for] maybe some kind of access for different information.”
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Discussion
Consumers of this integrated health clinic had numerous and varied physical health
conditions. Although they cited many different strategies to manage physical health
conditions, the most commonly endorsed health management strategy was medication. For
those who did identify a desire to make important behavioral modifications for physical
health conditions (e.g., smoking cessation, increasing exercise, eating healthier diets), they
reported struggling with these lifestyle changes. Some consumers indicated a need for
multiple strategies (i.e., nicotine patches, gum, and smoking cessation support classes) as
well as needing extra “inspiration” to make tough changes. Consumers with SMI may need a
combination of strategies and supports to initiate and sustain lifestyle changes that address
common physical health problems, in addition to medications. These notions are consistent
with literature indicating the need for multi-pronged, sustained approaches targeted toward
consumers with SMI, above and beyond interventions targeting the general population, to
address smoking cessation (Cook et al., 2014; Evins et al., 2014; Schroeder & Morris, 2010)
and weight reduction (S. Bartels & Desilets, 2012; Daumit et al., 2013).
Consumers’ perceptions of relationships between mental and physical health
overwhelmingly indicated they feel a link between the two, whether one-directional or
mutually influencing one another. Contrasting these findings were distinctions between how
consumers reported managing their physical and mental health conditions. While some
participants perceived less control over physical health conditions than mental health
conditions, others described managing both conditions using medications or other strategies.
The emphasis on medications was noteworthy in that, as a field, we may need to do more to
activate consumers to take steps to manage physical and mental symptoms with behavioral
lifestyle choices. Though medications may be underutilized for some conditions, such as
nicotine replacement and smoking cessation medications for people with SMI who smoke
(Schroeder & Morris, 2010), there seems to be a tendency to rely solely on medications for
at least a subsample of the SMI population.
When asked about their perceptions of integrated care, most participants endorsed the
convenience of co-located healthcare services, as well as more general characteristics of
being served by knowledgeable, friendly staff who are concerned with their whole health,
rather than just mental or physical health. Consumers also were pleased with the level of
collaboration and communication between providers overseeing primary care and mental
health needs. Respondents even alluded that primary care services in isolation of mental
health integration feel more stigmatizing (“oh, it’s all in her head”). Participants highlighted
how colocation facilitates collaboration: the ease of communication when a mental health
provider can simply walk down the hall to communicate something important to primary
care providers. This finding is consistent with past research indicating better treatment
engagement in co-located services (S. J. Bartels et al., 2004) and the use of warm hand-offs
often seen in well executed collaborative care models. Participants generated few
recommendations for improvement, other than the need to broaden the array of services and
procedures available at the integrated clinic (e.g., X-rays, wider range of blood work). This
particular program is relatively small in scale, compared to some larger mental health
programs. Larger programs may be able to justify the addition of these sorts of equipment or
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available procedures. Likewise, the relatively small caseloads of consumers in integrated
care programs embedded in community mental health centers make it difficult to justify the
employment of multiple primary care providers that would allow consumers a choice in
which doctor provides their care.
Conclusion
Overall, responses from consumers indicated a favorable view of the integration of primary
care services within a specialty mental health clinic, indicating some distinct advantages
from the consumers’ perspectives on this integration approach. There are notable
implications for practice. First, persons with SMI attending an integrated clinic may need
practitioners to weigh a variety of physical health management options. Secondly, the use of
medication should be emphasized in tandem with other behavioral and supportive techniques
for healing and wellness. Lastly, practitioners should continue to facilitate the collaboration
between integrated primary and behavioral healthcare, through communication and team
planning, keeping the consumer at the helm of the team.
Acknowledgments
This study was supported by the following grants: National Institute of Mental Health (R24 MH074670; PI:
Salyers), and Substance Abuse and Mental Health Services Administration (5H79SM059751; PD: McKasson). The
content is solely the responsibility of the authors and does not necessarily represent the official views of the
National Institutes of Health.
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Table 1
Common physical health conditions and management approaches
Physical Health Condition # reporting condition
Hypertension 25
Chronic Obstructive Pulmonary Disease 11
Heart Condition/Heart Disease (other than hypertension) 7
Diabetes 6
Thyroid conditions (e.g., hyperthyroid or hypothyroid) 5
Arthritis and other joint pain 5
Asthma 3
Epilepsy/seizures 3
Cancer 2
Gout 2
Back pain 2
Acid reflux 2
Hyperlipidemia 2
Other (e.g., HIV, brain tumor, Alzheimer’s disease, dysmenorrhea) 11
Ways to manage health conditions
Medication 26
Other prescribed intervention (ex: Using Oxygen, Surgery) 5
Frequent Monitoring of condition (ex: testing blood sugar) 5
Diet or healthy eating 17
Exercise 12
Smoking Cessation 7
Relaxation or stress reduction 6
Avoid triggers 2
Get support 2
Number of strategies used (N=37)
Reported 0 2
Reported 1 12
Reported 2 9
Reported 3 8
Reported more than 3 6
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