Understanding and Responding to Health and Substance Abuse Treatment Needs of Persons with Severe Mental Illness

  • Date: Jan 01 1999
  • Policy Number: 9928

Key Words: Substance Abuse

The American Public Health Association,

Cognizant that as many as half of all persons with severe mental illnesses (SMI) (including schizophrenia, major depression and bipolar disorder) also have co-morbid physical health disorders;1-4 and

Recognizing that these co-occurring physical health problems often go undiagnosed and untreated in community mental health systems;1,2,5 that are often ill equipped to address primary health care needs; and

Further realizing that approximately 50 percent of persons with SMI also have co-morbid substance abuse disorders;6,7 and

Understanding that the severity of illness and disability for persons with co-occurring disorders is greater than for persons with either a physical or mental disorder alone;4,8,9 and

Being aware that persons with SMI have mortality rates that are 2 to 3 times greater than general population groups matched on age, race and socio-economic status;10-12 and

Being consistent with APHA Policies 9701: For Nondiscriminatory Coverage of all Mental Health Treatment* and 9802: Managed Care and People with Physical/Mental Disabilities; ** and

Realizing that little is known definitively about the factors contributing to this excess morbidity and mortality but that factors related to fragmentation of health care systems, lack of provider education about the risk status of persons with SMI, poor integration of services, as well as the long term effects of psychotropic medications, high prevalence of tobacco use, low socio-economic status and social isolation have all been suggested as potential risk factors; and

Further realizing that effective strategies to reduce excess morbidity and mortality in this population have not been developed and tested rigorously;13-14 therefore

  1. Encourages the National Institutes of Health and particularly those Institutes concerned with mental health and substance abuse to sponsor programs of research to identify the factors contributing to excess morbidity and mortality in this population and to test prevention and treatment strategies;
  2. Urges the Substance Abuse and Mental Health Services Administration to sponsor multi-site research and demonstration projects to encourage best practices in identifying and appropriately treating persons with SMI who also have co-morbidities;
  3. Urges the Center for Mental Health Services to sponsor the development of professional educational programs that are designed to improve practice for providers who serve persons with SMI particularly related to their health and substance abuse status;
  4. Asks that the Health Care Financing Administration stimulate the development of health care financing and delivery strategies that better support integrated health, mental health and substance abuse services for persons with SMI; and
  5. Reaffirms the Association's call for a comprehensive national health care system that guarantees equal access to physical and mental health care for all persons in need of care.


  1. Roca RP, Breakey WR, Fischer PJ. Medical care of chronic psychiatric outpatients. Hospital and Community Psychiatry. 1987;38:741-745.
  2. Koran L, et al., Medical evaluation of psychiatric patient: Results in a state mental health system. Arch Gen Psychiat. 1989; 46:733-740.
  3. Maricle R, et al. The coexistence of physical and mental illness among two samples of Oregon's chronically mentally ill. New Directions for Mental Health Services. 1989;44:97-109.
  4. Felker B, Yazel J, Short D. Mortality and medical comorbidity among psychiatric patients: A review. Psychiatric Services. 1996;47(12):1356-1363.
  5. Mueske LN, Krueger DW. Physical findings in a psychiatric outpatient clinic. Am J Psych. 1981;133:1241-1242.
  6. Kessler RC, et al. The epidemiology of co-occurring addiction and mental disorders: Implications of prevention and services utilization. Am J Orthopsychiatry. 1996;66:17-31.
  7. Kessler RC, et al., Lifetime and 12 month prevalence of DSM III-R psychiatric disorders in the United States: Results for the national comorbidity study. Arch Gen Psychiat. 1994;51:8-19.
  8. Dvoredsky A. Cooley H. Comparative severity of illness inpatients with combined medical and psychiatric diagnoses. Psychosomatics. 1986;27(9):625-633.
  9. Bassett SS, et al. Disability and psychiatric disorders in an urban community: Measurement, revalence and outcomes. Psychological Medicine. 1998;28(3):509-517.
  10. Corten P, Ribourdouille M, Dramaix M. Premature death among outpatients at a community mental health center. Hospital and Community Psychiatry. 1991; 42(12):1248-1251.
  11. Black DW, Warrack G, Winoder G. Excess mortality among psychiatric patients: The IOWA record-linkage study. JAMA. 1995;253:58-61.
  12. Newman SC, Bland RC. Mortality in a cohort of patients with schizophrenia: A record linkage study. The Canadian Journal of Psychiatry. 1991;36:239-245.
  13. Schwab B, Drake RE, Burghardt EM. Health care of the chronically mentally ill: The culture broker model. Community Mental Health Journal. 1988;27(9): 625-630.
  14. Anonymous, Health care reform for Americans with severe mental illnesses: Report of the National Advisory Mental Health Council. Am J Psych. 1993;150(l0):1447-1465.

* APHA Policy Statement 9701: For Nondiscriminatory Coverage of all Mental Health Treatment. APHA Policy Statements; 1948-present, cumulative. Washington, DC: American Public Health Association; current volume.
** APHA Policy Statement 9802: Managed Care and People with Physical/Mental Disabilities: APHA Policy Statements: 1948-present, cumulative. Washington, DC: American Public Health Association; current volume.

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