A young man came to Sunset Terrace, a large Brooklyn outpatient mental health clinic, because he was depressed about his brother's death from diabetes. But that wasn't his only problem: His own blood sugar levels were dangerously high. He wasn't taking his insulin, a potentially life-threatening move. He had also stopped seeing his physician.
That's when psychologist Jon Marrelli, PsyD, stepped in. During the man's psychotherapy session with a staff social worker at the facility, which is part of the New York University Lutheran Family Health Centers, Marrelli and a nurse met with him to discuss his physical health. They convinced him to transfer his medical care to the clinic's own in-house physician. And they helped him understand the importance of taking his medication and getting his diabetes under control.
Stories like this illustrate how the Sunset Terrace Integration and Recovery (STIR) project Marrelli directs is enhancing the physical health of patients with schizophrenia, bipolar disorder, major depression and other serious mental illnesses. The program is funded by a four-year primary and behavioral health care integration grant from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). The grant program helps mental health clinics embed medical professionals within mental health care settings as a way to improve physical health outcomes for adults with serious mental illness.
"People with serious mental illness die about 20 years earlier than the general population, for reasons that are often preventable if they only had access to medical care or someone who could teach them better self-management skills or improve their health literacy," says Marrelli, director of primary and behavioral health care integration grants. "It's a public health tragedy."
Health-care connections
An example of what Marrelli calls "reverse integration," STIR has brought a physician, nurse and medical assistant together to work with more than 50 psychologists, social workers, psychiatrists and psychiatric nurses within the mental health center. If a mental health professional notices a patient has a physical health problem—or a patient hears about STIR—he or she is invited to join the program and get involved. Participants who don't have a primary-care provider get connected with the clinic's onsite physician. (If they already have a physician in the community, the program shares its assessments and coordinates care.) Participants are also invited to join the clinic's wellness classes, which focus on tobacco cessation, diabetes management, nutrition and chronic pain management. Over the 12-month program, Marrelli and his colleagues track participants' blood pressure, body mass index, waist circumference, smoking, cholesterol, blood sugar and other physical indicators.
The positive outcomes go far beyond the anecdotal. The 40 patients who have completed the program since it launched in 2015 have on average seen significant drops in their blood pressure, cholesterol levels and weight. The outcomes have been so positive the hospital system is exploring how to sustain the program after the SAMHSA grant ends.
Marrelli's efforts also include more traditional integration—placing psychologists and other mental health professionals directly into primary-care settings to fight stigma and ensure that those patients get the mental health services they need. That's because many people who need mental health services go to primary-care settings but avoid mental health clinics because of stigma, says Marrelli. As part of New York's Delivery System Reform Incentive Payment program, which is helping to redesign the state's Medicaid system, Marrelli is working to embed mental health professionals into all nine of NYU Lutheran's primary-care clinics as well as some of the system's community-based partners in the next 18 months.
'Inextricably linked'
While administrative tasks consume about 90 percent of Marrelli's time, he still carries a caseload of patients, most of whom have been diagnosed with schizophrenia. He co-chairs the Health Care Reform Task Force for APA's Div. 31 (State, Provincial and Territorial Affairs). And he's helping to train the next generation of integrated-care providers by supervising psychology externs. "Many mental health training programs have not yet caught up to teaching the important, emerging area of integrated care," says Marrelli, who prepared by supplementing his 2007 doctorate from the University of Hartford with the University of Massachusetts Medical School's certificate program in primary-care behavioral health. He also obtained a mentor from APA's Div. 18 (Psychologists in Public Service) and resources from Div. 38 (Society for Health Psychology).
In addition to helping mental health staff understand the importance of attending to their patients' physical health, Marrelli also works with medical staff to help them adjust to this often-unfamiliar patient population. The staff leading the health education classes, for instance, must learn how to adapt their teaching styles and materials to be appropriate for people with serious mental illness. That could mean understanding that classroom disruptions, such as standing up in class, may be a symptom of paranoia or the onset of mania rather than rudeness. Marrelli also encourages class facilitators to incorporate stretching breaks to boost concentration in participants with medication-induced grogginess.
"Some people joke that the medical side is only concerned with the neck down and the mental health side is only concerned with the neck up," says Marrelli. "What I'm trying to teach the staff is that the two are really inextricably linked."
