AS Young, VISN 22 MIRECC and UCLA; JA Cradock, VISN 22 MIRECC; EM Yano, HSR&D Sepulveda Center of Excellence

Objectives: Compared with the general population, people with severe mental illness (SMI) may be more likely to have serious medical problems and less likely to have these problems adequately treated. This population’s use of medical care decreases after the onset of their psychiatric illness, and the mortality rate due to medical disorders is substantially higher than expected. Individuals with SMI may have difficulty accessing typical medical services, be less likely to adhere to medical recommendations, and receive care that is not well coordinated among a range of involved providers. Many VHA facilities are working to reorganize and improve their medical and psychiatric services, but in the SMI population, substantial improvements are likely to require specialized approaches. However, there has been very little research evaluating medical care in the SMI. This study investigates access to medical care among veterans with SMI.

Methods: Analyses focused on veterans served in VISN 22. Data were obtained from the VA Austin Automation Center on psychiatric and medical diagnoses and treatment utilization. Subjects were categorized into 3 groups: SMI (schizophrenia or bipolar disorder), non-SMI mental health (depressive and anxiety disorders), and no mental disorder. Demographics and service utilization were examined in each of these groups.

Results: In fiscal year 1999, we classified 9,885 veterans with SMI, 17,365 veterans with other psychiatric disorders, and 163,210 with no psychiatric disorder. Compared with the other groups, veterans with SMI were younger, and more likely to be non-white, unmarried, and disabled. While rates of COPD did not differ across groups, rates of diagnosed diabetes and hypertension were lower in people with SMI. People with SMI were more likely to have no primary care visits during the past year (36% for SMI, 24% for other mental disorders, 32% for no mental disorder). However, average intensity of care was greater in the SMI group (3.0 visits/year for SMI, 3.6 for other mental health, 2.3 for no mental disorder). Among SMI, patients with COPD, diabetes, and HTN averaged 7.1, 7.6, and 7.8 medical visits per year, respectively. SMI patients with none of these disorders averaged 2.5 visits per year.

Conclusions: Since severe mental disorders typically start in young adulthood, veterans with SMI may enter care at a younger age, and be less likely to have medical conditions that typically start at a later age. Veterans with SMI use a higher intensity of medical services, suggesting that they may access care after they are more severely ill and/or have more trouble managing their medical illnesses. Further research is needed, and should control for baseline differences in need in the SMI population; attend to rates of morbidity and mortality; and examine whether the organizational structure of primary care affects access to services in the SMI.

Impact: Medical disorders are common in veterans with SMI and may be quite challenging to manage. There is a need for further research on access to medical care in people with SMI, so that services can be tailored to the needs of this challenging population.