Objective Poor quality of health care contributes to impaired health and excess mortality in individuals with severe mental disorders. This study tests a population-based medical care management intervention to improve primary medical care in community mental health settings. Method A total of 407 subjects with severe mental illnesses at an urban community mental health center were randomized to either care management or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education for patients, and support in overcoming system-level fragmentation and barriers to primary medical care. Results At 12-month follow-up, the intervention group received an average of 58.7% of recommended preventive services, compared to 21.8% in the usual care group (p<0.001). They received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% vs. 27.7%, p=0.03), and were more likely to have a primary care provider (71.2% vs. 51.9%, p=0.003). On the SF-36, the intervention group showed significant improvement on the Mental Component Summary score (8.0% improvement in intervention versus 1.1% decline in the control group, p=0.008) with a nonsigificant improvement on the Physical Component Summary score. Among subjects with available laboratory data, Framingham Cardiovascular Risk Scores were significantly lower (better) for intervention (6.9%) than control (9.8%) subjects (p=0.02). Conclusions Medical care management was associated with significant improvements in quality and outcomes of primary care. The findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings. Clinicaltrials.gov identifier NCT00183313

The results suggest that it is possible, even under challenging real-world conditions, to improve quality of care for patients with serious mental illness and cardiovascular risk factors. Improving quality of medical care may be necessary, but not sufficient, to improve the full range of medical outcomes in this vulnerable population.

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Classical estrogen receptor-signaling mechanisms involve estradiol binding to intracellular nuclear receptors [estrogen receptor-␣ (ER␣) and estrogen receptor-␤ (ER␤)] to promote changes in protein expression. Estradiol can also exert effects within seconds to minutes, however, a timescale incongruent with genomic signaling. In the brain, estradiol rapidly potentiates stimulated dopamine release in the striatum of female rats and enhances spontaneous rotational behavior. Furthermore, estradiol rapidly attenuates the K ϩ -evoked increase of GABA in dialysate. We hypothesize that these rapid effects of estradiol in the striatum are mediated by ER␣ located on the membrane of medium spiny GABAergic neurons. This experiment examined whether overexpression of ER␣ in the striatum would enhance the effect of estradiol on rotational behavior and the K ϩ -evoked increase in GABA in dialysate. Ovariectomized female rats were tested for rotational behavior or underwent microdialysis experiments after unilateral intrastriatal injections of a recombinant adeno-associated virus (AAV) containing the human ER␣ cDNA (AAV.ER␣) into the striatum; controls received either the same vector into areas outside the striatum or an AAV containing the human alkaline phosphatase gene into the striatum (AAV.ALP). Animals that received AAV.ER␣ in the striatum exhibited significantly greater estradiol-induced contralateral rotations compared with controls and exhibited behavioral sensitization of contralateral rotations induced by a low-dose of amphetamine. ER␣ overexpression also enhanced the inhibitory effect of estradiol on K ϩ -evoked GABA release suggesting that disinhibition of dopamine release from terminals in the striatum resulted in the enhanced rotational behavior.

The HARP program was associated with improved physical health- and mental health-related quality of life among individuals with serious mental illness and comorbid general medical conditions, suggesting the potential benefits of more widespread dissemination of peer-led disease self-management in this population.