People with chronic physical conditions experience poorer mental health compared
to the general population. Co-morbid depression and chronic disease are
associated with high healthcare use and high costs to the health system. Despite
improvements in mental health care service delivery, people experiencing mental
illness have high mortality from physical health issues, suggesting that the health
care needs of this group are not being met. This RESEARCH ROUNDup explores the
reasons for primary health care disadvantage among people with physical and
mental illness co-morbidity, and strategies to improve health care provision for this
group

Bywood, Petra Teresia

Lunnay, Belinda Kate

Flinders Academic Commons

 TO CONTACT PHC RIS: Web: www.phcris.org.au PHC RIS Assist: 1800 025 882 Email: phcris@flinders.edu.au RESEARCH ROUNDup: www.phcris.org.au/publications/researchroundup/ Keep up to date with new Australian primary health care research ISSN 1839-6348 Co-morbidity of mental and physical illness: Meeting unmet care needs People with chronic physical conditions experience poorer mental health compared to the general population.1,2,3,4,5,6 Co-morbid depression and chronic disease are associated with high healthcare use and high costs to the health system.7 Despite improvements in mental health care service delivery, people experiencing mental illness have high mortality from physical health issues, suggesting that the health care needs of this group are not being met.8 This RESEARCH ROUNDup explores the reasons for primary health care disadvantage among people with physical and mental illness co-morbidity, and strategies to improve health care provision for this group. Issue 18 August 2011  B Lunnay P Bywood Poor physical health is compounded by mental illness People with co-morbid depression and chronic disease not only have poorer clinical outcomes but also significantly higher healthcare costs compared to those with a chronic disease alone.7 That is, poor physical health is compounded by mental illness.1 For example, mild to moderate depression and anxiety is common in people with a physical illness or chronic disease like heart disease6,9,10, arthritis11 and diabetes;12,13 and worsens with the severity of physical symptoms14,15 or risk factors for disease such as metabolic syndrome.16 A shift away from in-patient treatment of mental illness toward community-based care settings and the incorporation of mental health care into mainstream health services has not reduced the mortality rates of people with mental illness.8 However, poorer mental health outcomes among users of health services are not necessarily the result of poorer engagement with primary health care providers.6,17 Hence, simply encouraging more frequent consultations may be fruitless. Physical illness is undiagnosed alongside mental illness Low rates of diagnosis and hospitalisation and high mortality for physical conditions among people with mental illness leads to increased mortality from physical illness8 and low hospitalisation rates among people with mental illness.1 People experiencing co-morbid physical and mental health problems do not always receive primary health care that is both adequate and appropriate to their needs.18 General practitioners and other primary service providers may attribute depression to physical illness.19 Similarly, mental health services, that focus on psychiatric symptoms may overlook physical symptoms or consider them psychosomatic.20  Strategies to improve care provision Interventions that consistently provide benefits for both physical and mental health for people with chronic conditions are required.12 However, providing financial incentives to primary health care providers to simply screen patients with chronic disease for depression is inadequate.21 Understanding the interaction between physical and mental health and developing integrated care that simultaneously considers people’s physical and mental health needs is essential. Reducing fragmentation of services, fostering service integration and improving the preventive value of existing contacts between patients with mental illness and their GPs may be beneficial.5,22,23 Practice, policy and patient level interventions can be effective. At the patient level, interventions to improve coping strategies were effective in reducing symptoms and psychological stress, as shown among people with asthma.24 The primary health care setting is ideal for identifying and addressing co-morbidity between mental and physical illness because of the potential for integrated clinical care.22 Australian and international evidence shows that, despite higher costs, Collaborative Care is the most effective approach.25,26,27 Effective strategies should be implemented to facilitate communication and Collaborative Care between specialists and PHC providers.28 Opportunities exist for collaboration between GPs, Divisions of GP/Medicare Locals and mental health services.1 Practice nurses may be well positioned to work collaboratively between these providers.23,29  The TrueBlue project provides a case example of a system of primary care for Australian patients with chronic heart disease and/or type 2 diabetes and co-morbid depression that is capable of improving clinical outcomes through nurse-led Collaborative Care.30 The TrueBlue Collaborative Care project has demonstrated effective management of complex patients with depression, heart disease and diabetes within the existing Medicare funding structure and primary health care workforce.31 Similarly, the US TEAMcare collaborative model has improved the quality of care as well as patients’ medical and psychiatric outcomes.32 Features of the Collaborative Care model are outlined in Table 1.  Summary Managing mental and physical health problems is a complex part of managing chronic conditions. Simply 12 Harkness E, MacDonald W, Valderas J, Coventry P, Gask L, Bower P. (2010). Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: A systematic review and meta-analysis. Diabetes Care, 33(4). 13 Reddy P, Ford D, Dunbar JA. (2010). Improving the quality of diabetes care in general practice. Aust J Rural Health, 18, 187-193. 14 Wilhelm K, Mitchell P, Slade T. (2003). Prevalence and correlates of DSM-IV major depression in an Australian national survey. J Affect Dis, 75, 155-162. 15 Clarke DD. (2009). Depression and physical illness: More complex than simple comorbidity. Med J Aust, 190(7), S52-S53. 16 Dunbar JA, Reddy P, Davis-Lameloise N, Philpot B, Laatikainen T, Kilkkinen A, et al. (2008). Depression: An important comorbidity with metabolic syndrome in a general population. Diabetes Care, 31(12), 2368-2373. 17 Mai Q, D’Arcy C, Holman J, Sanfilippo F, Emery J, Stewart L. (2010). Do users of mental health services lack access to general practitioner services? Med J Aust, 192(9), 501-506. 18 Kendrick T. (1996). Cardiovascular and respiratory risk factors and symptoms among general practice patients with long term mental illness. Br J Psychiatry, 169, 733-739. 19 Wade A. (1998). Diagnosis in primary care. Round Table Series - Royal Society of Medicine(56), 11-16, www.scopus.com/inward/record.url?eid=2-s2.0-0032451882&partnerID=40&md5= 240358fa263e8a2a8c4e7e03e273625d 20 Lawrence D, Coghlan R. (2002 ). Health inequalities and the health needs of people with mental illness. NSW Public Health Bull, 13(7), 155 - 158 21 Gilbody S, Sheldon T, Wessely S. (2006). Should we screen for depression? BMJ, 332(7548), 1027-1030,  www.bmj.com/content/332/7548/1027.short 22 Whiteford HA. (2008 ). Depression in primary care: Expanding the evidence base for diagnosis and treatment. Med J Aust, 188(12 Suppl), S101-102, www.ncbi.nlm.nih.gov/pubmed/18558906 23 Vreeland B. (2007). Bridging the gap between mental and physical health: A multidisciplinary approach. J Clin Psychiatry, 68(4), 26-33. 24 Barton C, Clarke D, Sulaiman N, Abramson M. (2003). Coping as a mediator of psychosocial impediments to optimal management and control of asthma. Respir Med, 97(7), 747-761. 25 Gilbody S, Bower P, Whitty P. (2006). Costs and consequences of enhanced primary care for depression: Systematic review of randomised economic evaluations. The British Journal of Psychiatry, 189(4), 297-308,  http://bjp.rcpsych.org/cgi/content/abstract/189/4/297 26 Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. (2006). Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes Arch Int Med, 166, 2314-2321, http://archinte.ama-assn.org/cgi/content/abstract/166/21/2314 27 Hickie IB, McGorry PD. (2007). Increased access to evidence-based primary mental health care: Will the implementation match the rhetoric? Med J Aust, 187, 100-103,  www.mja.com.au/public/issues/187_02_160707/hic10506_fm.pdf 28 WHO. (2008). Integrating mental health into primary care: A global perspective. Geneva: World Health Organization and World Organization of Family Doctors (Wonca), www.who.int/mental_health/policy/Integratingmhintoprimarycare2008 _lastversion.pdf 29 Piterman L, Jones KM, Castle DJ. (2010). Bipolar disorder in general practice: Challenges and opportunities. Med J Aust, 193(4), S14-S17, www.ncbi.nlm.nih.gov/pubmed/20712554 30 Morgan MA, Dunbar J, Reddy P. (2009). Collaborative care - The role of practice nurses. Aust Fam Physician, 38(11), 925-926. 31 Morgan M, Dunbar J, Reddy P, Coates M, Leahy R. (2011). The TrueBlue Study: Collaborative care for the management of depression, heart disease and diabetes. Paper presented at the Primary Health Care Research Conference, Brisbane, Australia. 32 McGregor M, Lin EH, Katon WJ. (2011). TEAMcare: An integrated multicondition collaborative care program for chronic illnesses and depression. J Ambul Care Manage, 34(2), 152-162, www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=21415613 33 Hickie IB, Fogarty AS, Davenport TA, Luscombe GM, Burns J. (2007). Responding to experiences of young people with common mental health problems attending Australian general practice. Med J Aust, 187(7 Suppl), S47-52. Acknowledgements Thank you to expert reviewer James Dunbar for his constructive comments on drafts of this paper. Table 1: Features of the Collaborative Care model (Modified from:33)  A structured and multi-faceted approach based on chronic disease management principles  A greater role for non-medical specialists like case managers, practice nurses/nurse practitioners, clinical psychologists and other mental health specialists, including occupational therapists and social workers  Key organisational and professional components, including:  Clinical education for GPs  Dissemination and implementation of treatment or management guidelines  Use of case-screening procedures  Reconfiguration of roles within primary care  Earliest appropriate use of specialised psychological or psychiatric assessment or brief psychological interventions  Case management, reminder systems and other active follow-up schemes (telephone or e-health-based) to enhance continuity of care and adherence to treatments  Consultation/liaison or other methods of improving working relationships between primary and specialist/secondary services  Formal integration of services, including collocation and common clinical governance schemes  Support for patient education, self-monitoring and consumer-based decision tools. relying on people with diagnosable mental illness to seek increased health care is not sufficient to reduce poorer physical health care outcomes. Improvement in the way health care is provided is required to meet the physical health needs of people with mental illness. Primarily, interventions focussed on multi-disciplinary care that integrate specialist care with general PHC are essential to improving physical health outcomes among people with mental illness. References 1 Coghlan R, Lawrence D, Holman D, Jablensky A. (2001). Duty to care: Physical illness in people with mental illness. Perth: The University of Western Australia. 2 Australian Bureau of Statistics. (2007). National survey of mental health and wellbeing: Summary of results. Canberra: Australian Bureau of Statistics,  www.abs.gov.au/ausstats/abs@.nsf/mf/4326.0 3 SANE Australia. (2007). Physical health care and mental illness. Melbourne: SANE Australia,  www.sane.org/information/factsheets-podcasts 4 Lawrence D, Holman C, Jablensky A, et al. (2000). Excess cancer mortality in Western Australian psychiatric patients due to higher case fatality rates. Acta Psychiatr Scand, 101, 382-388. 5 Lawrence D, Holman C, Jablensky A. (2001). Preventable physical illness in people with mental illness. Perth: University of Western Australia. 6 Lawrence DM, Holman CD, Jablensky AV, Hobbs MS. (2003). Death rate from ischaemic heart disease in Western Australian psychiatric patients 1980-1998. Br J Psychiatry, 182, 31-36, http://bjp.rcpsych.org/cgi/reprint/182/1/31.pdf 7 Egede LE, Ellis C. (2010). Diabetes and depression: Global perspectives. Diabetes Res Clin Pract, 87(3), 302-312, www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve &db=PubMed&dopt=Citation&list_uids=20181405 8 Lawrence D, Jablensky AV, Holman CD, Pinder TJ. (2000). Mortality in Western Australian psychiatric patients. Soc Psychiatry Psychiatr Epidemiol, 35(8), 341-347. 9 Wright CA, Osborn DPJ, Nazareth I, King MB. (2006). Prevention of coronary heart disease in people with severe mental illnesses: A qualitative study of patient and professionals' preferences for care. BMC Psychiatry, 6, 16,  www.ncbi.nlm.nih.gov/pubmed/16630335 10 Bunker SJ, Colquhoun DM, Esler MD, Hickie IB, Hunt D, Jelinek VM, et al. (2003). "Stress" and coronary heart disease: Psychosocial risk factors. Med J Aust, 178(6), 272-276,  http://ukpmc.ac.uk/abstract/MED/12633484 11 Lin EH, Katon W, Von Korff M, Tang L, Williams JW Jr, Kroenke K, et al. (2003). Effect of improving depression care on pain and functional outcomes among older adults with arthritis: A randomized controlled trial. JAMA, 290(18), 2428-2429. 

Co-morbidity of mental and physical illness: meeting unmet care needs

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Co-morbidity of mental and physical illness: meeting unmet care needs

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