Managing patients with mental and physical multimorbidityBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5559 (Published 03 September 2012) Cite this as: BMJ 2012;345:e5559
- Stewart W Mercer, professor of primary care research1,
- Jane Gunn, professor of primary care research2,
- Peter Bower, professor of health services research3,
- Sally Wyke, interdisciplinary professor of health and wellbeing4,
- Bruce Guthrie, professor of primary care medicine5
- 1General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
- 2Primary Care Research Unit, Department of General Practice, University of Melbourne, Vic, Australia
- 3NIHR School for Primary Care Research and the NIHR CLAHRC for Greater Manchester, Manchester Academic Health Science Centre, University of Manchester, UK
- 4College of Social Science, Institute of Health and Wellbeing
- 5Population Health Sciences Division, Medical Research Institute, University of Dundee, UK
Most people with chronic conditions now have more than one.1 Combinations of illness vary and so do the implications of such multimorbidity. For both patients and professionals, managing a cluster of conditions with synergistic management strategies (concordant conditions such as hypertension, coronary heart disease, and diabetes) is potentially simpler than dealing with conditions with non-synergistic management strategies (discordant conditions such as cardiovascular disease, chronic obstructive pulmonary disease, and arthritis). When the mix of conditions experienced includes both physical and mental health problems, however, the poorly stitched seams of professional care are at their most threadbare. The stigma that surrounds mental ill health may prevent patients with physical conditions from disclosing mental health concerns, which compounds problems of management. For these patients outcomes are usually worse.2
Although the clinical course of multimorbidity is not well understood,3 the relation between mental and physical problems seems to be bidirectional. Patients with severe and enduring mental health problems such as chronic depression, dementia, or psychotic disorder are at high risk of developing long term physical conditions, and the risk of mental health problems increases substantially in those with long term physical conditions.1 2 Rates of mental health problems also increase noticeably as the number of long term physical conditions increases4 and as socioeconomic deprivation worsens.1
So what needs to change? Firstly, policy must seek to address multimorbidity by applying the idea that there is “no health without mental health.”5 Most developed countries spend 10% or more of their gross domestic product on healthcare and this is projected to increase dramatically in coming decades. Multimorbidity is already the most important burden, and healthcare systems that continue to have a single disease led focus are no longer affordable.6 Several recent reports make the case for greater integration between physical and mental healthcare.2 5 7 However, policies will also be required that effectively tackle the social determinants of health, including the inverse care law.8 As reported recently by the UK think tank, the King’s Fund, the interaction between comorbidities and deprivation makes an important contribution to generating and maintaining inequalities.2 Recent reforms in the National Health Service may threaten these endeavours and it is crucial that clinical commissioning groups prioritise the integration of physical and mental healthcare to improve both patient outcomes and longer term productivity.
Secondly, research into multimorbidity requires shifts in design, funding, and outcomes of interest.9 Recent epidemiological research on multimorbidity challenges both the delivery of care and the conduct of research into care. Although there has been a welcome rise in the number of “comorbidity” studies, which investigate the association between a single physical condition and a single mental health disease (such as depression in diabetes), such research is usually limited by strict eligibility criteria. Research on patients with broader multimorbidity is in its infancy.10 The findings of trials undertaken on populations with single or even “twin” diseases may not generalise to the care of most patients with multimorbidity, especially in the primary care setting.
Thirdly, practice needs to develop new approaches to caring holistically for patients with mental-physical multimorbidity. In the United Kingdom, primary care is already the key provider of care for patients with long term conditions. A high proportion of patients with mental health problems are also managed largely in primary care settings. Generalist primary care has the potential to provide high quality, cost effective, accessible, and integrated care for patients with mental-physical multimorbidity.11 However, current variations in quality of care reflect the usual challenges of time and competing priorities, combined with the additional complexities raised by mental-physical multimorbidity. Practitioners must always consider mental health issues in patients with long term physical conditions, especially if they have multiple conditions or are having problems in self management and coping. Some elements of care may benefit from more systematic approaches to recognition and management of mental health problems (such as screening with appropriate follow-up in patients with long term conditions). The application of the principles of chronic disease management to depression provides a potentially useful model for the delivery of integrated care. The National Institute for Health and Clinical Excellence recommends the use of “collaborative care” models for complex cases. This involves structured, proactive management by multidisciplinary teams and enhanced interprofessional communication and has a developing evidence base that shows improvements in depression in patients with long term conditions.12 Isolated examples of interventions that improve both mental health and physical health have been reported,13 and the potential of synergistic interventions, such as exercise, mindfulness approaches, and social prescribing, which could help both physical and mental health disorders, is currently being explored. Finding practical and replicable ways of identifying and intervening to take advantage of such synergies is a key research and policy priority.
The increased clinical complexity that accompanies mental-physical multimorbidity also challenges the current tick box mentality of protocolised healthcare. Professionals need to be mindful of the potential burden on patients when treating multiple problems, the need to motivate and encourage achievable changes in behaviour, and the importance of sensitivity to the context in which patients are living each day. Such enabling care requires empathy, trust, and a therapeutic alliance with healthcare professionals who have sufficient time, training, and support.
Cite this as: BMJ 2012;345:e5559
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.