Managing patients with mental and physical multimorbidityBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5559 (Published 03 September 2012) Cite this as: BMJ 2012;345:e5559
All rapid responses
The article by Mercer et al is very thought provoking and timely. The recommendations they make about change of culture, policy and practice are all relevant and overdue.
They mention that "the stigma that surrounds mental ill health may prevent patients with physical conditions from disclosing mental health concerns, which compounds problems of management." (1). The impact of stigma goes even further. Even if they seek help, patients with co-morbid mental and physical health problems are not always given the treatment they need for their physical problems, due to prejudice, poor training and discrimination (2). I have personally heard and seen several instances over the years, of psychiatric patients attending hospitals for their physical symptoms, only to be told that their symptoms were a result of their mental ill health and being denied the right treatment, thereby leading to adverse outcomes.
Mercer et al's observations regarding practice are also relevant. However we need to go further. Training from the earliest stage should involve awareness of social determinants of health, the interplay of physical and psychological factors, being ecologically efficient, a public health perspective and a recovery model towards management of long term illness. Crucially, training is also needed to inculcate a consciously ethical approach to decision making- this involves dealing with uncertainty, self-reflection, being transparent and balancing conflicting needs. The latter are often considered to be 'soft' skills and training is heavily biased towards acquiring technical expertise rather than getting the balance between "doing it right" and "doing the right thing."
Also pertinent in the current economic climate is that implementing the above changes, while seeming resource-intensive in the short term, will be resource-efficient in the long term due to better use of clinical expertise and improved outcomes for patients (3).
Finally as a psychiatrist, it is heartening to see language that was previously reserved for psychiatric practice- "such enabling care requires empathy, trust, and a therapeutic alliance with healthcare professionals" (1) being generalised across healthcare. This is an opportunity for psychiatrists to be fully integrated into the physical healthcare system and use their unique blend of clinical skills to great advantage, for improving patient outcomes.
1. Mercer SW, Gunn J, Bower P, Wyke S, Guthrie B. Managing patients with mental and physical multimorbidity: BMJ 2012;345:e5559
2. Tarrier, N., & Barrowclough, C. (2003). Professional attitudes to psychiatric patients: a time for change and an end to medical paternalism. Epidemiologia e psichiatria sociale, 12(4), 238.
3. Wanless D. Securing our future health: taking a long-term view. Final report. HM Treasury, 2002.
Competing interests: A member of the Royal College of Psychiatrists' Special Committee on Professional Governance and Ethics.
Clinical management of multimorbidity is a complex task that large numbers of clinicians encounter in their everyday practice. Successful management of one illness often allows success in management of other disorders. Complex drug interactions and the need for optimal side effects management continue to offer further challenges in terms of treatment adherence and attainment of real life outcomes.
Estimating the effectiveness of complex interventions is a challenging task due to methodological and study design issues. It is not surprising that Smith et al (1) have identified difficulties in improving (or measuring) outcomes in multimorbidity management.
Neuropsychiatric conditions, such as mental or behavioural disorders following acquired brain injury, are prominent examples of co-occuring mental and physical health multimorbidity. This is a particularly underserved area of clinical research that requires urgent policy planning and research funding input. Clinical neuropsychiatry research has the potential to help develop models of studying effectiveness in other complex disease areas of multimorbidity management.
Mercer at al (2) have made valid recommendations in terms of policy, research, and practice developments. However, their recommendations fall short of much needed postgraduate medical training reform in the United Kingdom to allow higher specialist trainees from psychiatry, neurology, and general medicine to spend part of their training requirements in partner sub-specialties.
1. Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ 2012;345:e5205
2. Mercer SW, Gunn J, Bower P, Wyke S, Guthrie B. Managing patients with mental and physical multimorbidity: BMJ 2012;345:e5559
Competing interests: RF Chairs Section of Neuropsychiatry and Complex Neurodisability Working Group at the Royal Colege of Psychiatrists, London. Views expressed in this letter reflect RF personal views. No other conflicts of interest.