Impact of mental health on long-term conditions

Practice nurses should develop awareness of mental health problems in people with long-term conditions, advises a new report.

People with long-term conditions often have a mental health condition such as depression, anxiety or dementia, which goes undetected, say researchers.

These patients suffer poorer outcomes and are at increased risk of dying prematurely.

Failure to address these mental health problems can add billions to the cost of treatment.

A new report from The King's Fund and Centre for Mental Health says that people with long-term conditions, such as diabetes, COPD or heart disease, are two to three times more likely to experience mental health problems than the general population.

Overall, £1 in every £8 spent on long-term conditions is linked to poor mental health, equating to up to £13 billion of NHS spending each year.

By exacerbating physical illnesses, co-existing mental health problems substantially increase the costs related to care for long-term conditions.

For example, co-existing mental health problems can lead to:

• Increased hospitalisation rates - patients with chronic lung disease spend twice as long in hospital if they also have a mental health problem
• Increased outpatient service use - diabetes sufferers with mental health problems access twice the amount of outpatient services as those with diabetes alone
• Less effective self-management - poor mental health means that people with heart disease or other long-term conditions are less likely to look after their physical health, take medication as intended and attend medical appointments.

POORER OUTCOMES

The report also provides evidence that associated mental health conditions contribute to poorer clinical outcomes for patients and poorer quality of life. Studies, for example, have shown that depression increases mortality rates after a heart attack by 3.5 times; children with diabetes are more likely to suffer retinal damage if they also have depression; and co-existing mental health problems can have a greater effect on quality of life than the severity of the physical illness.

Where a mental health problem is identified alongside a physical health illness, the two have traditionally been treated separately with services designed around conditions rather than patients. A growing volume of research evidence suggests that more integrated approaches, with closer working between professionals responsible for patients' mental and physical health, can improve outcomes while also reducing costs, say the researchers.

There are also wider financial implications for individuals, families and the economy. People with both a long-term condition and a mental health problem are less likely to have a job than those with a physical illness alone; take twice as many sickness days; and are more likely to rely on informal care, which in turn leads to family members taking time off work.

The authors conclude that a more integrated approach will help the NHS to make savings, improve patient outcomes, and meet its targets on productivity improvement.

The benefits of integrated care can be far reaching for patients, the NHS and the economy. In one study at Hillingdon Hospital including a psychological component in a breathlessness clinic led to savings of lb837 per person. In another, tailored cognitive behavioural therapy packages reduced anxiety in COPD patients, improved self-management and reduced exacerbations and unnecessary admissions.

The report was published in the same week that the House of Lords voted in favour of an amendment to the Health and Social Care Bill to give mental health a higher priority and ensure that mental and physical health will have equal footing. It means for the first time there will be legal recognition that mental health is just as important as physical health.

The report's message also chimes with the aspiration of the Government's 2011 mental health strategy 'No health without mental health' published last year which places considerable emphasis on the connections between mental and physical health.

EDUCATION ISSUE

The Royal College of General Practitioners (RCGP) has also just produced a new guide for commissioners to guide their commissioning of mental health services.

Dr Helen Lester, a GP, professor of primary care at the University of Birmingham and author of the RCGP's new commissioning guide to mental health, said there was a lot of evidence which showed that people with mental illness did not get as much health promotion or as much health education as they needed. Yet they needed better care because their risk factors were higher.

'Self-management is incredibly important - something like 70-90% of people with serious mental illness smoke. For practice nurses that's a huge education issue - and that's before you even get into diet and lack of exercise. Practice nurses are immensely capable and it's well within their abilities to cope with this.'

She said the skills of both GPs and practice nurses in mental health issues could do with improving. But she added: 'I would argue that what we are asking practice nurses to do doesn't require a training course. A lot of this is attitudinal and connected to negative stereotypes about people with mental illness.

'If there is any training that is required then it's very much at an attitudinal level. This sort of thing could be done in-house in the practice and doesn't need a practice nurse to go off on a certified two day training course.'

Chris Naylor, lead author of the report, and Fellow at The King's Fund said: 'The prevailing approach towards improving care for people with long-term conditions is at risk of failing unless we look at patients' needs as a whole, including their mental health needs. To achieve this, mental health provision cannot simply be tacked on to physical care but needs to be an integral part of it.'

He said the message for practice nurses from the report was to be aware that, when dealing with people with long term conditions, first that mental health problems were very common amongst them, and secondly, those mental health problems could have a serious impact on their physical health.

MENTAL HEALTH AWARENESS

'It doesn't mean that all practice nurses have to necessarily suddenly rush out and get trained in cognitive behavioural therapy. It is more important that they develop an awareness of mental health and the importance of the role that it plays.

'For practice nurses it is also about making sure they have some knowledge about the support services that are available in their local area. For example in the voluntary sector there are mental health and wellness services for people who have low end mental health problems and would often just benefit from speaking to someone.

'They should also be aware that there are interventions available that can both prevent mental illness and promote positive health and wellbeing. For example there are initiatives which promote wellbeing in workplace and there are services which provide befriending interventions for older people. There is plenty of evidence that these things work.'

Mr Naylor said there was a growing political momentum around improving mental health services. 'Politicians from different sides of the political spectrum are recognising the importance of this interaction between mental and physical health both from the patient's point of view and also from a cost point of view.

'We hope that one of the things that could come out of this, as we move towards clinical commissioning, is that more integrated care for people with mental health problems will be established. This will be a good thing if it means that people working in primary care build relationships with clinicians in secondary care and have more of a dialogue about how services can be improved in their local area, including services for people with these kind of combined mental and physical health problems.'