People with long term physical conditions are the most frequent users of the NHS. Long term physical illnesses affect some 30% of the population of England, or some 15 million people. Mental health conditions, meanwhile, affect about 10 million of us. What is less widely acknowledged, and certainly less well managed, is that some 4.6 million people have both at the same time.
The excess cost of treating long term conditions among this group is at least £8 billion a year to the NHS alone (Naylor et al, 2012). This is because for each person with a mental health condition alongside their physical illness, the costs of treating the latter are 45% higher than for someone with the physical condition alone.
Depression and anxiety are significantly more common among people with a range of long term physical illnesses: depression is at least twice as common among those with cardiovascular diseases and those with diabetes, and it is extremely common among those with arthritis. People with chronic obstructive pulmonary disease (COPD), meanwhile, are 10 times more likely than average to have panic disorder.
Outcomes from cardiovascular care are poorer for patients with co-morbid mental health problems, even after taking severity of cardiovascular disease and patient age into account. Studies have shown that cardiovascular patients with depression experience 50% more acute exacerbations per year and have higher mortality rates. One study found that depression increases mortality rates after heart attack by 3.5 times, while another found that patients with chronic heart failure are 8 times more likely to die within 30 months if they have depression.
People with diabetes who also have co-morbid mental health problems, meanwhile, are at increased risk of poorer health outcomes and premature mortality. Co-morbid mental health problems are associated with poorer glycaemic control, more diabetic complications and lower medication adherence, and children with Type I diabetes are more likely to suffer from retinal damage if they also have depression.
The development of the long term conditions strategy is an opportunity to address these excess costs, morbidity and mortality.
While not all of the £8 billion can be saved, improved integration can have a dramatic effect. The RAID liaison psychiatry service in Birmingham City Hospital, cited in the NHS Operating Framework, saves the NHS some £3.5 million a year in reduced hospital bed use. And outside hospital, collaborative care arrangements between primary care and mental health services, including psychological therapies, can improve the quality of support people receive at little extra cost to the NHS.
Improving the management of co-morbidity should not be just an add-on but the norm in the provision of both physical and mental health care. An artificial divide between physical and mental health is no longer tenable in an NHS that values quality, integration and value for money. Understanding both, and they way they interact, is an essential skill for any health professional and fundamental to 21st century health care practice.
Reference: Naylor C et al 2012, Long-term conditions and mental health, London: The King’s Fund and Centre for Mental Health