Rethinking Recovery in Mental Illness - Integrating Physical and Mental Health

Krishna Prasad Muliyala; Pratima Murthy

doi:10.4103/wsp.wsp_59_21

PERSPECTIVE/VIEWPOINT

Year : 2021 | Volume : 3 | Issue : 3 | Page : 141-145

Rethinking Recovery in Mental Illness - Integrating Physical and Mental Health

Krishna Prasad Muliyala¹, Pratima Murthy²
¹ Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
² Director, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission	14-Nov-2021
Date of Decision	14-Nov-2021
Date of Acceptance	15-Nov-2021
Date of Web Publication	23-Dec-2021

Correspondence Address:
Dr. Pratima Murthy
National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_59_21

Abstract

Multimorbidity is the co-occurrence of more than one chronic condition. Multimorbidity is likely to rapidly rise in the lower- and middle-income countries (LAMICs). Multimorbidity involving noncommunicable diseases and mental illness negatively impacts the quality of life and clinical recovery in both conditions. Most health systems and programs cater to single diseases. In this article, we discuss the extent of the problem, potential challenges, and opportunities with focus on LAMIC exemplified by India. Integration of care is required in the context of multimorbidity. These can be provided in the existing national programs in India. Service provision needs to become personal recovery oriented. Service users should be engaged in the development of services and research in this area. Existing models emphasize on self-management/self-care and provider–patient partnership. These need to be adapted and tested for feasibility in LAMIC.

Keywords: Mental illness, multimorbidity, social psychiatry

How to cite this article:
Muliyala KP, Murthy P. Rethinking Recovery in Mental Illness - Integrating Physical and Mental Health. World Soc Psychiatry 2021;3:141-5

How to cite this URL:
Muliyala KP, Murthy P. Rethinking Recovery in Mental Illness - Integrating Physical and Mental Health. World Soc Psychiatry [serial online] 2021 [cited 2023 Mar 24];3:141-5. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/3/141/333425

Introduction

The National Mental Health Survey (NMHS), 2015–2016, India, reported a lifetime prevalence of 13.67% for any mental morbidity.^[1] The proportional contribution of mental disorders to the total disease burden in India has almost doubled from 1990 to 2017.^[2] This is true across many low- and middle-income countries (LAMICs). Persons with mental illness, specifically those with severe mental illness (SMI) such as schizophrenia, are at a higher risk for premature mortality as compared to the general population, worldwide. The Standardized Mortality Ratio has been reported to be in the range 1.4–3.02 for persons with schizophrenia in various settings in India, with mortality primarily from cardiovascular disease (CVD).^[3]

CVDs, diabetes, cancer, and chronic respiratory illnesses constitute the major noncommunicable diseases (NCDs). The overall prevalence of diabetes in 15 states of India has been reported as 7·3%.^[4] The Fourth District Level Household Survey reported hypertension in 25.3% of the adults with a greater prevalence among men (27.4%) as compared to women (20.0%).^[5] NCDs have been estimated to contribute to 63% of all deaths in India, with CVDs being a primary cause (27%).

Multimorbidity has been defined as the co-occurrence of more than one chronic condition. It has been estimated that in the LAMIC, the prevalence of multimorbidity is likely to rapidly rise.^[6] The health-care systems in most LAMIC cater to single diseases. The co-occurrence of physical health and mental health conditions has synergistic negative effects on disability, quality of life, costs of care, and mortality.^[7]

In the ensuing paragraphs, we will discuss the magnitude of the problem of multimorbidity, with the primary focus on mental illness and NCDs, the challenges and opportunities in integration of care for NCDs, and mental illness to enhance recovery. We have used the example of India to illustrate many of the issues, and these are likely to be applicable to other countries in the region and the LAMIC in general.

Noncommunicable Diseases and Common Mental Disorders

The recent studies that have included data from India have found that one in ten persons with Type 2 diabetes mellitus have a major depressive disorder and 18% of persons with Type 2 diabetes have anxiety disorders.^[8],[9] The pooled estimates from a systematic review are even higher, 40% for depression and 29% for anxiety disorders in diabetes.^[10] The pooled estimates are similar for depression in other NCDs–37% in patients with cancer, 38% in patients with hypertension, 39% in patients with stroke, and 44% in patients with chronic obstructive airway disease.^[10] In fact, common mental disorders such as depression and anxiety are now subsumed under the category of NCDs. Most of the NCDs share common risk factors such as age, gender, poverty, and illiteracy besides health risk behaviors such as unhealthy diet, physical inactivity, tobacco use, alcohol use disorders, stress, and indoor pollution.^[11] In the Global Adult Tobacco Survey, 2016–2017, data from India have revealed that 28.6% of all adults use tobacco; the NMHS reported tobacco dependence in 20.89% of adults.^[1] The National Survey on Extent and Pattern of Substance Use in India, 2019 has estimated harmful or dependent patterns of alcohol use in 5.2% of the adult population. Whereas the projected linear trends are down-sloping for tobacco use in India for both males and females, the trends for obesity and raised blood pressure are upward for both genders.

The presence of more than one condition increases the chronicity of the other disorder, impacting its course and leading to recurrence. An association with an increased rate of hospitalization, medical complications, poor adherence to medications, and suicide attempts has been observed for unrecognized depression/anxiety in NCDs. Psychological and behavioral symptoms of depression/anxiety interfere with the ability to adaptively cope and maintain self-care in NCDs. Persons with depressive disorders comorbid with NCDs, for example, suffer significant limitations in physical activities with restrictions in social and occupational participation. They experience poor quality of life, increased health-care utilization, and out-of-pocket expenditure.

The bidirectional relationship is further evident in the higher rates of diabetes mellitus in patients with anxiety disorders as compared to the general population.^[12]

The challenges to the detection of mental illness such as depression in chronic physical conditions can be due to the assumption of it as being reactive, and therefore, as a normal response to the situation. Cultural factors and existential crises may blur the distinction. Masked presentations and overlapping symptoms further compound the detection of depression/anxiety for physicians involved in the treatment of physical conditions.

Severe Mental Illness and Physical Health Conditions

Patients with SMI have a life expectancy that is on an average 10–20 years shorter compared to the general population.^[13] As mentioned earlier, CVDs are major contributors and metabolic syndromes in turn are an established group of risk factors for CVDs. The pooled prevalence of metabolic syndrome in persons with schizophrenia in India has been noted to be higher in hospital samples (33.5%) than the community-based studies (10.81%).^[14] The rates of metabolic syndrome are similar in bipolar disorder. Although atypical antipsychotics contribute to metabolic syndrome substantially, there may be a higher predisposition to metabolic syndrome even among drug naïve patients. The presence of metabolic syndrome in persons with SMI not only impacts functioning but also their overall quality of life.

The prevalence of tobacco use in persons with SMI has remained relatively stable (35%) over the past 15 years as observed in our setting, whereas the rates have declined in the general population.^[15] Smoking is more prevalent among men, whereas women tend to use smokeless tobacco possibly due to cultural reasons. Low physical activity and inadequate consumption of fruits and vegetables are prevalent among persons with SMI.^[16],[17] This seems to be so even in the general population as reported in the National NCD Monitoring Survey in India (2017–2018).^[18] We are comprehensively surveying physical health conditions in SMI in the three South Asian countries of India, Pakistan, and Bangladesh.^[19]

Despite the abovementioned findings and the presence of several guidelines, the rates of screening for these physical health conditions and health risk behaviors seem to be low.^[20] Even when tobacco use is detected in SMI, no interventions are provided even in tertiary mental health settings. There is a growing body of evidence about the effectiveness of bespoke nonpharmacological and pharmacological interventions in persons with SMI from high-income countries (HICs).^[21] Under the IMPACT project, we are adapting the interventions to South Asia and testing the feasibility of the intervention in persons with SMI.^[19] The COVID-19 pandemic has also necessitated the adaptation of the intervention for remote delivery.

Often, due to the symptoms of the mental illness and lack of insight, access to health care for physical illness is poor in persons with SMI. The only point of contact with health services may be the mental health professional. However, diagnostic overshadowing and primacy to the mental health symptoms in psychiatric services may preclude adequate focus on physical health conditions or their risk factors. The time constraints for consultation in large volume settings such as in crowded outpatient departments of LAMIC may additionally serve as a barrier in providing comprehensive care. Stigma and discrimination in physical health settings both from the health-care service providers and family members can be the important barriers to the delivery of services to persons with SMI.

Integration of Physical Health and Mental Health

There are the models of care for evidence-based integration of mental health and physical health in HIC at the primary care level and in specialist settings. These have been recommended by the World Health Organization for a broad range of services along the continuum from preventive to curative.^[7] They have been proposed to be cost-effective, patient-centric, and equitable. Collaborative care, case management, and multidisciplinary approaches to integrated care need to be tested in LAMIC.

Collaborative care interventions that focus on self-management support, electronic health records, and specialist reviews, and that are locally applicable in the Indian context have been reported to improve both depressive symptoms and cardiometabolic indices in patients with diabetes at 2-year follow-up in a multi-centric study from the country.^[22] We have adopted a behavioral activation module and are testing its feasibility of being delivered by behavioral counselors and NCD counselors for depression in diabetes.^[19]

The national programs in India such as the National Program for Prevention and Control of Cancer, Diabetes, CVD, and Stroke (NPCDCS), National Tuberculosis Elimination Programme, and the District Mental Health Programme (DMHP) provide opportunities for integration of care. The National AIDS Control Programme has provided some examples and lessons for the integration of care in the Indian cultural context. The medical officers and NCD counselors under the NPCDCS can be care providers in mild cases and care coordinators for higher levels of severity. Similarly, the psychologists and social workers employed under the DMHP can be utilized for lifestyle modification, facilitation of referrals, and case management. There is a need to develop and test the models that involve multidisciplinary approaches, pathways, and seamless mechanism of referral across the programs and consultation-liaison in various settings including the community. The Government of India has envisaged the Health and Wellness Centers under the Ayushman Bharat that provides comprehensive care that includes NCDs and mental health.

The Mental Health Care Act, 2017 and the Rights of Persons with Disabilities Act, 2016 of India have emphasized the rights of persons with mental illness with mention of integration of mental health-care services to general health services at all levels. Provision of adequate care for physical health conditions in persons with SMI could be well construed to be within the rights to access care and equality and nondiscrimination as mentioned in the Acts.

We propose that the following can be components of a policy for taking care of the multimorbidity involving SMI:

Greater focus on the identification and management of concurrent physical illnesses, particularly in persons with SMI
The development of locally applicable minimum standards of care for physical health conditions in SMI based on existing evidence and resources in our settings
Training and education of mental health professionals in the assessment and management of physical health conditions in SMI
Integrated physical and mental health assessment and management in all patients with NCDs
Periodic cycles of audit regarding adherence to the minimum standards of care
Generating evidence in the provision of models of integrated and holistic care for physical illness in persons with SMI besides treatment of the conditions may include interventions specifically addressing lifestyle, for example, addressing tobacco cessation including pharmacological assistance such as nicotine replacement therapy and other lifestyle changes
Sensitizing the health-care sector on the identification and cost-effective management of multimorbidity and research in this area
As the care provision may need a multidisciplinary approach, pathways of referral and consultation-liaison in the various settings including the community need to be devised. These pathways can be built into the existing mechanisms of implementation of the national programs
Strategies to reduce stigma and discrimination in the provision of care to persons with mental illness in physical health settings, thereby improving access to care
Funding toward both service provision in this area and research that generates evidence regarding the local burden of the problem, risk factors across settings and regions, thereby assisting in the development of locally applicable methods of intervening and prevention.

Rethinking Recovery

Conventionally, clinicians have been trained to look at clinical recovery that is an objective standpoint of the clinician. However, worldwide, clinical services are gradually adopting an approach that values subjective experiences. Recovery-oriented services see people beyond their problems, and the focus is on living as well as possible. Abilities, possibilities, dreams, aspirations, and personal assets of the individual are important drivers of the care. Such care needs to be collaborative and rights-based. The service users (sometimes called consumers) are important stakeholders in decision-making and are involved in the development of evidence-based services at all levels.

They are increasingly being involved in the development of the research plans, guide the execution, interpretation, and discussion of findings as stakeholders in community advisory panels.^[23] While generating evidence for the models and mechanisms of integration of care involving physical health and mental health, service users and their family members need to be involved. Many funders have also valued and actively sought this involvement. The authors have found this approach to be encouraging in the context of a multi-centric research project on multimorbidity in South Asia.

The interventions that are developed for multimorbidities are likely to be multidisciplinary in nature, but these need to be mindful of the local resources, and therefore, locally feasible.

Many of the chronic care models in NCDs and the recovery-oriented models of care in SMI such as the Illness Recovery and Management,^[24] emphasize self-management and self-care. Self-management has been reported to improve health behaviors, health outcomes, and quality of life.^[25] Benefits in reducing health-care utilization and costs of care have also been demonstrated. Patient–provider partnership is the bedrock of self-management that includes collaborative care and education in self-management. Self-management is a problem-based endeavor that is grounded in self-regulation and social cognitive theories. Illness Recovery and Management includes recovery strategies that are covered in 11 modules.^[24] The modules cover healthy lifestyle, adherence, drug use, and alcohol, and coping with stress besides other areas relevant to SMI. There is preliminary evidence regarding improvement in consumer-level outcomes.

These strategies need to be tested in the context of LAMIC as resource constraints impose a significant barrier in service provision. In LAMIC, as exemplified in India, persons with chronic conditions and mental illness are supported by their families. The involvement of the family in self-care may be an important addition to these strategies and may bring improvement in outcomes through family support in NCDs besides mental illness.

Indigenously acceptable methods such as yoga have increasingly been recognized as effective add-on treatments for both mental illness and NCDs and in prevention. Many of the interventions can be provided online – in groups, through recorded materials besides one-to-one care. Telephone and mobile/smartphone-based services have been attempted successfully in the general population for tobacco use in India. These will need to be adapted and tested for persons with mental illness.

Increasingly, patient-reported outcomes such as quality of life are recognized as the cornerstone for evaluating the effectiveness of treatments. Core outcome sets that include quality of life, mental health, and mortality have been operationally defined in multimorbidity research for HIC.^[26] However, in the context of LAMIC, the core outcome sets in multimorbidity have not been defined and efforts are ongoing.^[27] These have been deemed necessary to synthesize evidence in the context of disparate health systems and cultures.

Although we have discussed the literature mostly in the context of NCDs, many of the issues are pertinent to chronic communicable diseases such as HIV, hepatitis B and C, and tuberculosis. We have mainly focused on diabetes and CVDs as illustrative of the problem of multimorbidity and have not discussed specific issues surrounding cancer, chronic respiratory diseases, thyroid disorders, arthritis, and other chronic conditions. Many of the general principles and concerns, however, will remain the same across multimorbidity involving these conditions.

Conclusions

Multimorbidity is likely to rapidly rise in the LAMIC. The co-occurrence of NCDs and mental illness negatively impacts the quality of life and clinical recovery in both conditions. The existing health systems and programs provide care for single diseases. Therefore, integration of care is required in the context of multimorbidity. Models of integrated care can be envisaged in the existing national programs. The models of service provision, however, need to become personal recovery-oriented. Therefore, service users should be engaged in the development of these services from the beginning including in research in this area. Existing models in HIC that emphasize self-management and provider–patient partnership need to be adapted and tested for feasibility in LAMIC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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