Blog by Dr Duncan Edwards, NIHR Doctoral Research Fellow and GP
Much is made of the need to adapt health services for patients with multimorbidity, and much is made of the need to improve struggling mental health services. They’re often presented as separate challenges. News stories can conjure up images of older patients with multiple physical problems such as heart disease and osteoarthritis, or typically younger individuals struggling to get help living with their autism, schizophrenia or addictions. However, our analyses of primary care data demonstrate that mental health conditions more commonly occur in patients with physical health conditions – and vice versa. And health services are not designed well to help patients with both.
Take a 40 year old patient of mine – with schizophrenia and diabetes (as well as further co-morbidities)*. His mental state worsened, and he was managing his diabetes worse. In fact, he was probably experiencing hypoglycaemia and collapsing on most days. I admitted him three times to hospital on account of his diabetes, and he was discharged after a few days three times. The underlying cause of his health deterioration was his mental health, and yet a mental health team which could also intensively manage his diabetes (or vice versa) was simply not available. At last, a hospital bed was found hundreds of miles away; months later he was discharged, but by this point he had lost his home and his tenuous connection to his community, and greater difficulties ensued.
Mental-physical comorbidity – the presence of at least one physical health long term condition, and at least one mental health related long term condition is common (see figure). Though it increases in prevalence with age, this trend is less steep than for purely physical health multimorbidity, because many mental health conditions, including schizophrenia and addictions, start at a young age. The association with deprivation is strong.
At this year’s RCGP conference in October, Lord Victor Adebowale of Turning Point made a case for greater attention on the large group of patients with a combination of physical, psychological and social challenges who are experiencing health systems not designed to meet their needs: even if you didn’t care about them, looking after them badly with our current fragmented systems is expensive.
Figure: Co-existence of at least one physical and one mental health related long term condition is common in under 65s, especially in areas of greater socio-economic deprivation
from: The epidemiology of multimorbidity in primary care: a retrospective cohort study by Anna Cassell, Duncan Edwards, Amelia Harshfield, Kirsty Rhodes, James Brimicombe, Rupert Payne and Simon Griffin, Br J Gen Pract 2018; 68 (669): e245-e251. DOI: https://doi.org/10.3399/bjgp18X695465
*based on a real patient but anonymised
About the author
Dr Duncan Edwards is a National Institute for Health Research doctoral research fellow, and a GP whose research is focussed on the prevention and treatment of stroke and cardiovascular disease in the primary care setting. He also sits on the Independent Scientific Advisory Committee which advises on the use of the Clinical Practice Research Datalink (CPRD) for research. He is a core member of the CPRD@Cambridge team, which sits within the Cambridge Research Methods Hub at the Primary Care Unit, University of Cambridge.
Lucy Lloyd, Communications, Primary Care Unit
Image credit: devonlive.com