Chronic conditions include diabetes, obesity, cardiovascular disease, cancer, chronic respiratory diseases, some neurological conditions and mental health conditions. Chronic conditions are also referred to as non-communicable disease (NCDs)
(Non communicable dise...). The global burden of disease attributable to NCDs has now outstripped the burden of communicable conditions (Fig
1), a phenomenon known as the 'epidemiological transition'. The worldwide increasing burden of chronic conditions {GBD Mortality and Causes of Death Collaborators: 2014cx}, treatment gaps and treatment lag (Patel et al., 2010) (Wang, Berglund, Olfson, & Kessler, 2004) are major obstacles to be overcome. The treatment gap refers to the numbers of people who need treatment that are not receiving it. As an example, the treatment gap for mental health disorders has been estimated to exceed 50% in all countries of the world, and to reach 90% in those with less resources (Patel et al., 2010). The amount of time taken to receive mental health treatment when it does exist—treatment lag— has been estimated to be longer than a decade (Wang, Berglund, Olfson, & Kessler, 2004).
As a function of this epidemiological transition, healthcare systems are struggling to meet increasing demand
(Guzman-Castillo et al., 2017) (Fig
1). In the United Kingdom (UK), it is estimated that approximately 30% of the UK population have one or more chronic conditions and that this 30% accounts for 70% of the spend (Department of Health, 2012). People living with chronic conditions are the biggest users of the National Health Service (NHS). They are more likely to see their general practitioner (accounting for approximately 50% of consultations), to be admitted as inpatients and to use more inpatient days than those without such conditions (70% of all inpatient bed days), and account for 64% more outpatient appointments (Department of Health, 2012). Our theoretical models of health and wellbeing allow several inferences to be drawn regarding health care for people with chronic conditions.
Models of health care: Despite the epidemiological transition, healthcare models have not adapted to the changed landscape. The dominant model of health care, ‘the acute medical model’ was designed to treat acute conditions. Inherent in the medical model are several assumptions that are ‘not a good fit’ when applied to people with chronic conditions. For example, the acute model is underpinned by the assumption that a person’s ‘acute problem’ can be fixed and that they can be returned to a ‘pre-injury state’. However, chronic conditions cannot be fixed and whereas impairment may be reduced to some extent a healthcare approach that attempts only to reduce symptoms where possible misses’ opportunities to promote wellbeing. We have presented a plethora of evidence demonstrating the absence of illness or impairment does not equate to wellbeing. With reference to our framework we argue that by building positive psychological experiences (e.g. Individual strengths, optimism and resilience) within a supportive social network and environment, pathways to self-sustaining cycles of positive health and wellbeing may be triggered and maintained, supporting and facilitating wellbeing despite the limitations imposed by the condition. Accordingly, the management of people with chronic conditions requires a holistic approach both within the health service and beyond – an approach that extends beyond medicine which by definition is the science and practice of establishing diagnosis, treatment and prevention of disease. When it comes to conditions or disease that cannot be cured, medicine has an important role a part of a much wider holistic approach that seeks both to reduce suffering but also to facilitate wellbeing through the promotion of positive psychological experience, positive health behaviours, social and community integration and time spent in nature. However, in isolation the medical model alone will miss a host of opportunities to tackle the global burden of chronic conditions. Another assumption of the medical model a patient is typically a ‘passive recipient of care’. However, treatment outcomes for people with chronic conditions are contingent on active collaboration between clinician and patient. For example, adherence to treatment regimens, and adoption of recommended lifestyle changes etc. Thus, patients are no longer passive recipients of care, but need to be active and equal partners in the management of their condition.
Organisational and intuitional barriers within health services and beyond: Epidemiological studies have also shown that
common mental disorders [zf1] and physical disease are strongly inter-connected, highly co-morbid and share critical pathways to ill health and disease (O’Neil et al. 2015;
Druss, Walker, 2011[zf2] ),
(O’Neil 2015). This evidence has been captured by the tagline: 'there is no health without mental health'
(Prince 2007). As an example, the senior author on the current review (AHK) investigated the relationship between the mood and anxiety disorders and coronary heart disease (CHD) in Brazil
(Kemp 2015), observing that these common mental disorders are associated with a threefold increase in CHD, after full adjustment for potentially confounding factors. Common mood disorders share an underlying diathesis whereby mechanisms that predispose individuals to depression and anxiety for example, contribute to the development of a range of chronic physical health conditions across the life span, and vice versa. While the mechanisms for such a relationship are complex, our work on this topic
(Kemp 2017, Kemp 2017a, Kemp 2018, Kemp 2013, Kemp 2016) - including our GENIAL model
(Kemp 2017) - have emphasised a role for vagal function as a structural mediating link between mental and physical health
(Kemp 2017, Kemp 2017a, Kemp 2018, Kemp 2013, Kemp 2016). A greater appreciation - and understanding - of the relationships between mental and physical illnesses and their underlying mechanisms are needed so that improved interventions and treatments may be developed which bridge the gap between physical and mental health services. Relative to physical health conditions, mental disorders are much less likely to receive treatment and this holds true across the world (Von Korff MR, Scott KM, Gureje, 2009). However, if one considers the global burden of chronic conditions in terms of disability rather than mortality, major depression is the second leading cause of disability (O’neil, Jacka, Quirk, Cocker and Taylor and Berk, 2015) preceded only by cardiovascular disease. Moreover, there is a high degree of co-morbidity with mental and physical health conditions because we know that mental ill health affects adherence to treatments and prognosis (DiMatteo, Leeper and Croghan, 2000). Accordingly, the commissioning bias in favour of physical health services actually disadvantages the majority of people with chronic conditions given the tight linkage between physical and mental health and serves to exacerbates the challenges for the prevention and amelioration of chronic conditions. Moreover, there are also typically biases in the types of interventions offered by mental and physical health services (with the exception of pharmacological treatment). People with physical health difficulties are typically prescribed physical health treatments. For example, people with cardiovascular disease (CVD) are typically advised to partake in healthier diets and physical activity. However, we know that there is a strong reciprocal relationship between CVD and depression (Gasse, Laursen, Baune, 2014; O’Neil et al. 2015; Wilhelm K, Mitchell P, Slade T, 2003). This bias misses several opportunities to enhance health and wellbeing for people with CVD. For example, positive psychological experiences have been associated with decreased risk of secondary cardiovascular events and mortality (Boehm JK, Kubzansky LD., 2012; DuBois CM, Lopez OV, Beale EE, Healy BC, Boehm JK, Huffman JC, 2015). It has been argued that psychological wellbeing is a modifiable protective factor that could decrease the impact of CVD through its potential influences on health behaviours and CVD-related biomarkers (DuBois CM, Beach SR, Kashdan TB, Nyer MB, Park ER, Celano CM, et al.2012; Sin NL, Moskowitz JT, Whooley MA. 2015). Conversely, mental health services typically focus on offering psychological therapies in addition to medication whereas much research has shown that people with mental health conditions typical have poor diets (Storlein, Baur and Kriketos, 1996), sleep
(Lee 2012, Ancoli-Israel 2006), lower levels of physical activity (Goodwin, 2003) and are more social isolated (reference). Moreover, interventions that target these health behaviours significantly ameliorate symptoms
(Trauer et al., 2015), Stathpoulou and Power, (2006),
(Opie et al., 2015; Parletta et al., 2019).
Our extended GENIAL 2.0 framework also makes it clear that in order to promote the health and wellbeing of our nation, the NHS cannot shoulder the burden alone. There is a tendency to approach healthcare at an individual level but we present a range of compelling evidence that the health and wellbeing of individuals are not just determined by individual factors but that community and environmental factors are determinant of health that must be targeted to reduce the burden imposed by chronic conditions.
[zf1]ADD WHAT DO WE MEAN BY COMMON MENTAL HEALTH CONDITIONS
[zf2]Check this is an epidemiological study