Treating a Chronic Disease, Beginning with Mental Health

“Healthy mind, healthy body” has never been truer.

A sweeping new report, published in July in The Lancet Psychiatry, announced that people with depression and anxiety, along with other mental illnesses, are at higher risk for cardiovascular disease, diabetes and obesity.

“The message here is not to dismiss common mental disorders as ‘safe’ for physical health, and to begin addressing physical health in all populations diagnosed with mental illness,” said Joseph Firth, a research fellow at Western Sydney University and lead author of the report.

This isn’t news to health centers.

While a strong link between depression or anxiety and physical health has emerged only relatively recently in academic research, health centers have long experienced the correlation firsthand.

“We’ve been aware of this just by seeing our patients, that chronic illness and mental health go hand in hand,” said Jill Ellingson, mental health director of Community-University Health Care Center in Minneapolis.

Sometimes, explained Felix Valbuena, the CEO of Community Health and Social Services Center in Detroit, a psychological issue can exacerbate a chronic condition – and prevent progress.

“We’ll see a diabetic patient who’s doing everything we ask…and their A1C is through the roof,” he said, referring to a test used to measure blood glucose levels. “More often than not, it’s depression.”

“If you can treat the anxiety or depression, you’re going to have stabilization or improvement of the chronic disease,” said Kim Schwartz, CEO of Roanoke Chowan Community Health Center, which has several locations in North Carolina.

Like many other organizations, these health centers doing something about it, integrating behavioral healthcare into the management of chronic diseases like diabetes.

According to Colleen Diouf, Community-University Health Care Center’s CEO, successful management of a chronic disease often starts, unintuitively, with better mental health.

“People are afraid to get care, they have stigma, they’re not able to manage mental health symptoms,” she said. “Their symptoms are so exacerbated that treating their mental illness is really the first step.”

A Troubling History

Scientists have known about the relationship between mental illness and early death for more than a century. Globally, people with mental illness die 20 years younger on average than the general population, Firth said.

The “why” and “who” has become clearer over time. “In the 21st century, there’s been an exponential increase in the research,” Firth said. With that research has come an increasing awareness that those early deaths are more likely to be because of physical ailments.

While suicide and other “unnatural” causes are of real and grave concern, they account for about 17% of those premature deaths.

Most research focuses on severe mental illnesses, like bipolar disorder and schizophrenia. But the report, which summarizes about 100 reviews of existing research, found a strong link between more common psychological issues– like depression and anxiety – and physical ailments that can shorten lifespan.

There’s also evidence that the disparity in life expectancy is getting worse over time.

Firth said the increase in chronic disease among people with mental illness is due to a combination of lifestyle factors; side effects of medication (which can cause lethargy and increased appetite, and even affect insulin sensitivity in some cases); and social circumstances, such as poverty, that cause reduced access to care.

People with mental illness are more likely than the general population to have poor diets, to be overweight and obese, and to smoke. It works the other way around, too, Firth said: “People with disease are more likely to acquire mental health conditions.”

Forming a Team

Community-University Health Care Center is unusual: Almost as many patients access mental health services as they do primary care. Between 20% and 30% of the health center’s patients have a more severe mental illness, such as major depression, bipolar disorder, or schizophrenia.

They’ve also seen their number of diabetes cases nearly double over the past few years, to around 700-800 cases annually.

For the health center, putting the two together to treat chronic disease felt intuitive. Oftentimes, “we’re coming from the mental health lens rather than the primary care lens,” Diouf said.

Providers at the health center work in “medical teams”: groups of case managers, doctors, medical assistants, psychologists, and interpreters who are all working toward a common goal for each patient, like well-managed diabetes or a higher happiness level.

“It allows us to have really more in-depth, supportive conversations about our patients,” Ellingson said. The health center was awarded for its efforts to integrate mental health care with diabetes medication management in 2017, when it received an Innovations in Care award from BD.  The Community Health and Social Services Center and Roanoke Chowan were also awarded for their innovative approaches to helping patients manage diabetes.

Schwartz explained that the team structure, which Roanoke Chowan Community Health Center also uses, prevents information from falling through the cracks. A patient may mention something to a mental health provider without realizing it’s important for the overseeing physician to know as well.

Teams keep a close watch on all aspects of a patient’s care. A rough patch in a previously well-managed condition isn’t necessarily just about physical health. “Typically when your mental health is not OK, you’re not taking your meds on time, you’re not engaging in other services,” Diouf said.

A Warm handoff

“We’re not just a medical being. There’s a lot more to us than just the medical part,” said Valbuena, of Community Health and Social Services Center.

Although he’s a practicing physician, Valbuena is well aware of a telling statistic: Only about 20% of a patient’s health is determined by medical care; the other 80% is determined by socioeconomic factors and health behaviors.

That means addressing psychological well-being, which plays a major role in health behaviors like diet and exercise, is essential.

At Community Health and Social Services Center, mental health providers are close at hand. “They’re actually on the floor. We can pull them in, give them a warm handoff,” Valbuena said. Using motivational interviewing and cognitive-behavioral therapy, among other techniques, helps patients reach their healthcare goals.

But ultimately, Valbuena said, “I think the vast majority of the time, just having the time to spend with the patient and just listening” makes the biggest difference.

A Mobius Strip

For Schwartz, an essential component of treating a mental health issue is…making it feel like less of a mental health issue.

Patients often come to the health center unaware that there’s something wrong. Schwartz said. And for many of the center’s patients, psychological issues – even more common ones like depression and anxiety – are highly stigmatized.

“We have all kinds of ways to talk about that, so it doesn’t feel like ‘I have a diagnosis of mental illness,’” she said. The trick is to normalize it: to make it feel less like an independent, monumental problem and more like just another component of a patient’s health care.

And that’s really how it works, Schwartz said. Patients who are successfully treated for a mental illness begin to feel better. “Then they take better care because they feel better about feeling better. It’s a Mobius strip.”

Although the connection between mental illness and a shortened lifespan is undeniable, the health centers focus on the positive.

“You always give people hope. The data is just the data,” Schwartz said. It’s important for a patient to understand that “you can be healthier for longer if you can treat these together.”

Diouf feels it’s important for a patient to be aware of the risks that a mental illness can pose, but also to understand that they can change course.

“Just because you have a mental illness doesn’t mean you are going to die sooner,” she said. “It’s about the choices.”