Mental health in physical illness

Long-term conditions can have a significant impact on mental health, explains Dr Alan Cohen

Patients with long-term conditions (LTCs) such as diabetes, cardiovascular disease and COPD often have psychological and emotional needs.

These result from the burden of their symptoms, disability associated with their illness and the impact of living with more than one condition at any time. For some, a formal mental health disorder, such as depression or anxiety, may also be present.

Effective management requires a personalised care plan. RCGP Essential Knowledge Update 11 covers this topic in three sections:

  • General issues - the relationship between physical illness and mental health problems.
  • Specific issues - evidence of the impact of psychological need.
  • The relationship between those with severe mental illness, such as schizophrenia, and physical illnesses.

This article summarises some of the general issues.

Key learning Points
  • Consider using the GAD-7 questionnaire for assessing anxiety when managing patients with COPD.
  • Consider using the PHQ-9 questionnaire for assessing depression when managing patients with diabetes or supporting those who have had an MI.

The size of the problem

Evidence from the DH, NICE and a number of reviews provides a picture of the significance of the relationship between LTCs and wellbeing.

Some 30% of people say they have an LTC. This group accounts for 52% of GP consultations, 65% of outpatient appointments and 72% of inpatient bed days. Some 50% of people over 60 have an LTC.

Patients with an LTC are the most frequent users of healthcare services, using 70% of resources. They are more likely to be out of work, have a common mental health problem, come from a poor background and die prematurely.

In patients with one LTC, depression is two to three times more common than in the general population. In those with three or more LTCs, it is seven times more common.

In patients who have depression and an LTC, overall morbidity and health scores are worse than for the LTC alone. For example, depressed patients with CHD are twice as likely to die as those with CHD alone.

Between £8bn and £13bn of NHS spending is attributable to the consequences of comorbid mental health problems in patients with LTCs. Significant comorbidity occurs in children and older people, and the implications described above are more marked.

The implications of increased prevalence of common mental health problems in LTCs are:

  • Poorer objective health outcomes.
  • Poorer subjective health outcomes.
  • Greater use of resources.
  • Wider costs to the economy through unemployment, sickness absence and informal care.

What can be done?

The significance of this information is that clinical commissioners can exert a real change for the better, by more informed and innovative commissioning of service pathways. This can be at least cost-neutral and at best cost-saving, while still delivering improved health outcomes.

There are examples of new service pathways that deliver some of these innovations. Probably the best known is the NICE guideline, Depression with a chronic physical health problem (CG91) which describes a care model known as collaborative care.

Some debate still exists on the characteristics of this care system, but it usually includes:

  • Shared understanding of health problems (between patient and healthcare professional).
  • Shared agreement as to how the problems should be addressed.
  • Shared approach between primary and secondary services.
  • A nominated lead to co-ordinate care and a process to ensure all patients are followed up.
  •  Supervision and support for the nominated lead.

The presence of an evidence-based intervention, with improved access to psychological interventions (part of the 2012 NHS Mandate) means the components for effective intervention can be commissioned and implemented.

Individual GPs do not need to take on extra clinical work or prescribe new, costly medications to deliver this approach in the management of LTCs - the elements are already in place. What does need to happen is that GPs influence the commissioning strategy, so these clinical imperatives are translated into services that deliver improved health outcomes.

  • Dr Cohen is a GP and an EKU author for the RCGP


  • NHS Confederation. Investing in emotional and psychological wellbeing for patients with long-term conditions. London, NHS Confederation, 2012. tionalandPsychologicalWellbeing LongTermPatients.aspx

  • Cimpean D, Drake RE. Treating co-morbid medical conditions and anxiety/depression. Epidemiol Psychiatr Sci 2011; 20: 141-50.
  • NICE. Depression with a chronic physical health problem. CG91. London, NICE, 2009.


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