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Behavioural and physical aspects of chd management

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    September 19, 2014

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    long term conditions, comorbidity, behavioural healthcare

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It comes as little surprise that people with long-term physical conditions often have associated behavioural/mental health problems such as anxiety and depression. The stress alone of dealing with a chronic illness diagnosis can be enough to trigger behavioural/mental health symptoms and conditions. Equally someone with existing behavioural health difficulties can find it difficult to manage physical symptoms of a co-morbid long-term illness such as diabetes. At least 30% of people with chronic illnesses also have a mental health problem. Depression, for example, is two to three times more common among people with a range of cardiovascular diseases than the general population. The number of people suffering from long-term, chronic illnesses is on the increase. Also on the increase is the number of people with co-morbid illnesses - more than 15 million (30% of the population) in England have one or more long-term conditions such as diabetes or chd (coronary heart disease).

Implications for patients:

For the growing number of people living with a long-term condition/s and behavioural or mental health problems the prognosis for their long term condition and their quality of life can deteriorate. A person’s behavioural health condition can negatively impact their ability to manage their physical symptoms and vice versa. This can easily lead to a vicious cycle whereby they are unable to effectively manage either condition.

Need for intervention:

Recent research by Kings College London has found that supporting the behavioural/mental health needs of people with long-term conditions more effectively can lead to improvements in both mental and physical health. Currently treatment for people with long-term condition/s and behavioural health problems is often fragmented due to the current separation of mental and physical health care. There is a clear shortage of interventions for management of depression co-morbid with physical health problems, such as chd. Given the co-existence of these conditions it makes both practical and financial sense to treat them alongside one another. But for this to happen joined-up thinking amongst health professionals is required.

Increased cost to health services:

It has been found that people with long-term conditions are most frequent users of health services. Also a combination of a long-term condition/s and behavioural/mental health problems may lead to increased use of health services. This obvious increased cost and pressure on health services is further highlighted by international research which shows that co-morbid behavioural health problems increase the costs for long-term physical health conditions from 45 to 75%. As if these co-morbidities aren’t already complex enough to add to this is the uncertainty as to who should be paying for these costs. But one thing is for certain that improvements can be made by better integrating mental health support with primary care and chronic disease management programmes, with closer working between mental health specialists and other professionals.

Health policy Initiatives:

In the UK the NHS has begun to tackle this issue of treating comorbidities through health initiatives such as IAPT Pathfinder programme. The idea is to expand the current IAPT (Improving Access to Psychological Therapies) programme offering it to a wider range of people including those with long-term conditions. In the last few years there have been a number of pilot Pathfinder projects run to help identify a potential optimal stepped care pathway and core therapy competencies for treating people with long-term conditions.

It has been recommended in the NICE guidelines (2006) that people with long term conditions and co-morbid mental health problems should be targeted by service providers for referral to self-management support programmes such as evidence-based computerised CBT programmes like our online platform at SilverCloud as this is an efficient way to reach larger numbers of people in a shorter amount of time. Despite good headway being made through these pilot projects there is uncertainty about future funding, and consequent difficulties in planning, which is a major issue for the UK Pathfinders. However it’s important for health providers to acknowledge that the costs of including psychological or mental health initiatives within disease management or rehabilitation programmes can be more than outweighed by the savings gained from improved physical health and decreased service use. 

Practice initiatives:

At the recent IAPT Long Term Conditions conference (September 17th 2014) Kevin Jarman, Deputy Director – Adults, IAPT programme, NHS England, set the stage for the importance of the pathfinder projects in determining the optimal care pathways and interventions for people with long term conditions accessing IAPT services. IAPT services are the only service that could support the psychological needs of people with long-term conditions. There does not exist any other services in the NHS between primary care and specialist services.

Currently the Pathfinder sites are in their second phase and the evaluation will be carried out by Professor Simon Jones and his team at the University of Surrey – IAPT evaluation agency. The conference presentations highlighted the need for greater understanding and development of interventions for people with long-term conditions, including medically unexplained symptoms. Some very promising and interesting work has already begiun under the Pathway project sites, currently 15 in total.

While some difficulties have been identified in data collection and the use of standard minimum data sets presently used by IAPT, the Pathfinder projects are experimental and the outcomes should inform the development of good practice in delivering care to people with long-term conditions. It is essential to note that people with long-term conditions are somewhat different from the ‘normal’ user of IAPT services and that current measures may not adequately account for their distress nor measure adequately their outcomes from psychological therapy.

At the Pathfinders conference SilverCloud Health & King’s College London presented the newly developed online intervention for heart disease. Technology is already used in the IAPT services and its potential as an intervention for people with long-term conditions has not gone unnoticed. There is perhaps an even greater potential for technology as an aid for people with long term conditions especially since SilverCloud Health are designing from a mobile first position.

Imagine the scenario where someone with a long term condition has their management and wellbeing tool in their pocket. SilverCloud are committed to developing high quality evidence-based interventions for long term conditions that have a focus on self-management and also psychological wellbeing. SilverCloud Health has recently partnered with  WILEY, one of the world’s most well respected providers of education, medical and psychological information for professionals, patients, researchers and students alike, to develop  psychoeducational and therapeutic interventions for people with long-term conditions.

 It is evident that some work is underway; SilverCloud and their partners are leading this work to develop evidence-based interventions for long term conditions management and  psychological wellbeing. 

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