The concept of wellness of mind and body is ancient. We know
Read Pat's story and his long journey to turn his health around.
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The concept of wellness of mind and body is ancient. We know people who suffer the combination of mental and physical illness fare worse than people with one or the other.
A person living with schizophrenia or bipolar disorder who also has diabetes has a higher risk of dying than a person with diabetes alone.
It’s a vicious circle. People with physical illness are more likely to experience mental illness, especially anxiety and depression, and those with mental illness are more likely to develop physical illness.
The physical health issues of mental health consumers are often ignored, or risk factors such as smoking and obesity accepted as normal. Conversely, a dominant physical illness can mask a mental health problem.
The consequences are significant, not only for people, their families and carers but also for the health system which bears huge extra costs when physical and mental illness go hand in hand.
Mental health underlies about a quarter of GP visits so we must find better ways to support medical professionals to recognise and respond to overlapping needs.
More than a quarter of people with diabetes also suffer from mental illness, mainly anxiety and depression.
Research also shows a significant percentage of people living with schizophrenia are likely to suffer serious physical illness and this rises for people taking medications such as clozapine.
However, the norm is that the person with diabetes is treated for that, and the related mental health issues are treated separately or not at all.
Similarly, a person’s schizophrenia diagnosis dominates their interactions with the health system even if they are overweight, have high blood pressure or diabetes, heart or circulatory conditions, or other risk factors.
Labels mask a much more complex human being and we need to help health professionals see beyond the dominant diagnosis if we are to provide truly holistic care.
People receive different responses and levels of service depending on whether they are seen for a physical health problem or a mental health problem, even if they suffer from both. The story is worse for those with mental health issues.
Peter is 45 years old. He has schizophrenia and heart problems that are exacerbated by the medications he takes for his schizophrenia. He is a smoker, overweight and has never managed to build the confidence and focus needed to develop a more healthy diet and exercise habits. He lives with his mother. He has medicines, variously prescribed by his GP, cardiologist and psychiatrist. While a care plan was developed a number of years ago, it has never been reviewed, despite numerous changes to his medications. Apart from being told about possible side effects, no one has talked to him about the range of medicines he is taking and how they can be best managed.
Peter’s first crisis
Three years ago Peter started to feel severe pains in his chest. He was finding it hard to breathe and began feeling very faint.
Luckily his mother was at home and called an ambulance, which arrived within 20 minutes. The paramedics stabilised Peter and within the hour he was in the emergency department. He was triaged immediately, seen by the specialist who, after a short period of observation, admitted Peter to the cardiac ward.
All this occurred within three hours of feeling the chest pain.
Peter was discharged a week later with a clear care plan, including specialist follow-up. His discharge process included an appointment, the following day, with his GP.
Peter’s second crisis
Last year, after a few days of feeling unwell, Peter became increasingly psychotic. As his behaviour got worse, his mother became more concerned for his health and safety so rang emergency services.
She was put through to the ambulance service which said it couldn’t help, and suggested she ring Peter’s GP or, if he got violent, the police. Peter was not violent, but his behaviour was increasingly distressing and he began to talk about ending his life.
His mother tried his GP but was put through to the after-hours service which said it couldn’t help but suggested she call the local hospital. This also proved to be of little help. After talking to several people she was told no one from the mental health team was on duty, suggesting she call the regional hospital.
Peter’s mother was now trying desperately to ensure he didn’t leave the house as she was concerned she wouldn’t be able to stop him killing himself. She finally managed to get hold of someone in the mental health crisis team at the regional hospital, who told her someone could come to see Peter some days later.
By midnight his mother was becoming very tired, a little scared and fearful for Peter’s safety as talk of killing himself got more intense. She finally decided to take him to the emergency department. With the help of neighbours and a combination of encouraging words and physical restraint, she was able to get Peter into a car.
One of the neighbours drove them and they arrived at the emergency department at 2am where, after a considerable struggle, Peter was sedated. He was kept under sedation until late next morning when he was visited by a psychiatrist who admitted Peter to the psychiatric ward.
Peter was discharged a week later. He was back on his medication and seemingly stable. No appointment was made with his GP. No care plan was discussed.
Holistic care requires effective co-ordination of physical and mental health services. But there are no incentives for service providers to link up and no consequences if they don’t.
Progress has been slow or non-existent. Connections between hospitals and services in primary and community settings are poor or simply not there.
Vulnerable and unwell patients are often discharged into a vacuum with no care team set up to support them back in the community. It’s often up to patients themselves to create the wrap-around services often talked about and needed if physical and mental health needs are to be properly met.
While some are lucky enough to connect with a carer who can help create links, most have to create their own and many just can’t.
There is an overwhelming sense of disconnection between health services and the holistic needs of patients with physical and mental health concerns.
- More than 1/4 of people with diabetes will also be experiencing mental illness especially anxiety and depression
- Almost 27% of Australians with psychotic illness experience heart or circulatory conditions compared with 16.3% of the general population
- Community care teams
- Lived experience
We need to create a health services culture where mental and physical health needs are seen together because for too long the medical profession has treated the mind and body separately.
We must use the best evidence-based practice to manage both aspects effectively.
We can’t expect every medical professional in the health and mental health system to have all the necessary skills. We can, however, certainly expect partnerships to be formed, and the multiple disciplines and expertise to be wrapped around the person and co-ordinated for the best possible care and support. We need a culture of integration and respect between general practitioners and hospital specialist services.
Acknowledging the interplay between physical and mental health means the system of mental health becomes more clearly a partnership between people who experience mental illness, their networks of friends, loved ones and carers, and support available from a full range of voluntary, community, social and health services.
We can create an expectation that people will participate actively and effectively in the design of their own care.
Peta is in her early 50s, has diabetes and her kidney function is deteriorating. She’ll probably need renal replacement therapy within five years. She’s on an unemployment benefit. Despite being active in her youth she’s now severely overweight, smokes and does little exercise.
Peta found out about her diabetes in her late 30s during a routine visit to her GP. She was shocked. She was told there was no cure and that she had to see a specialist to organise appropriate treatment. Peta didn’t really understand all the information she was given. She left with the only message that she would have this for the rest of her life.
Peta saw the specialist, was put on medication and at times did feel better. However, fatigue, swollen ankles and chronic back pain got worse over time and she started to become less sociable, spending more time away from friends.
Two years after her diagnosis she cut down her work because of stress. This made life at home harder, and her depressed moods got worse and more frequent. Her GP gave her some medication but it had little effect and, as her depression became worse, she wasn’t able to stick to the medication and lifestyle program.
Over the next few years her visits to the GP and attendances at hospital increased. Three years ago she started to develop trouble breathing and was rushed to hospital three times. At no stage did anyone talk to her about depression. She was considered only as a patient who wasn’t good at sticking to her diabetes program.
This made her feel more guilty and depressed, and made it even harder to do what she needed to do to look after her health. Peta now experiences at least four unplanned admissions to hospital every year. Her physical and mental health continues to deteriorate, yet no one has talked to her about her depression. She hasn’t much hope that things will change and she hasn’t the confidence or resilience to do much about it.
I need easy access to early and holistic assessment: No matter what the health system might see as my primary diagnosis, I’ll do better in the long run if the connections between my physical and mental health problems are acknowledged early and taken seriously.
When things are serious I need better responses to my mental and physical issues: People like me need a partnership between community, GPs and other primary carers and hospitals, so that they can respond properly if my physical or mental health worsens. The responses will be better if I am involved in the decision making every step of the way, together with my family and carers.
I need the system to pass on all the important information: When people like me go back into the community, we need responsibility for our care to be transferred, not just a hospital discharge. If we are taking charge of our own care, that’s still a transfer and the health system has a duty to ensure we have the right knowledge and skills to look after ourselves.
I need genuine community-based options to manage my ongoing needs: If I can access the right care and support or care services in the community, I might not take up a hospital bed unnecessarily or be afraid of being discharged from hospital before I’m really ready or able to cope because my bed is needed for someone worse off.
Community-based care must respond effectively to all my issues: My care providers need to work in an integrated community-based system. Those people also need the skill and capability to care for both my mental and physical needs and to recognise when one might be masking the other. I want to look after myself but I need the right support and resources to do that.
I can manage my own life, especially with support from people who've been down this road:People like me will be better off generally if the mental health system puts in place supports such as self-management and peer support services that we know really work. Self-management lets me acknowledge the benefits I receive from pursuing my interests, my hobbies, my spirituality and any other healing approaches such as meditation or art.
I’ll do better if the whole community recognises I’m a valuable person: I’m committed to learning how to manage my physical and mental health needs so I can thrive in the community. But it’ll only work if everyone recognises that people like me have real lives, and that we’re not just patients.
*This composite story describes what the experience of someone on this journey might look like.
Source material for content on this page is from the Living Well Report