Grand Challenges: Integrating Mental Health Care into the Non-Communicable Disease Agenda

et al. (2013) Grand Challenges: Integrating Mental Health Care into the Non-Communicable Disease Agenda. PLoS Med 10(5): e1001443. doi:10.1371/ journal.pmed.1001443 Grand Challenges: Integrating Mental Health Care into the Non-Communicable Disease Agenda Victoria K. Ngo 0 Adolfo Rubinstein 0 Vijay Ganju 0 Pamela Kanellis 0 Nasser Loza 0 Cristina Rabadan-Diehl 0 Abdallah S. Daar 0 0 1 RAND Corporation , Santa Monica , California, United States of America, 2 Institute for Clinical Effectiveness and Health Policy, University of Buenos Aires , Buenos Aires, Argentina, 3 Behavioral Health Knowledge Management, Austin, Texas , United States of America , 4 Grand Challenges Canada , Toronto, Ontario , Canada , 5 Behman Psychiatric Hospital, Cairo, Egypt, 6 National Heart, Lung, and Blood Institute , Bethesda , Maryland, United States of America, 7 Dalla Lana School of Public Health and Dept. of Surgery, University of Toronto , Toronto, Ontario , Canada , 8 Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University , Stellenbosch , South Africa This is one article in a five-part series providing a global perspective on integrating mental health. - As countries develop and progress, health priorities must expand beyond eradication of communicable diseases to include control of non-communicable chronic diseases (NCD). Four primary NCD cardiovascular disease (mainly heart disease and stroke), type 2 diabetes, some cancers, and chronic respiratory diseases henceforth referred to as physical NCD are responsible for 35 million deaths annually. They are the leading cause of mortality in the world, much of which is premature and avoidable. Nearly 80% of NCD deaths occur in lowand middle-income countries [1]. Over the last 20 years, the burden of disease, i.e., the impact of NCD worldwide as measured by morbidity and mortality, rose from 47% to 54% [2]. An aging population, longer life expectancies, population growth, urbanization, and globalization of risk factors have made NCD a threat to worldwide development and economic growth and an urgent global health priority. This article, the third in a series of five, argues that mental health care should be integrated into the NCD agenda, reviews the evidence for models of integration in high- and low-income countries, identifies the challenges and opportunities for addressing the rising burden of mental health and NCD, and recommends strategies to advance a more integrated agenda. The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies. Evidence for Integration The Strong Connection between Mental Illness and NCD The burden of mental illness has been underestimated, in part, because the links between mental health and other health conditions are not well understood. As the population grows and ages, more individuals live longer with physical NCD and mental illness [2]. These chronic conditions are related in complex ways. Major modifiable risk factors for NCD, such as poor diet, physical inactivity, tobacco use, and harmful alcohol use, are exacerbated by poor mental health. Mental illness is a risk factor for NCD; its presence increases the chance that an individual will also suffer from one or more chronic illnesses. In addition, individuals with mental health conditions are less likely to seek help for NCD and symptoms may affect adherence to treatment as well as prognosis [3,4]. Depression and disorders related to alcohol use predict the onset, progression, management, and level of disability associated with the NCD [57]. The prevalence of major depression is consistently higher for persons with physical illnesses than for those without these disorders; e.g., 29% with hypertension, 22% with myocardial infarction, 27% with diabetes, and 33% with cancer [8]. The odds of noncompliance with medical treatment regimens are three times greater for depressed patients compared with nondepressed patients [9]. Health-related quality of life is significantly lower for depressed patients than for patients with asthma, arthritis, and diabetes [6]. Alcohol use is causally linked to eight different cancers, and the risk of developing these cancers increases with increased rate of consumption. Similarly, alcohol use is related to many adverse cardiovascular outcomes, including hypertension, hemorrhagic stroke, and atrial fibrillation, and to various forms of liver disease and pancreatitis [7]. The life expectancy of patients with psychotic disorders is two decades shorter due to the cardiovascular disease that may co-occur with their mental health condition [10]. Other major comorbidities among psychotic patients include prediabetes and diabetes mellitus. When antipsychotic drugs are prescribed, the risk of weight gain, obesity, type 2 diabetes, and sudden cardiac death [11] increases. The bottom line is that the pathways leading to comorbidity of mental disorders and physical NCD are complex and bidirectional, and care for persons with these conditions needs to be coordinated. Summary Points N Non-communicable chronic diseases (NCD) and mental disorders each constitute a large portion of the worldwide health care burden, and they often occur together. N Collaborative care models, where NCD care and mental health care are integrated and provided in the primary care setting, are effective for patients, strengthen health care service systems, and reduce costs. N Using lay health workers to supplement the services provided by mental health specialists, physicians, and nurses can extend services to more patients, but raises challenges related to training and coordination. N Implementation of collaborative care models and scale up of successful models will be enhanced by tapping local knowledge of social, political, cultural, and health system nuances. N Collaborative care approaches that integrate services for NCD and mental health conditions require investments in human resources, services, and additional research. N This is the third in a series of five articles providing a global perspective on integrating mental health. The NCD Care Agenda and Mental Health Care Despite the emerging evidence that links mental illness and physical NCD, and the high costs of unaddressed mental illness on society, mental health care is too often left out of discussions on NCD and the global health care agenda. Without integration of mental health care into the NCD agenda, current NCD initiatives will be less effective and more costly. The comorbidities of mental disorders and NCD are associated with substantial individual and societal health care costs [12]. According to the Agency for Healthcare Research and Quality (AHRQ), the five most costly conditions in the United States between 1996 and 2006 were heart disease, trauma-related disorders, cancer, asthma, and mental disorders, with the largest increase in e (...truncated)