Medicine Can Improve Physical Diseases Care
Addressing psychosocial and mental issues improves physical disease care.
Posted Jan 31, 2020
In an earlier post, I expressed my concern about poor mental health care in the U.S., and that it stems from the medical physicians who provide 85% of it. It’s not their fault, though. Our medical system failed to train them because of its isolated interest in physical diseases.
So, why does this post say physical disease care can be improved, aren’t medicine’s eggs all in this basket? To understand this conundrum, let’s go back to its origin. Acute diseases from the early and middle parts of the last century (mostly infectious diseases like tuberculosis, pneumonia, and diarrhea) were cured or controlled by advances in medicine, especially antibiotics. People now lived longer. But a new population emerged that needed care—patients with chronic diseases. Heart disease and cancer abound and account for nearly half of them, but stroke, diabetes, Alzheimer’s disease, and lung disease are also prominent.1 Extraordinarily common, six of ten adults in the U.S. today have at least one chronic disease, while four of ten have two or more.2
Here’s the problem. Medicine continued its old acute disease approach, centered on the physical, omitting the psychosocial. In contrast to acute diseases, however, the ignored psychosocial features often cause the chronic disease and always are central in treating it. Let’s explore how mental and other psychosocial factors come to play in crucial ways in all chronic diseases.
Co-occurring Mental and Chronic Medical Disorders
There is a co-occurring mental disorder in 17% of all chronic diseases, some 50 million Americans.3 Painfully ironic, modern medicine eschews mental disorders to focus on physical diseases, yet this practice impairs disease care when a mental disorder co-occurs. Disability, work absenteeism, quality of life, and health outcomes are far worse when a mental disorder occurs alongside a physical disorder compared to either disorder occurring alone.4 Research also demonstrates that if we treat the co-occurring mental disorder, the medical disease improves well beyond treating just the chronic disease.5
Sadly, as in a previous post, evidence-based treatments for mental disorders are seldom used because patients’ (untrained) primary care providers are unfamiliar with them.3 For example, only 12.7% of primary care patients received even minimally adequate treatment for depression co-occurring with medical diseases.6 With so many patients affected, research shows that $26-48 billion could be saved yearly by integrating mental health care with chronic physical disease care.7
Chronic Diseases Without A Mental Disorder But With Other Psychosocial Factors
Psychosocial and emotional factors are important in all chronic diseases even in the absence of a co-occurring mental disorder. Consider the psychological impact on your own health if you have negative or positive feelings about your clinician or are afraid to take a medication or to have a test; or the social impact of having no nearby health care facility or having no access to child care. Everyone has personal and emotional factors relevant to chronic disease care even if they are fortunate enough not to have a mental disorder. We are, after all, psychological and social beings. How does this play out in chronic diseases?
Most chronic diseases are “lifestyle” diseases, stemming from psychosocial factors that lead to overeating, not exercising, smoking cigarettes, and using alcohol or street drugs. These adverse health habits can lead to hypertension, heart attacks, strokes, cancer, obesity, diabetes, drug misuse, and emphysema. To be effective, treatment must address the personal and social issues responsible for the lifestyle shortcomings. Not so easy as simply prescribing an antibiotic and curing the acute disease patient, physicians must advise people to do something they usually do not want to do.
It’s no surprise to learn that treatment of chronic disease is complex and long-term. While even taking an antibiotic for a week is fraught with many missed doses, the person with a chronic disease often must take their medication indefinitely—and they may be on as many as 6-10 medications or more. And it’s not just a medication schedule they must adhere to, many have additional health care tasks such as sticking their finger to get blood samples, taking their blood pressure, going to physical therapy, and doing home exercises. To many with chronic diseases, caring for themselves is nearly a full time job.
This introduces a big problem, 30-50% of patients are non-adherent to medications for chronic disease problems.8 More concerning, this is almost completely unrecognized by their (untrained) physician and, thereby, not addressed or corrected. What psychosocial issues lead patients not take their medications: cost, lack of understanding, too complicated, inattention, and belief it doesn’t work and/or causes harm.8 Although often blamed, non-adherence to treatment is not the patient’s fault. Rather, physicians must engage them at the personal and social levels to understand their motivations, emotions, unique social circumstances, and beliefs about taking medications. Although ways to effect lifestyle change and adherence exist,9 present-day physicians are not trained to do this.
Let’s take another step in understanding the sad tale of medicine’s omission of patients’ psychosocial issues. Most chronic diseases are entirely preventable. Estimates are that 80% of all cardiovascular diseases (heart disease and strokes) and all diabetes could be prevented; 40% of all cancers.10 Prevention means physicians need to be trained to address lifestyle issues such as cigarette smoking, excessive alcohol use, inactivity, and poor diet habits.1,2,10 Unfortunately, in following its worn out approach centered on acute physical diseases, medicine waits until the (preventable) chronic disease occurs and then treats it—generating billions of dollars of income yearly.
In a healthcare system spending well over $3 trillion per year, chronic diseases accounted for 75% of all spending in 2005—99% of all Medicare spending.10 We are at ground zero regarding costs for U.S. health care. With from 40% to 80% of chronic diseases preventable, savings could be in the trillions of dollars.
Medicine has yet to realize the vastly improved physical disease care and savings that can accrue by training physicians in psychosocial and mental illnesses.
1. Distribution of the 10 Leading Causes of Death in the United States in 2017. Centers for Disease Control and Prevention, 2019. (Accessed May 31, 2019, at https://www.statista.com/statistics/248619/leading-causes-of-death-in-the-us/.)
2. About Chronic Diseases. Centers for Disease Control and Prevention, 2019. (Accessed May 31, 2019, at https://www.cdc.gov/chronicdisease/about/index.htm.)
3. Druss B, Reisinger-Walker E. Mental Disorders and Medical Comorbidity: National Library of Medicine; 2011.
4. Patel V, Chatterji S. Integrating Mental Health In Care For Noncommunicable Diseases: An Imperative For Person-Centered Care. Health Aff (Millwood) 2015;34:1498-505.
5. van Eck van der Sluijs JF, Castelijns H, Eijsbroek V, Rijnders CAT, van Marwijk HWJ, van der Feltz-Cornelis CM. Illness burden and physical outcomes associated with collaborative care in patients with comorbid depressive disorder in chronic medical conditions: A systematic review and meta-analysis. Gen Hosp Psychiatry 2018;50:1-14.
6. Melek S, Norris D. Chronic Conditions and Comorbid Psychological Disorders. Seattle, WA: Millman 2008 July 2008.
7. Melek S, Norris D, Paulus J. Economic Impact of Integrated Medical-Behavioral Healthcare -- Implications for Psychiatry. Denver, CO: Milliman, Inc.; 2014.
8. Marcum ZA, Sevick MA, Handler SM. Medication nonadherence: a diagnosable and treatable medical condition. JAMA 2013;309:2105-6.
9. Smith R, D'Mello D, Osborn G, Freilich L, Dwamena F, Laird-Fick H. Essentials of Pschiatry in Primary Care: Behavioral Health in the Medical Setting. New York: McGraw Hill, Inc; 2019
10. The Growing Crisis of Chronic Disease in the United States. 2019. (Accessed May 31, 2019, at https://www.fightchronicdisease.org/sites/default/files/docs/GrowingCrisisofChronicDiseaseintheUSfactsheet_81009.pdf.)