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Co-morbidity & mental health |
Physical health and mental health co-morbidity
The link between mental health and physical illness is gaining increased attention from researches and clinicians. The National Heart Foundation produced a position statement about the links between mental health (particularly depression) and coronary heart disease. This was published in the March 2003 edition of the Medical Journal of Australia and is available on: http://www.mja.com.au/public/issues/178_06_170303/bun10421_fm.html
The outcomes arising from this paper include:
- Depression, social isolation and lack of social support are significant risk factors for CHD that are independent of conventional risk factors such as smoking, hypercholesterolaemia and hypertension and are of similar magnitude to these conventional risk factors.
- Acute life-event ‘stressors’ can trigger coronary events.
- Psychosocial risk factors may cluster together in a similar way to conventional risk factors. Psychosocial and conventional risk factors often coexist (eg. patients with depression are more likely to smoke and be physically inactive).
- Depression is common and is clearly a risk factor for CHD. It can be identified and treated.
- Depression and CHD frequently coexist. Patients presenting with one should be assessed for the other.
- Social disadvantage is strongly associated with both adverse psychosocial and conventional risk factor status. At-risk groups include Aboriginal and Torres Strait Islander people, people with depression and anxiety disorder, and migrants.
- Attention to these psychosocial factors may also improve outcomes in CHD patients.
- The term ‘stress’ has proved to be so imprecise as to be unhelpful. It should be replaced in the clinical, public health and medicolegal environments by more specific terms.
Substance abuse and mental health co-morbidity
The National Comorbidity Project recently produced ‘A brief guide for the primary care clinician’. The principles of management of people with comorbidity of mental health problems and substance abuse are summarised below. The full guide is available at the Health Publications website: http://www.health.gov.au/pubhlth/publicat/document/comorbid_brief.pdf
Mental disorders and substance use occur together frequently and interact negatively on one another. Their management requires a long-term perspective. Actual GP interventions may be brief or extended over a period of time. A doctor-patient relationship based on honesty, trust and respect will form the basis for effective therapy. Active listening skills and a patient centered clinical method should be used to establish rapport, to develop a common understanding of the problems and an agreed management plan.
Detection
GPs should routinely enquire about substance use.
When a patient presents with either a substance use related problem or a mental disorder then the GP should enquire about the other.
Comorbidity should be suspected when progress or response to therapy is not straightforward.
Assessment
A full assessment often takes several consultations and should include determination of the:
- patterns of drug use,
- day to day problems associated with the substance use,
- reasons for the use,
- effect that the use might be having on the mental health problem,
- nature of the mental disorder itself, diagnosis, previous treatments and responses.
General management
Management should be based on the patient’s readiness for change. This readiness for change might be different for the management of the substance use than it is for the mental disorder.
Management should aim to increase the patient’s awareness of the negative effect that the substance use and the mental disorder are having on each other.
Management should involve family or carers where appropriate.
Specific management
Detoxification should be offered as a first step to enable engagement in long-term approaches and decision making. Specific management steps should include where appropriate:
- Information provision.
- Structured problem solving.
- Motivational interviewing.
- Brief behavioural or cognitive approaches.
Pharmacological approaches
Clinicians should avoid using drugs of dependence unless as part of a harm reduction plan (eg. methadone or buprenorphine).
Benzodiazepines should not be used for more than a few days. Generally longer acting benzodiazepines are preferable.
Clinicians should consider whether the current medication for the mental disorder is adequate or causing side effects as the patient may be self medicating with non-prescribed drugs to relieve symptoms or side effects.
The clinician should consider potential interactions between all substances used.
If there is drug-seeking behaviour, then engagement of the patient in a planned and limited prescribing program is required (eg. HIC consent for all prescribing information to go to the one prescriber).
Referral
Consider referral when:
- Self-harm risk or risk to others is present.
- Acute exacerbation of mental disorder occurs.
- Drug dependence with major associated problems is present.
- Complicated detox is anticipated.
It is important for GPs to develop links with local specialist mental health or drug and alcohol services (where they exist).
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