No Health Without Mental Health

 Week 2

 Context

Since the early 1920’s the incidence of increased physical health needs of people with mental health problems has been well documented. Mental health and physical health are intimately linked.

Taken from an article written by Professor Sally Hardy and Ben Thomas (who you will meet in week eight).

 Content

Physical and mental health comorbidity

A comprehensive review of key issues affecting the physical health of people with mental illness was completed by Seymour (2003), reporting that: evidence has been in existence of the prevalence of physical health needs of mental illness, as first reported in the British Medical Journal (Philips, 1934); research from many countries confirms that people with mental illness are almost twice as likely to have a physical illness than the general population (Koran et al. 1989; Makikyro et al. 1998; Lawrence et al. 2001); a person with a diagnosis of schizophrenia has a life expectancy of 10 years less than the general population (Barr 2001; Harris & Barraclough 1998; Phelan et al. 2001); and, the physical side-effects of psychotropic medication contribute to weight gain, which in turn influences a person’s ability and willingness to engage in physical exercise. This leads to higher risk of additional health problems, such as diabetes and heart disease (Brown et al. 2000; Goldman 1999; Kendrick et al. 1995).

Look also at the following websites for more information

 The physical health needs of people with mental health problems Links to an external site.

Physical Health and Mental Health Links to an external site.

Wellbeing & physical health Links to an external site.

Re-defining Health and Wellbeing

The World Health Organisation’s definition of health has come under scrutiny, for its total absence of illness. A wellbeing approach to health improvement advocates for a re-definition of health to one that incorporates recovery and individual self determinism, taking into consideration social (as well as physical and psychological health) context.

Redefining health is an ambitious and complex goal; many aspects need to be considered, many stakeholders consulted, and many cultures reflected, and it must also take into account future scientific and technological advances.

Discussion, has led to broad support for moving from the present static formulation of health as an absence of disease, towards a more dynamic one, based on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium, and sense of wellbeing. The preferred view on health is to consider health and wellbeing as “the ability to adapt and to self manage.”

However, debate continues in terms of attempts to separate and /or integrate notions of physical, mental and social health and wellbeing.

I have therefore identified the following basic assumption, in order to frame how indicators of success in the field of improved health and wellbeing might be seen when specifically aiming to improve the physical health disparities between people with mental health problems and the general population.

Basic assumption for improved wellbeing:

A holistic approach to health improvements is one that emphasises holistic health, wellness, strengths, and social support encourages people to move beyond simply managing symptoms to building a meaningful life in the community by using a highly individualized plan for recovery.

Consider how Carol Price shows specific need in all of the aspects highlighted in bold text from the statement on Wellbeing above.

A model for Mental Health Improvement Measures

Taken from the NIMHE (2005) report,' Improving the mental health and wellbeing in England', the following excerpt provides a framework for considering the different pathways through which the impact of programmes designed to improve mental health might be assessed. This is proposed as achieved via increases in four forms of ‘capital’:

●  economic capital (employment, investment, productivity)

●  human capital (knowledge, skills and awareness)

●  social capital (trust, reciprocity, networks and 
interdependency)

●  identity capital (positive self image, assertiveness and confidence)

Although this model was developed to explain improved health outcomes associated with adult learning (Feinstein et al 2003), the key elements (economic capital, human capital, social capital and identity capital) are recurring themes in the research literature on the importance of mental health and well being.

The value of this model for evaluating complex mental health promotion programmes is that it does not depend on specific data on health or health behaviour (e.g. prevalence of depression, smoking, substance abuse). Rather, it is based on a hypothesis for which there is a reasonably robust evidence base: that improved economic, social, identity and human capital are associated with improved health across a range of domains. Mapping the relationship between mental health interventions and health in this way draws on four areas of research:

• the emotional pathways through which material deprivation impacts on health
• social support as a protective factor for both mental and physical health
• health benefits of participation, involvement and reciprocity, drawn from research on social capital
• ;a return to more holistic definitions of health and the range of factors influencing quality of life 


Service providers are beginning to pilot mental health impact assessments (Cooke and Coggins 2005) and there is scope for including measures for the assessment of positive mental health in the ‘tools to assess local health and well-being’ proposed in Choosing Health, as well as in health impact assessments.

Across the NHS in England, millions of people come into contact with the NHS every day, and it is important to ensure staff are aware of maximising opportunity for healthy choices, in terms of  ‘every contact must count as an opportunity to maintain and, where possible, improve their mental and physical health and wellbeing Links to an external site.’.

 

What the research says about improving physical wellbeing

Improved physical health through exercise enhancement

Exercise interventions have a remarkable potential to improve cognitive function, functional and physiological status, and overall well-being:

• Exercise interventions have potential to reduce the risk for cardio-metabolic disease
• Mental health benefits are observed at a minimal level of at least 20 min/week of any physical activity,
• Modest enhancements in physical activity/fitness in previously inactive individuals can be associated with large improvements in health status
• Modest enhancement in physical activity/fitness demonstrates potential benefits of exercise training for mitigating the weight gain associated with psychotropic medications.
• Systolic blood pressure was reduced after the modest exercise increase intervention
• There is a clear trend for an improvement in body mass and abdominal obesity in those that complete moderate increased exercise intervention.
• There is an immediate effect obtained from the start of ‘green’ exercise. Exposure duration: both self- esteem and mood showed greatest changes for the least duration (5 min), both showed smaller positive improvements for short and half-day activities, and both increased for whole- day activities.

Exercise intensity: self-esteem improvements declined with growing intensity of activity, and mood improvements were greatest for light and vigorous activity. This suggests that there is a health benefit from any short engagement in green exercise.

Type of green space: all green environments improved both self-esteem and mood; the presence of water generated greater improvements. Although participants should be encouraged to undertake outdoor activities in both rural and urban environments, spending time near waterside (e.g., beach or river) or participating in water-based activities may give a greater benefit.

Gender: Both men and women reported similar improvements in self-esteem after green exercise, though men showed a difference for mood.

Age groups: for self- esteem, the greatest change was in the youngest category, Whole-day activities are likely to be qualitatively different activities, involving in some cases camping overnight and in others significant conservation achievements.

Increased sense of wellbeing achieved through social engagement and interpersonal support

Enhanced social support is often a vital component of recovery from a variety of mental health problems. The current work highlights the two-fold benefit of increased social support (directly and as a buffer from trauma).

• Creative, artistic expression provides clear indications that artistic engagement has significantly positive effects on health.
• Significant degree of improvement in ‘patient activation’, as a measure of an individual’s self-management capacity. (Hibbard et al. 2004; Hibbard et al. 2007; Mosen et al. 2007) There has been increasing attention in the medical literature about the importance of patient activation both in guiding clinical care and predicting outcomes. In longitudinal studies,
• Positive changes in patient activation have been found to be associated with improved self-management behaviors (Hibbard et al. 2007), medication adherence, and outcomes including quality of life (Mosen et al. 2007)
• Implications on returning to work was not captured through the health literature, but is a feature of changing policy and welfare agenda for people with mental health problems and capacity.
• Poverty and mental illness are well correlated, additional indicators might be achieved in this area. Related studies were not identified when searching health literature for this briefing paper. 

Integrated service provision to achieve sustainable public mental health promotion promoting wellbeing

Integrated health based care delivery approach improves outcomes and lowers costs

• interventions that are evidence ­based, (in the sense of having been shown to be effective in improving mental health) reveal from an economic analyses that, over and above gains in health and quality of life to the individual, the interventions also generate very significant economic benefits including savings in public expenditure.
• With appropriate resources, expertise and support, it appears possible to apply smoking cessation interventions that are successful within the general population to mental health patients

References and Further Reading

Barton, J., & Pretty, J. (2010). What is the best dose of nature and green exercise for improving mental health? A multi-study analysis. Environmental Science & Technology, 44(10), 3947-3955.

Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The effects of mindfulness-based stress reduction therapy on mental health of adults with a chronic medical disease: a meta-analysis. Journal of Psychosomatic Research, 68(6), 539-544.

Bredin, S. S., Warburton, D. E., & Lang, D. J. (2013). The Health Benefits and Challenges of Exercise Training in Persons Living with Schizophrenia: A Pilot Study. Brain Sciences, 3(2), 821-848.

Cook, J., Copeland, M. E., Hamilton, M., Jonikas, J., Razzano, L., Floyd, C., ... & Grey, D. (2009). Initial outcomes of a mental illness self-management program based on wellness recovery action planning. Psychiatric Services, 60(2), 246-249.

Druss, B. G., Zhao, L., von Esenwein, S. A., Bona, J. R., Fricks, L., Jenkins-Tucker, S., ... & Lorig, K. (2010). The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophrenia Research, 118(1), 264-270.

 Hardy S & Thomas B (2012) Physical and mental health co-morbidity: policy and practice implications.Submitted to Journal of Mental Health Nursing 21 (3) 289-298

Hamer, M., Stamatakis, E., & Steptoe, A. (2009). Dose-response relationship between physical activity and mental health: the Scottish Health Survey. British Journal of Sports Medicine, 43(14), 1111-1114.

Hays, R. D., Bjorner, J. B., Revicki, D. A., Spritzer, K. L., & Cella, D. (2009). Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Quality of Life Research, 18(7), 873-880.

Hert, M., Cohen, D., Bobes, J., Cetkovich‐Bakmas, M., Leucht, S., Ndetei, D. M., & Correll, C. U. (2011). Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry, 10(2), 138-151.

Huber, M., Knottnerus, J. A., Green, L., Horst, H. V. D., Jadad, A. R., Kromhout, D., ... & Smid, H. (2011). How should we define health?. British Medical Journal, 343.

Kathol, R. G., Kunkel, E. J., Weiner, J. S., Mccarron, R. M., Worley, L. L., Yates, W. R., ... & Huyse, F. J. (2009).Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface. Psychosomatics, 50(2), 93-107.

Knapp, M., McDaid, D., & Parsonage, M. (2011). Mental health promotion and mental illness prevention: The economic case.

Moak, Z. B., & Agrawal, A. (2010). The association between perceived interpersonal social support and physical and mental health: results from the National Epidemiological Survey on Alcohol and Related Conditions. Journal of Public Health, 32(2), 191-201.

Shuel, F., White, J., Jones, M., & Gray, R. (2010). Using the serious mental illness health improvement profile [HIP] to identify physical problems in a cohort of community patients: A pragmatic case series evaluation. International Journal of Nursing Studies, 47(2), 136-145.

Stuckey, H. L., & Nobel, J. (2010). The connection between art, healing, and public health: A review of current literature. American Journal of Public Health, 100(2), 254-263.

Wahlbeck, K., Westman, J., Nordentoft, M., Gissler, M., & Laursen, T. M. (2011). Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. The British Journal of Psychiatry, 199(6), 453-458.