Don’t separate the inseparable: the clinical case for mind and body
Dr Sean Cross is Clinical Director of the King’s Health Partners Mind and Body programme. Sean is a consultant liaison psychiatrist at King’s College Hospital and lead for liaison psychiatry services for South London and Maudsley. He is also Director of Maudsley Simulation, the UK’s first centre for mental health simulation. Kate Lillywhite is programme lead for the Mind and Body programme, working closely with Sean. Kate has worked on the delivery of a wide range of priority health and care policy issues in her previous role at the Department of Health. In this piece, they set out the clinical argument for why mind and body matters.
‘Integration’ has become a buzzword for clinical staff and services. So much so, we often forget what it really means. Most patients don’t ask for integrated services but they do ask for co-ordinated or joined-up care. We think for many, it is the reason why most of us came into clinical practice in the first place: our patients, and providing the care they need, when they need, and where they need it.
People aren’t separated into minds and bodies, and their health does not conform to medical specialties nor disease-specific diagnoses. We all recognise now more than ever before, that people have multiple, interacting health issues that create a complex picture that healthcare services need to respond to but which pose a significant challenge to the system as we know it.
Every day in clinical work, we see the result of a healthcare system that operates in silos. Take, for example, the case of a recent patient: a 66-year-old woman who was depressed in the context of a longstanding bipolar affective disorder, was also diagnosed with dangerously high calcium levels, and scheduled for a parathyroidectomy. The clinical dilemma was whether or not her lithium medication, which had been broadly successful at helping her stay stable for 30 years, was the cause of high calcium or not. We know that high levels of calcium can cause depression, but did the physical health problem create the mental health issue?
This is an age old dilemma. We can no longer afford to treat people’s mind and bodies in isolation from one another. We know that those with severe mental illness die somewhere between 15 and 20 years prematurely from a range of conditions, which often includes unassessed and untreated cardiac and lung diseases, diabetes, cancer and other treatable conditions. And we know that 30% of those with a long-term physical condition, such as diabetes or hypertension, also have a mental health condition such as depression or anxiety, which makes their long-term condition management so much more difficult. The relationship between mind and body is at once simple and complex. It is only clinically logical that a person’s health and wellbeing should involve at least these two dimensions of health, as well as others including social and cultural functioning, but our understanding of the bi-directional nature of physical and mental illness is still evolving.
A complex interplay can often create a perfect storm for recovery. People with mental health problems are less likely to report physical symptoms, and less likely to attend medical appointments compared with other patients. Non-adherence to medication regimes is another key issue – the figures vary but care pathways often find that 40-50% of their patients are non-adherent. Evidence points to depression being a key factor in making patients with a range of medical conditions three times less likely to follow the medication guidance of their doctors. But it is completely unclear as to whether most doctors or nurses realise this, ask about it or have the confidence to deal with it if they do. This results in both under-recognition of need, prolonged recovery times or even potentially harmful over-treatment.
Whilst there have been amazing pieces of work undertaken in patches across our organisations, our vision is to kick start a system-wide transformation to bring the mind and body back together. We have a great opportunity afforded through King’s Health Partners and our local health economy. We have partners from physical health, mental health, and from the university all of who provide a unique dynamic in which to roll out our Mind and Body programme. Our primary care, public health, and CCG colleagues, too, are already working towards a different mode of healthcare delivery for mental and physical health, and our work is in collaboration with them to form part of a whole system approach to mind and body.
Over the next few months, we will be developing an overarching programme with all our partners across Lambeth and Southwark with the ultimate aim of making integrated mind and body care a reality. This will not be purely about service delivery, but also the wider infrastructure required to create sustainable change – including supporting our staff to refresh and learn new skills, providing the tools for clinicians to better identify, support and monitor the complex needs of patients, and working with academia, public health and commissioners on population health intelligence.
Crucially, for us to be successful, we need every member of staff to help us, and every patient to feel in control of their own care, either independently or guided by staff. It is a hugely ambitious vision, but one that we can be proud to develop.