The Cascading Effect Of Comorbidities: Addressing Chronic Medical Disease Alongside Mental Health

Integrated, holistic care and technology hold hope to address the bi-directional effect of physical and mental illnesses 

After many years of research, the relationship between chronic medical and mental diseases is a well-accepted conclusion. Today, more people are living longer with more chronic conditions, having surpassed acute conditions as the leading causes of morbidity, mortality, and healthcare costs. Healthcare is looking to adopt a more holistic, integrated, data-driven, and technology-assisted approach as ways to address physical and mental comorbidities effectively and earlier in the patient’s medical journey.

Depression and chronic disease

Common chronic illnesses, including high blood pressure, coronary heart disease, heart failure, kidney disease, and diabetes affect over 48 million Americans. In addition to experiencing physical disease, most affected persons will also find themselves at risk for depression. Those with diabetes, for instance, are two to three times more likely to develop depression during the course of managing their condition.

The incidence of depression in conjunction with chronic disease varies depending on the condition: 

• 50% of patients with Parkinson’s
• 42% of patients diagnosed with cancer
• 39% of patients with neurological disorders
• 23% of people who’ve had a cerebrovascular event, like stroke
• 17% of people who have cardiovascular disease
• 11% of people living with Alzheimer’s

Which came first, the chronic disease or the mental health issue?

Chronic medical conditions contribute to mental illness, but the converse is also true. Epidemiologic studies have shown that 50.6% of people with mental disorders also had a chronic medical condition. This not only complicates diagnoses, but it highlights the importance and value of taking a holistic approach to care. When two conditions can be closely linked, or one creates causative conditions for the other, it’s vital to address both possibilities up front. 

A vicious cycle can exacerbate both physical and mental illnesses

The bi-directional nature of chronic illness and mental diseases is even more insidious. For example, a person living with heart disease is at greater risk of depression, which saps one’s motivation and energy for self-care, and can lead to a lack of exercise and weight gain. The cardiovascular disease worsens because of greater strain on the heart that can exacerbate depression. The causative cycle tightens. 

The same can be said of other chronic diseases like diabetes. Research by the American Diabetes Association revealed that people living with diabetes and depression show poorer glycemic control, decreased physical activity, higher obesity, and greater risk for more end-organ complications and impaired function.

Conversely, when a person has a mental health disorder -- bipolar/mania, major depression, substance use, schizophrenia – they often have disturbed sleep, forgetfulness, negative affect, or despair, which can lead to unhealthy behaviors like using alcohol, drugs, or overeating to cope. 

For example, people living with schizophrenia tend to develop chronic medical conditions like obesity and diabetes, many times due to the symptoms of mental illness that make healthy behaviors harder to attain or maintain. 
Again, these comorbidities confirm the need for tighter integration of mental health, primary care, and specialty care services. 

COVID-19 as a possible chronic illness and its impact on mental health

COVID-19 has had a devastating effect, globally; however, it’s impact on mental health and its long-term status as a chronic condition for many adds complexity to the existing challenge: 

Comorbidity risk: While age is the strongest risk factor for severe COVID-19 symptoms, chronic conditions like asthma, kidney disease, and cancer put people at greater risk of acute outcomes, which also adds greater stress and anxiety for those living with chronic conditions. One study found that 71.6% of people with chronic diseases experienced mild to extremely severe levels of depressive symptoms compared to 31.1% of those without chronic illnesses.

New mental illness from COVID-19: Since the pandemic began, 41% of Americans said that they experienced symptoms of anxiety or depression. This is a 30% increase since pre-pandemic 2019. With more people experiencing mental illnesses for the first time, an already-burdened and under-resourced mental health system cannot address adequately. New mental illness diagnoses could equate to new or exacerbated chronic physical conditions in the future.

Exacerbated mental illness: Due to COVID-19 fears or lockdowns, people with chronic or mental health illnesses reported missing daily exercise, routine check-ups, lab tests, or procedures, which could further worsen either condition or make a patient more susceptible to a new diagnosis.

Long COVID: For 7.5% of adults who’ve had COVID-19 now live with long COVID symptoms; Long COVID-19 has the potential of becoming a chronic illness of its own, which will require specialized treatment pathways. Long-term effects of COVID-19 can be multi-system, including pulmonary, cardiovascular, hematologic, renal, neurological, gastrointestinal, and psychosocial.

Any chronic illness management or mental health screenings should include questions around COVID-19 diagnoses and any ongoing symptoms that add complexity to a patient’s clinical picture.

Challenges in addressing the crises of mental health and chronic illness

Despite the clear connection between chronic illness and mental health conditions, the healthcare system is generally structured to diagnose and treat the concerns as separate and discrete manifestations. 

The greatest challenge to treating both mental health issues and chronic illness more proactively and holistically is an overwhelmed behavioral health profession. Thirty-seven percent of Americans live in a state facing a shortage of mental health professionals. Nearly 6,400 more providers are needed to fill the current gaps. Beyond resolving this fundamental barrier to care, healthcare providers and health plans can provide better care, potentially avoid future comorbidities, and save near-term and long-term costs.

Integrated medical-mental healthcare

Evolving from an acute medical model into a more integrated chronic care model has improved physical and mental health outcomes in randomized controlled trials. As populations age and accumulate more chronic medical conditions, there will be a greater need for mental health services and vice versa.

One Veterans Affairs (VA) program found that when integrated mental health specialists saw patients living with diabetes or cardiovascular disease, their clinical picture improved over those patients who did not have access to mental health services. 

Integrated programs are gaining momentum but moving slowly. Two issues to overcome include how to pay for integrated programs and having the right technologies to facilitate integrated care for complex populations, which may require data analytics for risk stratification, formalizing care coordination processes, connecting providers from various clinics, and platforms for team-based and interdisciplinary care.

Digital health can support integrated care

A 2021 review of digital health interventions for managing mental health in patients with chronic diseases found that “For individuals with a chronic disease or cancer, health provider directed digital interventions (e.g., teleconsultation) are effective and safe.”  

They discovered that web-based interventions and email garnered the most reports of improvement. Virtual reality, smartphone applications, and patient portals had limited reports of progress. And even though there is a large number of evaluated digital technologies for managing depression or anxiety, there needs to be more research on these interventions for people living with chronic diseases.

Another 2021 study published in the Journal of Medical Internet Research (JMIR) found that implementing a patient-centered mHealth-enabled integrated care model focused on empowering patients and connecting primary, hospital, and social care professionals had reduced unplanned contacts with the health system and health costs. It was found to be cost-effective as well. 

Predictive data analysis and population health focuses attention and resources on timely interventions

Knowing when and with whom to assess for possible mental-physical comorbidities requires data analysis. Plus, integrating predictive analysis, artificial intelligence, or machine learning alongside population health risk stratification has demonstrated the power of data and timely interventions.

Harrison County, Mississippi, for example, has a large Air Force base with 7,000 active duty personnel experiencing 50% higher active duty suicide rates than the rest of the state. Using machine learning algorithms and risk-prediction models helps uncover these patterns that enable care teams to create targeted proactive initiatives to improve health. 

Predicting correlations, assessing for risk, tapping technology, and integrating care for patients living with comorbidities holds promise to improve quality of life and break the cycle of mental-physical exacerbations of chronic illness and the associated increased cost.

Partner with RTI Health Advance

RTI Health Advance provides the scientific, technical, and operational support and guidance to integrate medical-mental care within a program, value-based care contract, or enterprise-wide. Learn more about our population health, digital health, and healthcare data analytics services. Learn more about RTI Health Advance and connect with us.