Lecture 8 - Physical and mental health

Question 1

Wy is it important not to conceptualise mental and physical health separately?

Answer 1

• Psychological reactions to acute and chronic pain - this impacts the physical experience
  
  • Health and clinical psychologist roles cross over a lot
  • Both disciplines address the role of psychological factors in the development and experience of health
  • Interaction of e.g. depression and obesity

Question 2

What is a relative risk?

Answer 2

• A ratio of the probability of an event occurring in the exposed group versus the probability of the event occurring in the non-exposed group
  In this case: Risk = mortality, exposure = mental health condition

Question 3

How much more likely is someone liekly to die when they have a MH condition vs not?

Answer 3

Around twice as likely

Question 4

What kind of MH condition has highest risk of mortality? What about lowest?

Answer 4

Psychosis
Anxiety

Question 5

What is an issue with RR?

Answer 5

• RRs do not give number of people that may be affected - do not take age into account - older people dying would be more expected than young people
  
  • Alternative way of expressing the association: years of life lost

Question 6

On average, how many years of life are lost to MDD?

Answer 6

7 to 11

Question 7

On average, how many years of life are lost to schizoaffective disorder?

Answer 7

8 to 18

Question 8

On average, how many years of life are lost to schizophrenia?

Answer 8

10 to 20

Question 9

On average, how many years of life are lost to bipolar disorder?

Answer 9

9 to 20

Question 10

On average, how many years of life are lost to personality disorder?

Answer 10

13 to 22

Question 11

What is the RR of unnatural causes of death for people with MH conditions?

Answer 11

7.22

- Unnatural deaths include suicide, violent deaths, accidental deaths
- Increased RR for both natural and unnatural, however RR for unnatural is much higher
- Risk of death from unnatural cause is higher for people with a mental health condition, however most people with MH condition will die of natural causes

Question 12

Are majority of mental health associated deaths due to suicide?

Answer 12

No - “Although suicide contributes to a considerable proportion of these premature deaths (with approximately 17% of mortality in people with mental [health problems] attributed to unnatural causes),
the majority of years of life lost in people with mental illness relate to poor physical health, specifically due to comorbid non-communicable and infectious diseases” (Firth et al, 2019)
i.e., people with mental health conditions experience health inequalities - differences in health status, this is unfair - unfair worse physical health in people with MH conditions

Question 13

What are health inequalities?

Answer 13

Avoidable, unfair and systematic differences in health between different groups of people

This includes differences in:
- Life expectancy
- Healthy life expectancy
- Avoidable mortality
- Prevalence of poor mental health
- Access to & experience of healthcare
- Long-term conditions
- Wider determinants of health like smoking and poor quality housing

Question 14

What are three possible mechanisms linking poor mental health to poor physical health?

Answer 14

1) Aspects of mental health problems that make physical health problems more likely

2) Aspects of physical health problems that make mental health problems more likely

3) Shared risk factors that make physical and mental health problems more likely
- Independently impact both e.g. genetics

Question 15

Do people with MH conditions on average experience
- Suboptimal diet
- More substance use
- More tobacco use
- Less physical activity
- Poorer sleep
- More sedentary time?

Answer 15

Yes

Question 16

What mental health-related reasons are there for poor health behaviours? (other than health inequalities)

Answer 16

• Low motivation / energy
  
  • Difficulties with social interaction & engagement
  • Avoidance of previously enjoyed activities
  • Altered appetite
  • Altered daily rhythms
  • Increased stress & distress
  • Occupational dysfunction / job loss
  • Maladaptive coping strategies

Question 17

Physical consequences of poor MH related health behaviours include increased risk of cardiometabolic syndrome. What different health conditions does this encompass?

Answer 17

• HBP
  
  • Stroke
  • CV disease
  • Insulin resistance - T2 diabetes
  • Weight gain
  • High cholesterol

Question 18

How much more frequent is cardiometabolic disease in people with MH problems?

Answer 18

1.4 to 2 times

Anorexia - exception to this - however other health problems can occur like osteoporosis

Question 19

What is the cycle of poor health? (physical health and behaviour) How do chronic inflammation and stress come into this?

Answer 19

Behavioural patterns can keep elevated physical risks going – but elevated physical risks also keep behavioural patterns going

Both are driven by, and result in, stress and inflammation
- e.g. on being first diagnosed with CV condition, people stray away from exercise to not work their heart too hard
- Pathways between these and external factors like socio-economic disadvantage

Question 20

When does stress occur?

Answer 20

When we experience or perceive challenges to physical/mental wellbeing

Question 21

What does long term stress (particularly starting in early life) predispose the development and maintenance of?

Answer 21

a. Chronic physical health problems
b. Most mental health problems

Stress response is disregulated across many MH conditions - and this also keeps MH condition going
Stress related to immune response - acute inflammation can be brought upon by stress

Question 22

Why can chronic systemic inflammation worsen symptoms of depression?

Answer 22

Adaptive response - forcing people to heal by having anhedonia and fatigue etc

Question 23

What impact does inflammation have on anti-depressant drugs?

Answer 23

It can make them less effective

Question 24

What evidence support that inflammation may cause depression?

Answer 24

Specific proteins involved in inflammation predicted depression regardless of many other factors to health and MH - is this the cause or an indicator of another cause?

Question 25

Why is linking MH to physical health important?

Answer 25

To reduce stigma

Question 26

What is weight gain caused by some antidepressants associated with?

Answer 26

Weight gain due to medications is associated with poorer quality of life and social disengagement People are less likely to stick to treatment and more likely to relapse if side effects are unacceptable

Question 27

What are consequences of extra-pyrimidal side effects of antipsychotics? (tremor, sexual dysfunction)

Answer 27

Socially stigmatizing & associated with low quality of life, treatment dissatisfaction & poorer adherence

Question 28

Why do people with MH conditions have problems with access to healthcare?

Answer 28

People with mental health problems may find it harder to: - communicate or describe physical symptoms, have to explain this to multiple people - distinguish between symptoms of physical and mental health conditions - access services due to practical or financial constraints e.g. getting to appointments if people cannot work or cannot drive - engage with services (e.g. attending follow-up appointments) if provision is non-inclusive e.g. if sleep is disrupted and people are given early morning appointment - maintain engagement with services if care is fragmented or under-resourced - people do not know who to go to so things sometimes left unsaid - stick to treatments which require high levels of motivation and/or organization, especially if energy is used up from managing symptoms People sometimes told to ignore anxiety symptoms - e.g. panic disorder woman was told to ignore her heart racing during (what she did not know were) panic attacks

Question 29

What are people with MH conditions problems with experience of healthcare (primary care)?

Answer 29

People with a mental health problem are: Less likely to: - Have a physical examination e.g. BP - Have cholesterol checked or treated - Have access to oral healthcare More likely to: - Have avoidable hospital admissions - case could have been dealt with in a primary healthcare setting previously but that was missed and person has gotten worse - Attend the emergency department for physical health reasons

Question 30

What are people with MH conditions problems with experience of healthcare (secondary care - referred from primary care)?

Answer 30

Less likely to: - Receive or be offered cancer screening - Receive surgery for operable cancer - Receive surgery or medication for heart problems More likely to: - Die of cancer although diagnosis rates are similar - Wait longer for cancer treatment

Question 31

Why might people with MH conditions not receive appropriate healthcare from practitioners?

Answer 31

Perception that person with MH condition needs to change their behaviour, or that they do not have capacity to consent, before procedure Reluctance to do certain procedures to avoid causing further stress or emotional distress - delayed or not offered

Question 32

What are limitations of the evidence based about people with MH conditions and access to healthcare?

Answer 32

- Tendency to recruit populations with very severe mental health difficulties: not fully representative of population - Lack of patient-reported outcomes: objective outcomes matter, but so do people’s experiences of services - Only a small number of studies address how to improve the situation, and most of these do not involve the views of service users

Question 33

What is an example of diagnostic overshadowing? (panic disorder and heart issues)

Answer 33

Ed is a teacher in his late 50s. He has lived with panic disorder for years, and he has learned what it feels like when he experiences a panic attack. He attends the hospital one day because of difficulty breathing. It takes him 10 hours to receive the correct diagnosis (pneumonia) and treatment, because the triage nurse and doctors initially attribute his sensations to a panic attack. Only when Ed asks to see another doctor is the pneumonia discovered. Ed returns home pleased that he knows what’s wrong, but annoyed that it took such a long time to be taken seriously. At one point, he had begun to doubt himself and wonder whether his sensations were indeed part of his panic disorder. Ed feels greater reluctance to seek medical help in the future and also realises that his level of trust in HCPs has reduced.

Question 34

When does diagnostic overshadowing occur? What might this cause?

Answer 34

Diagnostic overshadowing - occurs when HCPs attribute physical symptom(s) to the person’s underlying mental health problem - May cause missed diagnosis, inappropriate treatment (or lack thereof), and/or failure to refer for further investigation - It also potentially reduces the patient’s individual trust in the medical system and may reduce individual motivation and engagement with all aspects of care

Question 35

Why might diagnostic overshadowing occur in A&E? (situational factors in overcrowded departments)

Answer 35

- Busy / crowded environments - difficult place for MH person to be, so doctors want to get them out of this area of healthcare and instead get them treated for MH - Communication difficulties - Complex illness presentations - Challenging behaviours - Pressure to discharge rapidly

Question 36

Why might diagnostic overshadowing occur in A&E? (clinician contributing factors in emergency departments)

Answer 36

- Inadequate assessment and information gathering - not investigating things thoroughly enough - Clinician fear of violence - Stigmatising attitudes towards people with mental health problems

Question 37

What is compassion fatigue?

Answer 37

Physical emotional psychological impact on helping others - burnout syndrome related to helping other people - declining ability to empathise with others, results in physical and emotional exhaustion

Question 38

How can intrapersonal MH stigma obstruct healthcare access?

Answer 38

self-stigmatisation reduces care-seeking for mental or physical health needs - someone believing they do not deserve to be well so not approaching healthcare services

Question 39

How can interpersonal MH stigma obstruct healthcare access?

Answer 39

e.g., HCPs’ negative attitudes, therapeutic pessimism - attitude where HCP feels there is no point in treating somebody because they think they will not adhere to treatment plan, assumptions of malingering or fabrication

Question 40

How can structural MH stigma obstruct healthcare access? (discriminatory policies & systems)

Answer 40

Non inclusive policies e.g. not allowing a support person to attend appointments, having unrealistic expectations for patients to contribute towards their own care

Question 41

Does England have a high proportion of doctors per person?

Answer 41

No - low Intrinsic issue in healthcare system

Question 42

Is there understaffing of general practice in the UK?

Answer 42

Yes

Question 43

Is there under-resourcing of mental healthcare in the UK?

Answer 43

Yes - Result of COVID - more spending on physical health than MH

Question 44

Is there disparity between need for services and ability to access services?

Answer 44

Yes

Question 45

Where is the need for MH services greatest?

Answer 45

People in areas of greatest deprivation

Question 46

What socioeconomic disadvantages are commonly experienced by people with MH conditions?

Answer 46

Insecure housing / homelessness Unemployment / insecure employment & financial precarity Police involvement / incarceration Abuse and physical assault - ALL of these factors are also associated with higher rates of non-communicable physical illness and multimorbidity (having several conditions at once). Countries with greater levels of socioeconomic inequality have a higher burden of mental illness and certain physical illnesses

Question 47

Are MH problems more common in people who are migrants and who live in built-up urban environments?

Answer 47

Yes

Question 48

Are genes purely physical?

Answer 48

Yes, but... The expression of genes is determined by a host of variables, many of them psychologically and behaviourally mediated (and most of which we don’t understand yet)

Question 49

Does physical activity have measurable benefits for mental wellbeing?

Answer 49

Yes - RCTs for people with MDD and schizophrenia show that symptoms appear to reduce with physical activity - Physical activity interventions for people in the general population show decreased depressive symptoms across all age groups - Similarly, physical activity decreases anxiety symptoms in the general population - Reduces inflammatory markers: possible mechanism? - Many people need support to build this into their lives

Question 50

How can dietary strategies help with both physical and mental health problems? What are issues with this?

Answer 50

- A Mediterranean eating pattern reduces symptoms in those with depression (but evidence base is smaller than for physical activity) - This eating pattern also reduces inflammatory markers and decreases risk of cardiovascular disease amongst people with mental health conditions - Issues - expensive, education - some people do not understand how to make these changes to their diet

Question 51

What does emerging evidence show about the importance of the gut for mental health?

Answer 51

Largest immune organ in the body Microbiome (gut bacteria) as target for treatment - directly affected by food we eat - affects inflammatory state Stress and inflammation drive poor physical and mental health symptoms - cycle