Journal of Geriatric Mental Health

EDITORIAL
Year
: 2020  |  Volume : 7  |  Issue : 2  |  Page : 67--69

Mental disorders and noncommunicable diseases: A likeness, an overlap or an affiliation?


Devakshi Dua, Sandeep Grover 
 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India




How to cite this article:
Dua D, Grover S. Mental disorders and noncommunicable diseases: A likeness, an overlap or an affiliation?.J Geriatr Ment Health 2020;7:67-69


How to cite this URL:
Dua D, Grover S. Mental disorders and noncommunicable diseases: A likeness, an overlap or an affiliation?. J Geriatr Ment Health [serial online] 2020 [cited 2021 Jun 25 ];7:67-69
Available from: https://www.jgmh.org/text.asp?2020/7/2/67/307593


Full Text



The rubric of noncommunicable diseases (NCDs), include cardiovascular diseases such as coronary artery disease, diabetes mellitus, malignancies, and chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD).[1] These are traditionally defined as those which cannot be transmitted from one person to another, to distinguish them from infectious diseases. The NCDs are characterized by long and protracted course, long period of latency, multiple risk factors, complex etiopathogenesis, and generally a slow progression. The complex interplay of the above often leads to a life with disability and impairment, which may not be apparent to the lay observer.[2]

NCDs are a major cause of global mortality, especially in developed countries.[2] In the developing world, although infectious diseases and malnutrition contribute significantly to poor health and even as a cause of death, the NCDs are fast catching up.[3] The World Health Organization has brought NCDs into focus as a part of the Millennium Development Goals. However, the definition has been restricted to the “Big Four.”[4]

If one tries to understand various mental disorders, especially the severe mental disorders, these also are characterized by similar features as used to define NCDs. Mental disorders are the third biggest cause of disability adjusted life years (DALYs), globally.[5] Despite statistics suggesting that mental disorders, especially depression leads to significant morbidity as well as economic burden, the same has not been considered under the rubric of NCDs. Thus, some of the authors have argued and have urged that mental disorders should also be included in the realm of NCDs.[4]

It is also important to note that mental disorders are closely linked with other NCDs.[4] The link has been studied and understood on the basis of different models and the relationship is now considered to be bidirectional.[6] In addition, it is postulated that there may be a common underlying mechanism for mental disorders and other NCDs.[4],[6]

The elderly population is on rise.[7] Elderly people have higher prevalence of NCDs.[8] In addition, in elderly, NCDs are known risk factors for cognitive decline and dementia.[9] In a recent study conducted in India at an NCD clinic, the elderly population was screened for cognitive impairment. It was observed that nearly a quarter of the attendees had cognitive decline. Cognitive decline was also associated with patients suffering from hypertension, diabetes mellitus, and both of the illnesses.[9] In another similar study, nearly one-third of the participants recruited from an NCD clinic suffered from depressive and anxiety disorders.[10] Hence, it is of paramount importance that association of NCDs and mental disorders among the elderly.

 Mental Disorders as Risk Factors for Noncommunicable Diseases



Available evidence suggests that mental disorders are themselves a risk factor for the development of other NCDs.[11] Patients suffering from mental illnesses often have poor dietary habits, use substances like alcohol and tobacco, and have low physical activity, all of which predispose them to develop medical comorbidities.[12] These can range from obesity, hypertension and metabolic syndrome to the more sinister coronary artery disease, stroke, and cancer. Chronic smoking leads to COPD in many patients. More than one type of comorbidity is often present in patients with severe mental disorders.[4]

 Impact of Mental Disorder on Noncommunicable Diseases



There are robust data to suggest that the presence of mental disorder alters the course and progression of other illnesses.[4] The diagnosis of the physical illness is frequently delayed in the presence of a mental disorder.[13] It can be due to the neglect faced by the patients with mental disorders, which ranges from self-neglect, neglect by family members, as well as by the clinicians. In patients suffering from mental disorders, weight gain, lack of activity are considered as inevitable.[14],[15] These are not attended to, and investigations and efforts to make a diagnosis beyond the already diagnosed mental illness are often low.[13] It is only when complications arise due to the physical illness with marked impairment in functioning that these are diagnosed.[16] The presence of mental disorders has a negative impact on the medication and treatment adherence in patients with various NCDs.[12],[17] The patients' ability to follow the advice of the doctor, such as lifestyle modification may be hampered.[17],[18] Further, patient's perception of the physical illness is often colored by the presence of the mental disorder.[19] Patients with depression who are in the acute phase of the illness may become hopeless about their physical condition. They may have altered threshold for perception of pain and other symptoms. At the same time, they may not perceive the improvement in symptoms which may have occurred after the initiation of treatment.[20] On the other hand, patients suffering from psychotic disorders may not pay much heed to their physical symptoms even when they warrant treatment, or attribute it to some aspect of their psychopathology.[21] In both the scenarios mentioned above, the impact on treatment adherence may be significant.[13],[19] In addition, the progression of physical illness may be faster in patients with mental disorders due to the complex interplay of delayed diagnosis, poor lifestyle choices, treatment nonadherence, and adverse effects of medications.[13]

 Impact of Medical Illness on Mental Health



The presence of any kind of medical illness can be considered as stressful. This is particularly pronounced at the time of acute symptoms, diagnosis, and breaking of bad news, presence of chronic symptoms such as pain, associated disability, and dysfunction can lead to development of mental health issues. In addition, the financial burden accompanying the disease, dependency needs, impaired social relations, and burnout in caregivers can contribute further to the development of mental disorders.[20] In the background of a chronic medical illness, common mental disorders, such as depression and anxiety are more prevalent as compared to the general population.[22] The risk of developing depression has been reported to be higher in those suffering from medical illnesses.[23]

As the symptoms of medical illnesses often overlap with those of common mental disorders like depression and anxiety, the latter are often underdiagnosed. The symptoms are attributed to the medical condition and a more detailed evaluation is not undertaken. This invariably results in prolonged suffering. Due to the persistence of symptoms, the patient remains poorly satisfied with treatment, resorting to doctor shopping, trying alternative treatments, or giving up treatment for the medical as well as mental disorders.

 Common Factors Predisposing to Medical as Well as Mental Illness



NCDs are believed to have a complex etiology with multiple causal risk factors. Some of these include hyperfunctioning of the hypothalamo–pituitary–adrenal axis, genetic factors, childhood adversity, and stressful life events as well as substance use. All of these factors have also been implicated as risk factors with development of mental disorders too, suggesting a common etiology for both the group of disorders.[5]

 What is the Need of the Hour?



With the advancement in science as well as health standards, the NCDs are now the focus of disease prevention targets and goals. As a result, the “Big Four” were identified, considering the large-scale impact associated with them, in terms of morbidity and mortality, as well as the socioeconomic burden. Keeping this in mind, NCD clinics are coming up as a one-stop shop for the management of the “Big four.”

However, despite the fact that depressive disorders are the second largest contributor of DALYs globally, mental disorders have not received much attention in terms of prevention and treatment as an area of focus. Further, although the treatment of mental disorders has received some attention, there is no effort to promote mental health and reduce the disability associated with mental illness. Although the slogan “No health without mental health” is often raised by advocates for mental health, the same has not been extended to the sphere of prevention and treatment.

With an increase in prevalence of mental illness, in combination with other NCDs, the need of the hour is to develop a holistic, multi-pronged approach. It is time to include mental health in the ambit of NCDs and allocate appropriate resources to tackle the problem at hand. Easy availability of care will allow patients in need to avail facilities created for them. In addition, physicians must be equipped to deal with the problems plaguing the patients. This can be done by generalists as well as specialists. At the same time, awareness campaigns have to be made use of so that the stakeholders can appropriately utilize the services available.

In India, NCD clinics have been set up both in the urban as well as rural settings. These, continue to focus on the Big 4. As has already been demonstrated by recent studies from the rural setting, there is a high prevalence of mental disorders within these special populations, especially in the elderly. Thus, it is time to expand the focus to NCDs affecting the elderly.

Considering the overlap of etiological factors, and impact of NCDs and mental disorders on each other, it is important to have a holistic model to identify and manage these ailments together. Hence, it is important that mental disorders should be included under the broad rubric of NCDs and focus should shift from BIG 4 to BIG 5.

References

1WHO,World Health Organization. WHO. Available from: http://www.who.int/gho/ncd/en?/. [Last accessed on 2020 Feb 27].
2Hunter DJ, Reddy KS. Noncommunicable Diseases. N Engl J Med 2013;369:1336-43.
3Bloom DE, Cafiero-Fonseca ET, Candeias V, Adashi E, Bloom L, Gurfein L, et al. Economics of Non-Communicable Diseases in India: The Costs and Returns on Investment of Interventions to Promote Healthy Living and Prevent, Treat, and Manage NCDs. World Economic Forum, Harvard School of Public Health; 2014.
4O'Neil A, Jacka FN, Quirk SE, Cocker F, Taylor CB, Oldenburg B, et al. Shared framework for the common mental disorders and non-communicable disease: Key considerations for disease prevention and control. BMC Psychiatry 2015;15:15.
5Pryor L, Da Silva MA, Melchior M. Mental health and global strategies to reduce NCDs and premature mortality. Lancet Public Health 2017;2:e350-1.
6Stein DJ, Benjet C, Gureje O, Lund C, Scott KM, Poznyak V, et al. Integrating mental health with other non-communicable diseases. BMJ 2019;364:l295.
7United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing; 2019.
8Gong JB, Yu XW, Yi XR, Wang CH, Tuo XP. Epidemiology of chronic noncommunicable diseases and evaluation of life quality in elderly. Aging Med (Milton) 2018;1:64-6.
9Verma M, Grover S, Singh T, Dahiya N, Nehra R. Screening for cognitive impairment among the elderly attending the noncommunicable diseases clinics in a rural area of Punjab, North India. Asian J Psychiatr 2020;50:102001.
10Mehra A, Sangwan G, Grover S, Kathirvel S, Avasthi A. Prevalence of psychiatric morbidity and cognitive impairment among patients attending the rural noncommunicable disease clinic. J Neurosci Rural Pract 2020;11:585-92.
11Shao M, Lin X, Jiang D, Tian H, Xu Y, Wang L, et al. Depression and cardiovascular disease: Shared molecular mechanisms and clinical implications. Psychiatry Res 2020;285?:112802.
12Patel V, Chatterji S. Integrating mental health in care for noncommunicable diseases: An imperative for person-centered care. Health Aff (Millwood) 2015;34:1498-505.
13Sartorious N. Comorbidity of mental and physical diseases: a main challenge for medicine of the 21st century. Shanghai Arch Psychiatry 2013;25:68-9.
14Chwastiak LA, Rosenheck RA, Kazis LE. Association of psychiatric illness and obesity, physical inactivity, and smoking among a national sample of veterans. Psychosomatics 2011;52:230-6.
15Nyboe L, Lund H. Low levels of physical activity in patients with severe mental illness. Nord J Psychiatry 2013;67:43-6.
16Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms--a qualitative study. PLoS One 2014;9:e111682.
17Hoogendoorn CJ, Shapira A, Roy JF, Walker EA, Cohen HW, Gonzalez JS. Depressive symptom dimensions and medication non-adherence in suboptimally controlled type 2 diabetes. J Diabetes Complications 2019;33:217-22.
18Haskins CB, McDowell BD, Carnahan RM, Fiedorowicz JG, Wallace RB, Smith BJ, et al. Impact of preexisting mental illness on breast cancer endocrine therapy adherence. Breast Cancer Res Treat 2019;174:197-208.
19Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. J Psychosom Res 2002;53:859-63.
20Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003;54:216-26.
21Cohen A. Addressing Comorbidity between Mental Disorders and Major Noncommunicable Diseases. ?World Health Organization: WHO Regional Publications European Series; 2017.
22Gureje O. The pattern and nature of mental–physical comorbidity: Specific or general? In: Von Korff MR, Scott KM, Gureje O, editors. Global Perspectives on Mental-Physical Comorbidity in the WHO World Mental Health Surveys. Cambridge: Cambridge University Press; 2009. p. 51-83.
23Mukeshimana M, Mchunu G. The co-morbidity of depression and other chronic non-communicable diseases: A review of literature on the epidemiology, diagnosis and health effects. Rwanda J 2016;3: