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April 2008 – Volume 4, No. 2
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Mental health self-management in
patients with chronic illnessPatients can improve their own health outcomes
with supported self-managementby Dan Bilsker, PhD, RPsych
CARMHA, Simon Fraser University;
Clinical Assistant Professor, Faculty of Medicine, UBC
This brief discussion of mental health self-management in chronically ill individuals aims to provide an overview and suggest strategies for supporting patients in self-management. Self-management in chronically ill individuals brings together three streams of clinical research: (1) an increasing emphasis on chronic disease management; (2) mounting evidence that chronic physical illnesses are often associated with mental health problems; and (3) evidence pointing to supported self-management for mental health problems as a useful intervention modality.
Chronic Disease Management (CDM)
Over the last couple of decades, the health care system has increasingly adopted a CDM approach. CDM has a number of innovative features, such as care delivery through teams with well-defined roles—but one of the essential features is support for self-management by patients.(1)
Supporting self-management by patients with chronic disease recognizes that ongoing care will inevitably be a collaborative enterprise and reflects research findings that patients can improve their own health outcomes.(2,3)
There has been a substantial growth in the availability of self-management support groups for patients dealing with a range of chronic diseases. Most of these self-management groups have used the self-management framework developed by Dr. Kate Lorig and her colleagues at the Stanford University School of Medicine.(4)
In addition to the increasing availability of self-management groups, there has been a growing expectation that physicians educate and encourage patients with regard to self-management activities. However, this expectation has only recently been accompanied by systematic training in methods for supporting self-management. As noted by Sevick et al (2007), “the literature on how to best support self-management efforts in those with complex chronic diseases is lacking.�(5)
Chronic disease and mental health problems
A number of chronic illnesses are associated with elevated rates of depressive symptomatology. Studies of patients with coronary heart disease have found the incidence of depressive symptomatology to be as high as 30 to 50 per cent, compared to a baseline of 15 per cent in the general population.(6) It has also been demonstrated that depression is an important coronary risk factor.(7)
This is a complex area of research where the nature of causal relations between psychiatric symptomatology and chronic disease is unclear. The extent to which a disorder such as depression may directly contribute to worsened prognosis in chronic illness is unclear. But the research findings do indicate that mental health problems occur with surprisingly high frequency in those with chronic disease and should be addressed by the health care system.
Supported self-management for mental health problems
Systematic reviews and clinical guidelines have called for the integration of supported self-management into the care for mental health problems.
Supported self-management for mental health problems has two main components. The first component is a self-management tool, usually a workbook given to the patient that teaches self-management skills derived from treatment research. The second component is support by the health care provider who offers encouragement and advice. This component requires minimal time and effort by the health care provider.
Supported self-management may be provided as a stand-alone intervention or as an adjunct to other treatment, depending on the severity and complexity of a particular situation.
Most of the outcome research in this area has focused on self-management for depression. It has been demonstrated that individuals with mild to moderate depression show significant benefit from being provided with self-management materials.(8) In primary care, depressed individuals who are provided self-management material show a generally positive attitude toward intervention, significant uptake, and increased knowledge of effective change strategies.(9)
A recent review of self-management tools for mental health problems concluded that “the majority of trials reported some significant advantages in outcome associated with self-help treatments.�(10) Depression care guidelines produced by the UK National Institute for Clinical Excellence suggest: “For patients with mild depression, health care professionals should consider recommending a guided self-help program based on cognitive-behavioural therapy (CBT).�(11)
Positive Coping with Health Conditions: a new tool
A workbook is under development, with support from the Vancouver Coastal Health Authority, the intent of which is to transmit mental health self-management skills to individuals with chronic illness.(12) The goal is to provide this workbook as a tool to assist healthcare providers and their patients. The workbook, entitled Positive Coping with Health Conditions, has several components:
- A self assessment component that helps patients to identify areas in which they may be experiencing mental health problems, including: depressed mood; worry and anxiety; anger and irritability; or social isolation.
- A step-by-step explanation of seven “positive coping skills�, which are mapped onto the mental health problems to which they are most relevant. The seven coping skills are: behavioural activation; structured problem solving; realistic thinking; relaxation; worry management; anger management; and relationship enhancement. Each of these skills has a substantial evidence base to support its relevance for one or several of these mental health problems. For example, realistic thinking (or cognitive restructuring) has been shown to be beneficial for the treatment of depression, anxiety and excessive anger.
- A series of vignettes which illustrate the application of the coping skills to better manage mental health problems.
- Recommendations for applying coping skills to problems often encountered by individuals with chronic health conditions (pain, impaired sleep, insufficient physical activity and problematic eating habits).
A first version of this workbook will be ready for distribution in the latter part of 2008, posted for free download and available at cost through a print-on-demand service.
We do not yet know how effective this self-management workbook will be with regard to enhancing care delivery for chronically ill individuals, but it does serve the purpose of suggesting intervention strategies for psychiatrists, family practitioners and other health care providers. It may also have particular relevance for patients presenting with chronic mental health problems such as recurrent depression and anxiety disorders.(13)
Free downloads of other mental health self-management material are available at www.carmha.ca/publications under Self-Care.
References
1. Wagner E.H. Chronic disease care. BMJ 328(7433):177-178, 2004.
2. Jovicic A., Holroyd-Leduc J.M. and Straus S.E. Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review a randomized control led trials. BMC Cardiovascular Disorders 6:243, 2006.
3. Gibson P.G., Powell H., Coughlan J., Wilson A.J., Abramson M., Haywood P., Bauman A. Hensley M.J. and Walters E.H. Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews 2, 2005.
4. Lorig K.R., Sobel D.S., Ritter P.L., Laurent D. and Hobbs M. Effect of a self-management program on patients with chronic disease. Eff Clin Pract 4:256–62, 2001.
5. Sevick M.A., Trauth J.M., Ling B.S., Anderson R.T., Piatt G.A., Kilbourne A.M. and Goodman R.M. Patients with complex chronic diseases: perspectives on supporting self-management. Journal of General Internal Medicine 22 (Suppl 3), 438-444, 2007. (Page 438)
6. Lespérance F. and Frasure-Smith N. Depression in patients with chronic disease: a practical review. Journal of Psychosomatic Research 48:379-91, 2000.
7. Frasure-Smith N. and Lespérance F. Reflections on depression as a cardiac risk factor. Psychosomatic Medicine 6 (Suppl 1):S19-S25, 2005. (Page S23).
8. McKendree-Smith N.L., Floyd M. and Scogin F.R. Self-administered treatments for depression: a review. J Clin Psychol 59(3):275–288, 2003.
9. Robinson P., Katon W., et al. The education of depressed primary care patients: What do patients think of interactive booklets and a video? Journal of Family Practice 44:562-571, 1997.
10. Bower P., Richards D., et al. The clinical and cost-effectiveness of self-help treatments for anxiety and depressive disorders in primary care: a systematic review. Br J Gen Pract 51(471):838-45. Page 838, 2001.
11. National Collaborating Center for Mental Health. Management of depression in primary and secondary care. Clinical Guideline 23 developed by the National Institute for Clinical Excellence (NHS). Available from: www.nice.org.uk/guidance/CG23/niceguidance. 2004.
12. The positive coping with health conditions workbook is being developed by the Centre for Applied Research in Mental Health & Addiction at Simon Fraser University, with support by the Vancouver Coastal Health Authority.
13. Tylee A. and Walters P. We need a chronic disease management model for depression in primary care. British Journal of General Practice 57:348-50, 2007.
© Copyright 2008. Canadian Psychiatry Aujourd’hui. All rights reserved.
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