No physical health without mental health: lessons unlearned?

Dr Brock Chisholm, the first Director-General of the World Health Organization (WHO), was a psychiatrist and shepherded the notion that mental and physical health were intimately linked. He famously stated that “without mental health there can be no true physical health”.1 Half a century later, we have strong evidence elucidating the bidirectional relationship between mental illnesses – specifically depression and anxiety – and physical health outcomes. However, policy continues to lag behind the evidence in this regard, as demonstrated by our global noncommunicable disease response. Over a decade ago, the World Health Assembly adopted a global strategy for the prevention and control of noncommunicable disease. At the time, these were limited to the following four illness types: cardiovascular disease, diabetes, respiratory illness and cancers. Such a categorization would set a precedent for the exclusion of mental illnesses from all future WHO discussions on noncommunicable diseases. It is not surprising then, that in the 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases mental illnesses were relegated to a footnote, with the justification that they do not share risk factors with the other four types of illnesses.2 We take issue with this viewpoint, as mental illnesses are themselves risk factors that affect the incidence and prognosis of diseases traditionally classified as “noncommunicable”. Patients with type II diabetes mellitus, for example, are twice as likely to experience depression as the general population,3 and those patients with diabetes who are depressed have greater difficulty with self-care.4 Patients suffering from mental illness are twice as likely to smoke cigarettes as other people, and in patients with chronic obstructive pulmonary disease mental illness is linked to poorer clinical outcomes.5,6 Up to 50% of cancer patients suffer from a mental illness, especially depression and anxiety,7 and treating symptoms of depression in cancer patients may improve survival time.8 Similarly, in patients who are depressed, the risk of having a heart attack is more than twice as high as in the general population;9 further, depression increases the risk of death in patients with cardiac disease.10 Moreover, treating the symptoms of depression after a heart attack has been shown to lower both mortality and re-hospitalization rates.11 In light of this evidence, how can we possibly address the burgeoning epidemic of noncommunicable diseases without tackling co-morbid mental illnesses? Mental illnesses were declared a regional priority in Africa during the WHO African Region Ministerial Consultation on Noncommunicable Diseases, held in Brazzaville, Congo, in April 2011. Later that month the WHO’s African Member States and India reiterated this priority at the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, held in Moscow, Russia.12 As a result, mental illnesses were featured prominently in the preambles of the Moscow Declaration, as well as in the political declaration issued by the United Nations General Assembly at the high-level meeting on noncommunicable diseases held in New York City in September 2011.13 Despite this progress, however, mental illnesses received no mention at all in the resolution on noncommunicable diseases that WHO’s Member States adopted during the 130th session of WHO’s Executive Board.14 Mental illnesses were also omitted from WHO’s proposed monitoring framework, indicators and voluntary targets for the prevention and control of noncommunicable diseases, which was released in November 2012.15 The 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases will be revised over the coming year, and the WHO’s Executive Board and World Health Assembly are preparing their deliberations for 2013. During this critical time we urge Member States to recognize the importance of co-morbid mental illnesses as amplifiers of the burden of other noncommunicable diseases. To this end, we call on Member States to assess and monitor co-morbid mental illnesses in primary care settings, prioritize the training of professionals in mental health care, and, critically, incorporate mental health interventions within chronic disease programs as part of a vigorous global response to noncommunicable diseases. We now know that addressing mental illnesses in primary care settings will delay progression, improve survival outcomes, and reduce the health care costs of other noncommunicable diseases. The time has now come to do away with the artificial divisions between mental and physical health, as WHO’s first Director-General championed so many decades ago.