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> T : @ Integrating mental health in care for non-communicable diseases: an imperative for Universal Health Coverage and person-centered care
Summary
Mental disorders, such as depression and alcohol use disorders, often co-occur with other common non-communicable diseases (NCDs) such as diabetes and heart disease, while NCDs are frequently encountered in patients with severe mental disorders like schizophrenia. The pathways underlying co-morbidity are complex, . for For example they mental and physical NCDs may share common environmental risk factors such as unhealthy lifestyles, and or the treatments for one condition may have side-effects which that enhance the risk of the other. Building on the robust evidence base on forthe effective treatments for a range of mental disorders in routine health care platforms, there is now a growing evidence base on for how such treatments can be integrated into the care of persons with NCDs. The most well established delivery model is that of a team approach that at the heart of which isfeatures a non-specialist case manager who coordinates care in collaboration with primary care physicians and specialists. Such This approach es maximize maximizes the efficiencies in shared and person-centered care that are are essential for achieving universal health coverage for both NCDs and mental disorders. While there a number of research gaps, there is sufficient evidence for policy makers to immediately embark onundertake measures to integrate mental health and NCD care in primary care platforms.
The burden of co-morbidities
The ageing of populations around the world has been accompanied by marked increases in the burden of chronic non-communicable diseases (NCDs) such as cardiovascular disease, chronic respiratory conditions, cancers, diabetes and musculoskeletal diseases ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_1" \o "Murray, 2013 #5356" 1). With effective interventions, mortality associated with many of these conditions has continued to fall, although these interventions do not reach all and may not be universally affordable. Several studies from across the world show reveal that up to half of the global population has at least one chronic condition and nearly a quarter has more than one co-existing chronic condition ADDIN EN.CITE Arokiasamy20156190(2)6190619017Arokiasamy, P. UttamacharyaJain KBiritwum RBYawson AEFan WGuo YMaximova TEspinoza BMSalinas-Rodriguez AAfshar SPati SIce GBanerjee SLiebert MASnodgrass JJNaidoo NChatterji SKowal PThe impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the Study on global AGEing and adult health (SAGE) reveal?BMC.Med.BMC.Med.Not in FileAdultMental HealthHealth20152015( HYPERLINK \l "_ENREF_2" \o "Arokiasamy, 2015 #6190" 2).
Alongside these daunting global health challenges are those posed by the mounting burden of mental disorders, a heterogeneous group of conditions that includes some disordersconditions, notably depression and alcohol use disorders, which that have shown amongstexhibited some of the largest proportionate increases in global burden in the past two decades.
Not surprisingly, given the high prevalence of both NCDs and mental disorders, comorbidity of these two groups of health conditions also occurs frequently ADDIN EN.CITE Prince20073336(3)3336333617 Prince, M.Patel, V.Saxena, S.Maj, M.Maselko, J.Phillips, M. R.Rahman, A.King's College London, Centre for Public Mental Health, Health Service and Population Research Department, Institute of Psychiatry, London, UK. m.prince@iop.kcl.ac.ukNo health without mental healthLancetLancet859-773709590Cardiovascular Diseases/etiologyCommunicable Diseases/etiologyComorbidityDisabled Persons/statistics & numerical dataFemale*Health StatusHumansMaleMaternal WelfareMental Disorders/*classification/complications/epidemiologyMortalitySeverity of Illness IndexSuicide/prevention & control/psychology/*statistics & numerical data2007Sep 817804063http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17804063 ( HYPERLINK \l "_ENREF_3" \o "Prince, 2007 #3336" 3). Estimates from the US indicate that almost 30 percent% of those living with a NCD report a concurrent mental disorder. The prevalence of a mental disorder is elevated in those who live with NCDs compared to those without NCDs , and especially so among those with multiple chronic conditions. Conversely, more than two-thirds of persons with a mental disorder have been shown to have at least one other chronic NCD. The comorbidity between NCDs and mental disorders is particularly associated with a strong social gradient and is more commoner in those living in deprived than in well-resourced areas ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_4" \o "Barnett, 2012 #6142" 4).
The relationships between mental disorders and other NCDs are complex and bi-directional ADDIN EN.CITE Prince20073336(3)3336333617 Prince, M.Patel, V.Saxena, S.Maj, M.Maselko, J.Phillips, M. R.Rahman, A.King's College London, Centre for Public Mental Health, Health Service and Population Research Department, Institute of Psychiatry, London, UK. m.prince@iop.kcl.ac.ukNo health without mental healthLancetLancet859-773709590Cardiovascular Diseases/etiologyCommunicable Diseases/etiologyComorbidityDisabled Persons/statistics & numerical dataFemale*Health StatusHumansMaleMaternal WelfareMental Disorders/*classification/complications/epidemiologyMortalitySeverity of Illness IndexSuicide/prevention & control/psychology/*statistics & numerical data2007Sep 817804063http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17804063 ( HYPERLINK \l "_ENREF_3" \o "Prince, 2007 #3336" 3) (Exhibit 1). Poor mental health exacerbates a number of NCD risk factors including poor diet, obesity, inactivity, and tobacco use due to poor lifestyle choices, poor health literacy, poor access to health promotion activities, and symptoms such as lack of motivation and energy. Heavy alcohol use, besides being frequently associated with a range of mental disorders, is also a major risk factor for cancer, cardiovascular disease, stroke, and liver disease and may compromise immune and cognitive functions the latter further complicating the delivery of and adherence to complex treatment regimens for comorbid conditions. The adverse cardiometabolic reactions of drug treatments given forof some mental disorders, notably schizophrenia, that lead to weight gain, hyperglycemia, and dyslipidemia, may help explain some of the higher burden of NCDs in these patients ADDIN EN.CITE Von20096216(5)621662165Von,Korff M.Von,Korff M.Scott,K.Gureje,O.Understanding consequences of mental-physical comorbidityGlobal perspectives on mental-physical comorbidity in the WHO World Mental Health Surveys193-20917Not in FileComorbidityMental HealthHealthHealth Surveys20092009New YorkCambridge University Press( HYPERLINK \l "_ENREF_5" \o "Von, 2009 #6216" 5). Living with a chronic, painful or disabling NCD can, unsurprisingly, lead to greater stress and consequent mental disorders. Both NCDs and mental disorders may share similar risk factors such as genetic determinants which that increase susceptibility to cytokine- mediated inflammatory responses and to , and adverse social and environmental determinants such as childhood adversity and poverty.
The impact of co-morbidity
Among those living with NCDs, comorbidity with a mental illness often has profound and detrimental impacts on health including, for example, poorer glycaemic control among people with diabetes and inadequate blood pressure control among people with hypertensives hypertension. Such impacts are often due due toto a lack of compliance to with treatment regimens that may be complex and necessitate lifestyle changes ADDIN EN.CITE Von20096216(5)621662165Von,Korff M.Von,Korff M.Scott,K.Gureje,O.Understanding consequences of mental-physical comorbidityGlobal perspectives on mental-physical comorbidity in the WHO World Mental Health Surveys193-20917Not in FileComorbidityMental HealthHealthHealth Surveys20092009New YorkCambridge University Press( HYPERLINK \l "_ENREF_5" \o "Von, 2009 #6216" 5).
Conditions such as panic attacks increase the risk of future cardiovascular events. Comorbid mental disorders lead to significant worsening in of disability among those with NCDs. Such comorbidity may have a synergistic deleterious effect, as the odds of severe disability and resulting, including days out of role or work absences, among those with a mental disorder and an NCD are greater than the sum of the odds for each of the single conditions ADDIN EN.CITE Moussavi20073335(6)3335333517 Moussavi, S.Chatterji, S.Verdes, E.Tandon, A.Patel, V.Ustun, B.Department of Measurement and Health Information Systems, World Health Organization, Geneva, Switzerland.Depression, chronic diseases, and decrements in health: results from the World Health SurveysLancetLancet851-83709590AdultAgedAged, 80 and over*Chronic DiseaseComorbidityDepressive Disorder/complications/diagnosis/*epidemiologyFemaleHealth StatusHealth SurveysHumansInternational Classification of DiseasesMaleMiddle AgedPopulation Surveillance/*methodsPrevalenceQuestionnairesRegression AnalysisSocial Class*World Health2007Sep 817826170http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17826170 ( HYPERLINK \l "_ENREF_6" \o "Moussavi, 2007 #3335" 6). The burden of a mental disorder may also hinder the ability to adapt to symptoms of NCDs.
Beyond disability, poor mental health is also associated with increased higher mortality in persons with NCDs like cardiovascular disorder, stroke, and rheumatoid arthritis than among , as compared to thosepersons without comorbid mental health conditions. Recent analyses have shown that mortality is significantly higher among persons with mental disorders, as compared to the general population, and about two-thirds of these mortality is due to natural causes which that can primarily be attributable attributed to NCDs, notably cardiovascular diseases ADDIN EN.CITE Walker20155944(7)5944594417Walker, E.McGee, R. E.Druss, B. G.Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysisJAMA PsychiatryJAMA PsychiatryJAMA psychiatry20152168-622Xhttp://dx.doi.org/10.1001/jamapsychiatry.2014.250210.1001/jamapsychiatry.2014.2502( HYPERLINK \l "_ENREF_7" \o "Walker, 2015 #5944" 7).
These impacts are well illustrated in the WHOs multi-national SAGE study, one of the few primary data sources from pertaining to health in low and middle income countries (LMIC, ). Itwhich shows that, compared with a number of NCDsof all chronic conditions (Exhibit 2), depression has the worst impact on overall health status (measured as a composite of the capacity to function in multiple domains of day to day life activities) of among those people currently living with a range of health conditions. It also shows that and,, when comorbid with other NCDs, depression further worsens health significantly especially for those with diabetes, COPD and stroke even after controlling for age, sex, education, household wealth and place of residence in a multivariable regression analysis (Exhibit 2).
Patients with comorbid mental illnesses and NCDs experience more complicated treatments and poorer treatment outcomes than do patients with isolated conditions, partly because of , for example because of depressed motivation and poorer impaired memory interfering with adherence with treatment. Another reason is the or sstigma associated with the mental disorder, limiting access to timely, appropriate and patient-centered care. Thus, patients with such co-morbidities have higher rates of health care utilisation, and poorer overall quality of care, and are more likely to use emergency care than those who have NCDs without a comorbid mental illness.
This has consequences on for health care expenditure spending, potentially increasing a patients and associated out-of-pocketcosts spending on health care and raising the likelihood of subsequent impoverishment. As one example, data from the US Medical Expenditure Panel Survey observed that that, among obese adults, comorbidity with mental disorders was associated with higher total, outpatient and pharmaceutical expenditures, than those without such comorbidity ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_8" \o "Shen, 2008 #6204" 8). In the SAGE study, of those diagnosed with depression and who were hypertensiveon, 23.6% were poorly controlled despite being on treatment as compared to 16.8% of those with hypertenstion but no out depression. This study also showed that dDepression, when comorbid with NCDs, significantly increased the odds of contact with outpatient and inpatient services for persons with diabetes, arthritis, angina, stroke, and or COPD as well as for persons with multiple chronic conditions.
Patients with severe mental disorders often have cardiovascular disease and diabetes that go unrecognized due to their difficulties accessing appropriate health care and effectively communicating with their health care providers; . Even even when these conditions are recognized, they patients often receive often treatment that is not concordant with guidelines, in part because of within aa fragmented and specialist-dominated health care system.
In short, co-morbidities lead to poorer quality of care, higher health care costs, and poorer outcomes for both the mental disorder and NCD. In LMICs, these relationships are likely to be further complicated by the existence of chronic infectious diseases, notably HIV AIDS, and by health systems that may not be equipped to deal with NCDs or mental disorders, due to low investments, weak human resource capacity, and low political will ADDIN EN.CITE Jenkins20116235(9)6235623517Jenkins, R.Baingana, F.Ahmad, R.McDaid, D.Atun, R.Professor of Epidemiology and International Mental Health Policy, King's College London, Institute of Psychiatry, London, UK.Health system challenges and solutions to improving mental health outcomesMent Health Fam MedMental health in family medicineMent Health Fam MedMental health in family medicineMent Health Fam MedMental health in family medicine119-27822011Jun1756-8358 (Electronic)
1756-834X (Linking)22654975http://www.ncbi.nlm.nih.gov/pubmed/226549753178194( HYPERLINK \l "_ENREF_9" \o "Jenkins, 2011 #6235" 9).
It is also important to note that the impact of mental disorders and NCDs extends beyond those directly affected, by adversely impacting on the health of their caregivers. Caring for a person with a chronic, disabling NCD or mental disorder, such as cancer or dementia, is stressful and associated with a higher risk of chronic health problems, including depression, hypertension, sleeping problems, and fatigue, increased use of psychotropic drugs, and premature mortality ADDIN EN.CITE Feinberg20116177(10)6177617727Feinberg, L.Reinhard S.C.Houser AChoula RAARP Public Policy InstituteValuing the invaluable: 2011 update. The growing contributions and costs of family caregiving20112011( HYPERLINK \l "_ENREF_10" \o "Feinberg, 2011 #6177" 10). The indirect costs of such non-uncompensated caregiving are also considerable. These impacts on caregivers, who are often other members of the household, can lead to clustering of NCDs and mental disorders within households creating sick households.
Addressing co-morbidities: the evidence
There is a robust evidence base testifying to the effectiveness and cost-effectiveness of a range of interventions, including medicines, psychological treatments and social interventions, for mental disorders ADDIN EN.CITE Patel20156058(11)605860586Patel, V. Chisholm, D. Dua, T. Laxminarayan, R. Medina-Mora, ME.Mental, Neurological, and Substance Use Disorders. Disease Control Priorities,4Third Edition2015Washington DCWorld BankEnglish( HYPERLINK \l "_ENREF_11" \o "Patel, 2015 #6058" 11). This evidence also demonstrates the effectiveness of the delivery of psychosocial interventions by non-specialist health workers in routine primary care platforms in LMICs, as well as the effectiveness of collaborative care models in LMICs. In this delivery model, front-line care, comprising tasks such as screening, case management, and provision of psychosocial interventions, is delivered by non-specialist health workers working in partnership with primary care physicians and/or mental health professionals ADDIN EN.CITE Patel20135410(12)5410541017Patel, V.Belkin, G.S.Chockalingam, A.Cooper, J.Saxena, S.Unutzer, J.Integrating Mental Health services into Priority Health Care platforms: addressing a Grand Challenge in Global Mental HealthPLoS MedicinePLoS Medicinee10014481020132013English( HYPERLINK \l "_ENREF_12" \o "Patel, 2013 #5410" 12) ADDIN EN.CITE van Ginneken20135569(13)5569556917van Ginneken, N.Tharyan, P.Lewin, S.Rao, G. N.Meera, S.Pian, J.Chandrashekar, S.Patel, V.Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, Keppel St, London, UK, WC1E 7HT.Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countriesCochrane Database Syst RevThe Cochrane database of systematic reviewsCochrane Database Syst RevCD0091491120131469-493X (Electronic)
1361-6137 (Linking)24249541http://www.ncbi.nlm.nih.gov/pubmed/2424954110.1002/14651858.CD009149.pub2( HYPERLINK \l "_ENREF_13" \o "van Ginneken, 2013 #5569" 13). There is a small, but consistent, evidence base testifying to the cost-effectiveness of such task-sharing, which typically entails additional human resources ADDIN EN.CITE Buttorff20125398(14)5398539817Buttorff, C.Hock, R. S.Weiss, H. A.Naik, S.Araya, R.Kirkwood, B. R.Chisholm, D.Patel, V.Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.Economic evaluation of a task-shifting intervention for common mental disorders in IndiaBull World Health OrganBull World Health Organ813-2190112012/12/122012Nov 11564-0604 (Electronic)
0042-9686 (Linking)23226893http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=23226893350640510.2471/BLT.12.104133
BLT.12.104133 [pii]eng( HYPERLINK \l "_ENREF_14" \o "Buttorff, 2012 #5398" 14).
This evidence base is now being complemented by studies specifically evaluating the integration of effective interventions for mental disorders with the care of persons with NCDs, in particular the management of depression co-morbid with diabetes or coronary artery disease (CAD), although almost all the evidence is from high-income countries. Amongst patients with CAD, both psychological and pharmacological (SSRI antidepressants) interventions have a modest beneficial effect on depression compared to usual care for CADcoronary artery disease ADDIN EN.CITE Baumeister20116113(15)6113611317Baumeister, H.Hutter, N.Bengel, J.Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Engelbergerstr. 41, Freiburg, Germany, 79085.Psychological and pharmacological interventions for depression in patients with coronary artery diseaseCochrane Database Syst RevThe Cochrane database of systematic reviewsCochrane Database Syst RevCD0080129AdultAntidepressive Agents/*therapeutic useCoronary Artery Disease/mortality/*psychologyDepression/*therapyHumansPsychotherapy/*methodsRandomized Controlled Trials as Topic20111469-493X (Electronic)
1361-6137 (Linking)21901717http://www.ncbi.nlm.nih.gov/pubmed/2190171710.1002/14651858.CD008012.pub3( HYPERLINK \l "_ENREF_15" \o "Baumeister, 2011 #6113" 15) .
Some trials of pharmacological interventions in this patients with coronary artery diseasegroup of patients have shown a reduction in hospitalization rates and emergency room visits while some trials of psychological interventions have also shown an effect on a reduction of cardiac mortality. In general, for the effective treatment of depression co-morbid with CAD, there seems to be no difference between various types of psychological treatments, or between various types of SSRI antidepressants ADDIN EN.CITE Baumeister20116113(15)6113611317Baumeister, H.Hutter, N.Bengel, J.Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Engelbergerstr. 41, Freiburg, Germany, 79085.Psychological and pharmacological interventions for depression in patients with coronary artery diseaseCochrane Database Syst RevThe Cochrane database of systematic reviewsCochrane Database Syst RevCD0080129AdultAntidepressive Agents/*therapeutic useCoronary Artery Disease/mortality/*psychologyDepression/*therapyHumansPsychotherapy/*methodsRandomized Controlled Trials as Topic20111469-493X (Electronic)
1361-6137 (Linking)21901717http://www.ncbi.nlm.nih.gov/pubmed/2190171710.1002/14651858.CD008012.pub3( HYPERLINK \l "_ENREF_15" \o "Baumeister, 2011 #6113" 15). Similarly, there is a promising evidence base pointing to the benefits of integrated care on both mental health and physical health outcomes in people with diabetes. A systematic review of collaborative care for patients with depression and diabetes mellitus provides clear evidence to support its effectiveness in improving depression outcomes and improved adherence to treatment for both depression and diabetes ADDIN EN.CITE Huang20136127(16)6127612717Huang, Y.Wei, X.Wu, T.Chen, R.Guo, A.School of General Practice and Continuing Education, Capital Medical University, Beijing 100069, China. guoaiminlaoshi@126.com.Collaborative care for patients with depression and diabetes mellitus: a systematic review and meta-analysisBMC PsychiatryBMC psychiatryBMC PsychiatryBMC psychiatryBMC PsychiatryBMC psychiatry26013AdultDepressive Disorder/complications/psychology/*therapyDiabetes Mellitus, Type 1/complications/psychology/*therapyDiabetes Mellitus, Type 2/complications/psychology/*therapyHumans*Patient Care TeamPrimary Health Care20131471-244X (Electronic)
1471-244X (Linking)24125027http://www.ncbi.nlm.nih.gov/pubmed/24125027385468310.1186/1471-244X-13-260( HYPERLINK \l "_ENREF_16" \o "Huang, 2013 #6127" 16).
Two recent trials evaluated collaborative care for multiple NCDs (coronary heart disease, diabetes or both) and depression providing evidence which that is of particular relevance to the real-world of primary care practice where multiple morbidities are common. These two trials, one from the UK ADDIN EN.CITE Coventry20155941(17)594159416Coventry, PeterLovell, KarinaDickens, ChrisBower, PeterChew-Graham, CarolynMcElvenny, DamienHann, MarkCherrington, AndreaGarrett, CharlotteGibbons, Chris JBaguley, ClareRoughley, KateAdeyemi, IsabelReeves, DavidWaheed, WaquasGask, LindaIntegrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease35020152015-02-16 15:01:00Journal Articlehttp://www.bmj.com/bmj/350/bmj.h638.full.pdf10.1136/bmj.h638( HYPERLINK \l "_ENREF_17" \o "Coventry, 2015 #5941" 17) and one from the US ADDIN EN.CITE Katon WJ120106108(18)6108610817Katon WJ1, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D.Collaborative care for patients with depression and chronic illnesses.New England Journal Of MedicineNew England Journal of Medicine2611-20363272010PMC3312811doi: 10.1056/NEJMoa1003955.English( HYPERLINK \l "_ENREF_18" \o "Katon WJ1, 2010 #6108" 18)One trial in the US reported significantly superior health outcomes for that patients in the a collaborative care intervention group. The US trial is described in more detail in the Case Study. (Panel 1) had greater overall improvement across glycated haemoglobin levels, LDL cholesterol levels, systolic blood pressure and depression scores than those patients who received usual care for their NCD ADDIN EN.CITE Katon WJ120106108(18)6108610817Katon WJ1, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D.Collaborative care for patients with depression and chronic illnesses.New England Journal Of MedicineNew England Journal of Medicine2611-20363272010PMC3312811doi: 10.1056/NEJMoa1003955.English( HYPERLINK \l "_ENREF_18" \o "Katon WJ1, 2010 #6108" 18). The COINCIDE trial from the UK reported that the intervention had modest benefits in reducing depression and improved self- management in the short term ADDIN EN.CITE Coventry20155941(17)594159416Coventry, PeterLovell, KarinaDickens, ChrisBower, PeterChew-Graham, CarolynMcElvenny, DamienHann, MarkCherrington, AndreaGarrett, CharlotteGibbons, Chris JBaguley, ClareRoughley, KateAdeyemi, IsabelReeves, DavidWaheed, WaquasGask, LindaIntegrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease35020152015-02-16 15:01:00Journal Articlehttp://www.bmj.com/bmj/350/bmj.h638.full.pdf10.1136/bmj.h638( HYPERLINK \l "_ENREF_17" \o "Coventry, 2015 #5941" 17).
Panel 1Case study: Collaborative care for NCDs and depression ADDIN EN.CITE Katon WJ120106108(18)6108610817Katon WJ1, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D.Collaborative care for patients with depression and chronic illnesses.New England Journal Of MedicineNew England Journal of Medicine2611-20363272010PMC3312811doi: 10.1056/NEJMoa1003955.English( HYPERLINK \l "_ENREF_18" \o "Katon WJ1, 2010 #6108" 18) ADDIN EN.CITE Katon WJ120106108(17)6108610817Katon WJ1, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D.Collaborative care for patients with depression and chronic illnesses.New England Journal Of MedicineNew England Journal of Medicine2611-20363272010PMC3312811doi: 10.1056/NEJMoa1003955.English( HYPERLINK \l "_ENREF_17" \o "Katon WJ1, 2010 #6108" 17)
In thea U.S. trial carried out in 14 primary care clinics in the state of Washington, USA,(17) p, 214 pPatients with coronary heart disease or diabetes (or both) who also suffered from depression worked collaboratively with nurses and primary care physicians to agree to individualized clinical and self-care goals. In 2 to 3 weekly structured visits in primary care, nurses monitored the level of depression, and control of the NCD, and adherence with interventions. First line medications included diuretics and angiotensin-converting-enzyme inhibitors for hypertension, statins for hyperlipidemia, metformin for hyperglycemia, and citalopram or bupropion for depression. Using motivational techniques, nurses helped patients solve problems and set goals for improved adherence and self-care. Once a patient achieved targeted levels for relevant outcomes, the nurse and patient developed a maintenance plan that included stress reduction, behavioral goals, continued use of medications, and identification of prodromal symptoms of deteriorating depression and glycemic control. The nurses then followed patients with telephone calls every 4 weeks to assess depression and review adherence and laboratory test results. Patients with disease control that worsened were offered enhanced follow-up. xPatients who received the collaborative care intervention had greater overall improvement across glycated haemoglobin levels, LDL cholesterol levels, systolic blood pressure and depression scores than patients who received usual care for their NCD. This model of care, christened TEAMCare, is now being rolled out in clinics and hospital systems in regions of the United States and Canada ( HYPERLINK "http://www.mhinnovation.net/innovation/teamcare" http://www.mhinnovation.net/innovation/teamcare).
While there is less evidence on the impacts of integrating the care of mental disorders besides depression with NCD care, there is a small evidence base to support the integration ofintegrating the prevention of NCD risk factors in people with serious mental disorders such as schizophrenia. Recent reviews ADDIN EN.CITE Gierisch20136133(19)613361335Gierisch, J. M.Nieuwsma, J. A.Bradford, D. W.Wilder, C. M.Mann-Wrobel, M. C.McBroom, A. J.Wing, L.Musty, M. D.Chobot, M. M.Hasselblad, V.Williams, J. W., Jr.Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental IllnessAHRQ Comparative Effectiveness Reviews2013Rockville (MD)23700634http://www.ncbi.nlm.nih.gov/pubmed/23700634eng( HYPERLINK \l "_ENREF_19" \o "Gierisch, 2013 #6133" 19) ADDIN EN.CITE Bonfioli20126130(20)6130613017Bonfioli, E.Berti, L.Goss, C.Muraro, F.Burti, L.Department of Public Health and Community Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy. elena.bonfioli@univr.itHealth promotion lifestyle interventions for weight management in psychosis: a systematic review and meta-analysis of randomised controlled trialsBMC PsychiatryBMC psychiatryBMC PsychiatryBMC psychiatryBMC PsychiatryBMC psychiatry7812Body Mass IndexCognitive Therapy/methods/statistics & numerical dataHealth Promotion/*methodsHumansObesity/complications/*therapyPatient Education as TopicPsychotic Disorders/complications/*therapy*Randomized Controlled Trials as Topic*Risk Reduction BehaviorWeight Reduction Programs/*methods/statistics & numerical data20121471-244X (Electronic)
1471-244X (Linking)22789023http://www.ncbi.nlm.nih.gov/pubmed/22789023354978710.1186/1471-244X-12-78( HYPERLINK \l "_ENREF_20" \o "Bonfioli, 2012 #6130" 20) have reported modest evidence of the effectiveness of lifestyle interventions including diet and physical activity, and the switching of antipsychotic switching medications to medications drugs that pose with less risk of adverse effects associated with NCDs (such as aripiprazole) on improvingsuch as weight controlgain.. Few studies have evaluated interventions to address other CVD risk factors in patients with serious mental disorders, or interventions with agents known to be effective in other populations, or interventions for people with NCDs and co-morbid alcohol use disorders. Thus, integration of mental health with NCD care should be viewed not only from the perspective of general medical care, but also within in the context of psychiatric care where many persons with serious mental and substance use disorders would expect to be managed.
Research questions ahead
There are two key research questions which remain to be addressed. First, the existing evidence clearly points to the need for improving the effectiveness of interventions, both by improving the quality of available interventions and by
identifying new interventions, to enhance the modest effects observed in trials to date. Second, there is a need for evaluating approaches to the integration of mental health and NCD care for more diverse contexts, particularly in LMICs, and integrating the care of other mental disorders that have strong associations with NCDs, notably alcohol use disorders. Several ongoing trials in LMIC promise to generate such evidence in the coming years.
The MWELLCARE program, supported by the Wellcome Trust, in India is using a mobile health app for decision support and continuing care for people with diabetes or hypertension. It which integrates the management of a range of co-morbidities including depression and alcohol use disorders in routine primary health care; the platform is being evaluated in a cluster RCT in two Indian states. In South Africa, the national Department of Health is piloting the integration of mental health care intoNCD care into routine primary health care and NCD care in all ten national health insurance pilot districts, one in each province, with the view togoal of eventually scaling up to all districts. The screening and management tool used by nurses in South Africa is Primary Care 101, which is a symptom-based clinical management guideline that uses algorithms for multi-disease management of common chronic NCDsconditions (including mental disorders). The PRIME program in South Africa, supported by UKAID ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_21" \o "Lund, 2012 #5618" 21), has is specifically piloting the piloted the strengthening of the mental health component of the this training and is now embarked on has begun a pragmatic cluster randomized controlled trial in 20 public sector primary care clinics in one district in to assess mental and physical health outcomes for depressed adults receiving hypertensive treatment.
The IntegratingDEPrEssioN and Diabetes TreatmENT in India (INDEPENDENT) project, supported by the NIMH, is evaluating an adapted version of the collaborative care intervention (Panel Case study1) to address co-morbid depression and diabetes or cardiovascular disease in India ADDIN EN.CITE Katon WJ120106108(18)6108610817Katon WJ1, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D.Collaborative care for patients with depression and chronic illnesses.New England Journal Of MedicineNew England Journal of Medicine2611-20363272010PMC3312811doi: 10.1056/NEJMoa1003955.English( HYPERLINK \l "_ENREF_18" \o "Katon WJ1, 2010 #6108" 18) . In this study, among patients with diabetes, co-morbid depressive symptoms, and poor control of their cardiovascular risks, researchers are comparing standard NCD care with a multi-faceted intervention consisting of non-physician care coordinators to who activate patients and encourage better self-care, . They also use asmart electronic health record that uses in-builtbuilt-in decision algorithms to provide physicians with guideline-based care prompts. , and tTwice monthly offline specialist supervision meetings are used to guide population health management and oversee care.
The potential impacts of trials such as these include the opportunity toleverage patients existing point of contact with the health system to simultaneously treat depressive symptoms and improve NCD care, . They also present an opportunity and todocument processes ofidentify ways how to cost-effectively integrate this combined care delivery approach into health settings in the challenging health care milieu of LMICs.
Implications for policy makers
Thus, Tthere is consistent, if modest, evidence of the effectiveness of SSRI antidepressant and structured psychological interventions in reducing depressive and anxiety symptoms in people with CAD and diabetes and co-morbid depression, but less consistent evidence on their impact in improving the NCD outcomes. There is also modest evidence pointing to the health benefits of integrating NCD care with the care of persons with serious mental disorders. There is also growing evidence demonstrating how the care for these diverse conditions could be integrated in the same platform.
Such efficiencies point to the high probability that integrated care is likely to be more cost-effective compared with vertical care models for specific disorders. However, beyond the beneficial effects of integrated care on economic or biomedical outcomes is the impact on improving patient satisfaction and quality of life, and thereby achieving the goals of patient-centred health care ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_22" \o "Bayliss, 2012 #83" 22).
In most countries, both LMIC and HIChigh-income, the management of mental disorders and NCDs almost completely largely ignores the existence of multiple morbidities, both in the same individual and in members of the household, leading to poorer quality of care, and higher levels of patient dissatisfaction and costs of care ADDIN EN.CITE Patel20156050(23)6050605017Patel, V.Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK; Centre for Control of Chronic Conditions, Public Health Foundation of India, Institutional Area Gurgaon 22002 Delhi, India; Sangath, Goa, India. Electronic address: vikram.patel@lshtm.ac.uk.Rethinking personalised medicineLancetLancetLancetLancet1826-738599802015May 91474-547X (Electronic)
0140-6736 (Linking)25987146http://www.ncbi.nlm.nih.gov/pubmed/2598714610.1016/S0140-6736(15)60917-5( HYPERLINK \l "_ENREF_23" \o "Patel, 2015 #6050" 23). Instead, patients are required to consult multiple specialists for each condition or, more commonly, are denied care for one or more of the co-existing conditions due to physicians ignoring those conditions which that are outside their specialty. The principles underlying effective integration are are consistent with the recommendations for the management of any chronic condition, what we term as the 4C model: Collaborative, involving a partnership between the patient, a non-specialist case manager who delivers psychosocial interventions, a primary care physician and specialist services with an emphasis on shared-decision making and seamless communication; Coordinated across health care delivery platforms with integrated electronic health records and liaison, multidisciplinary guidelines, and clearly defined care pathways; Continuing with an emphasis on pro-active monitoring of health outcomes to ensure optimal results, and regular reviews with specialists regarding patients who do not show clinical improvement; and patient-Centred with an emphasis on promoting self-management, and prioritising patient defined outcomes and delivery expectations ADDIN EN.CITE Patel20135410(12)5410541017Patel, V.Belkin, G.S.Chockalingam, A.Cooper, J.Saxena, S.Unutzer, J.Integrating Mental Health services into Priority Health Care platforms: addressing a Grand Challenge in Global Mental HealthPLoS MedicinePLoS Medicinee10014481020132013English( HYPERLINK \l "_ENREF_12" \o "Patel, 2013 #5410" 12).
However, for successful integration to take place, policy makers and health programs will need to address a number of potential barriers and lessons learnt from recent efforts ADDIN EN.CITE Foundation.20146109(24)6109610927World Health Organization and Calouste Gulbenkian Foundation.Integrating the response to mental disorders and other chronic diseases in health care systems.ISBN 978 92 4 150679 32014Geneva, SwitzerlandWorld Health OrganizationEnglish( HYPERLINK \l "_ENREF_24" \o "Foundation., 2014 #6109" 24). Truly integrated care involves more than co-locating health workers with diverse specialties into the same building. It and requires a systems approach to implementation. Primary health workers, in particular the case managers who are the critical human resource in integrated care, need competency-based training and supervision. The major risks posed by integration, such as the systematic lower quality of care for mental disorders compared with that of other conditions, and primary health worker burn-out ADDIN EN.CITE Padmanathan20135629(25)5629562917Padmanathan, P.De Silva, M. J.Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, UK; University of Leeds, UK. Electronic address: um08pp@leeds.ac.uk.The acceptability and feasibility of task-sharing for mental healthcare in low and middle income countries: a systematic reviewSoc Sci MedSocial science & medicineSoc Sci MedSocial Science & Medicine82-697*Attitude of Health Personnel*Attitude to Health*Developing CountriesFeasibility StudiesHealth Personnel/*psychologyHumansMental Health Services/manpower/*organization & administrationQualitative Research2013Nov1873-5347 (Electronic)
0277-9536 (Linking)24161092http://www.ncbi.nlm.nih.gov/pubmed/2416109210.1016/j.socscimed.2013.08.004( HYPERLINK \l "_ENREF_25" \o "Padmanathan, 2013 #5629" 25), need to be explicitly addressed. Above all, health workers at all levels need access to timely, useful data about patients in the form of integrated clinical information systems in which individual patients can be tracked across sectors of the health care system. New technologies, such as mhealth mobile health enabled decision support algorithms, cloud-based electronic medical records which can be accessed and updated by any provider, automated medication and appointment reminders, and telemedicine- based supervision by specialists offer unique opportunities to address these barriers ADDIN EN.CITE Jones20146243(26)6243624317Jones, S..Patel, V.Saxena, S.Radcliffe, N.Al-Marri, S. Darzi, A. How Googles Ten Things We Know To Be True Could Guide The Development Of Mental Health Mobile Apps.Health AffairsHealth Affairs1603-1611332014( HYPERLINK \l "_ENREF_26" \o "Jones, 2014 #6243" 26). Successful integration also requires attention to vested interests and potential resistance, in particular from medical specialists and the industry which seek to promote a predominantly biomedical, hospital-centric, approach to care.
Integration needs to happen across the entire spectrum of interventions from promotion to prevention to management of disorders as well as across all levels of care from primary to tertiary. Such seamless integration takes into account the need for continuity of care, and the reality that some individuals need long-term care, and the legitimate expectations of communities. Finally, integration takes time and typically involves a series of developments spanning several years with continuous loops of monitoring, evaluation, feedback, and service improvements.
In September 2015, the nations of the world will be convened by the United Nations to are scheduled to unite to finalize the shape of the Sustainable Development Goals, a global consensus on the major challenges facing our planet ADDIN EN.CITE Touraine20146057(27)6057605717Touraine, M.Grohe, H.Coffie, R. G.Sathasivam, S.Juan, M.Louardi el, H.Seck, A. C.Ministry of Health, Paris, France. Electronic address: marcosl@who.int.
Ministry of Health, Bonn, Germany.
Ministry of Health, Abidjan, Cote d'Ivoire.
Ministry of Health, Putrajaya, Malaysia.
Ministry of Health, Mexico City, Mexico.
Ministry of Health, Rabat, Morocco.
Ministry of Health, Dakar, Senegal.Universal health coverage and the post-2015 agendaLancetLancetLancetLancet1161-23849949Economic Development/trendsHealthy People Programs/*trendsHumansPoverty/prevention & control/trendsUniversal Coverage/*trends2014Sep 271474-547X (Electronic)
0140-6736 (Linking)25242037http://www.ncbi.nlm.nih.gov/pubmed/2524203710.1016/S0140-6736(14)61419-7( HYPERLINK \l "_ENREF_27" \o "Touraine, 2014 #6057" 27). Within the health goal, the draft proposals call for the promotion of mental health and wellbeing and the prevention and treatment of substance abuse; additionally, there is a growing advocacy for inclusion of mental disorders along with the target foramong the NCD target NCDs ADDIN EN.CITE Thornicroft20146056(28)6056605617Thornicroft, G.Patel, V.Centre for Global Mental Health, King's College London, Institute of Psychiatry, London SE5 8AF, UK graham.thornicroft@kcl.ac.uk.
Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, India.Including mental health among the new sustainable development goalsBMJBmjBMJBMJg5189349Educational StatusEmployment*Global Health*Goals*Health PolicyHealth PrioritiesHumans*Mental HealthMental Health ServicesUnited Nations20141756-1833 (Electronic)
0959-535X (Linking)25145688http://www.ncbi.nlm.nih.gov/pubmed/2514568810.1136/bmj.g5189( HYPERLINK \l "_ENREF_28" \o "Thornicroft, 2014 #6056" 28). With the United Nations General Assembly unanimously adopting the a resolution endorsing universal health coverage (UHC) as a global priority for sustainable development in 2012, it is likely that the health target on universal health coverage (UHC) will be included as a specific target within the broader health related SDG will receive further impetus ADDIN EN.CITE Touraine20146057(27)6057605717Touraine, M.Grohe, H.Coffie, R. G.Sathasivam, S.Juan, M.Louardi el, H.Seck, A. C.Ministry of Health, Paris, France. Electronic address: marcosl@who.int.
Ministry of Health, Bonn, Germany.
Ministry of Health, Abidjan, Cote d'Ivoire.
Ministry of Health, Putrajaya, Malaysia.
Ministry of Health, Mexico City, Mexico.
Ministry of Health, Rabat, Morocco.
Ministry of Health, Dakar, Senegal.Universal health coverage and the post-2015 agendaLancetLancetLancetLancet1161-23849949Economic Development/trendsHealthy People Programs/*trendsHumansPoverty/prevention & control/trendsUniversal Coverage/*trends2014Sep 271474-547X (Electronic)
0140-6736 (Linking)25242037http://www.ncbi.nlm.nih.gov/pubmed/2524203710.1016/S0140-6736(14)61419-7( HYPERLINK \l "_ENREF_27" \o "Touraine, 2014 #6057" 27). In 2013, the World Health Assembly unanimously approved the WHOs Comprehensive Mental Health Action Plan ADDIN EN.CITE Saxena20135522(29)5522552217Saxena, S.Funk, M.Chisholm, D.World Health Assembly adopts Comprehensive Mental Health Action Plan 20132020The LancetThe Lancet1970-19713819882201310.1016/S0140-6736(13)61139-3English( HYPERLINK \l "_ENREF_29" \o "Saxena, 2013 #5522" 29). The integration of the care of mental and physical co-morbidities is particularly relevant within these important global policy instruments: .
Nnot only does the integration of integrated care provide a route to addressing both NCDs and mental disorders effectively, but it also carries the potential for to produce efficiencies in the health care delivery, for example by providing care for multiple conditions using the same human resources and through a common primary care platform. Such efficiencies will enhance the probability of their scale-up within universal health coverage UHC which will require substantial increases in public financing of health care ADDIN EN.CITE Beaglehole20083716(30)3716371617 Beaglehole, R.Epping-Jordan, J. E.Patel , V . ,Chopra , M . ,Ebrahim , S . ,Kidd , M . ,Haines , A . ,Improving the prevention and management of chronic disease in low-and middle-income countries:a priority for primary health care Primary careLancetLancet2008( HYPERLINK \l "_ENREF_30" \o "Beaglehole, 2008 #3716" 30).
Such eEfficiencies arising from integration inintegrated primary care are the imperative is essential in both in high-income countries HIC where the costs of care for NCDs and mental disorders are already very high and spiralling, as well as in LMIC low and middle-income countries where large proportions of people with these conditions do not receive adequate care. Integration is key to improving the access to appropriate interventions for those with comorbid conditions, reduce the fragmented manner in which care is delivered and deliver care that is responsive to the needs and expectations of people. Such an approach is also consistent with the need for an integrated, people-centred approach to health care, which is particularly relevant in the area of chronic diseases in all countries ADDIN EN.CITE World Health Organisation20156087(31)6087608727World Health Organisation,World Health OrganisationWHO global strategy on people-centred and integrated health services - Interim reportWHO/HIS/SDS/2015.62015SwitzerlandWorld Health Organisationhttp://www.who.int/servicedeliverysafety/areas/people-centred-care/global-strategy/en/English( HYPERLINK \l "_ENREF_31" \o "World Health Organisation, 2015 #6087" 31).
References
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10. Feinberg L, S.C. R, A H, R C. Valuing the invaluable: 2011 update. The growing contributions and costs of family caregiving. 2011 2011. Report No.
11. Patel VC, D. Dua, T. Laxminarayan, R. Medina-Mora, ME. Mental, Neurological, and Substance Use Disorders. Disease Control Priorities,. Third Edition ed. Washington DC: World Bank; 2015.
12. Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, Unutzer J. Integrating Mental Health services into Priority Health Care platforms: addressing a Grand Challenge in Global Mental Health. PLoS Medicine. 2013 2013;10:e1001448. English.
13. van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera S, Pian J, et al. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev. 2013;11:CD009149. PubMed PMID: 24249541.
14. Buttorff C, Hock RS, Weiss HA, Naik S, Araya R, Kirkwood BR, et al. Economic evaluation of a task-shifting intervention for common mental disorders in India. Bull World Health Organ. 2012 Nov 1;90(11):813-21. PubMed PMID: 23226893. Pubmed Central PMCID: 3506405. Epub 2012/12/12. eng.
15. Baumeister H, Hutter N, Bengel J. Psychological and pharmacological interventions for depression in patients with coronary artery disease. Cochrane Database Syst Rev. 2011 (9):CD008012. PubMed PMID: 21901717.
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18. Katon WJ1 LE, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. Collaborative care for patients with depression and chronic illnesses. New England Journal Of Medicine. 2010;363(27):2611-20. Pubmed Central PMCID: PMC3312811. English.
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31. World Health Organisation. WHO global strategy on people-centred and integrated health services - Interim report. Switzerland: World Health Organisation, 2015 Contract No.: WHO/HIS/SDS/2015.6.
Exhibit 1: The mechanisms of co-morbidity of mental disorders and other noncommunicable diseases
Exhibit 2: The impact of NCDs, Depression and comorbidity on health status (Data source WHO, SAGE, 2010. Data available from HYPERLINK "http://www.who.int/healthinfo/sage/en/" http://www.who.int/healthinfo/sage/en/ Accessed July 1, 2016
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Author: edit ok? I wasnt sure if you were saying that the efficiencies are necessary for universal health care or if this approach (and others like it) is. Please clarify if necessary.
VIKRAM: YES, THIS IS FINE, BUT SUGGEST WE DELETED SHARED AND IN THIS SENTENCE AS THE WORD SHARED IS IMPLIED IN THE VERY NATURE OF COLLABORATIVE CARE?
Author: edit ok?
YES
Author: since youre making a comparison here, I think the word higher works better.
AGREE
Author: This is a little unclear because the total group people living with a range of health conditions is so broad that it would seem hard to rank any one health condition as having the biggest impact on health status. Can you define your terms more clearly so the sentence follows logically?
I HAVE EDITED THIS SENTENCE AND INSERTED A REFERENCE TO EXHIBIT 2 HERE (IT BELONGS BETTER HERE THAN THE END OF THE PARA) WHICH INFORM THE READER OF THE OTHER CONDITIONS. HOPE THIS IS MORE SPECIFIC?
Author: Is this from the same study (SAGE)? If so, please insert a phrase saying so or add a reference to another source.
IT IS THE SAME STUDY AND I HAVE ADDED AN EDIT TO CLARIFY THIS
Author: please indicate what this group is coronary artery disease patients or a larger group of people with various NCDS?
CLARIFIED
Author: Since you identify the COINCIDE trial in the next sentence, please provide the name of the U.S. trial here.
UNFORTUNATELY, THE PAPER DESCRIBING THIS TRIAL DOES NOT HAVE A NAME GIVEN TO THE TRIAL. THIS IS THE SAME TRIAL AS THE CASE STUDY AND I HAVE EDITED THE TEXT HERE TO TAKE ACCOUNT OF YOUR SUGGESTIONS AND TO AVOID DUPLICATION.
Author: please explain if this is the same intervention as in the US trial or something else.
CLARIFIED AND EDITED
I ASSUME THIS WILL BE IN A BOX (WHICH IS WHY I CALLED IT A PANEL)
Author: Ive inserted this phrase as a placeholder, but you need to readers where this trial was performed and what it was called. Also, make sure this tracks from the above paragraph, which ends with a statement about the UK (COINCIDE) trial. We need to make sure there is no confusion. Also, I am assuming that this trial is the same one as reported above, but make any needed adjustments if this is not the case.
DONE
Please write a sentence here that concisely reports the results of this trial.
RELOCATED THIS TEXT FROM THE MAIN MANUSCRIPT TO THIS LOCATION AND ADDED TEXT REGARDING THE WIDER IMPLEMENTATION OF THE PROGRAM.
Author: I wasnt sure If you mean to say that aripiprazole was an example of a risky drug that triggers weight gain or of a less risky drug thats poses less risk and is thus a good alternative. You may insert the drug name back into the sentence but please do so in a way that makes this distinction clear.
DONE, THE DRUG IS A LESS RISKY ONE.
Since the previous sentence says adverse effects such as weight gain, the phrase other CVD risk factors in this sentence is ambiguous. Please make the distinction clear between side effects in the first sentence and in the second.
WEIGHT GAIN IS BOTH A SIDE EFFECT AND A RISK FACTOR, WHICH IS WHY I USE THE TERM OTHER IN THIS SENTENCE. IF YOU FEEL THIS IS AMBIGUOUS, THEN YOU COULD DROP THE TERM OTHER.
Author: populations other than what? Please make the comparison clear.
Author: comorbid with what? Please clarify.
DONE
Author: this is confusing since you begin by saying the country is doing this in all ten insurance districts? What else is left? Are you drawing a distinction between pilot districts and other kinds of districts? Clarify.
HOPE THE EDITS ARE NOW CLEAR?
Author: Edit ok?
YES WITH ONE INSERTION OF OF
Author: Is this the name of the program you introduce in previous sentences or is this something different. Please clarify.
HAVE EDITED THE ENTIRE TEXT REGARDING THIS PROGRAM, HOPE ITS NOW CLEAR.
Author: I eliminated this earlier because it was unexplained and seemed unnecessary but now I wonder. If you need to use it, define it the first time you use it.
DONE, REFERRING TO THE CASE STUDY
Author: it doesnt really tract that the smart electronic health record does this. Please clarify.
THESE ARE TWO SEPARATE AND UNRELATED COMPONENTS. HAVE SEPARATELY THE TWO POINTS BY A SENTENCE.
Author: Since you describe most of the effects as modest, can we really say theres a high probability of what you describe. Please adjust your terminology to stay consistent.
HAVE DELETED THE TERM HIGH
Author: so what can you say about this impact? Is it likely or still open to debate and further research?
THE CITATION POINTS TO THE ADDITIONAL IMPACTS, SUCH AS PATIENT SATISFACTION AND QOL, WHICH I HAVE NOW INSERTED.
Author: this isnt quite clear. Are you saying that mental health care can suffer if integrated into other care, or that mental health care is generally of lower quality than care for other conditions? Please clarify.
EDITED.
Author: please spell this out
DONE AND INSERTED A HEALTH AFFAIRS CITATION
Author: these labels are a little confusing, but also, its hard to distinguish these from all levels of care. Please write this more clearly.
HOPE THIS IS CLEAR?
Author: this is a UN meeting right? Please indicate the name of this conference and indicate under whose auspices.
DONE
Author: It is unclear where this would happen. Is this part of the sustainable development meeting you just referred to or something else? Please clarify.
DONE
Author: please spell out
DONE, BUT IF WE ARE SPELLING OUT UHC EACH TIME IT IS USED, THEN I SUGGEST REMOVING THE (UHC) ABBREVIATION THROUGHOUT.
I would keep this sentence to make the case for integration stronger hopefully, this addition wont stretch the word limit too much.
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