The Sustainable Development Goals approved by the United Nations General Assembly in 2015 include a specific target in goal 3.4 for non-communicable diseases (NCDs): by 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. This target aligns well with the paper by Liu et al, which offers a multilevel intervention framework to reduce excess mortality in persons with severe mental disorders (SMDs). The World Health Organization (WHO)'s Global Action Plan for the Prevention and Control of NCDs (2013-2020) shares this goal and provides a menu of options, including risk factor control, scaling up management in primary health care, surveillance and other cross cutting areas. A life course approach including human rights and equity and universal health coverage are overarching principles in implementing this global action plan.
A focus on prevention, especially on the four common shared risk factors of tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity, is a cornerstone of NCD control. The impact of general population interventions, such as taxation or restriction to access, may not be the same in people with SMDs. People suffering from SMDs will need a tailored approach to risk reduction: cognitive capacity, enabling factors, information and skill building of care providers and family members are needed. Some of the risk factors, such as weight gain and eating patterns, are influenced by people with SMDs’ condition and medications and will have to be factored in. A perception change in carers and health providers may be needed for them to see the relevance of risk factor control in people with SMDs.
NCDs, especially cardiovascular diseases (CVDs), diabetes, cancer and chronic respiratory diseases, are becoming more prevalent due to an epidemiological and demographic transition. In addition to prevention, early identification and prompt management can reduce premature mortality and morbidity and improve the quality of life. Treatment of NCDs in earlier stages is more feasible, less expensive and can be taken up at lower levels of health care.
The WHO has developed a Package of Essential NCD (PEN) interventions which are suitable for primary health care and can be applied in resource constrained settings. They include protocols for identifying people at high risk for CVDs, identification and management of asthma and chronic pulmonary diseases, along with a protocol for individual counselling. A short list of essential medicines and technology is provided to support the use of these protocols. The proposed approach of Ask (for risk factors), Assess (examination and tests), Estimate (CVD risk), Refer (for high risk) and Counsel and treat is a feasible framework that can be appropriately integrated in the WHO Mental Health Gap Action Programme (mhGAP).
Health care providers for SMDs, including mental health professionals, can be informed, and their capacity can be enhanced to undertake this simple assessment depending on the clinical condition. Individuals at high risk for CVDs based on the risk assessment can be offered additional support and checking of parameters along with the follow-up of their mental health condition. This integration will have to be taken up through active engagement of care providers of both streams (NCDs and mental health) and also through appropriate operational interventions in health care settings. Mental health services may have to be supported with NCD medicines and technology, and skill building of providers. Including NCDs as part of the medical records will also help to identify and focus on people who have SMDs and NCDs.
Diabetes is also an important consideration in SMDs. The WHO PEN offers a protocol for management of diabetes, and the special needs for people with SMDs will have to be reflected in developing care plans. Dietary restrictions and physical activity which are part of the management plan may have more challenges in people with SMDs than medication interventions. Self-care which is often proposed to people with NCDs may not be directly applicable to people with SMDs.
Respiratory diseases like asthma are overtly symptomatic and are more amenable to detection and management. Awareness of signs and symptoms of common cancers among mental health care providers can potentially lead to early diagnosis, for instance of breast cancer.
All major NCDs need prolonged treatment, including adherence to medicines. Periodic follow-up and checking for signs of complications can help to prevent or delay adverse events in NCDs. Including these tests in protocols and adhering to them as part of the care for SMDs will have to be part of the management plan.
People with NCDs may have mental health conditions such as depression and anxiety, and it is also important that NCD care providers have the skills and capacity to detect and manage or refer these comorbidities as needed.
Integration of NCD prevention and management for people with SMDs will happen only through a systematic and sustained process at different levels. National programmes for NCDs, mental health and primary care services can work together to develop operational guidance and resource allocation. National strategies and action plans in these areas and in overall health sector plans should reflect this adequately.
Appropriate system level interventions, including changes in protocols, health workforce capacity, medicines and technology, counselling support and financial protection measures, will have to be developed and implemented in a structured manner. Context specific approaches can be developed based on the general guidance, and sustained practice can benefit both people with SMDs and those with NCDs.
The WHO is planning to demonstrate this approach in settings which are implementing mhGAP to include PEN protocols and vice versa. The framework proposed in Liu et al's paper will help to accelerate this work.
Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention Department, World Health Organization, Geneva, Switzerland