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Coping with long-term physical health conditions

This is an excerpt from Physical Activity and Mental Health by Angela Clow & Sarah Edmunds.

Key Concepts

• Approximately 30% of people with a long-term condition have a comorbid mental health condition.
• Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
• Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
• Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
• Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
• Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.

Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.

The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.

Long-Term Conditions and Mental Health Issues

People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.

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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).

Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).

Long-Term Conditions and Quality of Life

Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).

Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.

Long-Term Conditions and Physical Activity

Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.

Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.


Chronic Obstructive Pulmonary Disease

COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).

The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.

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