INTERVIEW

Dr. Hiroto Ito

Director, Department of Social Psychiatry National Institute of Mental Health, National Center of Neurology and Psychiatry

Japan's six national centers for specialized care and research (National Cancer Center, National Cerebral and Cardiovascular Center, National Center of Neurology and Psychiatry, National Center for Global Health and Medicine, National Center for Child Health and Development, and National Center for Geriatrics and Gerontology ) integrate services for mental health and non-communicable diseases (NCDs) through a collaborative care model for the diagnosis and treatment of depression and support in patients with chronic illness. A follow-up system for comorbid patients with physical illness and mental disorder has been developed based on the sharing of patient information within a community.
The Connection between NCDs and Mental Health
There are well-established connections between the development and the poor prognoses of NCDs (such as cancer, cardiovascular disease, diabetes mellitus and chronic obstructive pulmonary disease) and factors such as treatment non-adherence and lifestyle factors including smoking, unhealthy diet, lack of exercise and excessive drinking. Moreover, a high prevalence of depression has been reported among individuals with NCDs; one out of five patients with an NCD suffers from depression. Unhealthy lifestyle habits and treatment non-adherence are commonly encountered in clinical practice, when patients are not well aware of their NCDs or have impaired mental health due to depression. The aim of this national project is to improve patient’s lifestyle choices and treatment adherence by integrating mental health care into the NCD therapy agenda, which will eventually lead to improvement s in the prognoses of NCDs.

The essence of mental health care (i.e., medication and cognitive behavioral therapy) can be useful in clinical practice for patients with NCDs through depression screening and referrals, timely and efficient information delivery for disease and treatment, and thorough follow-up. There is a compelling need for care for delirium and cognitive impairment in patients with physical illness. Useful mental health skills can be provided to patients at the stages of prevention (e.g., sleep education and support skills for stopping smoking and alcohol abuse), acute care (informed decision-making for diagnosis and treatment), chronic disease management (support and follow-up skills related to the specific disease/disorder), and palliative care (e.g., cancer and heart failure). In addition to support for smoking cessation, healthy diet, exercise, and medication adherence, these evidence-based skills can contribute to the improvement of NCDs prognoses.

A National Project: Development of a Mental Health Care Model for Patients with Physical Illness
The national project launched in April 2012 to support the provision of mental health care at the six national centers, with a following goals: (a) the development and implementation of training programs for mental health care professionals by specialized care teams; (b) the development of a multidimensional model for community collaboration and the introduction of innovative activities; and (c) the development of clinical research infrastructure and a clinical practice support model.

This is the first time that the six national centers have worked together to develop a clinical practice support model. The project is supported by the Ministry of Health, Labour and Welfare and scientific societies, including the Japan Psycho-oncology Society, the Japan Society of Diabetic Complications and the Japan Society of Psychosomatic Cardiology. The strength of this project comes from the strong initiative of the directors of national centers in collaboration with the specialty department directors, psychiatrists and nurse managers. With the sharing knowledge regarding depression diagnosis, treatment and care, the program can also be customized to individual needs.

Regarding the healthcare systems among the member nations of the Organisation for Economic Co-operation and Development (OECD), Japan is characterized by medical care led by private sector without a formal gatekeeping system under universal insurance scheme. Although Japan’s system has an advantage in that medical care is covered by health insurance at any healthcare institution, challenges remain: a follow-up system has not been established for drop-out patients, and healthcare providers are not aware of their responsibility for the care of a defined population. A follow-up system for the management of chronic disease is needed for discharged patients with NCDs. As we developed our clinical practice support model, we learned from the findings of a cancer control study suggesting that a multidisciplinary meeting to establish the prioritization of community issues is one of the effective methods to facilitate gatekeeping while maintaining free access to health care (Morita et al., 2013). For example, a patient’s psychiatrist participates in such a community meeting, and each patient is followed up in a comprehensive community care system. Integrating mental health care into chronic disease management is the goal of the national project.

Since it is difficult for communities to organize meetings to share patient information due to a lack of healthcare manpower, local authorities join the community meetings that we organize for monitoring. Commencing in 2013, all 47 prefectures in Japan are required to assess local mental health care needs and to develop a healthcare strategic plan. The prefectural governments now need to integrate mental health care into their healthcare services. This policy shift prioritizing mental health care as well as NCDs (e.g., cancer, acute myocardial infarction, stroke and diabetes) is a strong incentive to promote the national project.

The Role of Information and Communication Technology (ICT)
The protection of personal healthcare information is extremely strict in Japan. The recent development of information and communication technology (ICT) has offered many advantages but the protection of the privacy of the healthcare provider-patient relationship is essential. In the national project, we decided to not rely on ICT to solve health and disparity issues, but to use ICT to reinforce interpersonal interactions.

Toward this goal, a "contact notebook-type" follow-up support system was developed as part of the national project, based on a patient handbook (Ito et al., 2013). All relevant healthcare information is recorded in the patient’s handbook, whereas only contact notebook information is shared on the supporting website that will be created for the community meetings. This system enables us to follow up patients, and to send information to the patients through mobile phones. The patients can also input their own information into the contact notebook. De-identified health information is also available with an ID number in the project’s ICT system.

A community website limited to certain users involved in treatment support is under construction. On this site, information can be shared among healthcare team members at multiple facilities. A medication tracking program is also under development.

The primary concepts of NCD management in this project are (a) following patients through the community meetings regarding their healthcare (including health facility visits) based on the patient handbook, and (b) sharing information through the treatment support website and mobile phones.

Development of a Comprehensive Comorbid Patient Handbook
The National Cerebral and Cardiovascular Center developed a handbook called “Stroke Note” for maintaining records of stroke patients’ care from acute hospitalization to rehabilitation at home. Kumamoto Prefecture developed a similar handbook for patients with dementia and their families. Because these handbooks are in binder form, additional information is easily inserted into the handbook if and when a patient develops depression or another NCD. We are planning to create a customized patient handbook in binder form for multiple diseases, rather than different handbooks for different diseases.

The NCD Alliance Japan: Expectations
I would like to convey my following expectations to NCD Alliance Japan.

1.    The establishment of chronic disease management system in each community.
For example, accumulating and sharing experiences regarding healthcare catchment areas and comprehensive management systems for multiple diseases will help improve patient management.

2.    The integration of mental health care into the NCD control agenda.
Mental health care needs to be integrated into the NCD control agenda, and the involvement of mental health professionals is essential to provide the best support for comorbid patients (approx. 3% - 5% of all patients). Mental health professionals “back up” the NCD control agenda. Evaluation and collaboration among health care professionals should also be included in the integration of mental health care to as part of NCD management.

I look forward to the continuous support of and collaboration with NCD Alliance members, who share these challenges and future directions. Through a sophisticated initiative for NCD control (that is, evidence-based comprehensive treatment integrating mental and physical healthcare), we can work together for better health maintenance and the prevention of recurrence and disease progression. 

I sincerely hope that the NCD Alliance continues to be active and effective.



References
Morita T, et al. Effects of a programme of interventions on regional comprehensive palliative care for patients with cancer: a mixed-methods study. Lancet Oncology 14: 638- 646, 2013.
Ito H, et al. Creating an online patient follow-up system. Shakai Hoken Jyunpo 2531: 10-14, 2013 (in Japanese).



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