This chapter considers what is known about multimorbidity when long term conditions and mental health problems coexist and explores the challenges faced by clinicians and services to respond to the needs of patients.

Irrespective of controversies over cause and effect, the major concern of clinicians is on the impact of mental health and long-term conditions on patient experience, mortality and morbidity, and quality of life.

The UK Department of Health defines self-management as ‘the care taken by individuals towards their own health and well being’ and includes a healthy lifestyle, social and emotional needs, managing the condition and prevention. Depression can reduce motivation and capacity for self-management and poor outcomes in people with comorbid depression alongside long-term conditions such as diabetes may reflect poor self-management. Patients with depression may have a feeling of hopelessness (which may influence feelings about treatment effectiveness), may be more likely to be socially isolated and lacking support and may struggle with limited concentration and energy. Sometimes, the management of one condition actively conflicts with the management of another. For example, treating a depressed patient might lead to a better mood but that might lead to a return of their appetite with potential negative effects on diet and diabetes care.

Equally important is the potential for the management of the long-term condition to have an impact on mood. Patients with long-term conditions are expected to monitor symptoms and make changes to their lifestyle, and many patients might find such activities to have a significant impact on their quality of life. Patients with multimorbidity have to deal with many self-management activities with only limited resources of energy, time, attention and motivation. This has led to calls for clinicians to think about not only the burden of disease in such patients but also the burden of treatment (see Chapter 8).

The organization of the healthcare system may contribute to the problem. Some aspects of the management of depression are better in patients with long-term conditions because the routine follow-up of patients with long-term conditions increases the opportunity to effectively manage depression, and single interventions can confer benefits for multiple disorders (e.g., exercise prescribed for the control of diabetes may impact favourably on mood).

However, the presence of mental and physical health multimorbidity can be problematic for a variety of reasons. The time-limited nature of primary care consultations means that decision-making is often centred around immediate patient concerns. Opportunities to offer patients an integrated approach to care, responding to physical and mental health problems are limited. Competing demands on health professional time often leads to priority being given to physical health problems. Those priorities are often reflected in patient behaviour as well.

It is possible that patients with comorbid depression and long-term conditions have difficulty in communicating effectively with practitioners. People with depression may not be active in seeking care at certain points in their lives, especially when symptoms are severe. In the presence of long-term conditions, both health professionals and patients normalize depression as a natural consequence of symptoms and loss of function. Even where health professionals are skilled at detecting depression, our case study (Box 9.1) highlights the difficulties in negotiating labels and treatment strategies with patients who may attribute symptoms of depression to other causes. Practitioners may avoid discussing self-management because they feel it might upset or annoy the patient.

A UK primary care study (Coventry et al. 2011; see Box 9.2) that examined barriers to depression care in multimorbidity found that recognition of depression is difficult. Depression can be misconstrued as part of ageing. If depressive symptoms appear periodically, there may be greater focus on physical problems.

In discussing mental health, patients with multimorbidity are acutely aware of the stigma associated with depressive illness, delaying help-seeking. In response to this, some have highlighted the benefits of using non-psychiatric language with patients with multimorbidity and how drawing on metaphors and figurative language can help patients to discuss their emotional health in less stigmatizing ways.

The burden of long-term conditions and multimorbidity has led to important innovations in the delivery of care, such as the chronic care model (described in earlier chapters). In mental health, an