The Connection Between Physical and Mental Health: An Overview

Much has already been written about COVID-19’s impact on our mental health.

The World Health Organization (WHO) reported that in the first year of the pandemic, global prevalence of anxiety and depression increased by an estimated 25%, with the greatest impact among women, younger adults (ages 20-24), and people living in low- and middle-income countries.¹

WHO also reported that the pandemic increased Global Burden of Disease (GBD) levels associated with mental health conditions, as measured by Disability-Adjusted Life Years (DALY). Mental health conditions are also estimated to account for approximately one-third of all Years Lived with Disability,² a metric that is likely low, due in part to the human bias of generally attributing illness to a physical condition when one is present.

To fully understand how mental health conditions may drive GBD increases, we must understand the many linkages between human physical and mental health. While mental health is still a relatively young area of medical research, the more we learn, the more we understand that physical and mental health are fundamentally linked. Mental illness is not a diagnosis that stands alone, but rather, is a foundational component of overall health, as it impacts physical, behavioral, and social wellbeing.

There are many clear connection points between physical and mental health.

• Mental health disorders increase the risk for chronic physical health conditions.

  People with serious mental illness are at greater risk of developing a variety of chronic health ailments, such as diabetes, heart disease, and respiratory conditions.³ These conditions have the potential to impact nearly every system in the body. Population-based studies show that depression alone is an independent risk factor for stroke and for the development of type 2 diabetes and heart disease.^{3, 4} Mental illness also increases the likelihood of developing a broad range of respiratory conditions such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, and asthma.³

• Conversely, many physical health conditions may increase the risk for mental health disorders.

  People living with chronic conditions such as diabetes or heart disease have been shown to experience mood-specific mental health disorders such as anxiety and depression at a rate three times higher than that of the general population.⁵ For individuals with fibromyalgia and chronic fatigue syndrome the prevalence is even higher, impacting more than a quarter of the population with those conditions.⁵

  Further, many physical ailments may increase a patient’s risk of developing new mental health disorders after diagnosis.⁴ For example, the incidence of major depression increases following a heart attack or stroke, and patients living with cancer also face increased risk of developing a mental health disorder.

• Mental health comorbidities can complicate the diagnosis and treatment of associated physical health conditions.

  People living with mental health disorders may delay or avoid seeking help for the physical symptoms they are experiencing, which can adversely impact detection and diagnosis. In addition, once a physical condition is diagnosed, people with comorbid mental health disorders tend to have more difficulty adhering to recommended treatment plans for that condition, including medication adherence or blood glucose monitoring.⁴ The presence of mental health disorders can therefore adversely impact the prognosis of conditions such as diabetes, stroke, and cancer.

• Mental health disorders can affect the adoption of healthy behaviors.
  
  Mental health disorders commonly occur concurrently with known unhealthy or risky behaviors, such as problematic use of alcohol or other substances.⁶ People living with obesity are also more likely to also have a mental health disorder.⁷
  
  These disorders can make changing or adopting new, healthier behaviors more difficult. Looking at diabetes alone, patients with comorbid depression have greater difficulty making needed changes to their diet, increasing activity levels, or taking medications as prescribed.⁴
  
  More broadly, mental health disorders impact the key factors necessary for behavior change: it negatively impacts patients’ perceptions of their capabilities to execute change, their ability to develop or maintain the social connections crucial to providing support, and their ability to accept opportunities to adopt new behaviors. Further, lack of motivation is a common symptom among those with many mental illnesses.

• Mental illness can present as a physical condition in some patients.
  
  It has been estimated that at least one-third of all physical symptoms are medically unexplained. Common symptoms in this category, including pain, fatigue, dizziness, and “somatization” (medically unexplained physical symptoms coupled with psychological distress) are found in conditions such as chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, and temporomandibular joint dysfunction.⁴
  
  Somatization adds significant costs to healthcare systems, and research evidence supports that when the underlying psychological distress is treated, whether with antidepressant medication or cognitive behavioral therapy, healthcare costs can be reduced by as much as a third.⁴

How Insurers Can Help

The increasingly evident connections between physical and mental health have obvious risk management implications on underwriting and claims management, particularly for occupational disability and income protection products. However, due to our deep understanding of mortality and morbidity and our connections to policyholders through the variety of available insurance products, insurers and reinsurers are uniquely positioned to play a more proactive role in meeting society’s evolving mental health needs.

• Provide meaningful insurance coverage for mental health conditions.

  In some countries, it remains common to limit coverage for claims arising from mental health conditions. However, the more we learn, the more difficult it becomes to draw a clear line between physical and mental health. Claimants experiencing a mental health condition such as depression may not receive appropriate intervention during the early part of their claim should the insurer focus on this primary claim cause only. However, a claimant may already have or be developing a complicating physical condition such as a pain disorder for which cover cannot be limited, and because of this, the opportunity for early intervention, which would benefit both the claimant and the insurer, could be lost.

  On the other hand, a claimant who presents with a physical condition as a primary claim cause may well receive full necessary support, even though their condition may be complicated by the presence of mental health symptoms. As both individuals may experience the same level of impairment in performing their occupational duties, even though the primary driver may be different, their need for insurance cover and particularly early intervention to return to work would be the same.

  The increasing prevalence and awareness of mental health conditions over the last several years has governments and regulators around the world signaling a shift towards more equitable treatment of physical and mental health conditions in a variety of areas, including insurance. These trends, coupled with increasing customer awareness and desire for insurance products to keep pace with their evolving needs, suggest it would be a significant advantage for insurers to be proactive in creating mental health protection solutions.

• Shifting mindsets from protection to prevention.

  The concept of loss reduction is not new to insurers or claims managers, particularly as it relates to disability and medical coverage. Insurers are uniquely positioned at claim time to assess the full details of a claimant’s situation and identify holistic interventions that may improve prognosis and reduce escalation or recurrence. These are increasingly including innovative mental health interventions. For example, insurers around the world are dabbling with providing digital mental health apps to disability claimants early in the claim process, to get critical interventions to claimants earlier, while they wait to see a therapist. And, noting again the connection between physical and mental health conditions, these interventions are even being used with claimants where mental health is not the primary diagnosis, but where an increased risk exists of a mental health condition developing that is likely to adversely impact the prognosis of a physical condition such as cancer.

  Must insurers wait until a loss or illness occurs before taking action? When it comes to mental health, it has already been shown that the earlier the intervention, the more effective it may be. It is time for insurers to evaluate models for providing lower-intensity interventions to all policyholders, to determine if claims could be avoided altogether.

• Creating shared value through insurance. 
  
  Detection, prevention, and treatment of mental health conditions represents a significant and growing social issue – one already too big for governments to tackle on their own. If these challenges could be addressed, insurers would stand to benefit through reduced claims and claim severity as well as improved overall mortality and morbidity experience. Further, customers increasingly want to do business with companies that have purpose, are contributing to social progress, and generally care about customer wellbeing. Taking prevention one step further, insurers also have the opportunity to address mental illness as a social need through the products and services they offer. Life and health insurers have been applying this concept for many years via wellness programs attached to their protection products, which incentivize and reward customers who take steps to adopt healthy lifestyles. While the focus has traditionally been on physical activity, insurers are increasingly incorporating mental health themes through assessments and check-ins, rewarding behaviors which improve resilience and mental health literacy, and integrating themes of social connectivity and community.

Conclusion

In recent years and particularly in light of the pandemic, mental health has become recognized much more prominently as a leading factor in a person’s overall health and wellness. Insurers clearly recognize this shift, as evidenced in the increasing incorporation of mental health needs into benefits and customer offerings. It would be advisable for our industry to keep a sharp eye on trends in mental health, to be sure cover continues to recognize and incorporate consumer and market needs.