Another important factor influencing health and wellbeing of people
living with chronic conditions is sleep. Many chronic conditions are
associated with sleep-related problems, including sleep-related
breathing disorders, insomnia, sleep-related movement disorders and
sleep-related epilepsy \citep{Basnet2016,Dyken2012}. Critically, sleep quality is vitally important
for people living with chronic conditions as it can worsen their already
existing symptoms, for example, sleep quality has been shown to impact
on metabolic function of type 2 diabetes \citep{Lee2012}. More generally, comorbid
insomnia with a chronic condition is more severe and persistent than in
cases where insomnia is the only disorder \citep*{Ancoli-Israel2006}. Among an elderly population
with comorbid medical and mental illness, sleep is a useful predictor
for general physical and mental health-related quality of life status \citep{Reid2006}.
Sleep – in both the general population and among people with chronic
conditions – can be improved through physical activity \citep{Hartescu2015,Kredlow2015}. Alternative
forms of exercise such as Tai Chi are now being adopted and researched
to encourage greater physical activity \citep{Raman2013}. Other methods through which
sleep can be improved include music therapy, with research highlighting
benefits for both acute and chronic sleep disorders \citep*{Wang2014}. Massage,
acupuncture, natural sounds and music videos have also been reported to
be effective in health care settings \citep*{Hellström2011}. Environmental modifications may
also be another option for improving sleep, especially for those living
in care homes, and this opportunity is discussed further within the
section on the environment below.
In addition to positive health behaviours, the promotion of individual
strengths such as acceptance, optimism and resilience are likely to
promote health and wellbeing in people living with chronic conditions.
These strengths are developed through cognitive-behaviour therapy,
acceptance and commitment therapy and positive psychotherapy \citep{Hughes2017,Joyce2018} (Neenan, 2011).
Understandably, people living with chronic conditions have a much lower
level of resilience compared to healthy individuals although notably,
increased resilience among those living with a chronic condition is
associated with reduced psychological distress, and reduced symptoms of
anxiety and depression [REF]. Strikingly, a strong sense of coherence (or
SOC) is associated with a 30% reduction in mortality rate from
cardiovascular disease, cancer and all cause-related death [REF]. SOC
reflects feelings of confidence that stimuli in the (internal and
external) environment are comprehensible, manageable and meaningful.
Common resilience-related protective factors that are employed by this
population include self-efficacy and adaptive coping [REF]. A recent study
involved administering a 6-week programme that incorporated mindfulness
and CBT techniques to build resilience in individuals living with
chronic physical conditions including heart disease and diabetes [REF].
Findings emphasised positive experiences around well-being, condition
management, and social engagement. In another study, a mind-body
intervention involving dance and movement has also been shown to be
effective in improving resilience in people suffering from chronic pain [REF].
INTEGRATE INTO THE ABOVE: Psychological flexibility (PF) is another area
in which clinicians can work with to indirectly improve health and
wellbeing through influencing one’s ability to
respond flexibly to demands and alter mindsets and behaviours when
necessary, subsequently impacting both physical and mental health. For
example, research supports the use of Acceptance and Commitment Therapy
(ACT) to target PF [REF], with PF mediating the extent to which ACT
influences both mental and physical health outcomes, including anxiety,
depression, pain and medical visits [REF].
Many interventions based on the principles of positive psychology have
been applied to those living with chronic conditions and there are
promising results. For example, mindfulness meditation has proven
effective in reducing pain (Hilton et al., 2017; Veehof, Trompetter,
Bohlmeijer & Schreurs, 2016; Zeidan & Vago, 2016) and optimism
training can be effective among people with heart disease in increasing
life satisfaction and hope, along with reducing anxiety (Mohammadi et
al., 2018). Optimism has also been associated with higher quality of
life among people with heart failure (Kraai et al., 2018).
Research has also focused on the relationship between health behaviours
and mental health, with a systematic review of randomised controlled
trials concluding that dietary changes have the potential to improve
depression symptomology [REF]. For example, an RCT investigated the impact of
the Mediterranean diet on adults with self-reported depression [REF]. Results
highlighted a negative correlation between adherence to the
Mediterranean diet and depression and quality of life scores at both the
3- and 6-month time points. Using exercise as a clinical target to
improve mental health has also proven beneficial, with evidence to
suggest exercise to be as effective as medication and psychotherapy in
the treatment of mild to moderate depression [REF]. A meta-analysis on 25
RCTs found exercise to have a significant effect on reducing depression,
even among those major depressive disorders [REF], with another review
finding exercise to be beneficial in the treatment of mood disorders
more generally [REF]. Given that depression is associated with a high
incidence of cardiovascular diseases, diabetes and metabolic syndrome,
using exercise as a treatment will be beneficial for the symptoms of
both depression and the chronic illness [REF]. In a Brazil survey, almost
half of those living with a mood or anxiety disorder also suffered from
comorbid chronic pain [REF], and data from 17 countries provides evidence of
mental health disorders increasing the likelihood of developing a
chronic physical condition [REF], further highlighting associations between
chronic illness and mental health and the importance of understanding
both the physical and mental benefits of modifying health behaviours.
In summary, there is tremendous opportunity for improving the health and
wellbeing of people living with chronic conditions by focusing on the
individual. Traditional routes for improving physical health, such as
physical activity, diet and sleep may now be considered as opportunities
to support mental wellbeing, when combined with strategies for behaviour
change. Treatments that build strengths, resilience, optimism and
positive psychological attributes will provide useful strategies to
promote health and wellbeing, as has been discussed previously [REF].
INTEGRATE THE FOLLOWING FROM ABOVE: Targeting Resilience & Sense of Coherence