Comorbidity of mental and physical illness Professor N. Sartorius, MD, PhD, Geneva, Switzerland.

Comorbidity of mental and physical illness

Professor N. Sartorius, MD, PhD,Geneva,

Switzerland

Norman Sartorius, Prague 2012

At least 50% of those admitted to the mental hospital in Tajikistan will be dead before the year of their admission is over, because of a physical illness*

*Report by a doctor working with Physicians without borders, 2008


Warning

On the whole the literature about comorbidity of mental and physical illness is giving a patchy and incomplete picture because• The studies were done outside some Western

European countries, Australia and the USA• Current reporting systems in health services hide

comorbidity• There is far too little interest in research on

comorbidity• Medicine is increasingly disjointed.


Verona, 1982-2001): Avoidable mortality (SMR) for persons with mental disorders

All patients 4.31

Males 6.13

Females 2.84

Schizophrenia et al. 4.83

Severe mood disorders 4.86

Mild mood disorders 2.41

Substance abuse 18.84

Neurotic/somatoform 2.48

Personality disorders 3.03


Increased death rates of mentally ill peopleDeath rates in people with mental illness compared to the rest

of the population, Western Australia (1980-1998)

Lawrence D, Coghlan R. NSW Public Health Bull. 2002; 13:155-158.

Malignant Neoplasm

s

Diabetes Mellitus

Acute Myocaridal Infarction

Other Ischaemic Heart disease

Cerebrovascular disease

Other ciruclatory system

Pulmonary disease

Accidental death

Suicide

050

100150200250

Mentally IllWA Population


Mortality • Sites in which patient SMR is

not different from populations’ SMR– Sofia (1.04)– Cali (1.31)– Moscow (1.41)

• Sites in which patients’ SMR is higher than the populations’ SMR– Agra (1.86)– Chandigarh urban (1.88)– Prague, 16 years FU (2.53)– Chandigarh rural (3.02)– Honolulu (3.13)– Nottingham (3.31)– Prague 26 years FU (3.84)– Dublin (4.10)– Mannheim (5.55)– Nagasaki (5.71)– Groningen (8.88)


Causes of death of people with schizophrenia

• In developing countries natural causes prevail• In developed countries there are more un-

natural causes, mainly suicide • Until the upsurge of tuberculosis and AIDS

communicable and infectious diseases were not more frequent causes of death in the developing countries than in the developed


Prevalence of comorbidity

• Two thirds of people over 55 have more than one disorder at the time of the enquiry*

• Comorbidity increases with age• Comorbidity is higher in women than in men

at all age strata • Comorbidity is the rule, not the exception.

• Ustun, B. (2005) Comorbidity & ICD


Comorbidity between mental and physical illness

• Mental disorders are frequently comorbid with physical illness and can precede it, follow it or occurr simultaneously

• The impact of a comorbid mental and physical illnesses on disability is not additive but usually potentiated


Cost of comorbidity: an example

• Depression associated with diabetes doubles the cost of treating diabetes (Ciechanowski, 2000)

• Cost of medical services for people with depression is four times higher than in people without depression (Egede, 2002)

• Disability resulting from mental illness is amplified by the simultaneous presence of somatic illness (and vice versa) causing presenteism and absenteism


Medical comorbidity with schizophrenia

• Tuberculosis• HIV++• Hepatitis B/C• Osteoporosis/decreased bone

mineral density• Poor dental status• Impaired lung function• Sexual dysfunction• Extrapyramidal side effects of

antipsychotic drugs; motor signs in antipsychotic-naïve patients

• Breast cancer• Obstetric complications++• Hyperprolactinemia-related

side effects of antipsychotics (eg. Irregular menses, galactorrhea)

• Cardiovascular problems++• Hyperpigmentation (side effect

of chlorpromazine)• Obesity++, diabetes,

hyperlipidemia, metabolic syndrome

• Thyroid dysfunction

Physical disease with increased frequency in schizophrenia

(++) very good evidence for increased risk (eg, population-based studies,

Leucht S. Physical illness and schizophrenia. Presented at the 14th European Congress of Psychiatry, 4-8 March 2006, Nice, France


Prevalence of medical disorders in seriously mentally ill Medicaid patients

Diagnosis Prevalence

Pulmonary disease 31%

Heart disease 22%

Gastrointestinal disease 25%

Skeletal & connective tissue disease 19%

Metabolic disease 15%

Diabetes 12%

Any medical illness 75%


Depression in people with other diseases

Cancer (depending on location) 13-57%Diabetes 9-27%Myocardial infarction 30-50%Coronary disease and Congestive heart failure 20%


Reasons for high prevalence of comborbidity of mental and physical illness

• Life style of people with mental illness• Constitutional factors• Consequences of treatment• Consequences of attempted suicide• Developmental (e.g. childhood adversity)


Depression and cardiovascular illness

Appropriate treatment of depression decreases the mortality of people with depression from these diseases.Yet, mortality of people with heart disease and depression, remains higher than the mortality from heart disease in the general population.


Childhood adversity, depression and cardiovascular illness (odds ratios)

Childhood adversity events

Cardiovascular illness

1 1.24

2 1.60

3 or more 2.40

Early onset depression 1.91

Van Korff et al (2009)


Other reasons for higher morbidity and mortality (and unawareness about it)

• Widely held wrong beliefs• Neglect of physical illness in psychiatric

patients and of mental illness in general medicine

• Disparities of care• Attitudes of policy makers


Beliefs and doctrines

• Mentally ill people are less likely to have physical illnesses than those without mental illness

• Mentally ill people are not a credible source of information about their somatic illness

• The best place to treat a person with mental illness (almost regardless of illness) are mental health institutions


Beliefs and doctrines

• It is more probable that a mental illness has somatic symptoms than that it is co-morbid with physical illness

• When someone has a mental and a physical illness the one that is more severe should be treated first

• One diagnosis per person suffices in hospital statistics

Neglect of examinations in Veterans’ Aministration hospitals

313.586 patients in VA hospitals had diabetes and of those 25% (76.799) had a mental disorder as well depression, anxiety, psychosis, substance abuse or personality disorders.)

Except for those with anxiety they received fewer HbA tests, fewer eye examinations, no LDL tests and had poor lipemic and glycemic control.

Frayne et al, Arch. Intern. Med., 2005


Unawareness of health care of people with mental and physical illness in Europe

• In a general population in Belgium, France, Germany, Italy, the Netherlands and Spain 6% of those seen had a mental disorder.

• 48% of the people with mental health problems had no formal health care compared to 8% of those with diabetes.

Alonso et al, BPJ 2007



Reduced access to services of mentally ill

Dementia

Alcohol/Drugs

Schizophrenia

Affective Psychosis

Other Psychosis

Neurotic Disorder

Personality Disorder

Adjustment Reaction

Depressive Disorder

0

0.5

1

1.5

2

2.5

3

Procedures

Hospitalisation

Death

IHD Hospitalisation Revascularisation Procedure and Death Rates by Principal psychiatric Diagnosis, Western Australia (1980-1998)

IHD:ischaemic heart diseaseLawrence D, Coghlan R. NSW Public Health Bull. 2002; 13:155-158.


Disparities in care

• In developing – and some other countries mental health institutions are not equiped nor supported in a manner that would allow them to adequately treat physical illness

• Psychiatrists know little about physical illness• Non-psychiatrists know little about psychiatry


Disparities in care

• The decision on the choice of treatment in people with comorbid illnesses and reporting about them depends more on the health care facility which they have contacted than on the diseases they have


The UN Assembly debate

In September 2011 the UN, “convinced that the non-communicable diseases are a major threat to public health”, will have a special session dealing with problems related to non-communicable diseases . Mental disorders will not be considered in that session.


Comorbidity: prospects for the immediate future

Comorbidity of mental and physical illness is likely to grow in the years to come because of:• Success of medicine in saving lives• Changes of the demographic structure of

populations (e.g. longer life expectancy)• Increasing gaps between disciplines of medicine• Immunological changes of populations that may

be due to environmental factors• Iatrogenic diseases


Conclusions

• Comorbidity of mental and physical illness is frequent and neglected. The disability and cost it produces are not simply additive.

• The organization of health services is currently not fit to offer proper care to people with comorbid physical and mental illness

• Comorbidity is the major challenge to health care in the 21st century

Comorbidity of mental and physical illness Professor N. Sartorius, MD, PhD, Geneva, Switzerland.

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