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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
Norman Sartorius, Prague 2012
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.
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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)
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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%
Norman Sartorius, Prague 2012
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%
Norman Sartorius, Prague 2012
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)
Norman Sartorius, Prague 2012
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.
Norman Sartorius, Prague 2012
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)
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
Norman Sartorius, Prague 2012
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.
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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.
Norman Sartorius, Prague 2012
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
Norman Sartorius, Prague 2012
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