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ORIGINAL ARTICLE
Year : 2013  |  Volume : 4  |  Issue : 1  |  Page : 12-17

Medical comorbidity in in-patients with psychiatric disorder


Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka, India

Date of Web Publication20-May-2013

Correspondence Address:
P John Mathai
Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka
India
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Source of Support: Indian council of medical research-short term research support for undergraduates, Conflict of Interest: None

DOI: 10.4103/0975-9727.112264

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  Abstract 

Objective: To study the prevalence of concurrent medical comorbidity in patients admitted with psychiatric disorders. Materials and Methods: One hundred patients with psychiatric disorders admitted to the general wards of the Department of Psychiatry, Father Muller Medical College, Mangalore were assessed for evidence of concurrent medical comorbidity. The assessment included clinical examination and investigations. Results: 49% of in-patients with psychiatric disorders had medical comorbidity. 26% of patients with bipolar disorder, 13% of patients with schizophrenia and 8% of patients with depressive disorders had medical comorbidity. Diabetes mellitus, hypothyroidism, and hypertension were the most common medical comorbidity. The medical comorbidity was not related to any of the socio-demographic variables. The medical comorbidity was not related to the clinical variables such as duration, age of onset of the psychiatric disorders. The medical comorbidity was significantly more in patients with bipolar mood disorder. Conclusions: 49% of in-patients with psychiatric disorders have concurrent medical comorbidity. Diabetes mellitus is the most common medical comorbidity. The present investigation is an observational, descriptive, cross-sectional clinical study. It has certain merits and limitations. Future studies with more refined methodology are required to draw definite conclusions.

Keywords: Clinical examination, concurrent comorbidity, medical comorbidity, psychiatric disorders


How to cite this article:
Manuel CM, Rao PP, Rebello P, Safeekh A T, Mathai P J. Medical comorbidity in in-patients with psychiatric disorder. Muller J Med Sci Res 2013;4:12-7

How to cite this URL:
Manuel CM, Rao PP, Rebello P, Safeekh A T, Mathai P J. Medical comorbidity in in-patients with psychiatric disorder. Muller J Med Sci Res [serial online] 2013 [cited 2019 Oct 16];4:12-7. Available from: http://www.mjmsr.net/text.asp?2013/4/1/12/112264


  Introduction Top


Comorbidity refers to the occurrence of two clinical disorders in the same patient. Defined literally, every pair of disorders where the diagnosis of one does not categorically exclude the diagnosis of the other is potentially comorbid. The two disorders should occur concurrently. Relevant comorbidity can be illustrated in clinical, familial, or epidemiological settings.

Medical diseases are present in at least 50% of psychiatric patients and it is generally believed that the medical comorbidity are under recognized, misdiagnosed, and inadequately treated. [1] Severe mental disorders are associated with significant excess of physical comorbidity and mortality. [2],[3],[4],[5] This fact is a major health concern. The medical diseases could be the result of the psychiatric syndromes, the consequences of the psychiatric disorders, adverse effects of the psychiatric medicines or co-existent incidental medical disorders. Although, suicide is prevalent in this population, ischemic heart disease may be the major contributor to the excess mortality. [6] Published guidelines from the United Kingdom (National Institute for Clinical Excellence 2006) recognize the impact of physical comorbidity in schizophrenia and bipolar mood disorders as well as the paucity of high quality research in this field. There are number of recent studies that have estimated the prevalence of coronary heart disease and metabolic disorders in-patients with schizophrenia and non-affective psychosis. [7] There is a significant medical comorbidity in schizophrenia that include the common medical diseases that occur very frequently and certain uncommon diseases. Between 46-80% of in-patients and 20-43% of out-patients with schizophrenia have comorbid medical diseases. Communicable diseases such as HIV/AIDS, hepatitis C and tuberculosis, obesity with concomitant metabolic syndrome and diabetes mellitus are common in schizophrenia. Rare genetic or idiopathic disorders such as metachromatic leucodystrophy, intermittent porphyria and celiac disease are reported to occur in schizophrenia. [8],[9]

Current models of care appear to be insufficient for a large proportion of people with major psychiatric disorders and comorbid medical diseases. Even after significant contact with health-care services, the rates of undiagnosed medical diseases are often high. There is need for greater communication and collaboration between psychiatrists and medical-health professionals. The current training is inadequate to prepare physicians to deal effectively with medical diseases in psychiatric patients.

Consistent evidence spanning many decades, different countries and various practice settings indicates that patients with schizophrenia have shortened life expectancy. [9] This evidence has a rich heritage dating back to the 19 th century. Today, a large body of literature describes a significantly higher mortality rate in patients with mental disorders in general and schizophrenia in particular when compared to that of the general population. Leucht et al. in a review of 44,202 papers from MEDLINE data base in 2007 reported that to a large extent the papers were specific to schizophrenia. They also reported that 86% of the papers were from the industrialized countries. [10] The papers reported that there are at least 23 categories of medical diseases that are comorbid with schizophrenia. These medical disorders include: (1) diseases that cause excess mortality such as diabetes mellitus, cardiovascular diseases, infectious diseases, cancer, and pulmonary diseases as well as (2) diseases that are risk-factors for other diseases such as obesity, hypertension, dyslipidemia, insulin resistant hyperglycemia, and metabolic syndrome. Many of the risk-factors attributed to the second generation anti-psychotics and anti-depressants. [11],[12]

A meta-analysis of 18 recent studies estimated a crude mortality rate of 189 deaths/10,000 population per year and 10 year survival rate of 80% in patients with schizophrenia. Mortality rate in males was significantly higher than that of females with schizophrenia. The higher mortality rate in males was attributed to excess of suicides and accidents. Unnatural causes of death apart from the leading causes of death in schizophrenia are similar to that of the general population. [8] Between 46% and 80% of in-patients with schizophrenia and 20% and 43% of out-patients with schizophrenia are found to have concurrent medical diseases. [13]

Miller et al. investigated 20,018 patients admitted to a public-mental hospital in Ohio between 1998 and 2002. They have reported that there was excess mortality in patients with severe mental disorders. Heart disease (21%) and suicide (18%) were the most common causes of death. [14] Available papers on medical comorbidity and mood disorders are not substantial enough to draw definite conclusions. The medical comorbidities reported include brain tumor, head trauma, Darier's disease, asthma, obesity, diabetes mellitus, hypothyroidism, polycystic ovarian syndrome, renal failure, and skin rashes. [15]

Aims and Objectives

  1. To evaluate frequency and nature of medical comorbidity in in-patients with psychiatric disorders
  2. To study the relationship between medical comorbidity and psychiatric clinical factors
  3. To study the relationship between medical comorbidity and socio-demographic factors.

  Materials and Methods Top


The present investigation is an ongoing research project in the Department of Psychiatry in Father Muller Medical College since July 2009. This is a preliminary report on 100 in-patients. Father Muller Medical College Hospital is a multi-specialty general teaching hospital in Mangalore. There are three clinical units in the Department of Psychiatry with 10 consultants and 14 resident doctors. The department has 60 general psychiatry, 30 family psychiatry, 60 de-addiction, and 17 special ward beds for psychiatric in-patients. The average daily admission to the department ranges from 7 to 10 patients. All psychiatric patients admitted to the general and family psychiatry wards under psychiatry unit-B, in the Father Muller Mental Health Center constituted the population for the investigation. One hundred consecutive in-patients that satisfied the inclusion and exclusion criteria were selected as the sample for the study. The specific inclusion and exclusion criteria are given below.

Inclusion Criteria

  1. Adult psychiatric in-patients between 18 years and 65 years
  2. Male and female in-patients.
Exclusion Criteria

  1. Patients with organic mental disorders
  2. Patients with substance use disorders
  3. Mental retardation.
The following were the tools used in the investigation:

  1. A specially designed pro-forma to collect and document the socio-demographic and psychiatric clinical data
  2. The socio-economic status schedule (SESS) to assess the socio-economic status of the patients (Sodhi and Sharma 1986).
The methods for assessment for medical comorbidity in patients admitted with psychiatric disorders included the following:

  1. Thorough clinical examination
  2. Laboratory investigations (Complete blood count, Random blood sugars, Renal function tests, Liver function tests, Thyroid stimulating hormone, Lipid profile, Electrocardiography)
  3. Other investigation when required (Treadmill test, Echocardiography, Electroencephalography, Brain imaging)
  4. Medical consultation when required.
The institutional ethical committee clearance was obtained. The design and nature of the clinical study was explained to the patients and to significant relatives of patients. Informed consent was obtained from patients and significant relatives when required.

All the patients ( n = 100) were subjected to a thorough clinical examination, which included physical and mental status examination. When indicated extended neurological examination was carried out to rule out neuro-behavioral disorders. The socio-demographic data was collected and recorded in the specially designed pro-forma. The socio-economic class was assessed using the SESS. The clinical psychiatric data was recorded in the pro-forma. For patients who were not co-operative for detailed clinical examination due to their psychopathology, the examination was repeated after remission of psychiatric symptoms.

Samples for routine laboratory investigations were sent. This included samples for CBC, RBS, RFT, LFT, lipid profile and TSH. ECG was taken for all the patients when they were co-operative for the same. Other investigations such as TMT, echocardiography, CT scan brain, MRI brain, EEG, and others suggested by consultants were carried out when required.

The diagnosis of medical diseases was confirmed by consultants from general medicine, neurology or endocrinology. The data collection was carried out during January 2011 to December 2011 . The results obtained were analyzed with appropriate statistical methods.


  Results Top


Medical comorbidity is present in 27% of males compared to 22% of females. It is highest in the age group of 31-40 years (30.6%) followed by 18-30 and 41-50 years (24.5% each) and least in the age group of 51-64 years (20.4%). In the present study, 60% belong to Hindu religion, 25% are Muslims and 15% Christians and medical comorbidity is seen in 63.3%, 24.5%, and 12.2% of individuals, respectively. Most patients are from a backward caste (52.7%) and comorbidity was seen in 48.6% of them followed by dominant caste (45.7%). 55.1% of the 52 married patients have comorbid medical illness compared to 38.8% of 43 individuals who are single. Highest proportion of patients in the sample are from rural area (62%) followed by from semi-urban area (25%) and comorbidity is seen in 63.3% and 26.5% respectively. 35% of the patients are middle class pass, 28% intermediate, and 15% with BA/BSc degree with comorbid conditions in 34.4, 18.4, and 20.4% respectively. Majority of the patients in the present study are in business (42%) followed by 20% with semi-skilled jobs and most patients with comorbidity are from these groups (40.8 and 16.3% respectively). 55% of the 52 patients are from nuclear family and 30.6% of 27 are from a joint family who are suffering from medical disorders. 60% are with an average monthly income of lesser than Rs. 3000 and 55% of these have medical comorbidity. Majority are from SESS category III (51%) and II (39%) with medical comorbidity seen in 40.8 and 42.9% respectively. No significant correlation is found between socio-demographic characteristics of psychiatric patients, such as, age, gender, religion, caste, marital status, domicile, educational status, occupation, type of family, average monthly income, and socio-economic status, with medical comorbidity [Table 1]. 51% of the patients have the age of onset of the psychiatric disorders at the age group of 18-30 years of which medical disorders are present in 53% patients. Only 5% of individuals have onset of psychiatric disorders between 51 and 64 years with medical disorders present in only 6%. 24.5% individuals with medical comorbidity have psychiatric disorders for duration of 5-10 and 10-20 years each. Most common substance use in the subjects are coffee/tea (54%) followed by smoking and alcohol (17% each). Medical disorders are comorbid in 53% of patients using coffee/tea and 18.4% each in smokers/alcohol users. The age of onset and the total duration of psychiatric disorders and history of substance use do not significantly correlate with the presence of medical comorbidity [Table 2]. A diagnosis of bipolar affective disorder, schizophrenia, and depression are made in 48, 32, and 16 patients respectively. Diabetes mellitus (8), hypothyroidism (6), hypertension (5) and the total medical comorbidity (26), are significantly more in Bipolar mood disorders when compared to schizophrenia, depression, and other disorders [Table 3], [Figure 1].
Figure 1: Psychiatric diagnosis and medical comorbidity

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Table 1: Socio‑demographic factors and medical comorbidity

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Table 2: Psychiatric clinical variables and medical comorbidity

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Table 3: Psychiatric diagnosis and medical comorbidity

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  Discussion Top


The results of the present investigation indicate that medical concurrent comorbidity is common in psychiatric in-patients. 49% of in-patients with major psychiatric disorders have at least one concurrent medical comorbidity; 26% of patients with bipolar disorder; 13% of patients with schizophrenia and 8% of patients with depressive disorders have concurrent medical comorbidity. Patients with bipolar disorder have significantly more medical comorbidity compared to the other two groups of patients. Diabetes mellitus, hypothyroidism, and hypertension are the most common medical comorbidity.

Earlier studies report that there is excess mortality and medical comorbidity in in-patients and out-patients with major psychiatric disorders. [14] The results of the present study are in concordance with that of the earlier studies. The findings of the present investigation do not agree with the very high prevalence of medical comorbidity in out-patients and in-patients with schizophrenia. [13] The higher prevalence of medical comorbidity in bipolar disorder is a unique finding of the present study. [8],[13],[14],[15]

The medical comorbidity does not have any significant relationship to any of the socio-demographic factors. The medical comorbidity does not have any significant relationship to age of onset of psychiatric disorders, duration of psychiatric illness or any other clinical factors except the diagnostic category. Earlier investigations report that the medical comorbidity may be related to psychiatric medicines. [11],[12]

The present investigation is an observational, descriptive, cross-sectional clinical study. This investigation is perhaps one of the few published studies to compare medical comorbidity in mood disorders to that of schizophrenia. The present study has certain merits and limitations. Although, selection bias is avoided the sample is not representative of the general population of such patients. The sample size is inadequate and the assessment is not double-blind and hence assessment bias is possible. The relationships of medical comorbidity and the medications are not investigated. The out-patients are not investigated.

Future studies with better methodology are required to draw definite conclusions. A much larger sample of representative population without selection bias and more rigorous and unbiased assessment for medical comorbidity are required.


  Conclusion Top


The following are the conclusions of the present clinical investigation on prevalence of medical comorbidity in in-patients with psychiatric disorders.

  1. 49% of in-patients with psychiatric disorders have medical comorbidity
  2. 26% of patients with bipolar disorder, 13% of patients with schizophrenia and 8% of patients with depressive disorders have medical comorbidity
  3. Diabetes mellitus, hypothyroidism, and hypertension are the most common medical comorbidity
  4. The medical comorbidity is not related to any of the socio-demographic variables
  5. The medical comorbidity is not related to the clinical variables such as duration and age of onset
  6. The medical comorbidity is significantly more in patients with bipolar mood disorder
  7. Future research with better methodology is required to draw definite conclusions.


 
  References Top

1.Manu P, Suarez RE, Barnett BJ. Hand Book of Medicine in Psychiatry. Washington DC: American Psychiatric Publishing Inc.; 2006. p. xxv-xxvii.  Back to cited text no. 1
    
2.Brown S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry 1997;171:502-8.  Back to cited text no. 2
    
3.Phelan M, Stradins L, Morrison S. Physical health of people with severe mental illness. BMJ 2001;322:443-4.  Back to cited text no. 3
    
4.Osborn DP, Nazareth I, King MB. Risk for coronary heart disease in people with severe mental illness: Cross-sectional comparative study in primary care. Br J Psychiatry 2006;188:271-7.  Back to cited text no. 4
    
5.Osborn DP, Levy G, Nazareth I, Petersen I, Islam A, King MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Rsearch Database. Arch Gen Psychiatry 2007;64:242-9.  Back to cited text no. 5
    
6.Lawrence DM, Holman CD, Jablensky AV, Hobbs MS. Death rate from ischaemic heart disease in Western Australian psychiatric patients 1980-1998. Br J Psychiatry 2003;182:31-6.  Back to cited text no. 6
    
7.Mackin P, Bishop D, Watkinson H, Gallagher P, Ferrier IN. Metabolic disease and cardiovascular risk in people treated with antipsychotics in the community. Br J Psychiatry 2007;191:23-9.  Back to cited text no. 7
    
8.Jablensky A. Epidemiology of schizophrenia. In: Gelder MG, Andreasen NC, Lopez-Ibor Jr JJ, Geddes JR, editors. New Oxford Textbook of Psychiatry. 2 nd ed.: Oxford University Press; 2009. p. 540-53.  Back to cited text no. 8
    
9.Newcombwe JW, Fahnestock PA, Haupt DW. Medical health in schizophrenia. In: Sadock BJ, Sadock VA, Ruiz P, editors. Comprehensive Textbook of Psychiatry. 9 th ed. New York: Wolters Kluwer; 2009. p. 1572-82.  Back to cited text no. 9
    
10.Leucht S, Burkard T, Henderson J, Maj M, Sartorius N. Physical illness and schizophrenia: A review of the literature. Acta Psychiatr Scand 2007;116:317-33.  Back to cited text no. 10
    
11.Mackin P, Bishop D, Watkinson H, Gallagher P, Ferrier IN. Metabolic disease and cardiovascular risk in people treated with antipsychotics in the community. Br J Psychiatry 2007;191:23-9.  Back to cited text no. 11
    
12.Strom BL, Eng SM, Faich G, Reynolds RF, D'Agostino RB, Ruskin J, et al. Comparative mortality associated with ziprasidone and olanzapine in real-world use among 18,154 patients with schizophrenia: The Ziprasidone Observational Study of Cardiac Outcomes (ZODIAC). Am J Psychiatry 2011;168:193-201.  Back to cited text no. 12
    
13.Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophr Bull 1996;22:413-30.  Back to cited text no. 13
    
14.Miller BJ, Paschall CB 3 rd , Svendsen DP. Mortality and medical comorbidity among patients with serious mental illness. Psychiatr Serv 2006;57:1482-7.  Back to cited text no. 14
    
15.Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med 2005;67:1-8.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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