Psychiatry and Primary CareComorbidity between common mental disorders and chronic somatic diseases in primary care patients☆
Introduction
Chronic somatic diseases are the main cause of disability throughout the world [1]. Mental diseases likewise affect a large percentage of the population and constitute another important cause of morbidity, mortality and disability [2], [3]. Different studies have reported a high prevalence of mental disorders in patients with chronic somatic illnesses. Metabolic, gastrointestinal and pulmonary diseases, as well as cardiovascular, muskuloeskeletal and neurological diseases show the highest prevalence rates of mental disorder [4], [5], [6], although no powerful association between any specific medical illness with a particular mental disorder has been found [7]. Such comorbidity in turn results in a poorer prognosis, increased resource utilization, higher costs, disability and poorer treatment compliance [8], [9], [10].
Most of these studies have analyzed the prevalences of mental disorders in populations with specific chronic diseases such as asthma, arteriosclerosis or cancer, and have been limited to the prevalences of affective or somatization disorders, or to elderly population groups [8], [11], [12], [13], [14]. The NIMH Epidemiological Catchment Area Study [15] was the first study to include a broad range of chronic medical disorders and mental illnesses, though the medical diagnoses were based on reports from the patients themselves not on the information supplied by the attending physicians. Furthermore, all the subjects were outpatients and were recruited from general population. Recently, the World Mental Health Surveys included a limited range of self-reported chronic physical conditions (arthritis, heart disease, respiratory disease, chronic back/neck pain, chronic headache and diabetes) [10]. The differences in mental disorders rates among medical patients suggest that epidemiological data are largely dependent on clinical setting, sample composition, psychopathology, chronicity, age, inconsistent diagnostic criteria, overlapping symptoms and other features [16], [17].
Most of these comorbidity studies were conducted in specialized services or specific groups and so might not be generalized to primary care patients. According to several epidemiologic studies, between 20% and 53% of primary care patients have a mental disorder [18], [19], [20], [21], [22]. Patients with medical–psychiatric comorbidity compose the majority of the population seen in primary care (PC). The aim of the present study was to estimate the comorbidity of common psychiatric disorders (affective and anxiety disorders) and complete range of medical diseases in a large sample of primary care patients; additionally, to analyze the relationship between the amount of somatic comorbidity and the higher risk for common mental disorders; to estimate if the prevalence rates of affective and anxiety disorders differ between different types of chronic somatic diseases; and finally, to find significant association between any specific medical illness and a particular mental disorder. This is the first nationwide cross-sectional epidemiological study carried out in the primary care setting in Spain and the largest in a European country.
Section snippets
Sample and procedure
A Spanish national cross-sectional epidemiological study was designed. Two thousand general practitioners (GPs) — distributed proportionally by provinces and health centers in Spain's 17 regional communities — were randomly selected to participate in this study. Male/female, rural/urban and age proportions were as well guaranteed. One thousand nine hundred twenty-five GPs joined the study after having received an open invitation (96.2% was the response rate). The GPs were instructed in the use
Results
Patients with medical diseases showed an increased risk of having any mental disorder compared with physically healthy subjects. When multivariate logistic regression analyses were conducted with adjustments for differences in sex, age, education and employment status, the prevalence rate of mental disorder (Table 1) was significantly higher in patients with chronic somatic diseases (56.8%) compared with physically healthy subjects (48.9%; AOR: 1.46).
Table 2 shows increased prevalence rates of
Discussion
The main conclusion drawn from our study is the high comorbidity between the most common mental conditions (depressive and anxiety disorders) and medical diseases in patients seen in the primary care setting. To date, the great majority of studies analyzing medical–psychiatric comorbidity are not population-based or have not been conducted in the primary care setting [17]. The investigation of comorbidity in population-based samples or in PC is essential in order to minimize the effect or
Acknowledgments
We thank all the Spanish GP physicians of the SCREEN GROUP who participated in data collection.
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The project was possible due to an unrestricted educational grant from Almirall Spain.