Psychiatric aspects of chronic physical disease

doi:10.1016/j.mpmed.2008.07.003

Medicine

Volume 36, Issue 9, September 2008, Pages 471-474

https://doi.org/10.1016/j.mpmed.2008.07.003 Get rights and content

Abstract

Chronic diseases are now the leading cause of death and disability within developed countries. An increasing awareness of how individuals cope with chronic, life-long health problems has required clinicians to develop alternative models of care to those traditionally used for acute medical illness. Concepts such as the biopsychosocial model of illness, stigma, expert patients, treatment adherence and the recovery model are crucial to the understanding of how patients with chronic illness should be managed. The diagnosis of a life-long medical condition requires an individual to make a number of adjustments, and may contribute to the development of psychiatric illness. Rates of psychiatric disorders, such as depression and anxiety, are increased at least two-fold amongst individuals with chronic medical problems. There is increasing evidence that depression may also be a risk factor in the development of some chronic diseases, especially those related to lifestyle, such as type 2 diabetes and cardiovascular disease and may influence their prognosis. As a result the early detection and management of psychiatric morbidity in those with chronic illness is essential.

Section snippets

The biopsychosocial model

The philosophical dualistic separation of mind and body was a feature of the biomedical models which dominated medical thinking for much of the 20th century. However, in 1977 George Engel proposed that to understand and respond to a patient’s suffering clinicians must simultaneously consider the biological, psychological and social dimensions of an illness.⁴ This model came to be known as the biopsychosocial model and is now central to the understanding and management of chronic medical

The role of ‘patient’

When a person is diagnosed with an illness they become a patient. This idea was famously conceptualized by Parsons’ notion of a ‘sick role’, in which an ill individual was exempt from normal social roles provided they undertook certain obligations, such as to seek professional advice and try to return to good health.⁶

Patients with a chronic illness are experts in their own illness and have a major role in the monitoring and treatment of any relapses. Some patients experience this increased

Treatment adherence

It has been estimated that as many as 60% of patients with a chronic illness are poorly adherent to treatment.⁸ There are multiple factors which may contribute to low levels of treatment adherence. Patients may not have received understandable instructions or may forget when they are meant to take medication. Many chronic illnesses do not have obvious physical symptoms, leading many patients to assume they do not need to continue to take medication. Sometimes patients may have difficulties

Stigma and the recovery model

In 1963, the sociologist Erving Goffman described how some individuals were disqualified from full social acceptance, or stigmatized, due to their ill health, behaviour or appearance, ‘their spoilt identity’.¹⁰ Individuals suffering with chronic diseases continue to suffer the consequences of stigma in a number of different ways. Some conditions are viewed differently from others; for instance, there is a societal widespread sympathy for people with breast cancer whereas diabetes is sometimes

Some specific chronic diseases

Psychiatric problems are relevant in all types of chronic disease. We have chosen four examples of chronic illnesses to demonstrate the way in which psychiatric and chronic physical health problems can interact.

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Old age depression: worse clinical course, brighter treatment prospects?
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It is well established that depression is more common among those with chronic physical health problems and that these patients are often challenging to diagnose and treat.1,2
Depression and the older medical patient - When and how to intervene
2014, Maturitas
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In addition to antidepressants and ECT, psychological treatments have also been shown to be effective in older depressed subjects, either as a stand-alone treatment or as a component of a stepped-care programme [7]. Developing physical illness in old age has long been recognised as a major risk for depression [8,9]. For example, Pfaff et al. [10] demonstrated that depression was 3–4 times more likely to occur amongst older adults with the highest number of medical comorbidities and the greatest level of functional impairments.
Depression in the elderly, particularly those with chronic physical health problems, is a common, but complex problem. In this paper we review the research literature on both the epidemiology and management of depression in the older medical patient. After a general overview of depression in the elderly, we discuss some of the particular issues relevant to depression and co-morbid physical illness amongst elderly patients. Depression can be difficult to diagnose in medically unwell older adults, particularly when there is substantial overlap in symptomatology. The epidemiology and evidence base for the treatment of depression in a number of chronic health problems common in an older adults population are then discussed, specifically cardiac disease, cerebrovascular disease, cancer, chronic kidney disease, chronic obstructive pulmonary disease, and Parkinson's disease. For many of these conditions there is emerging evidence that treatments can be effective in reducing depressive symptoms. However, these potential benefits need to be balanced against the often-increased risk of adverse events or interactions with medical treatments. Although co-morbid depression is consistently associated with poorer medical outcomes, there is limited evidence that standard anti-depressive therapy has additional benefits in terms of physical health outcomes. Collaborative care models appear particularly well suited to medically unwell older adult patients, and may provide more generalised benefits across both mental and physical health measures.
Associations between physical activity and mental health among bariatric surgical candidates
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After controlling for bodily pain and role limitations due to physical problems, associations between PA parameters and depressive symptoms were no longer significant. It is possible that they confounded the relationship (i.e., pain and physical health factors may have limited PA), while also independently increasing depressive symptoms [55]. However, it is also possible that pain and physical role limitations mediated the relationship between PA and depressive symptoms, given that PA participation can decrease pain and improve physical health, thereby lessening role limitations due to physical problems [56].
To examine associations between physical activity (PA) and mental health among adults undergoing bariatric surgery.
Cross sectional analysis was conducted on pre-operative data of 850 adults with ≥ class 2 obesity. PA was measured with a step activity monitor; mean daily steps, active minutes, and high-cadence minutes (proxy for moderate–vigorous intensity PA) were determined. Mental health functioning, depressive symptoms and treatment for depression or anxiety were measured with the Medical Outcomes Study 36-item Short Form, Beck Depression Inventory, and a study-specific questionnaire, respectively. Logistic regression analyses tested associations between PA and mental health indicators, controlling for potential confounders. Receiver operative characteristic analysis determined PA thresholds that best differentiated odds of each mental health indicator.
Each PA parameter was significantly (p < .05) associated with a decreased odds of depressive symptoms and/or treatment for depression or anxiety, but not with impaired mental health functioning. After controlling for sociodemographics and physical health, only associations with treatment for depression and anxiety remained statistically significant. PA thresholds that best differentiated those who had vs. had not recently received treatment for depression or anxiety were < 191 active minutes/day, < 4750 steps/day, and < 8 high-cadence minutes/day. Utilizing high-cadence minutes, compared to active minutes or steps, yielded the highest classification accuracy.
Adults undergoing bariatric surgery who meet relatively low thresholds of PA (e.g., ≥ 8 high-cadence minutes/day, representative of approximately 1 h/week of moderate–vigorous intensity PA) are less likely to have recently received treatment for depression or anxiety compared to less active counterparts.
Common mental disorders and disability pension award: Seven year follow-up of the HUSK study
2010, Journal of Psychosomatic Research
Rates of disability pension (DP) awards remain high in most developed countries. We aimed to estimate the impact of anxiety and depression on DPs awarded both for mental and for physical diagnoses and to estimate the relative contribution of sub case-level anxiety and depression compared with case-level symptom loads.
Information from a large cohort study on mental and physical health in individuals aged 40–46 (N=15,288) was linked to a comprehensive national database of disability benefits. Case-level and sub case-level anxiety and depression were defined as scores on the Hospital Anxiety and Depression Scale of ≥8 and 5–7, respectively. The outcome was incident award of a DP (including ICD-10 diagnosis) during 1–7-year follow-up.
DP awards for all diagnoses were predicted both from case-level anxiety [HR 1.90 (95% CI 1.50-2.41)], case-level depression [HR 2.44 (95% CI 1.65–3.59] and comorbid anxiety and depression [HR 4.92 (95% CI 3.94–6.15)] at baseline. These effects were only partly accounted for by adjusting for baseline somatic symptoms and diagnoses. Anxiety and depression also predicted awards for physical diagnoses [HR 3.26 (95% CI 2.46–4.32)]. The population attributable fractions (PAF) of sub case-level anxiety and depression symptom loads were comparable to those from case-level symptom loads (PAF anxiety 0.07 versus 0.11, PAF depression 0.05 versus 0.06).
The long-term occupational impact of symptoms of anxiety and depression is currently being underestimated. Sub case-level symptom loads of anxiety and depression make an important and previously unmeasured contribution to DP awards.
Overcoming barriers to diabetes care: Perceived communication issues of healthcare professionals attending a pilot Diabetes UK training programme
2010, Diabetes Research and Clinical Practice
Citation Excerpt :
People with diabetes have to undertake many life-long self-care tasks, lifestyle modifications, and often make adjustments to aspirations, self-image, relationships, employment, and social activities [1], which can result in significant psychological distress [1,2].

View all citing articles on Scopus

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Psychiatric aspects of general medicinePsychiatric aspects of chronic physical disease

Abstract

Section snippets

The biopsychosocial model

The role of ‘patient’

Treatment adherence

Stigma and the recovery model

Some specific chronic diseases

Gen Hosp Psychiatr

J Clin Epidemiol

Gend Med

J Psychosom Res

Emotional dimensions of chronic disease

Western J Med

The need for a new medical model: a challenge for biomedicine

Science (New York)

Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem

Diabet Med

The social system

Patients as partners in managing chronic disease. Partnership is a prerequisite for effective and efficient health care

BMJ