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Psychiatric aspects of chronic physical disease
Psychiatric aspects of general medicine
Psychiatric aspects of chronic physical disease
What’s new? • The ‘recovery model’ is a new way of conceptualizing the management of chronic illness with treatment moved away from a sole focus on cure, towards broader goals such as reduced symptoms, hope and improved social and occupational functioning
Samuel B Harvey Khalida Ismail
• Depression is associated with increased mortality in cardiovascular disease and diabetes. However, it remains unclear whether standard treatments for depression reduce this risk
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.
• Sexual dysfunction is a very common, but under-diagnosed problem amongst those with chronic medical problems
increased by at least two-fold in most common chronic conditions.3 As demonstrated in Figure 1 the prevalence of depression differs depending on the type of chronic illness. It is essential that psychological co-morbidity in those with chronic illness is recognized and treated.
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 problems.5
Keywords chronic disease; depression; diabetes mellitus; heart iseases; mental disorders; models; rheumatoid arthritis; sexual d dysfunction; stigma
Chronic diseases are the leading causes of death and disability in most developed countries.1 Patients diagnosed with a chronic, life-long medical condition may have to adjust their aspirations, relationships, employment and social activities.2 Such adjustments will result in a degree of psychological distress in most, and in some may contribute to the onset of a psychiatric disorder. It is now well established that rates of depression are
The twelve month prevalence of major depression in various chronic medical conditions No chronic illness Congestive heart failure Diabetes Hypertension
Samuel B Harvey MRCPsych is a Clinical Research Worker at the Institute of Psychiatry, King’s College London, and an Honorary Specialist Registrar in Liaison Psychiatry at the Maudsley Hospital, London, UK. His research interests include the effects of exercise and obesity on mental health, chronic fatigue syndrome, liaison and occupational psychiatry. Competing interests: none declared.
Coronary heart disease Cerebral vascular accident Chronic obstructive pulmonary disease End-stage renal disease
Khalida Ismail MRCP MRCPsych MSc PhD is a Clinical Senior Lecturer in Liaison Psychiatry at the Institute of Psychiatry, King’s College London and Consultant Psychiatrist at King’s College Hospital, London, UK. Her research interests include the epidemiology of psychiatric disorders and psychological problems in chronic physical illness and evaluating complex interventions to improve diabetes control. Competing interests: none declared.
MEDICINE 36:9
0
2
4
6
8
10
12
14
16
18
12- month prevalence of depression(%) Source: Egede LE. Gen Hosp Psychiatry 2007; 29: 409–16.4
Figure 1
471
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
The role of ‘patient’
Some specific chronic diseases
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 responsibility with difficulty. Despite this, there is some evidence that programmes which enhance patients’ participation in their own healthcare result in reduced symptoms, decreased disability and reduced costs.7
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. Coronary heart disease There is increasing evidence that psychosocial factors can influence both the risk of coronary heart disease (CHD) developing and the outcome of established disease. Some early studies suggested that individuals with a type A personality (highly ambitious, competitive and potentially hostile) were at increased risk of developing CHD, although a number of subsequent studies have failed to confirm this finding. Recent studies have tended to focus on more specific elements of personality and have demonstrated that hostility and suppressed anger are risk factors for the development of CHD.13 Prospective studies have also demonstrated that both depression and anxiety increase the risk of later CHD.14 One UK based study found the risk of ischaemic heart disease was three times higher among men with a recorded diagnosis of depression compared to controls of the same age.15 Psychiatric variables are also important in predicting clinical outcomes once CHD is established. Around 30% of patients suffer from depression following an acute myocardial infarction (MI).16 As demonstrated in Figure 2, suffering from depression increases the risk of death in the first 6 months after an MI.17 While antidepressant treatment and cognitive–behavioural therapy has been shown to reduce depression symptoms in this group, it remains unclear if this leads to improved survival rates for CHD.18 Anxiety is also an important differential diagnosis in some cases of chest pain or palpitations (see pages 449–451), and needs to be adequately assessed and managed.
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 accepting or believing a diagnosis. Such patients are unlikely to comply with treatments for a disorder they do not acknowledge. Studies have also shown that individuals with depression are less likely to comply with suggested treatments for chronic medical problems.9
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 thought of as having been brought upon oneself. People with chronic disease may be discriminated against in the workplace and are legally excluded from certain jobs. They may also have difficulty obtaining insurance or a licence to drive a car. Others may also suffer stigma as a result of their treatment. For example, people with diabetes report being mistaken for intravenous drug users as a result of having visible injection marks. In recent decades a new model of chronic disease management has emerged; the recovery model. The recovery model is based around the concept that people can ‘recover’ from an illness even though the illness is not cured.11 There is not a fixed definition of what recovery means, but it should include hope, social inclusion, supportive relationships and a return to a quality of life that the individual finds acceptable. Medical management is only one part of the personal recovery journey and should not be focused solely on cure, but assist in broader goals such as reduced symptoms with improved social and occupational functioning.12 This model has mainly been used in the conceptualization of chronic mental illness, but is equally relevant to the care of those with chronic physical diseases.
MEDICINE 36:9
Cumulative mortality curve for depressed and non-depressed patients following a myocardial infarction (MI) 30
Mortality (%)
25
20
Depressed patients 15
10
Non-depressed patients
5
0 0
1
2
3
4
5
6
Months after infarction Reproduced with kind permission from the BMJ Publishing Group. Peveler R, Carson A, Rodin G. BMJ 2002; 325: 149–52. 26
Figure 2
472
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
common problems are loss or reduction of sexual desire and failure of orgasmic response. Sexual dysfunction may be caused by either physical or psychological problems, or a combination of both. Sexual dysfunction is often present in patients with chronic medical problems; due to the effects of the physical disease (e.g. vascular disease), side effects of medication or co-morbid psychological problems. Taking a history of sexual problems can be a sensitive task, but a good history will often provide the best evidence of the underlying cause. It should include a detailed description of the current problem, including the duration and specificity of any symptoms. Details should also be gained on the individual’s sexual development, past relationships, current situation and sexual preferences. Recent life events, mood disorders, anxiety or relationship difficulties may be of particular importance. A physical and mental state examination is also required. When a psychological component to sexual dysfunction is identified there are a number of treatment options, including behavioural and cognitive– behavioural techniques. Pharmacological treatments may also have a role in some cases, although these should be used with caution and their use should not mean that psychological factors are overlooked.
Diabetes mellitus There is currently an epidemic of diabetes. People with diabetes have to adhere to many life-long self-care tasks to achieve optimal glycaemic control. These include self-monitoring of blood glucose and titrating insulin doses accordingly. Modifying lifestyle behaviours such as diet, exercise and weight are particularly important, especially in the early stages. Additionally, complications of diabetes need to be managed carefully, including good foot-care and taking various oral medications to minimize the cardiac risk. As demonstrated in Table 1, there are some differences in the psychiatric problems commonly seen in type 1 and type 2 diabetes. As with many chronic illnesses, the detection and treatment of co-morbid psychiatric problems is essential for improving outcomes. In predominantly cross-sectional studies depression is associated with worse glycaemic control,19 although it remains unclear whether this can be reversed with antidepressant treatment.20 Depression is also associated with increased mortality from diabetic complications.21 These effects are likely to be mediated to some degree by behavioural changes such as reduced self care but biological processes associated with depression, such as release of inflammatory markers have also been postulated. Sexual dysfunction It is estimated that 40% of females and 22% of males could be diagnosed with sexual dysfunction according to ICD-10 criteria.22 The most common problems identified in men are erectile failure and a lack or loss of sexual desire, while in women the most
Rheumatoid arthritis Studies have shown that around one-fifth of patients with rheumatoid arthritis (RA) have a psychiatric disorder, usually depression or anxiety.23 The increased risk of depression is likely to be,
The types of psychiatric problems commonly seen in type 1 and type 2 diabetes Type 1 diabetes
Type 2 diabetes
Depressive disorders
Depression present in 15% of patients (three times higher than the general population)26
Eating disorders
Eating disorders (most often bulimia nervosa) almost twice as common in adolescent females with diabetes28 Under-use of insulin may be used as a way of controlling weight Eating disorders are associated with worse glycaemic control and higher mortality Needle phobia, present in around 3.5% of the general population,29 can cause difficulties in the management of type 1 diabetes Some patients will also develop a phobic fear of hypoglycaemia
Some evidence that depression increases the risk of type 2 diabetes27 Depression present in 15% of patients26 Binge-eating disorder in around 4 – 5% of patients Eating disorders are associated with worse glycaemic control and higher mortality
Anxiety disorders
Schizophrenia
The use of antipsychotic medication, especially atypical antipsychotics, increases the risk of type 2 diabetes
Substance misuse
Heavy alcohol use can lead to diabetes via acute or chronic pancreatitis
Other problems
Developing type 1 diabetes during childhood can disrupt a child’s education and socializing. Some adolescents with diabetes will go through a ‘rebellious phase’, while others will develop an ongoing pattern of self-destructive behaviour associated with poor glycaemic control
The diagnosis of diabetes may require a number of psychological, physical and social adjustments to be made. Some patients may have life-long unhealthy lifestyles
Table 1
MEDICINE 36:9
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© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
in part, due to the pain, deformity and disability of RA. There is evidence that treating depression in patients with RA may reduce pain and improve functioning.24,25 RA is also an example of how treatments for chronic medical problems can precipitate psychiatric illness. Affective symptoms, especially euphoria or mania, may be precipitated by steroid therapy. These symptoms usually resolve with a reduction in the steroid dose, but at times specific treatment or prophylaxis may be needed. ◆
17 Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993; 270: 1819–25. 18 Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA 2003; 289: 3106–16. 19 Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes care 2000; 23: 934–42. 20 Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004; 61: 1042–49. 21 Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Diabetes care 2007; 30: 1473–79. 22 Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: cross sectional study. BMJ 2003; 327: 423. 23 Creed F, Murphy S, Jayson MV. Measurement of psychiatric disorder in rheumatoid arthritis. J Psychosom Res 1990; 34: 79–87. 24 Bradley LA, Young LD, Anderson KO, et al. Effects of psychological therapy on pain behavior of rheumatoid arthritis patients. Treatment outcome and six-month followup. Arthritis Rheum 1987; 30: 1105–14. 25 Peveler R, Carson A, Rodin G. Depression in medical patients. BMJ 2002; 325: 149–52. 26 Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes. An epidemiological evaluation. Diabetes care 1993; 16: 1167–78. 27 Eaton WW, Armenian H, Gallo J, Pratt L, Ford DE. Depression and risk for onset of type II diabetes. A prospective population-based study. Diabetes care 1996; 19: 1097–102. 28 Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ 2000; 320: 1563–66. 29 Bienvenu OJ, Eaton WW. The epidemiology of blood-injection-injury phobia. Psychol Med 1998; 28: 1129–36.
References 1 Murray CJL, Lopez AD, eds. The global burden of disease. Harvard: Harvard University Press, 1996. 2 Turner J, Kelly B. Emotional dimensions of chronic disease. Western J Med 2000; 172: 124–28. 3 Egede LE. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psychiatr 2007; 29: 409–16. 4 Engel GL. The need for a new medical model: a challenge for biomedicine. Science (New York) 1977; 196: 129–36. 5 Devries JH, Snoek FJ, Heine RJ. Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem. Diabet Med 2004; 21: 1263–68. 6 Parsons T. The social system. New York: The Free Press, 1951. 7 Holman H, Lorig K. Patients as partners in managing chronic disease. Partnership is a prerequisite for effective and efficient health care. BMJ 2000; 320: 526–27. 8 Dunbar-Jacob J, Mortimer-Stephens MK. Treatment adherence in chronic disease. J Clin Epidemiol 2001; 54(Suppl 1): S57–60. 9 Nau DP, Aikens JE, Pacholski AM. Effects of gender and depression on oral medication adherence in persons with type 2 diabetes mellitus. Gend Med 2007; 4: 205–13. 10 Goffman E. Stigma. Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall, 1963. 11 Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosoc Rehabil J 1993; 16: 11–23. 12 Liberman RP, Kopelowicz A. Recovery from schizophrenia: a concept in search of research. Psychiatr Serv 2005; 56: 735–42. 13 Miller TQ, Smith TW, Turner CW, Guijarro ML, Hallet AJ. A metaanalytic review of research on hostility and physical health. Psychol Bull 1996; 119: 322–48. 14 Shah SU, White A, White S, Littler WA. Heart and mind: (1) relationship between cardiovascular and psychiatric conditions. Postgrad Med J 2004; 80: 683–89. 15 Hippisley-Cox J, Fielding K, Pringle M. Depression as a risk factor for ischaemic heart disease in men: population based case-control study. BMJ 1998; 316: 1714–19. 16 Lesperance F, Frasure-Smith N, Talajic M. Major depression before and after myocardial infarction: its nature and consequences. Psychosom Med 1996; 58: 99–110.
MEDICINE 36:9
Practice points • Chronic diseases are now the main cause of death and disability in developed countries • Clinicians need to be aware of psychosocial issues if they are going to effectively manage chronic illness as the two often co-exist • A patient’s participation in their own healthcare can result in reduced symptoms, decreased disability and reduced costs • Psychiatric disorders such as depression and anxiety are very common amongst individuals with chronic disease • Early detection and treatment will help improve the psychiatric morbidity and also sometimes the medical outcomes
474
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of chronic physical disease
What’s new? • The ‘recovery model’ is a new way of conceptualizing the management of chronic illness with treatment moved away from a sole focus on cure, towards broader goals such as reduced symptoms, hope and improved social and occupational functioning
Samuel B Harvey Khalida Ismail
• Depression is associated with increased mortality in cardiovascular disease and diabetes. However, it remains unclear whether standard treatments for depression reduce this risk
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.
• Sexual dysfunction is a very common, but under-diagnosed problem amongst those with chronic medical problems
increased by at least two-fold in most common chronic conditions.3 As demonstrated in Figure 1 the prevalence of depression differs depending on the type of chronic illness. It is essential that psychological co-morbidity in those with chronic illness is recognized and treated.
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 problems.5
Keywords chronic disease; depression; diabetes mellitus; heart iseases; mental disorders; models; rheumatoid arthritis; sexual d dysfunction; stigma
Chronic diseases are the leading causes of death and disability in most developed countries.1 Patients diagnosed with a chronic, life-long medical condition may have to adjust their aspirations, relationships, employment and social activities.2 Such adjustments will result in a degree of psychological distress in most, and in some may contribute to the onset of a psychiatric disorder. It is now well established that rates of depression are
The twelve month prevalence of major depression in various chronic medical conditions No chronic illness Congestive heart failure Diabetes Hypertension
Samuel B Harvey MRCPsych is a Clinical Research Worker at the Institute of Psychiatry, King’s College London, and an Honorary Specialist Registrar in Liaison Psychiatry at the Maudsley Hospital, London, UK. His research interests include the effects of exercise and obesity on mental health, chronic fatigue syndrome, liaison and occupational psychiatry. Competing interests: none declared.
Coronary heart disease Cerebral vascular accident Chronic obstructive pulmonary disease End-stage renal disease
Khalida Ismail MRCP MRCPsych MSc PhD is a Clinical Senior Lecturer in Liaison Psychiatry at the Institute of Psychiatry, King’s College London and Consultant Psychiatrist at King’s College Hospital, London, UK. Her research interests include the epidemiology of psychiatric disorders and psychological problems in chronic physical illness and evaluating complex interventions to improve diabetes control. Competing interests: none declared.
MEDICINE 36:9
0
2
4
6
8
10
12
14
16
18
12- month prevalence of depression(%) Source: Egede LE. Gen Hosp Psychiatry 2007; 29: 409–16.4
Figure 1
471
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
The role of ‘patient’
Some specific chronic diseases
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 responsibility with difficulty. Despite this, there is some evidence that programmes which enhance patients’ participation in their own healthcare result in reduced symptoms, decreased disability and reduced costs.7
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. Coronary heart disease There is increasing evidence that psychosocial factors can influence both the risk of coronary heart disease (CHD) developing and the outcome of established disease. Some early studies suggested that individuals with a type A personality (highly ambitious, competitive and potentially hostile) were at increased risk of developing CHD, although a number of subsequent studies have failed to confirm this finding. Recent studies have tended to focus on more specific elements of personality and have demonstrated that hostility and suppressed anger are risk factors for the development of CHD.13 Prospective studies have also demonstrated that both depression and anxiety increase the risk of later CHD.14 One UK based study found the risk of ischaemic heart disease was three times higher among men with a recorded diagnosis of depression compared to controls of the same age.15 Psychiatric variables are also important in predicting clinical outcomes once CHD is established. Around 30% of patients suffer from depression following an acute myocardial infarction (MI).16 As demonstrated in Figure 2, suffering from depression increases the risk of death in the first 6 months after an MI.17 While antidepressant treatment and cognitive–behavioural therapy has been shown to reduce depression symptoms in this group, it remains unclear if this leads to improved survival rates for CHD.18 Anxiety is also an important differential diagnosis in some cases of chest pain or palpitations (see pages 449–451), and needs to be adequately assessed and managed.
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 accepting or believing a diagnosis. Such patients are unlikely to comply with treatments for a disorder they do not acknowledge. Studies have also shown that individuals with depression are less likely to comply with suggested treatments for chronic medical problems.9
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 thought of as having been brought upon oneself. People with chronic disease may be discriminated against in the workplace and are legally excluded from certain jobs. They may also have difficulty obtaining insurance or a licence to drive a car. Others may also suffer stigma as a result of their treatment. For example, people with diabetes report being mistaken for intravenous drug users as a result of having visible injection marks. In recent decades a new model of chronic disease management has emerged; the recovery model. The recovery model is based around the concept that people can ‘recover’ from an illness even though the illness is not cured.11 There is not a fixed definition of what recovery means, but it should include hope, social inclusion, supportive relationships and a return to a quality of life that the individual finds acceptable. Medical management is only one part of the personal recovery journey and should not be focused solely on cure, but assist in broader goals such as reduced symptoms with improved social and occupational functioning.12 This model has mainly been used in the conceptualization of chronic mental illness, but is equally relevant to the care of those with chronic physical diseases.
MEDICINE 36:9
Cumulative mortality curve for depressed and non-depressed patients following a myocardial infarction (MI) 30
Mortality (%)
25
20
Depressed patients 15
10
Non-depressed patients
5
0 0
1
2
3
4
5
6
Months after infarction Reproduced with kind permission from the BMJ Publishing Group. Peveler R, Carson A, Rodin G. BMJ 2002; 325: 149–52. 26
Figure 2
472
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
common problems are loss or reduction of sexual desire and failure of orgasmic response. Sexual dysfunction may be caused by either physical or psychological problems, or a combination of both. Sexual dysfunction is often present in patients with chronic medical problems; due to the effects of the physical disease (e.g. vascular disease), side effects of medication or co-morbid psychological problems. Taking a history of sexual problems can be a sensitive task, but a good history will often provide the best evidence of the underlying cause. It should include a detailed description of the current problem, including the duration and specificity of any symptoms. Details should also be gained on the individual’s sexual development, past relationships, current situation and sexual preferences. Recent life events, mood disorders, anxiety or relationship difficulties may be of particular importance. A physical and mental state examination is also required. When a psychological component to sexual dysfunction is identified there are a number of treatment options, including behavioural and cognitive– behavioural techniques. Pharmacological treatments may also have a role in some cases, although these should be used with caution and their use should not mean that psychological factors are overlooked.
Diabetes mellitus There is currently an epidemic of diabetes. People with diabetes have to adhere to many life-long self-care tasks to achieve optimal glycaemic control. These include self-monitoring of blood glucose and titrating insulin doses accordingly. Modifying lifestyle behaviours such as diet, exercise and weight are particularly important, especially in the early stages. Additionally, complications of diabetes need to be managed carefully, including good foot-care and taking various oral medications to minimize the cardiac risk. As demonstrated in Table 1, there are some differences in the psychiatric problems commonly seen in type 1 and type 2 diabetes. As with many chronic illnesses, the detection and treatment of co-morbid psychiatric problems is essential for improving outcomes. In predominantly cross-sectional studies depression is associated with worse glycaemic control,19 although it remains unclear whether this can be reversed with antidepressant treatment.20 Depression is also associated with increased mortality from diabetic complications.21 These effects are likely to be mediated to some degree by behavioural changes such as reduced self care but biological processes associated with depression, such as release of inflammatory markers have also been postulated. Sexual dysfunction It is estimated that 40% of females and 22% of males could be diagnosed with sexual dysfunction according to ICD-10 criteria.22 The most common problems identified in men are erectile failure and a lack or loss of sexual desire, while in women the most
Rheumatoid arthritis Studies have shown that around one-fifth of patients with rheumatoid arthritis (RA) have a psychiatric disorder, usually depression or anxiety.23 The increased risk of depression is likely to be,
The types of psychiatric problems commonly seen in type 1 and type 2 diabetes Type 1 diabetes
Type 2 diabetes
Depressive disorders
Depression present in 15% of patients (three times higher than the general population)26
Eating disorders
Eating disorders (most often bulimia nervosa) almost twice as common in adolescent females with diabetes28 Under-use of insulin may be used as a way of controlling weight Eating disorders are associated with worse glycaemic control and higher mortality Needle phobia, present in around 3.5% of the general population,29 can cause difficulties in the management of type 1 diabetes Some patients will also develop a phobic fear of hypoglycaemia
Some evidence that depression increases the risk of type 2 diabetes27 Depression present in 15% of patients26 Binge-eating disorder in around 4 – 5% of patients Eating disorders are associated with worse glycaemic control and higher mortality
Anxiety disorders
Schizophrenia
The use of antipsychotic medication, especially atypical antipsychotics, increases the risk of type 2 diabetes
Substance misuse
Heavy alcohol use can lead to diabetes via acute or chronic pancreatitis
Other problems
Developing type 1 diabetes during childhood can disrupt a child’s education and socializing. Some adolescents with diabetes will go through a ‘rebellious phase’, while others will develop an ongoing pattern of self-destructive behaviour associated with poor glycaemic control
The diagnosis of diabetes may require a number of psychological, physical and social adjustments to be made. Some patients may have life-long unhealthy lifestyles
Table 1
MEDICINE 36:9
473
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
in part, due to the pain, deformity and disability of RA. There is evidence that treating depression in patients with RA may reduce pain and improve functioning.24,25 RA is also an example of how treatments for chronic medical problems can precipitate psychiatric illness. Affective symptoms, especially euphoria or mania, may be precipitated by steroid therapy. These symptoms usually resolve with a reduction in the steroid dose, but at times specific treatment or prophylaxis may be needed. ◆
17 Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993; 270: 1819–25. 18 Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA 2003; 289: 3106–16. 19 Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes care 2000; 23: 934–42. 20 Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004; 61: 1042–49. 21 Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Diabetes care 2007; 30: 1473–79. 22 Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: cross sectional study. BMJ 2003; 327: 423. 23 Creed F, Murphy S, Jayson MV. Measurement of psychiatric disorder in rheumatoid arthritis. J Psychosom Res 1990; 34: 79–87. 24 Bradley LA, Young LD, Anderson KO, et al. Effects of psychological therapy on pain behavior of rheumatoid arthritis patients. Treatment outcome and six-month followup. Arthritis Rheum 1987; 30: 1105–14. 25 Peveler R, Carson A, Rodin G. Depression in medical patients. BMJ 2002; 325: 149–52. 26 Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes. An epidemiological evaluation. Diabetes care 1993; 16: 1167–78. 27 Eaton WW, Armenian H, Gallo J, Pratt L, Ford DE. Depression and risk for onset of type II diabetes. A prospective population-based study. Diabetes care 1996; 19: 1097–102. 28 Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ 2000; 320: 1563–66. 29 Bienvenu OJ, Eaton WW. The epidemiology of blood-injection-injury phobia. Psychol Med 1998; 28: 1129–36.
References 1 Murray CJL, Lopez AD, eds. The global burden of disease. Harvard: Harvard University Press, 1996. 2 Turner J, Kelly B. Emotional dimensions of chronic disease. Western J Med 2000; 172: 124–28. 3 Egede LE. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psychiatr 2007; 29: 409–16. 4 Engel GL. The need for a new medical model: a challenge for biomedicine. Science (New York) 1977; 196: 129–36. 5 Devries JH, Snoek FJ, Heine RJ. Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem. Diabet Med 2004; 21: 1263–68. 6 Parsons T. The social system. New York: The Free Press, 1951. 7 Holman H, Lorig K. Patients as partners in managing chronic disease. Partnership is a prerequisite for effective and efficient health care. BMJ 2000; 320: 526–27. 8 Dunbar-Jacob J, Mortimer-Stephens MK. Treatment adherence in chronic disease. J Clin Epidemiol 2001; 54(Suppl 1): S57–60. 9 Nau DP, Aikens JE, Pacholski AM. Effects of gender and depression on oral medication adherence in persons with type 2 diabetes mellitus. Gend Med 2007; 4: 205–13. 10 Goffman E. Stigma. Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall, 1963. 11 Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosoc Rehabil J 1993; 16: 11–23. 12 Liberman RP, Kopelowicz A. Recovery from schizophrenia: a concept in search of research. Psychiatr Serv 2005; 56: 735–42. 13 Miller TQ, Smith TW, Turner CW, Guijarro ML, Hallet AJ. A metaanalytic review of research on hostility and physical health. Psychol Bull 1996; 119: 322–48. 14 Shah SU, White A, White S, Littler WA. Heart and mind: (1) relationship between cardiovascular and psychiatric conditions. Postgrad Med J 2004; 80: 683–89. 15 Hippisley-Cox J, Fielding K, Pringle M. Depression as a risk factor for ischaemic heart disease in men: population based case-control study. BMJ 1998; 316: 1714–19. 16 Lesperance F, Frasure-Smith N, Talajic M. Major depression before and after myocardial infarction: its nature and consequences. Psychosom Med 1996; 58: 99–110.
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Practice points • Chronic diseases are now the main cause of death and disability in developed countries • Clinicians need to be aware of psychosocial issues if they are going to effectively manage chronic illness as the two often co-exist • A patient’s participation in their own healthcare can result in reduced symptoms, decreased disability and reduced costs • Psychiatric disorders such as depression and anxiety are very common amongst individuals with chronic disease • Early detection and treatment will help improve the psychiatric morbidity and also sometimes the medical outcomes
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