Authors

• Ante Silić — Klinika za psihijatriju „Vrapče“, Zagreb, Hrvatska

Abstract

The concept of somatic illnesses that is separate from mental illness is a concept that harms the optimal treatment of our patients. There are more and more arguments showing that the mental is inseparable from the somatic in the context of diagnostics and treatment.

Keywords

Ključne riječi: tjelesno zdravlje, mentalno zdravlje, komorbiditeti, integrativni pristup liječenju, physical health, mental health, comorbidities, integrative approach to treatment

DOI

Full Text

In the first written traces that resemble medicine as we practice it today, somatic illnesses were conceptualized as inseparable from mental illness. For instance, Asclepius and Hippocrates do not distinguish between mental and somatic disorders or illnesses (1, 2). On the other hand, the concept of “madness” as a disease that is significantly different from other physical diseases appears only at the end of the 18th century, when it was argued that mental illness should be treated by philosophers, not physicians. But while this concept did not last, the term mental illness continues to be used, just as the etiopathogenesis of some psychiatric diseases or disorders remains unclear. Today there is still a distinction between somatic and mental disorders, both among laymen and physicians in current clasifications (3, 4). The consequences of such a distinction are still present in the context of stigmatization and discrimination against mental patients (5-7). Realistically speaking, every disease or disorder involves the whole human organism. Pain, for instance, the best example a “pure” somatic condition, is actually a psychological phenomenon, and the first manifestations of many infections are psychological and subjective (usually a general feeling of weakness). On the other hand, fear and other emotions play an important role in the manifestation of diseases such as myocardial infarction, increased arterial pressure, or asthma. The simultaneous presence of somatic and psychological diseases can severely reduce the quality of life and lead to poorer prognostic outcomes for any individual illness. Such comorbidity also leads to increased treatment costs. Understanding the link between the physical and mental is the first step in developing strategies to reduce the coexistence of these conditions. Both the body and the mind are under the influence of changes in physiological emotional processes, just as they are under the influence of social factors such as financial or living situations. No single person can be viewed outside the bio-psycho-social context. Persons suffering from psychiatric diseases have numerous physical symptoms due to the illness itself but also often due to the side-effects of treatment. Psychiatric diseases can be linked with disordered hormonal conditions and circadian rhythm, while psychopharmaceuticals can cause weight gain or heart rhythm disorders. Such conditions and side-effects increase sensitivity for the development of many physical disorders. At the same time, the way the patients view their psychiatric illness can increase their sensitivity to somatic diseases by disrupting their social and cognitive functions, reducing levels of energy and motivation, etc., all of which compromises successful adoption of healthy habits. Unhealthy habits and lifestyles are often present, such as an overly sedentary lifestyle, lack of physical activity, consumption of nicotine, alcohol, cannabis, etc. (8, 9). It is a fact that there is no specific characteristic, whether symptomatic or etiological, that would indubitably distinguish mental illness from physical illness (10). Realistically, the differences between mental and physical illness is generally quantitative rather than qualitative. Why then do we still use such a distinction in classifications? The answer is in the introduction to the IVth (1994) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV): ìThe term mental disorder unfortunately implies a distinction between ‘mental’ disorders and ‘physical’ disorders that is a reductionist anachronism of mind/body dualism. A compelling literature documents that there is much ‘physical’ in ‘mental’ disorders and much ‘mental’ in ‘physical’ disorders. The problem raised by the term ‘mental disorders’ has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute” (4). Persons suffering from mental disorders often have low or no income and are unemployed and socially isolated (11). These social factors exacerbate their vulnerability to physical disorders. For instance, people who cannot afford healthier dietary options can develop various nutritional deficits. Poor diet quality is a significant risk factor for the development of diabetes or heart disease (12, 13). Some chronic physical conditions such as hyperglycemia due to diabetes can compromise microcirculation in the brain itself, which will then directly influence its function. There is evidence indicating that the more symptoms a somatic disorder has, the greater the probability of the development of mental difficulties. It is thus not surprising that persons with chronic somatic conditions often self-report that their mental health has deteriorated as well (14-16). Depressive disorder is perhaps the best illustration of the impossibility of strictly delineating the somatic from the mental. Lately, more and more scientific evidence has emerged on the association between depressive disorder and various somatic diseases. For instance, depressive disorder has been associated with different cardiovascular risk factors such as obesity, arterial hypertension, dyslipidemia, hyperglycemia, smoking, alcohol abuse, and abuse of other psychoactive substances (17, 18). Depression influences the whole of the human organism, and we can say that it is a systemic disease since it has been associated with changes in the circadian rhythm, sleep disorders, changes in the autonomous nervous system, hyperactivity of the hypothalamus-pituitary gland-adrenal gland axis, and changes in the immunological system (19-21). On the other hand, somatic diseases such as obesity, hyperlipidemia, arterial hypertension, and diabetes mellitus type 2 have recently garnered attention as significant comorbid conditions in patients with severe mental illnesses such as schizophrenia and depressive disorder. Whether these disorders are a part of the pathological process or a consequence of treatment is still not completely clear (22). However, there is growing evidence showing that severe psychiatric illnesses also influence the physical health. As with depressive disorder, the pathogenesis of metabolic syndrome is complex and insufficiently studied; it is however believed that the interactions between chronic stress, psychological trauma, hypercortisolemia, and disordered immunological functions contribute to the development of depressive disorder and metabolic syndrome (17, 23-25). It is a fact (according to a study by Canadian authors (26)) that: - Persons with depressive symptoms are three times as likely to have chronic somatic conditions compared with the general population - Persons with chronic somatic conditions have twice the risk of developing mood disorders or anxiety disorders - One out of two persons suffering from depressive disorder comorbid with a chronic somatic disorder is clearly limited in everyday functioning (27-29). The life expectancy of persons suffering from mental illnesses is generally shorter compared with the general population. This increased mortality is associated with physical causes/diseases. Some studies showed as much as a 50% increase of risk of death from health-related causes or a 20% shorter expected lifespan (12, 14, 15). This population has an increased risk of disease in all organs, including the neurological, urological, gynecological, cardiovascular, dermatological, metabolic, endocrine, musculoskeletal, and respiratory systems (15). Analysis of 20 studies that included almost 36000 participants suffering from schizophrenia found that there the rate of death from natural causes increased by 1.4 times in total for this population (30, 31). One retrospective Canadian study on mortality and life expectancy in persons suffering from schizophrenia showed that the life expectancy in patients was 20% shorter compared with the general population (32). One Swedish study estimated the total and specific mortality in newly-diagnosed patients with schizophrenia using existing registries (33). The analysis included 7784 patients and found that rates of all causes of death (except malignant diseases) were increased. Mortality among patients with schizophrenia in comparison with the expected rates was: - 2.7 times higher for diabetes (endocrine disease) - 2.3 times higher for cardiovascular disease - 3.2 times higher for respiratory diseases - 3.4 times higher for infective diseases. The highest absolute cause of death in patients with schizophrenia was cardiovascular disease (33). Such data indicate the need for preventive programs, since cardiovascular comorbidity can be prevented. Increased mortality rates have also been observed for bipolar and unipolar depression. Ösby et al. (33) reported that standardized mortality rates in Sweden for bipolar disorder were 1.9 for men and 2.1 for women, while the rates for depressive patients were 1.5 for men and 1.6 for women. (33) It is clear that there are many obstacles to optimal treatment of psychiatric patients, an important part of which stems from stigmatization and discrimination. Stigmatization is present in the patients themselves but also in physicians (11, 13, 14). A single patient is often treated for only one condition (either mental or physical). Limited financial resources in healthcare institutions certainly do not contribute to the quality of treatment. Some psychiatric patients are not treated at all, and some are treated by family medicine specialists who are often not educated enough to provide optimal care to such patients. Available data clearly suggest a need for further research on lifestyles and stigmatization as well as a need for prevention programs and community psychiatry. - Persons suffering from schizophrenia have a significantly poorer risk factor profile for cardiovascular diseases in comparison with the general population, for two reasons: - Persons suffering from schizophrenia have less access to the healthcare system due to stigma, and - When healthcare is available to them, persons suffering from schizophrenia are usually less cooperative in implementing preventive measures, lifestyle changes, and conducting recommended interventions (taking medication, tests, etc.). Persons suffering from schizophrenia are less inclined to seek help and medical aid even for acute cardiovascular incidents. Even when they do seek help, the care they receive is usually suboptimal (or they are offered less cardiovascular procedures than someone not suffering from schizophrenia or they seek help in places where these procedures are not available). It is important to note that some psychopharmaceuticals also carry an increased risk of developing metabolic syndrome, which makes the need for primary prevention of cardiovascular incidents in persons suffering from schizophrenia even greater (34, 35). An example of the above is the comparison of the prevalence of metabolic syndrome in the CATIE study (conducted on persons suffering from schizophrenia) with a control group consisting of non-schizophrenic patients from the NHANES III study. The groups were compared by age, sex, and ethnicity (36, 37). The prevalence of metabolic syndrome was greater in the CATIE study for most age groups and for both sexes. Additionally, the participants in the CATIE study had greater waist diameter and higher arterial pressure in both sexes and a higher prevalence of triglyceride values and lowered HDL in both sexes, whereas blood glucose levels were elevated only in female participants. All of the individual components of metabolic syndrome including waist diameter, triglycerides, HDL, arterial pressure, and blood glucose levels were higher in this comparison. Due to all of the above, the American Diabetes Association and the American Psychiatric Association published the Consensus Statement on Atypical Therapy, which states that olanzapine and clozapine are associated with the greatest weight gain as well as dyslipidemia and diabetes. Ziprasidone and aripiprazole are not associated with significant weight gain, diabetes, or dyslipidemia, and there were disparate results for risperidone and quetiapine. It is thus recommended to carefully assess the risk for the development of metabolic syndrome before introducing psychopharmaceuticals to therapy and carefully choose the specific medication to be used. The recommendation further states that the use of a pharmaceutical should be reconsidered if the patients gains 5% or more of the baseline body weight, if glycemia is exacerbated, or if the patients develops dyslipidemia (38). ## Cardiovascular and cerebrovascular diseases in persons suffering from psychiatric disorders Persons suffering from psychiatric diseases or disorders often have increased arterial pressure as well as elevated levels of stress hormone and adrenalin, which cause elevated heart rates. Some antipsychotics are also associated with heart rhythm disorders (lengthening of the QTc interval). All of this significantly interferes with heart function and significantly increases the risk of developing heart disease in persons suffering from mental illnesses (39). At the same time, persons suffering from mental illnesses often have a higher prevalence of other risk factors for the development of cardiovascular diseases (**Figure 1**) such as inadequate diet, poor access to preventive health programs, and obesity. In Canada for instance, a woman suffering from depressive disorder is 80% more likely to develop cardiovascular disease than a woman not suffering from depression (40). Persons with mental illness are also three times more likely to suffer a stroke (41). Viewed from another angle, persons with cardiovascular diseases have significantly greater chances of developing depressive disorder (42). Depression also commonly occurs after strokes (43-45). Figure 1. Association of Comorbid Mood Disorders and Chronic Illness (adapted from Chronic Dis Can. 2008;28(4):148-54.). In conclusion, the mental is inseparable from the physical, and every patient needs an integrative approach to treatment from primary prevention to rehabilitation and resocialization. We can now say that there is satisfactory cooperation of psychiatry specialists and other specialists with family medicine physicians as coordinators and the first line of healthcare. But we can also say that there is room to improve in each of these branches of medicine regarding the care for this especially vulnerable group of patients.

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