Medical comorbidity is common among chronic psychiatric inpatients. Associated risk factors include use of psychotropic medications, nature of the mental illness and behavioral factors. This cross-sectional study was conducted among chronic psychiatric inpatients at Taif mental hospital, who had been admitted for at least one year and with no plan for future discharge, with or without medical condition. The aims of the study were to evaluate the mental diseases pattern, pattern of medical illnesses and pattern of psychotropic medication use among chronic psychiatric inpatients. Data were collected by direct observation of the patients and the surrounding environment and by chart review during the months of April and May 2008 (1429 H).
During the study period there were 465 permanent psychiatric inpatients at the hospital, distributed over 13 wards, 76.8% males and 23.2% females. The highest percentage of inpatients of both sexes fell within the age group 41-50 years. Most inpatients had been admitted for over 10 years (89.2%), and almost all were Saudis (97.6%).
Among the total inpatients, 72.5% were diagnosed as schizophrenics, 20.2% as mentally retarded and 7.3% other psychiatric diagnoses; 91.0% were on antipsychotic medication. Over half of the inpatients (55.5%) had at least one associated medical comorbidity. The highest percentage (95.2%) of medical comorbidities fell within the > 70 year age group, while the lowest (40.7%) fell within the 31-40 year age group.
At least one medical illness was seen among 51.3% of patients with schizophrenia, 74.5% among patients with mental retardation, and 44.1% among those with other mental illnesses. Among all inpatients, 70.5% had medical comorbidity withknown onset of medical illness either before or after mental illness diagnosis, and 29.5% with unknown onset.
The pattern of comorbidities among psychiatric inpatients was: heart diseases (37.9%), epilepsy (35.7%), hypertension (19.2%), diabetes mellitus (19.8%), respiratory diseases (18.3%), skin diseases (6.0%), infectious diseases (18.7%), and other medical diseases (15.4%).
Some patients had more than one medical illness. Patients with schizophrenia and mental retardation had the highest medical comorbidities. Heart diseases were the highest medical comorbidity among schizophrenics followed by diabetes mellitus, while epilepsy was the highest among patients with other mental illnesses and those with mental retardation. Infectious diseases and hypertension were higher among patients with other psychiatric diagnoses. The frequency of medical illnesses distributed by psychiatric illnesses among psychiatric inpatients is demonstrated in table 1.
Among the total permanent psychiatric inpatients, 16.5% had associated psychiatric comorbidity; 17.8% among schizophrenics, 2.12% among mentally retarded patients, and 44.1% among other mentally ill patients.
Editorial note:
The medical comorbidity of psychiatric patients is a topic of increasing clinical and research interest. High rates of a wide range of comorbid medical illnesses have been described among psychiatric patients, with chronic medical illnesses, such as hypertension, heart disease, pulmonary disease, and diabetes mellitus, being the most common.
Medical illness complicates the treatment of mental illness, and patients with severe mental illness die at an earlier age from physical health problems than do those without mental illness.1,2
Psychiatric patients are less motivated to seek medical care for illness, and often have limited access to medical care. Psychiatric medications are also associated with negative health effects, such as impaired glucose tolerance, effects on renal and liver function, weight gain and many others.1 The association between manic-depressive illness and diabetes mellitus has been attributed to genetic relations between the diseases or to pathogenic mechanisms that are common to both.1 Also, the frequency of diabetes mellitus in hospitalized patients diagnosed with bipolar disorder is higher than in the general population. Manic-depressive patients with diabetes mellitus have a more severe course of illness.3
Several factors increase the risk of medical comorbidity among psychiatric patients, such as certain medications that cause weight gain, which is associated with diabetes and hypertension; Poor attention to personal hygiene, which is associated with skin infections; high rates of smoking, which contributes to asthma, acute respiratory disease, heart disease, and lung cancer; reduced physical activity and fitness, which contributes to hypertension and heart disease. Psyciatric patients with a comorbid substance use disorder have the highest risk for medical disorders such as heart diseases, asthma and gastrointestinal diseases.4 The duration of institutionalization and behavioral factors such as nail-biting and sexual contact may also play a role in acquiring infectious diseases mainly Hepatitis B and C.5
The major two mental illnesses among patients in this study were schizophrenia followed by mental retardation. Schizophrenia was higher than other mental illnesses among both genders and in all age groups. It was also higher among males than females in all age groups. On the other hand, mental retardation was higher among females although it showed fluctuations among different age groups.
In our study, medical comorbidity was present in a substantial number of psychiatric inpatients. Heart diseases, epilepsy, hypertension, diabetes mellitus, respiratory diseases and infectious
diseases represented the main bulk of the medical illnesses. Contributing risk factors were likely the nature of mental illness, antipsychotics use, in addition to behavioral risk factors, inactivity in particular.
Both psychiatrists and physicians should increase their efforts to detect, document and treat medical comorbidities among their psychiatric inpatients. It is recommended that Taif mental hospital administration should reconsider the integration between drug treatment and psychosocial treatment as deinstitutionalization, besides introduction and maintenance of sports and outings program for their inpatients. The study findings could be used as the basis for future studies.
References:
1.Lyketsos CG, Dunn G, Kaminsky MJ, Breakey WR. Medical comorbidity in psychiatric inpatients relation to clinical outcomes and hospital length of stay. Psychosomatics 2002; 43: 24–30.
2.Kamara SG, Peterson PD, Dennis JL. Prevalence of Physical Illness Among Psychiatric Inpatients Who Die of Natural Causes. Psychiatr Serv 1998; 49: 788-793.
3.Cassidy F, Ahearn E, Carroll BJ. Elevated frequency of diabetes mellitus in hospitalized manic-depressive patients. Am J psychiatry 1999; 156:1417–1420.
4.Dickey B, Normand ST, Weiss RD, Drake RE, Azeni H. Medical morbidity, mental illness, and substance use disorders. Psychiatric services 2002; 53(7): 861-867.
5.Ahmet K, Aykut O, Yasemin B, Yunus S, Mehmet O, Neslihan K, et al. Prevalence and Genotypic Distribution of Hepatitis GB-C/HG and TT Viruses in Blood Donors, Mentally Retarded Children and Four Groups of Patients in Eastern Anatolia, Turkey. Jpn. J. infect. Dis 2005; 58, 222-227.
Table 1: Frequency of medical illnesses distributed by psychiatric illnesses among chronic psychiatric inpatients in Taif mental hospital, Taif, Saudi Arabia, 2008 (1429H).
|
Medical illnesses
|
Schizophrenia
N=106
(58.2%)
|
Mental
Retardation
N=70 (38.5%)
|
Other
psychiatric
diagnoses
N=6 (3.3%)
|
Total
N=182
|
|
Heart diseases
|
60 (56.6%)
|
7 (10.0%)
|
2 (33.3%)
|
69 (37.9%)
|
|
Epilepsy
|
16 (15.1%)
|
45 (64.3%)
|
4 (66.7%)
|
65 (35.7%)
|
|
Hypertension
|
24 (22.6%)
|
9 (12.9%)
|
2 (33.3%)
|
35 (19.2%)
|
|
Diabetes mellitus
|
32 (30.2%)
|
2 (2.9%)
|
2 (33.3%)
|
36 (19.8%)
|
|
Respiratory diseases
|
20 (18.8%)
|
12 (17.1%)
|
1 (16.7%)
|
33 (18.3%)
|
|
Skin diseases
|
10 (9.4%)
|
1 (1.4%)
|
0 (0.0%)
|
11 (6.0%)
|
|
Infectious diseases
|
24 (22.6%)
|
7 (10.0%)
|
3 (50.0%)
|
34 (18.7%)
|
|
Other medical diseases
|
6 (5.6%)
|
22 (31.4%)
|
0 (0.0%)
|
28 (15.4%)
|