This document summarizes research on the relationship between physical and mental health conditions. It finds that around 16-20% of cancer patients experience depression, and rates of other mental health issues like anxiety are also elevated in various physical illnesses. Longer time since diagnosis is linked to higher rates of some mental health problems. Having a physical and mental health condition simultaneously is associated with much greater impairment and higher health care costs and mortality risk compared to having just one or neither. Integrated treatment of both physical and mental health issues is recommended.

1. Physical Health / Mental Health:
Evidence based exploration of co-morbidity
Alex J Mitchell ajm80@le.ac.uk
Long term conditions and mental health, Northampton November 2012

2. Alex J Mitchell (2012)
Contents
1. Psychiatric ‐ Physical illness Comorbidity
2. Psychiatric complications of Specific Physical illnesses
3. Psychiatric Physical Comorbidity => Burden
4. Psychiatric Physical Comorbidity => Mortality
5. Medical Care for Psychiatric Patients
6. Monitoring and Treatment

3. National Reports
Alex J Mitchell (2012)

4. 1. Psychiatric ‐ Physical illness Comorbidity
Large Surveys

5. Alex J Mitchell (2012)
2007 Australian National Survey of Mental
Health and Wellbeing (n= 8841, 16-85 years)
Women
19%
8%
anxiety affective
3.9
12.6
2.5
1.6
0.2
0.8
substance use
1.7
4%

6. Alex J Mitchell (2012)
Washington State Survey (n=23,000)
69%
31% alone
32%
5% alone
36%
5% alone

7. Alex J Mitchell (2012)
Depressive Symptoms in Medical
Conditions (on CES-D8) n=8400

8. Alex J Mitchell (2012)
Mental Health Comorbidity in Medical dis
(n=8800 (WMH-CIDI 3.0)
35
50%
Any affective disorder
Any anxiety disorder 29.7
30
Any affective or anxiety disorder
25.6
25 23.3 23.4
22.5
21.9
21.2
20.5
19.7
20 18.7
17.4 17.6
15 13.5
12.8
11.4
10 9.6
10
7.9
7 6.8
5
5
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Data from Teesson et al.Affective and anxiety disorders and their relationship with chronic physical conditions in Australia: findings of the 2007
National Survey of Mental Health and Wellbeing. Aus NZJP 2011 Nov;45(11):939-46.

9. Alex J Mitchell (2012)
Gili: Mental Comorbidity in Medical dis
(n=8000 PRIME-MD Spain)
>
0.7 42%
0.604
0.6 Affective Disorder Anxiety Disorder Alcohol Use Disorder
0.566
0.514
0.5 0.477 0.47 >
0.411 0.412 0.418 0.42
0.4 0.38 0.385
0.365
0.346
0.294
0.3 0.281
0.259
0.217
0.2
0.13 0.129
0.093 0.084
0.1 0.064 0.072 0.066
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Data from Gili et al.- Comorbidity between common mental disorders and chronic somatic diseases in primary care patients. General Hospital
Psychiatry 2010; 32: 240-245 PRIME-MD interview DSMIV 1925 GPs 8000 patients. 57% vs 49%

10. 2. Psychiatric complications of Specific Phys illness
Whats new?

11. Prevalence of depression in Oncology settings Plumb & Holland (1981)
Proportion meta-analysis plot [random effects]
0.7750 (0.6679, 0.8609)
Levine et al (1978) 0.5600 (0.4572, 0.6592)
Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)
Massie et al (1979) 0.4850 (0.4303, 0.5401)
70 studies involving 10,071 individuals;14 countries. Bukberg et al (1984)
Passik et al (2001)
0.4194 (0.2951, 0.5515)
0.4167 (0.2907, 0.5512)
16.3% (95% CI = 13.9% to 19.5%) Baile et al (1992)
Morton et al (1984)
Hall et al (1999)
0.4000 (0.2570, 0.5567)
0.3958 (0.2577, 0.5473)
0.3722 (0.3139, 0.4333)
Burgess et al (2005) 0.3317 (0.2672, 0.4012)
Jenkins et al (1991) 0.3182 (0.1386, 0.5487)
Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%
Green et al (1998) 0.3125 (0.2417, 0.3904)
Kathol et al (1990) 0.2961 (0.2248, 0.3754)
Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)
Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)
Golden et al (1991) 0.2308 (0.1353, 0.3519)
Spiegel et al (1984) 0.2292 (0.1495, 0.3261)
Evans et al (1986) 0.2289 (0.1438, 0.3342)
Grandi et al (1987) 0.2222 (0.0641, 0.4764)
Maunsell et al (1992) 0.2146 (0.1605, 0.2772)
Berard et al (1998) 0.2100 (0.1349, 0.3029)
Joffe et al (1986) 0.1905 (0.0545, 0.4191)
Berard et al (1998) 0.1900 (0.1184, 0.2807)
Devlen et al (1987) 0.1889 (0.1141, 0.2851)
Leopold et al (1998) 0.1887 (0.0944, 0.3197)
Akizuki et al (2005) 0.1797 (0.1376, 0.2283)
Razavi et al (1990) 0.1667 (0.1189, 0.2241)
Gandubert et al (2009) 0.1597 (0.1040, 0.2300)
Alexander et al (1993) 0.1333 (0.0594, 0.2459)
Kugaya et al (1998) 0.1328 (0.0793, 0.2041)
Payne et al (1999) 0.1290 (0.0363, 0.2983)
Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)
Prieto et al (2002) 0.1227 (0.0825, 0.1735)
Morasso et al (1996) 0.1121 (0.0593, 0.1877)
Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)
Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)
Costantini et al (1999) 0.0985 (0.0535, 0.1625)
Morasso et al (2001) 0.0985 (0.0535, 0.1625)
Ozalp et al (2008) 0.0971 (0.0576, 0.1510)
Love et al (2002) 0.0957 (0.0650, 0.1346)
Alexander et al (2010) 0.0900 (0.0542, 0.1385)
Coyne et al (2004) 0.0885 (0.0433, 0.1567)
Kawase et al (2006) 0.0851 (0.0553, 0.1240)
Walker et al (2007) 0.0831 (0.0568, 0.1165)
Grassi et al (1993) 0.0828 (0.0448, 0.1374)
Grassi et al (2009) 0.0826 (0.0385, 0.1510)
Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)
Lee et al (1992) 0.0660 (0.0356, 0.1102)
Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)
Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)
Singer et al (2008) 0.0519 (0.0300, 0.0830)
Katz et al (2004) 0.0500 (0.0104, 0.1392)
Mehnert et al (2007) 0.0472 (0.0175, 0.1000)
Lansky et al (1985) 0.0455 (0.0291, 0.0676)
Derogatis et al (1983) 0.0372 (0.0162, 0.0720)
Hardman et al (1989) 0.0317 (0.0087, 0.0793)
Massie and Holland (1987) 0.0147 (0.0063, 0.0287)
Colon et al (1991) 0.0100 (0.0003, 0.0545)
combined 0.1730 (0.1375, 0.2116)
0.0 0.3 0.6 0.9
proportion (95% confidence interval)

12. 3
< 2 years
2.5 2 to 10 years
> 10 years
1.99
2
1.46
1.5
1.32
1.29
1.12
1.05
1
0.5
0
Depression Anxiety

13. 3. Psychiatric Physical Comorbidity => Burden
How to measure burden?
Subjective
Objective

14. Impairment: Days totally out of role per year
50
(Alonso n=63,000) WHO WHM survey x 24co.
Yearly DOR
45 Unique
42.9 42.7
PAR%
41.2
39.8
40 39.3
36.6
35 34.4
33.8
30.6
30
25
20
17.3
15.2
15 14.3
10 9
7.3 7.7
5.1
5 3.9
2.6 2.2 2.5
1.8 1.7 1.9
1.4 1
0.3 0.1
0
Depression Panic disorder PTSD Specific phobia Social phobia Bipolar disorder GAD Alcohol abuse Drug abuse

15. Alex J Mitchell (2012)
2007 Auz National Survey of Mental Health
& Wellbeing(n=8800 18-65)
120
109.2
100
80 73.2 72
64.8
60
48
40
31.2
26.4
20
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Teesson et al.Affective and anxiety disorders and their relationship with chronic physical conditions in Australia: findings of the 2007 National
Survey of Mental Health and Wellbeing. Aus NZJP 2011 Nov;45(11):939-46.

16. n=245 404 participants from 60 countries
Quality of life: Moussavi et al (2007) Lancet 2007; 370: 851–58

17. 4. Psychiatric Physical Comorbidity => Mortality
Whats new?
Morbidity
Mortality

18. Alex J Mitchell (2012)
Mortality and Depression - IHD
Psychosomatic Med (2004) Barth et al

19. Alex J Mitchell (2012)
Mortality after MI => +11%

20. Alex J Mitchell (2012)
Five-year Mortality rates
30 People with schizophrenia 28%
People without schizophrenia
25
22%
20 19%
15
12%
10 9%
8%
5
0
CHD Diabetes Stroke
Hippisley-Cox J et al (2006) A comparison of survival rates for people with mental health
problems and the remaining population with specific conditions.
Disability Rights Commission. Equal treatment: closing the gap, July 2006
Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust

21. Alex J Mitchell (2012)
Schizophrenia – all cause mortality
>
Pooled estimate=2.50
Saha (2007) AGP
(95% CI=2.18‐2.83)
Mortality Gap: 22.5
yrs

22. Alex J Mitchell (2012)
Osborne – Mortality CVD

23. Alex J Mitchell (2012)
Problem….poor matching
 Severity and type of mental illness
 Age matched
 Suicides
 socioec, IQ, education
 BP, smoking, BMI

24. Alex J Mitchell (2012)
Mortality HR by Hospital Admission Diag.
for 1million men born b1951-b1958
10
9.01
9
8 7.66
7
6
5 4.3
3.9
4 3.56 3.41 3.28
2.98
3
2
1
0
58
8
58
58
8
58
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Gale CR, Arch Gen Psychiatry. 2012 Aug;69(8):823-31. Adj for suicide, age socioec, bmi, IQ, BP, education

25. Sc
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Mortality HR by Hospital Admission Diag.
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Gale CR, Arch Gen Psychiatry. 2012 Aug;69(8):823-31. Adj for suicide, age socioec, bmi, IQ, BP, education
Alex J Mitchell (2012)

26. Alex J Mitchell (2012)
Mortality trends in Stockholm County
1976–79 to 1990–95, cardiovascular causes of death
1.4
Patients with schizophrenia*
1976–79 period of reference
1.2
1.0
Deaths/100,000
0.8
0.6
General population**
0.4
0.2
0
1976–79 1980–85 1986–89 1990–95
**Standardised by the sex and age distribution of the patients Osby et al 2000

27. Alex J Mitchell (2012)
Cardiovascular disease is primary cause of
death in persons with mental illness*
50
Percentage of deaths
40 10-20%
30
20
10
0
MO OK RI TX UT VA
Heart disease Cancer Cerebrovascular Chronic respiratory
Accidents Diabetes Influenza/pneumonia Suicide
*Average data from 1996–2000 Lutterman et al 2003; Colton & Manderscheid 2006

28. Alex J Mitchell (2012)

29. Depression as a
risk for dementia
RR = 1.75
Over mean of 7 years

30. 5. Medical Care for Psychiatric Patients
Psychiatric Care
Comparative Care

31. Alex J Mitchell (2012)
Quality of Care comparisons
Psychiatric Care vs Psychiatric Care
General patients
Medical patients
Psychiatric Care vs Medical Care
Medical patients
Medical patients
Medical Care vs Medical Care
Medical patients Psychiatric patients

32. Alex J Mitchell (2012)
% Receiving Any treatment for Depression
20
n=84,850 face-to-face interviews 17.9
18
16 15.4
13.8
14
12 11.3
10.9 10.9
10
8.8
8.1
8 7.2
6.8
6 5.6 5.5
4.3
4 3.4
2
0
SA
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Wang P et al (2007) Lancet 2007; 370: 841–50

33. Alex J Mitchell (2012)
12mo Service Use (NIH, 2002)
40
34.6
35 32.7 Cancer n=4878
No Cancer n=90,737
30
25 % Receiving Any treatment for Mental Health
19.1
20
16.1
14
15
11.7 11
8.9
10 7.7
7.2 6.5
5.7 5.7 5 6.3 6.4 6.2
5
5 3.9 3.2
2.3 1.8
0
alth
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Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical
Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590

34. Alex J Mitchell (2012)
1660 Cancer Patients in Florida (Jacobsen, 2010)
100 Emotional Wellbeing Assessed 97 52%
95
Pain Assessed 93
90
90 88 88 88
86
84 84 84
82
80
73 74
70
60 57
55
50
50 47 47
40 38
34
30
26
20
14
12
10
0
A B C D E F G H I J K Mean
Psychooncology. 2011 Nov;20(11):1221-7. doi: 10.1002/pon.1849. Epub 2010 Sep 27.

35. Alex J Mitchell (2012)
Quality of care medical vs psychiatric
High income Low & middle income
% treated % treated
Physical disorders
Diabetes 94% 77%
Heart disease 78% 51%
Asthma 65% 44%
Mental disorders
Depression 29% 8%
Bipolar disorder 29% 13%
Panic disorder 33% 9%
Ormel J. et al (2008) British Journal of Psychiatry, 192, 368‐375
Thornicroft, G. (2007) Lancet, 370, 807‐808

36. Alex J Mitchell (2012)
Adherence to Quality Indicators by Condition
(McGlynn/ Rand, 2003)
Condition % Of Recommended Care
Senile Cataract 78.7
Breast Cancer 75.7
Prenatal Care 73.0
Low Back Pain 68.5
Coronary Artery Disease 68.0
Hypertension 64.7
Congestive Health Disease 63.9
Depression 57.7
Osteoarthritis 57.3
Asthma 53.5
Diabetes Mellitus 45.4
Headache 45.2
Urinary Track Infection 40.7
Atrial Fibrillation 24.7
Alcohol Dependence 10.5

37. Quality of medical care

38. Alex J Mitchell (2012)
Mammography and Schizophrenia
 Chochinov (2009) Canada n=110,240
 In comparison to the general population (without schizophrenia)
(n=108,792), women with schizophrenia (n=1448)
 OR 0.64 of mammography in the selected two year period.
 Carney and Jones (2006) n=191,356
 No difference over five years
 less likely in the last two years
 OR 0.31 (95% CI 0.12-0.83).
 Werenke (2006) UK n= 533,340
 Those with a diagnosis of psychosis were the least likely to attend
for mammography
 OR 0.33 (95% CI 0.18-0.61)
 Druss (2002) US
 less likely to have had a mammogram in last 2 years (for women
aged 50-69 years) adjusted
 OR 0.78 (95% CI 0.67-0.91).

39. OR 0.69 mental illness (n=29)
OR 0.53 Psychosis (n=7)
OR 0.82 Affective (n=7)

40. Quality of Medical Treatment i Procedures
Summary meta-analysis plot [random effects]
[Angiography] Petersen 2003 0.90 (0.83, 0.98)
[Any Revascularisation] Abrams 2009 IP 1.00 (0.91, 1.10)
[Any Revascularisation] Abrams 2009 OP 0.92 (0.85, 0.99)
[Any Revascularisation] Druss 2001 0.74 (0.56, 0.95)
[Any Revascularisation] Druss 2001 0.87 (0.79, 0.95)
[Any Revascularisation] Kisely 2007 0.92 (0.86, 1.07)
Summary meta-analysis plot [random effects]
[Any Revascularisation] Laursen et al 0.69 (0.68, 0.70)
[Any Revascularisation Men] Lawrence 2003 0.31 (0.21, 0.45)
[Any Revascularisation] Petersen 2003 0.89 (0.79, 0.98)
[CABG] Druss 2000 0.90 (0.85, 0.96) [Any Revascularisation Women] Lawrence 2003 0.34 (0.18, 0.64)
[CABG] Jones 2005 0.91 (0.75, 1.09) [CABG] Jones 2005 0.24 (0.04, 1.41)
[CABG] Plomondon 2007 1.02 (0.99, 1.06)
[CABG] Young et al 2000 [Younger] 0.71 (0.54, 0.92)
[CABG] Young et al 2000 0.79 (0.75, 0.84)
[CABG] Young et al 2000 [Older] 0.67 (0.46, 0.95)
[CABG] Young et al 2000 0.67 (0.62, 0.72)
[Cath] Druss 2000 0.74 (0.70, 0.78) [Cath] Young et al 2000 [Older] 0.51 (0.42, 0.62)
[Cath] Plomondon 2007 1.05 (0.98, 1.13) [Cath] Young et al 2000 [Younger] 0.70 (0.63, 0.77)
[Cath] Young et al 2000 0.88 (0.86, 0.90)
[PTCA] Jones 2005 0.74 (0.41, 1.08)
[Cath] Young et al 2000 0.77 (0.75, 0.80)
[PTCA] Young et al 2000 [Younger] 0.55 (0.46, 0.65)
[PTCA/PCI] Plomondon 2007 1.06 (0.97, 1.15)
[PTCA] Druss 2000 0.96 (0.91, 1.02) [PTCA] Young et al 2000 [Older] 0.32 (0.21, 0.47)
[PTCA] Jones 2005 1.04 (0.98, 1.10) combined 0.53 (0.44, 0.64)
[PTCA] Young et al 2000 0.70 (0.68, 0.73) 0.01 0.1 0.2 0.5 1 2
[PTCA] Young et al 2000 0.68 (0.65, 0.72) relative risk (95% confidence interval)
combined 0.86 (0.80, 0.92)
0.5 1 2
odds ratio (95% confidence interval)
Any Mental illness Schizophrenia
HR = 0.86 (0.80-0.92) HR = 0.53 (0.44 – 0.64)

41. Quality of Medical Treatment ii Medication
OR =0.92 OR =0.79 OR =0.72
Summary meta-analysis plot [random effects] Summary meta-analysis plot [random effects] Summary meta-analysis plot [random effects]
ACE (Kreyenbuhl) 0.23 (0.12, 0.44)
ACE (Druss2001) 0.81 (0.65, 0.98) ACE (Kreyenbuhl) 0.46 (0.18, 1.19)
ACE-I or ARBb (Weiss) 0.83 (0.61, 1.14)
ACE (Petersen) 0.92 (0.79, 1.09) Aspirin (Desai) 0.75 (0.39, 1.43)
Arthritis (Redelmeier) 0.59 (0.57, 0.62)
ACE-I or ARBb (Plomondon) 0.93 (0.84, 1.01) Aspirin (Desai) 1.07 (0.49, 2.30) Bblocker (Desai) 0.70 (0.48, 1.03)
Aspirin (Hippisley-Cox) 1.00 (0.97, 1.04)
Aspirin (Druss2001) 0.81 (0.65, 0.98) Bblocker (Hippisley-Cox) 1.18 (0.94, 1.56)
Aspirin (Weiss) 0.89 (0.64, 1.24)
Aspirin (Petersen) 0.96 (0.81, 1.15) Bblocker (Wang) 0.55 (0.45, 0.55)
Bblocker (Desai) 0.70 (0.43, 1.15)
Aspirin (Plomondon) 0.93 (0.83, 1.04) Bblocker (Hippisley-Cox) 0.96 (0.88, 1.06) Chemotherapy (Goodwin) 0.65 (0.43, 1.00)
Bblocker (Druss2001) 0.85 (0.72, 0.98)
Bblocker (Weiss) 0.96 (0.54, 1.71) Cholesterol (Desai) 1.31 (0.57, 3.00)
Cholesterol (Desai) 1.01 (0.37, 2.77)
Cholesterol (Hippisley-Cox) 0.86 (0.70, 12.30)
Bblocker (Plomondon) 1.11 (0.97, 1.28)
Cholesterol (Weiss) 1.85 (1.11, 3.09)
HAART (Tegger) 0.36 (0.25, 0.50)
BBlockers (Petersen) 0.78 (0.69, 0.92) Insulin (Weiss) 1.44 (0.96, 2.16)
Osteoporosis (Bishop) 0.38 (0.15, 0.97)
HAART (Yun) 1.43 (1.18, 1.74)
HAART (Mijch) 1.28 (1.04, 1.57)
Statin (Hippisley-Cox) 0.85 (0.80, 0.91) Statin (Hippisley-Cox) 1.15 (0.80, 1.95)
HAART (Himelhoch2004) 2.28 (1.24, 32.50)
Statin (Kreyenbuhl) 0.29 (0.11, 0.77)
Statin (Kreyenbuhl) 0.14 (0.05, 0.44)
HAART (Himelhoch2007) 0.85 (0.71, 1.23)
Statin (Weiss) 0.54 (0.36, 0.51)
combined 0.72 (0.51, 1.00)
combined 0.92 (0.85, 1.00) combined 0.79 (0.66, 0.95)
0.1 0.2 0.5 1 2 5 0.01 0.1 0.2 0.5 1 2 5 10 100
0.5 1 2 5 10 100
odds ratio (95% confidence interval) odds ratio (95% confidence interval)
odds ratio (95% confidence interval)
SMI Schz Affective

42. Alex J Mitchell (2012)
Example
 If you have cancer, how likely is it that you will
receive treatment?
 Would this be affected by your mental health
condition?

43. Chances of No Treatment for Colorectal Ca (2011)
14
12
10
8
6
4
2
0
No m ental Substance Other m ental Mood disorder Any m ental Psychotic Dem entia
disorder abuse disorder disorder disorder disorder
Baillargeon et al Effect of mental disorders on diagnosis, treatment, and survival of older adults with colon cancer.
J Am Geriatr Soc. 2011 Jul;59(7):1268-73.

44. 6. Monitoring and Treatment
Monitoring metabolic problems
Treating metabolic complications

47. Alex J Mitchell (2012)
CATIE: rates of pharmacological interventions for
abnormal blood pressure, lipids and glucose
Nasrallah et al 2006
n=1488 n=685 n=690
100
89.4
80
68.3
Patients (%)
62.4
60
45.3
40 33.2
20 10.9
0
n=481 n=300 n=75 n=34 n=471 n=421
Hypertension Diabetes Dyslipidaemia
Prevalence Lack of medical intervention

48. Alex J Mitchell (2012)
Don’t just SCREEN – INTERVENE

49. Alex J Mitchell (2012)
END: ……..Rule of 50’s
 Cancer, neurological disease: 50% clinical disorder
 Hepatic disease: almost 50% AUD
 Affective disorder: 50 days lost per year
 Two people with Schz will suffer 50 years YLL
 50% have evidence of depression assessment
 50% of CNS identify depression in cancer
 50% of identified depressions are treated (1yr)
 50% of Schz receive CABG after MI
 50% on antipsychotics receive Gc testing
 50% on antipsychotics with diabetes receive treatment