This publication presents evidence about the magnitude and severe consequences of comorbidity of mental and physical illnesses from a personal and societal perspective. Leading experts address the huge burden of co-morbidity to the affected individual as well as the public health aspects, the costs to society and interaction with factors stemming from the context of socioeconomic developments. The authors discuss the clinical challenge of managing cardiovascular illnesses, cancer, infectious diseases and other physical illness when they occur with a range of mental and behavioral disorders, including substance abuse, eating disorders and anxiety. Also covered are the organization of health services, the training of different categories of health personnel and the multidisciplinary engagement necessary to prevent and manage comorbidity effectively. The book is essential reading for general practitioners, internists, public health specialists, psychiatrists, cardiologists, oncologists, medical educationalists and other health care professionals.
178 - 181: Conclusions and Outlook
The reviews of evidence presented in the chapters of this volume lead to several conclusions and four recommendations. The prevalence and incidence of comorbidity of mental and physical disorders are high and likely to grow. The problems of comorbidity are not the simple addition of problems related to the diseases involved, as they worsen the prognosis of all diseases involved to a significantly greater extent. At present there is no clear strategy of action concerning comorbidity at the primary, secondary or tertiary levels of healthcare or in the local, provincial, national or international decision-making systems. The evidence presented in the book also allows the formulation of recommendations concerning the training of healthcare staff and the organization of healthcare. To support the changes proposed and to evaluate their effects it will be necessary to strengthen research concerning comorbidity and seek ways of sharing experience obtained by the use of different models of care catering to the needs of people with comorbid illnesses.
Several conclusions emerge from the chapters that have been included in this volume. First, comorbidity between mental and physical disorders is frequent in the population and its prevalence grows with age and with successes of medicine saving lives (but not curing diseases) [Rosenblat et al., pp. 42-53; Holt, pp. 54-65; Monteleone and Brambilla, pp. 66-80; Kariuki-Nyuthe and Stein, pp. 81-87; Lawrence et al., pp. 88-98; Müller, pp. 99-113; Gordon et al., pp. 114-128]. Second, comorbidity does not simply add problems related to one disease to those of the other: by and large the simultaneous presence of several diseases makes the prognosis of all the diseases involved worse, their complications more frequent and their treatment more complicated [Fisher et al., pp. 1-14; Oldenburg et al., pp. 15-22]. Third, no medical discipline has a clear strategy of action required when a disease that does not belong to its special field of interest accompanies one that is within the domain of their specialty. Fourth, the current trend of super-specialization and fragmentation of medicine may make matters worse unless appropriate action is taken promptly [Fisher et al., pp. 1-14]. Fifth, primary healthcare professionals (e.g. general practitioners or family physicians) are aware of the problems related to comorbidity because they encounter them even more frequently than other medical specialists; however, most have not received specific training in the use of skills that might be central in dealing with comorbidity [Boeckxstaens et al., pp. 129-136; Cushing and Evans, pp. 137-147; Gask, pp. 157-164].
The material presented also indicates directions of future work at different levels. First, it is clear that changes in the delivery of education of healthcare personnel are urgently needed [Cushing and Evans, pp. 137-147; Millar et al., pp. 148-156; Gask, pp. 157-164]. This is true for all categories of healthcare professionals including nurses, medical assistants, general practitioners and specialists, at both undergraduate and postgraduate levels. Problem-based learning was seen as an educational method that would lead to a better understanding of the problems and solutions and that would be in harmony with the environment in which the patient lives and the service operates. Unfortunately, the training materials that were produced by specialists, who were to lead problem-based learning as well as the implementation of the training, have neglected, to a large degree, the comorbidity of mental and physical disorders. The education of healthcare personnel in institutions which are usually uneasy federations of specialized departments did not help in developing an attitude of dealing with illnesses fully aware of the person who suffers from that illness and possibly from various other ills and problems. Teachers of the disciplines are usually specialists knowledgeable in their own field and somewhat distant or even possibly disdainful of other specialists and matters with which they deal. In many parts of the world, family physicians are rarely invited to train medical students and other students of health professions. By contrast, in the UK general practitioners are invited to teach increasingly often and it is to be hoped that this will soon happen elsewhere. Carers who often have a vast array of experiences in dealing with comorbid chronic mental and physical diseases are only exceptionally invited to serve as teachers of health professional students.
The distinction of psychological reactions to being ill and mental disorders in a strict sense is also a problem. Many of those surrounding the patient - professional and nonprofessional carers - are ready to dismiss the notion that the patient they have before them has a depressive illness that requires specific treatment, preferring to explain the symptoms in ‘logical' terms as the reaction of patients who were told that they have a serious illness and that they have to live with it. Occasionally both the patient and the doctor realize that a mental disorder as well as a physical illness is present, but they are united in a tacit collusion about the presence of the mental illness which they hope will vanish once the treatment of the physical illness has been successfully completed and therefore focus on the treatment of the physical illness only. This way of proceeding is also seen and emulated by the medical students who in later years of their training often learn by imitating the behavior of more experienced general practitioners or other specialists.
A second line of recommendations that could be made concerns in-service training of doctors and other health personnel. The two examples given in the chapters by Cushing and Evans [pp. 137-147] and Millar et al. [pp. 148-156] concern the in-service training of nurses and general practitioners. In the chapter by Cushing and Evans, which describes the training of senior nurses and nurse trainers in African countries, the participants are cited as saying they found it useful to discuss how to organize their service in a manner that would facilitate the management of problems arising for people with comorbid depression and diabetes because they have not been trained in ways in which this should be done. Bearing in mind that in the countries from which the nurses attending the course came, and where nurses are the backbone of health service, it is clear that the training of nurses about the ways in which their service should be organized is a neglected priority in the effort to provide appropriate care to people who have the misfortune of suffering from more than one illness at the same time [Beran, pp. 33-41; Millar et al., pp. 148-156]. Family physicians seem to be clear about the need to see the patients in their totality and to pay attention to all of their ills; there is, however, no consensus about the ways in which this type of approach to the patients they see can best be supported by referral and feedback arrangement within the health system as a whole [Boeckxstaens et al., pp. 129-136].
A third recommendation that could be formulated concerns funding. At present a considerable proportion of research funding is channeled through institutions which deal with a single disease or a group of diseases. This is the principle on which the National Institutes of Health in the USA as well as many funding agencies in other countries have been constructed. Some of the major foundations fund various types of research, but even there a major part of the funding follows a call for proposals on a single disease or disease group. There are very few calls for proposals on comorbidity and even fewer that would specifically invite applications for research on comorbid mental and physical disorders [Hosman, pp. 165-177]. Universities, which should, if true to their mission, fund research on topics of major public health importance and could therefore be expected to fund research on comorbidity, are increasingly adopting the strategy of making a good part of their living from overhead charges to projects which have been funded by someone else and only rarely provide their researchers funds for projects that would express the universities' public health mission. It might therefore be recommended that universities take it upon themselves to fund research and other work related to comorbidity at least until it dawns on the other agencies that comorbidity should be at the center of their interest rather than being seen as a confounding factor. Whether the universities will be in a position to play the role of being leaders in research which is of public health importance will to a large extent depend on the support of their governments - which unfortunately in recent times they have refused to provide.
Finally, in addition to the recommendations on funding of research and reorientation of training, a fourth recommendation could be directed to the search for opportunities to study and test the most appropriate models of service for people with comorbid mental and physical disorders. In the 19th century, mental hospitals were obliged to have wards for inpatients who in addition to their mental disorder also had a physical illness. These wards were usually run by specialists in internal medicine who in the course of time acquired considerable experience and knowledge about mental disorders. In the early 20th century a new category of super-specialists came into existence - the liaison psychiatrists who often, in addition to their postgraduate education in psychiatry, also had attended postgraduate courses in internal medicine. To an extent, the existence of this group is a sad admission of the fact that the vast majority of psychiatrists was not willing or able to deal with physical illness in their patients. This refusal to perform all that undergraduate and postgraduate education gave to these doctors has not been typical for other specialties; for example, there are no liaison surgeons, liaison dermatologists or liaison ophthalmologists although these specialists, among others, often deal with patients who have a mental disorder as well as a dermatological illness or problems with their eyes. Liaison psychiatry and ‘general hospital psychiatry' are clearly not the best way to a solution of the comorbidity problem and therefore there is an urgent need to develop service models that will be better suited to meet the needs of people with comorbid illnesses and to provide training in ways of doing it.