Physical comorbidities in patients with severe mental disorders: a brief narrative review on current challenges and practical implications for professionals

Physical comorbidities in patients with severe mental disorders: a brief narrative review on current challenges
and practical implications for professionals

Gaia Sampogna1, Matteo Di Vincenzo1, Bianca Della Rocca1, Emiliana Mancuso1,
Antonio Volpicelli1, Francesco Perris1, Valeria Del Vecchio1, Vincenzo Giallonardo1,
Mario Luciano1, Andrea Fiorillo1

1Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Naples.

Summary. A paradox of the modern world is represented by the increasing rate of comorbidities, although the life expectancy is increasing worldwide, the number of disease-free years is not improving consequently. Physical comorbidities are often overlooked in people with severe mental disorders, although this problem needs to be adequately managed since it is associated with a worse quality of life and a poorer personal and social functioning. In this paper, we aim to: 1) carry out a narrative review of the recent literature in order to provide an update on the prevalence and incidence of the most frequent comorbid physical disorders in people with severe mental disorders; 2) highlight the most important difficulties in managing comorbidities in people with severe mental disorders in ordinary clinical care; 3) discuss possible solutions to overcome those difficulties, particularly through the role of education and scientific associations.

Key words. Comorbidity, lifestyle, mortality gap, physical illness, severe mental disorders.

La gestione delle comorbilità fisiche nei pazienti con disturbi mentali gravi: una revisione narrativa delle sfide e delle implicazioni pratiche per gli operatori della salute mentale.

Riassunto. L’aspettativa di vita media sta aumentando in maniera significativa nella società moderna, sebbene vi sia un aumento anche della prevalenza delle malattie fisiche in comorbilità. Pertanto, tale situazione determina una condizione paradossale per cui il numero complessivo di anni vissuti senza malattie (disease-free years) si mantiene stabile. Questo fenomeno è ulteriormente accentuato nei pazienti con disturbi mentali gravi, la cui salute fisica è spesso trascurata, sebbene un maggior numero di comorbilità fisiche si associ a una peggiore qualità di vita e a un peggiore funzionamento sociale. Il presente lavoro è una revisione narrativa della letteratura che ha l’obiettivo di: 1) fornire dati aggiornati di prevalenza e incidenza delle principali comorbilità fisiche nei pazienti con disturbi mentali gravi; 2) evidenziare le principali difficoltà legate alla gestione delle comorbilità fisiche nella pratica clinica ordinaria; 3) discutere le possibili soluzioni per superare queste difficoltà, soprattutto attraverso il coinvolgimento delle società scientifiche internazionali.

Parole chiave. Comorbilità, disturbi mentali gravi, malattie fisiche, mortalità, stili di vita.

Background

Comorbidity, i.e. the simultaneous presence of two or more disorders in a given person, represents a paradox of the modern world. In fact, while life expectancy is increasing worldwide, the number of disease-free years is not improving consequently. Therefore, people live longer but suffering from a variety of physical conditions. This increase of physical comorbidities needs to be adequately managed since it is associated with a worse quality of life and a poorer personal and social functioning1,2.

Comorbidity is rapidly increasing also in young people, when the negative consequences of comorbid conditions are as numerous and as troublesome as those occurring later in life. The rate of people affected by comorbidities is expected to increase in the next years due to several conditions, including the success of medicine in prolonging life without curing disease, the phenomenon of population aging, the tendency to adopt unhealthy life behaviours, the climate changes and environmental pollution3.

Comorbidity does not mean the simple addition of two diseases that independently follow their usual trajectories. The simultaneous presence of two or more diseases will worsen the prognosis of all the diseases that are present, lead to an increasing number (and severity) of complications and make the treatment of all of them more difficult and, possibly, less efficacious.

What is worse is that one of the comorbid diseases is often overlooked. This is particularly true for mental disorders which are frequently comorbid with physical illnesses. In fact, the comorbidity of two or more somatic illnesses – for example cardiovascular disease and diabetes – is generally recognized as being frequent and requiring simultaneous attention to both diseases. The situation is different when it comes to the comorbidity between physical and mental disorders. People with severe mental disorders, including schizophrenia spectrum disorders and affective disorders, have more physical health comorbidities4 and poorer prognoses from those comorbidities5 compared to the general population. The presence of physical comorbidities can lead to reduced quality of life, worsening mental health, and excess mortality in people with severe mental disorders (SMD)6-14.

It has been estimated a reduction of life expectancy in people with severe mental disorders of at least 10-25 years compared to the general population, thus requiring urgent actions from healthcare professionals and governments worldwide. This increased mortality rate is primarily due to the high rates of cardiovascular, metabolic and infectious diseases in such patient population15,16.

The most frequently identified non-communicable physical illnesses in people with severe mental disorders in high income countries include obesity, diabetes, cardiovascular disease, chronic respiratory diseases and metabolic syndrome17,18.

In this paper, we aim to: 1) carry out a narrative review of the recent literature in order to provide an update on the prevalence and incidence of the most frequent comorbid disorders in people with severe mental disorders; 2) highlight the most important difficulties in managing comorbidities in people with severe mental disorders in ordinary clinical care; 3) discuss possible solutions to overcome those difficulties, particularly through the role of education and scientific associations.

Methods

This narrative review was performed according to the following procedure: definition of the problem, literature search, data evaluation and presentation of findings.

The search terms “comorbidity”, “severe mental disorders”, “depression”, “bipolar disorder”, “schizophrenia”, “cardiovascular diseases”, “metabolic syndrome”, “obesity”, “infectious diseases”, “tubercolosis”, “HIV”, “psychiatry” were entered in ERIC, MEDLINE, PsycARTICLES, PsycINFO, Scopus and PubMed. Terms and databases were combined using the Boolean search technique, which consists of a logical information retrieval system (two or more terms combined to make search more restrictive or detailed).

The search was limited to studies published in English. Only studies focused on adult population (aged 18 or more) have been included. Only studies on patients with severe mental disorders, including schizophrenia spectrum disorders and affective disorders were considered. Studies on adolescent population were excluded since available prevalence data of physical comorbidities in such population is extreme heterogeneous and requires a different management plan compared to adult population.

Results

Included studies have been grouped in three categories: studies on cardiovascular diseases in people with severe mental disorders, studies on metabolic syndrome and obesity in people with severe mental disorders and studies on infectious diseases in people with severe mental disorders. Main findings of the included studies have been summarized in table 1.

Cardiovascular diseases in people with severe
mental disorders

Cardiovascular diseases (CVD) represent a major cause of premature death in people with severe mental disorders, contributing by 17.4% and 22.0% to the reduction in overall life expectancy in men and women, respectively. Risk factors for cardiovascular diseases, such as smoking, unhealthy diet and lack of physical exercise, are common in these patients, and lifestyle interventions have been shown to produce small benefits.

A recent study by Tan et al.16 on a sample of 5,000 patients with schizophrenia, major depression disorder or bipolar disorder found that aberrant tests of high-density dyslipidaemia (HDL) and diastolic blood pressure during hospitalization period were associated with a higher risk of a psychiatric readmission compared to patients with optimal monitoring of blood lipids and blood pressure.

Pharmacological interventions to reduce risk factors for cardiovascular diseases have been proven to be effective. Treatment with antipsychotic drugs is associated with reduced mortality, but also with an increased risk of weight gain, dyslipidaemia and diabetes mellitus. These patients have a higher risk of both myocardial infarction and stroke but a lower risk of undergoing interventional procedures compared with the general population. Data indicate a negative attitude from clinicians not working in mental health towards patients with severe mental illness. Education might be a possible method to decrease the negative attitudes towards these patients, thereby improving diagnosis and treatment rates13.

If ageing is the primary driver for the higher mortality, patients with SMD might need earlier and more intensive treatment for cardiovascular risk factors than individuals without those disorders19.

The level of CVD mortality and morbidity has sustained high in people with SMDs during the past decades, but the causal mechanism must be further elucidated. Psychosocial and socioeconomic challenges are frequent in SMDs as well as in CVD. Further, recent studies have revealed genetic variants jointly associated with SMDs, CVD risk and social factors. Recent genome-wide association studies (GWASs) have identified several genetic variants associated with mental disorders and with CVD risk factors, including body mass index, type 2 diabetes mellitus, total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, systolic blood pressure (SBP), diastolic blood pressure (DBP), along with coronary artery disease. Among social factors, loneliness has a central role in limiting the physical health of people with severe mental disorders. Rødevand et al.20 have investigated the polygenic overlap between loneliness, severe mental disorders, and cardiovascular disease risk factors suggesting the presence of shared molecular mechanisms. These findings further confirm the complex interplay between gene, environment and mental disorders, which hamper the optimal management of physical comorbidities in people with severe mental disorders.

Metabolic syndrome and obesity in people with severe mental disorders

People with severe mental disorders are 3.04 more likely (95% CI=2.42-3.82) to have obesity than the general population, but there is no difference in the prevalence of overweight. Women with schizophrenia are 1.44 (95% CI=1.25-1.67) times more likely than men with schizophrenia to be obese; no gender differences were found among people with bipolar disorder. In a recent study carried out in six Italian university psychiatric units, 35.4% of patients were overweight and 34.9% were obese, with a mean BMI of 32.2 (±5.5); and 53.4% of recruited patients suffered from metabolic syndrome13,14.

Afzal et al.21 estimated that the pooled prevalence of obesity in people with SMD is 25.9% (95% CI=23.3-29.1), increasing up to 60.1% (95% CI=55.8-63.1) when considering the combination of overweight and obesity. The highest prevalence of obesity is found in North Africa and in the Middle East.

Furthermore, the prevalence of metabolic syndrome, defined as the presence of metabolic changes related to insulin resistance, prothrombotic and inflammatory status, ranges from 29.4 to 67.9%, with a prevalence risk of 1.58 higher among people with mental disorders compared to the general population22.

Glycaemic alterations are untreated in 63.9% of patients and lipid alterations remain untreated in 81.7% of people with severe mental disorders referred to mental health centres22,23, which clearly shows that physical health is often overlooked in this group of patients.

In conclusion, people with SMD have a markedly higher prevalence of obesity and metabolic syndrome compared to the general population. People with SMD around the world would likely benefit from interventions to reduce and prevent obesity.

Infectious diseases in people with severe mental disorders

Research has shown that people with mental disorders are more susceptible to infectious diseases such as tuberculosis (TB), HIV or hepatitis C24. Several studies have documented that patients with depression are exposed to a doubled risk to have TB compared to the general population25 and the same applies to people with schizophrenia26.

One of the greatest challenges is the complexity of the comorbidity between tuberculosis and severe mental illness; in fact, several vulnerability factors to severe mental illness, such as homelessness, HIV, diabetes, poverty, and alcohol/substance abuse, strongly predispose patients with SMD to tuberculosis. Furthermore, people hospitalized in long-term care facilities have a higher risk of developing some infectious diseases, particularly tuberculosis, due to the lack of routine infection control or to the fact that are densely populated.

The frequency of HIV infection in patients with pre-existing mental disorder ranges between 5 and 7%. Although being sexually active tends to be less common among patients with schizophrenia compared to nonpsychotic individuals, patients with schizophrenia are more likely to engage in high-risk sexual behavior. Moreover, many patients with schizophrenia have inadequate knowledge about the risks and consequences of HIV. Comorbidity of schizophrenia and life-threatening viral illnesses is associated with a worse prognosis for both conditions.

Estimates of new-onset psychosis in patients with HIV-spectrum illness range between 0.2 and 15% and may increase as the stage of HIV illness progresses. Regardless of which illness comes first, their occurrence together is associated with more morbidity and mortality than would be expected with either illness alone. Moreover, HIV has direct effects on the central nervous system, which may lead to cognitive and behavioral changes, and some antiretroviral therapies have psychiatric side effects.

The prevalence of major depressive disorder ranges from 16.2 to 36% among HIV patients in the USA. Another study in Kenya and in Democratic Republic of Congo found that depression is more frequent in HIV patients than in HIV negative individuals27.

Discussion

The present narrative review highlights that people suffering from severe mental disorders, namely schizophrenia and affective disorders, present a higher rate of physical comorbidities compared to the general population. Several underlying factors have been identified including those related to the patients, to psychiatrists, to other non-psychiatrist medical doctors and to the healthcare system28.

The factors related to patients include cognitive impairment, psychotic symptoms29,30 and patient’s reluctance to attend check-up visits18,31. Moreover, carers of persons with severe mental disorders often overlook physical health needs and tend to treat and manage only psychiatric symptoms.

Some antipsychotic and antidepressant medications have metabolic side effects and could further improve the risk of developing physical comorbidities32-38.

A relevant role is played by the healthcare system, which suffers from the long-standing separation between physical and mental disorders, with psychiatrists focusing only on mental conditions and other physicians rarely undertaking physical examinations in patients with severe mental disorders. Moreover, the collaboration and communication between primary care physicians and mental health professionals is often poor, due also to the physical distance of many mental health centres from other medical wards or hospitals39,40. Conversely, non-psychiatric clinicians frequently have a negative attitude towards people with mental disorders, underestimating the seriousness of patients’ complaints of physical signs and symptoms41,42. The over-specialization of medical disciplines and the excessive fragmentation of medical knowledge43,44 have further contributed to the lack of collaboration among the different branches of medicine.

Another healthcare-related factor hampering the physical care of patients with severe mental disorders is related to the lack of clarity about the person or the team who is responsible for detecting and managing physical problems in patients with severe mental disorders45,46. In this regard, a care manager with adequate knowledge and skills about mental, psychological and physical health may help to overcome at least this obstacle47.

Finally, it has been recently highlighted that the neglect of physical comorbidity in patients with severe mental illnesses is also due to the lack of a dedicated training on physical and mental comorbidities in medical schools and in specialty training courses48,49.

The present review has some limitations due to the narrative approach used, which is useful in order to provide a global overview on a debated topic, but it does not include methodological rigour in terms of inclusion and exclusion criteria. Moreover, it would have been beyond the scope of the present narrative review to assess and evaluate the prevalence and incidence rates of all physical conditions in patients with severe mental disorder. Therefore, the present review has been limited to the most frequent and disabling physical conditions in people with severe mental disorders.

Conclusions and way forward

Patients suffering from severe mental disorders have a higher rate of mortality and morbidity compared to the general population, which is not directly related to the presence of a given mental disorder, but rather to the consequence of the simultaneous presence of comorbid physical health problems, such as cardiovascular, metabolic, and infectious diseases19,50-54.

For several decades the physical health of people with severe mental disorders has been overlooked, contributing to the unacceptable “scandal” of premature mortality in such group of persons. Several scientific associations are promoting innovative strategies to improve the levels of knowledge, confidence and expertise of medical professionals in managing physical comorbidities in people with severe mental disorders20,55,56.

International scientific associations including the World Psychiatric Association (WPA), the European Psychiatric Association (EPA), the UK Royal College of Psychiatrists and the UK Royal College of General Practitioners are now committed to improve the quality of training and knowledge of healthcare professionals on the management of physical comorbidities in people with severe mental disorders57,58. In particular, a revision of training curricula has been proposed in order to improve the educational requirements on detection and management of physical comorbidities. Among the educational initiatives promoted by the WPA – the world’s largest professional association of psychiatrists and mental health professionals59-62 – a specific Working Group on Physical Comorbidities, held by Prof. N. Sartorius has been established in 202163-64. The WPA Working Group has promoted several educational and research activities on the management of physical comorbidities65-70.

The European Psychiatric Association is also committed to improve the quality of education on physical comorbidities and healthy lifestyle behaviours. In fact, the EPA is involved in the European Alliance for Sport and Mental Health (EASMH) project, funded by the European Commission under the Erasmus+ actions, aiming to identify the best practices available in Europe in the field of sport and mental health, and to improve the levels of knowledge and expertise of healthcare professionals in disseminating sport-based interventions in routine clinical care71.

All these initiatives are highly needed, since it could be associated with a significant improvement in the levels of knowledge, confidence and expertise of medical professionals in managing physical comorbidities in people with severe mental disorders.

Acknowledgments: the present study has been supported by “VALERE: VanviteLli pEr la RicErca” programme.

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