Acta Psychiatr Scand 2018: 137: 369–370 © 2018 John Wiley & Sons A/S.

n Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All rights reserved ACTA PSYCHIATRICA SCANDINAVICA
DOI: 10.1111/acps.12888

Editorial
Comorbidity of mental and physical
disorders: a key problem for medicine in the
21st century
Comorbidity – the simultaneous presence of two Gradually, the situation changed and medical
or more diseases is undoubtedly one of the most departments in mental hospitals vanished. Better
important challenges to medicine of the 21st cen- transport made it easier for medical specialists to
tury. Our success in prolonging life expectancy did come to the mental hospitals, and patients could
not greatly increase the number of disease-free be transported to the general hospitals for exami-
years: the years gained are years in which people nations and care. The diagnostic apparatus in
tend to suffer from a variety of chronic diseases, mental hospitals, for example, for radiography
impairments and disabilities. The survival into grew obsolete and usually left to decay. At the
higher age brought with it also a true, still not suffi- same time, departments of psychiatry in general
ciently well recognized, epidemic of comorbidity. hospitals became more frequent. The public in
The comorbidity of two or more somatic dis- many countries – and health administrators –
eases – for example cardiovascular disease and dia- increasingly perceived psychiatry as being distant
betes – is generally recognized as being frequent from classical medicine. Psychoanalysis became
and requiring simultaneous attention to both dis- better known and entered the public mind replac-
eases. The situation is different when it comes to ing previous images of psychiatry. Psychiatrists no
the comorbidity of mental and physical illness. longer made physical examinations at the begin-
Psychiatry has grown and developed without much ning of their acquaintance with the patient. The
linkage to general medicine or any of the other psychiatry of the asylum with its inhabitants, for-
medical specialties. Oncologists and other special- gotten by all miles away from other medical insti-
ists who deal with particularly lethal diseases are tutions, was not seen as dealing with the same kind
perhaps an exception – although even there, the of people as other medical institutions or for that
co-existence of cancer and a mental disorder such matter with people with common mental disorders
as depression led to the development of a subspe- such as depression or anxiety treated in the psychi-
cialty – that of psycho-oncology – rather than to a atric departments of the general hospital. Some
close collaboration between oncology and main- psychiatrists still saw themselves as doctors and
stream psychiatry. emerged as a subdiscipline of ‘liaison psychiatry’
In the late 19th century when many countries indicating that they are linked with general medi-
constructed mental hospitals, it was normal and cine – a sad admission by the majority of psychia-
expected that one of the departments or a pavilion trists (who did not claim to be liaison psychiatrists)
will be reserved for the treatment of somatic illness that they did not feel interested nor competent to
of the in-patients. Frequently, the reason for plac- deal with mental health issues presented by
ing a mentally ill person in such a ward was tuber- patients who were treated for a physical illness.
culosis, but there were many who were suffering The situation is perhaps gradually improving.
from other communicable or non-communicable The excellent studies of mortality of people with
disorders. Many of the mentally ill had a short life mental illness undertaken in Scandinavia, Aus-
expectancy, died early because of neglect, physical tralia and elsewhere (1–4) made it gradually obvi-
hardships, poor access to medical care, and thus, ous that comorbidity of mental and physical
there were not all too many people with mental disorders is frequent, deadly and growing.
and a physical illness. The ward for patients with Physical diseases do not only kill people who
comorbid physical illness were therefore usually of suffer from mental illness: they also make their life
a modest size and rarely had more than 10% of the even more difficult. The comorbidity does not only
institution’s beds. produce suffering. It also makes the cost of

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Editorial

treatment of the participating diseases much higher The current fragmentation of medicine into ever
than it would have been had these diseases finer specialties makes the management of comor-
appeared alone (5). Mental disorders still carry bidity ever more difficult: a reorientation of post-
stigma, which makes access to care less easy and graduate training might improve the situation.
the quality of care less good – both of which con-
tribute to the probability of complications of phys- N. Sartorius
Association for the Improvement of Mental Health Programmes
ical illnesses such as diabetes. It is still uncertain (AMH), Geneva, Switzerland
whether stigma and discrimination in health care E-mail: [email protected]
and self-neglect often present in depressive and
other mental disorders is the main reason for the
higher likelihood of complications: recent findings References
of immunologists open the door to thinking that
1. Lawrence D, Hancock KJ, Kisely S. The gap in life expec-
mental disorders such as depression perhaps share tancy from preventable physical illness in psychiatric
some of the aetiopathogenetic pathways with patients in Western Australia: retrospective analysis of pop-
disorders such as diabetes affecting not only the ulation based registers. BMJ 2013;346:f2539.
likelihood of comorbidity but also that of 2. Brown S, Kim M, Mitchell C, Inskip H. Twenty five year
complications. mortality of a community cohort with schizophrenia. Br J
Psychiatry 2010;196:116–121.
For all these reasons, it is of great importance to 3. Thornicroft G. Premature death among people with mental
promote research into comorbidity and think of illness. BMJ 2013;346:f2969.
ways in which health care could be reorganized so 4. Nordentoft M, Wahlbeck K, H€allgren J et al. Excess mor-
as to facilitate treatment and recovery of people tality, causes of death and life expectancy in 270,770
struck by comorbid mental and physical disorders. patients with recent onset of mental disorders in Denmark,
Finland and Sweden. PLoS ONE 2013;8:e5517.
An important support to this effort is publications 5. McDaid D, Park AL. Counting all the costs: the economic
about comorbidity – such as that by Dickerson impact of comorbidity. In Sartorius N et al., eds. Comor-
et al. (6) in this issue of Acta. Such publications bidity of mental and physical disorders. Basel: Karger
will not only help to move research forward and Publ., 2015.
towards new goals: they might also in time – and I 6. Dickerson F, Origoni A, Schroeder J et al. Natural cause
mortality in persons with serious mental illness. Acta Psy-
hope soon – influences the education of health chiatr Scand 2018;137:371–379.
workers at undergraduate and postgraduate level.

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