REVIEW ARTICLE

www.indianjpsychiatry.org

Fourth revolution in psychiatry Addressing comorbidity with chronic

physical disorders
Shiv Gautam
Department of Psychiatry and Superintendent, Psychiatric Center, Jaipur, India

ABSTRACT

The moral treatment of mental patients, Electro Convulsive therapy (ECT), and Psychotropic medications constitute the
first, second, and third revolution in psychiatry, respectively. Addressing comorbidities of mental illnesses with chronic
physical illnesses will be the fourth revolution in psychiatry. Mind and body are inseparable; there is a bidirectional
relationship between psyche and soma, each influencing the other. Plausible biochemical explanations are appearing
at an astonishing rate. Psychiatric comorbidity with many chronic physical disorders has remained neglected. Such
comorbidity with cardiac, respiratory, Gastrointestinal, endocrinal, and neurological disorders, trauma, and other
conditions like HIV and so on, needs to be addressed too. Evidence base of prevalence and causal relationship of
psychiatric comorbidities in these disorders has been highlighted and strategies to meet the challenge of comorbidity
have been indicated.

Key words: Fourth revolution, Psychiatric comorbidity, chronic physical disorder

INTRODUCTION effective and easily feasible treatment option for a variety

At the outset, I would like to express my gratitude for
considering me to deliver this prestigious oration instituted
by the Indian Psychiatric Society in memory of late Professor
DLN Murthy Rao, a great teacher, scholar, clinician. and
healer. I have been a student of Professor DLN Murthy Rao
and have been trained in the institution where he worked.
I have felt his aura in the teachings of my teachers and am
delighted to be here before you.
The first revolution in psychiatry is generally acknowledged
to be the unchaining and moral treatment offered to mental
patients by Pinel in the year, 1793.[1] The second revolution
was heralded by the invention of electroconvulsive therapy
(ECT) in the year 1935, by Cerletti and Bini.[2] It was the first
Address for correspondence: Dr. Shiv Gautam,
Department of Psychiatry and Superintendent,
Psychiatric Center, Gokul 1, Civil line, Jaipur 302006, India
E-mail: dr_shivgautam@yahoo.com
DOI: 10.4103/0019-5545.70973
of mental illnesses. Another leap for psychiatry was the
introduction of psychotropic agents, chlorpromazine to be
particular, in the year 1952, and the later discovery of a
series of antidepressants, anti-anxiety, anti-psychotic, and
other neuroleptic drugs. It changed the face of psychiatry
forever and allowed domiciliary treatment.[3] This is
generally regarded as the third revolution of psychiatry and
combined with the treatment of the mentally ill outside
the four walls of the mental hospital has revolutionized the
outcome of mental illnesses.
Addressing comorbidities of mental illnesses with chronic
physical illnesses will be the fourth revolution in psychiatry.
Mind and body are inseparable and there is a bidirectional
relationship between psyche and soma, each influencing
the other. Psychological factors must be taken into account
when considering all disease states. Physical diseases have
a large overlap with mental disorders. All physical illnesses
and their management cause a psychological reaction.
This may or may not reach morbid levels, similarly mental
illnesses and stress predispose to a large variety of physical

How to cite this article: Gautam S. Fourth revolution in This paper won the DLN Murthy Rao Oration Award at
psychiatry Addressing comorbidity with chronic physical the Sixty-second Annual National Conference of the Indian
disorders. Indian J Psychiatry 2010;52:213-9. Psychiatric Society, Jaipur in January 2010

Indian Journal of Psychiatry 52(3), Jul-Sep 2010 213

 Gautam: Fourth revolution Addressing psych. comorbidities

illnesses. A bidirectional relationship has been established PREVALENCE OF DEPRESSION IN VARIOUS

and the evidence grows by the day. Plausible biochemical PHYSICAL DISORDERS
explanations are appearing at an astonishing rate. We are
all aware of the neurochemical response, immune response, It has been reported that prevalence of depression
and endocrine response to stress.[4] associated with various chronic physical disorders is
comparatively higher than in the general population.[6]
The catabolism of tryptophan is stimulated under the
General population 17%
influence of stress, hormones, and inflammation, by the
Post-partum 51%
induction of the enzyme tryptophan pyrrolase. On account
Diabetes 27%
of the reduction in blood levels of tryptophan under these HIV 45%
circumstances, the formation of cerebral serotonin is Coronary artery disease 45%
decreased. Depression is associated with many chronic Stroke 80%
disorders and aging: in each case depressed individuals have
the worse outcome. In all these conditions there is now Cardiovascular disorders
evidence of impaired phospholipid metabolism and impaired Cardiovascular disorders are one of the leading causes of
fatty acid-related signal transduction processes. This may be death. Depression, anxiety, type A behavior, hostility, and
a primary cause of depression in chronic illnesses.[5] the like, have all been evaluated as risk factors for cardiac
disease. A bidirectional relationship has been noted.
Addressing psychiatric comorbidities with chronic physical
Sixteen to twenty-three percent prevalence of depression
disorders shall be the fourth revolution in psychiatry. Let
is noted in patients with Coronary Artery Disease. Acute
us look at the comorbidities with various chronic physical
emotions can cause autonomic arousal and thereby
disorders and strategies of treating them.
precipitate arrhythmia in the predisposed.[7] Hypertension
COMMON PHYSICAL DISORDERS WITH and its relationship with certain personality types has been
PSYCHIATRIC COMORBIDITY widely reported.[8] Acutely stressful situations are known
etiological factors of vasovagal syncope.
Cardiovascular disorders a) One plausible contributing mechanism is the tendency
Coronary artery disease of those with psychiatric disorders to ruminate
Arrythmia on stressful events. This phenomenon, sometimes
Hypertension called perseverative cognition, can extend to the
Congestive heart failure psychological and physiological effects of stress, which
Mitral valve prolapse could contribute to cardiovascular disease etiology [9]
Respiratory system Certain genes (5-HTTLPR and STin2 VNTR, but not
Asthma the rs25531), responsible for polymorphisms of SERT
COPD (serotonin reuptake transporter), are associated with
Pneumonia post stroke depression (PSD) in stroke survivors and
Embolism patients with MI (myocardial infarction). This gives
Pneumothorax further evidence for a role of SERT polymorphisms
Gastrointestinal in mediating resilience to biopsychosocial stress.[10]
Peptic ulcer In a sample of outpatients with CAD (coronary heart
IBS disease), the association between depressive symptoms
Celiac disease and adverse cardiovascular events was largely explained
Endocrine by behavioral factors, particularly physical inactivity.[10]
Thyroid disorders
Diabetes After adjustments for gender, age, ethnicity, education, and
Cushings syndrome employment status, sympathetic arousal and early-morning
Neurological insomnia were significantly associated with cardiac disease.[11]
Epilepsy
Parkinsonism In the setting of cardiovascular rehabilitation, approximately
Stroke 45% met the criteria for at least one anxiety disorder, and
Alzheimers disease 20% met the criteria for either major depressive disorder
Encephalopathy or dysthymic disorder at the time of evaluation or in their
Miscellaneous lifetime. Across all participants, 26% met yjr criteria for at
Accidents least two PD (personality disorders).[12]
HIV
Cancer In CHF (congestive heart failure) patients as a whole, 20%
Skin disorders of the patients met the DSM-IV criteria for a current major
214 Indian Journal of Psychiatry 52(3), Jul-Sep 2010
 Gautam: Fourth revolution Addressing psych. comorbidities
depressive episode, 16% for a minor depressive episode,
and 51% scored above the cutoff for depression on the Beck
Depression Inventory (>10).[13]
Vijayvergia and Vyas (1987), reported that essential
hypertensives perceived more number of stressful life events
and were unable to express themselves. Certain personality
factors associated with hypertension were reported to be,
being reserved, detached, cool, emotionally less stable,
with low frustration tolerance, and so on.[14] Patients
undergoing open heart surgery had pre- and postoperative
psychiatric disturbances. Anxiety, depression, and delirium
were the common diagnosis. (Shekhawat and Gautam
(1994))[15] Sharmaand Gautam (1997), reported that 80% of
Non-Cardiac Chest Pain patients identified psychological
factors as the precipitating factor; 67.5% of the patients had
psychiatric morbidity. (Studies carried out at PCJ)[16]
Respiratory disorders
Disturbances of breathing can perturb psychic calm as in
the terror of any asthmatic patient. Likewise, psychological
distress may become evident by disrupted breathing as
seen in depressed and anxious patients.
At least half of the children with anxiety disorders had a
comorbid physical illness. Allergies and asthma were the
most common comorbid physical illnesses.[17]
When comorbid with COPD (chronic obstructive pulmonary
disease), mental health symptoms of depression and anxiety
are some of the most salient factors associated with quality-
of-life outcomes. A possible causal effect of depression
on COPD exacerbations and hospitalizations has been
suggested.[18] Chronic bronchitis is strongly associated with
depression and anxiety.[19] As depression and/or anxiety may
not only interfere with an attempt to stop smoking, but also
contribute significantly to experiencing low quality of life, it
is important to consider these disorders.[20]
Trials of nortriptyline, buspirone, and sertraline have been
found to reduce symptoms of anxiety in the Patients of
COPD. Similarly, cognitivebehavioral programs that focus
on relaxation and changes in thinking also produce declines
in anxious symptoms.[21] Finally, multicomponent pulmonary
rehabilitation programs can also result in reductions in
anxious symptoms.[22]
Tyagi and Vyas (1989), reported that 65% of asthmatics
suffered from psychiatric morbidity, chief among them
being anxiety and depression. (Study carried out at PCJ)[23]
Gastrointestinal disorders
Gastrointestinal disorders are very prevalent and a large
proportion of these disorders are functional in nature.
Psychological and psychiatric factors commonly influence
the onset, severity, and outcome of many gastrointestinal
Indian Journal of Psychiatry 52(3), Jul-Sep 2010
disorders. IBS (Irritable bowel syndrome) and psychiatric
illness have high rates of bi-directional comorbidity;[24] 35.1%
of the patients with OCD (Obsessivecompulsive disorder)
satisfied criteria for IBS. SSRIs (Selective serotonin reuptake
inhibitors) could potentially worsen such symptoms and
lead to non-adherence.[25] The prevalence of IBS and other
functional gastrointestinal disorders with panic disorder
were substantially higher[26] Improved depression was
associated with improved role functioning.[27] Cognitive-
behavioral therapy (CBT) has received increased attention
in light of a recent shift in the conceptualization of IBS
as a disorder of braingut function.[28] One-third of the 30
patients with IBS suffered from psychiatric comorbidity and
perceived a greater number of stressful life events.(Arun
and Vyas(1989), (study conducted at PCJ)[29]
Any childhood abuse was associated with a significantly
increased odds ratio for recurring stomach problems, and
frequent childhood abuse was associated with a significantly
increased likelihood of recurring stomach problems and
ulcer.[30] Generalized anxiety disorder (GAD) was associated
with a significantly increased risk of self-reported PUD
(Peptic Ulcer Disease). Peptic ulcer patients perceived more
number of stressful life events and had higher alexithymia
scores.(Banerjee and Vyas (1988), study conducted at PCJ)[31]
A high prevalence of depressive symptoms, hypothetically
related to serotonergic dysfunction, have been reported
among adults with celiac disease[32] Adolescent celiac
disease patients with depression have significantly lower
pre-diet tryptophan/competing amino-acid (CAA) ratios and
free tryptophan concentrations, and significantly higher
biopsy morning prolactin levels compared to those without
depression[33]
Diabetes
Psychiatric comorbidity with diabetes is common and
impacts its course and outcome. Up to 30% of such
patients are depressed, and anxiety disorders are also
very common. A bidirectional relationship is apparent.
People with depression have poorer glycemic control
and depressed people are prone to develop diabetes.[34]
Depressive symptoms were associated with increased risk
of MCI (Mild Cognitive Impairment), and this association
was independent of the underlying vascular disease.[35]
People with diabetes, smoking, and obesity were associated
with a greater likelihood of meeting the criteria for major
and minor depression.[36] Among patients with diabetes,
both minor and major depression are strongly associated
with increased mortality.[37] Depressive symptom severity
is associated with poorer diet and medication regimen
adherence, functional impairment, and higher healthcare
costs in primary care diabetic patients.[38] The occurrence
of eating disorders was increased compared to the rates
observed in the general population, with the predominance
of binge eating disorder. Dubey and Solanki (2004), studied
215
 Gautam: Fourth revolution Addressing psych. comorbidities
cognitive impairment and depression in diabetes and found
that 48% of the diabetics showed cognitive impairment
and 36% of the patients were suffering from depression.[39]
Sushil and Vyas (1990), reported that 74% of the diabetics
suffered from psychiatric comorbidity; 44%depression, 10%
mixed anxiety and depression, 14% anxiety neurosis, 2%
phobia, and 4% sexual problems. (Studies carried out at
PCJ)[40]
Thyroid
Hyperthyroidism may present with psychiatric symptoms
like anxiety, irritability, lability, fatigue, restlessness, and
so forth. Hypothyroidism can cause depression, cognitive
impairment, and rapid cycling mood disorder. Subclinical
hypothyroidism is also an important cause of depression.
The relationship between basal thyroid hormone levels and
acute antidepressant response has been studied. Time to
recurrence of major depression was inversely related to T3
levels and not to T4 levels.[41] Erectile Dysfunction (ED) is
extremely common in males with dysthyroidism. Treatment
of the latter restores erectile function.[42] A significant
association of subclinical hypothyroidism with psychiatric
disorders and an increased frequency of subsyndromic
depression and anxiety symptoms is reported.[43] Jain and
Gautam (1988), reported that 58.33% of patients with
thyroid dysfunction had psychiatric illnesses (n=60). (Study
carried out at PCJ)[44]
Central nervous system
Headaches are the most common neurological complaint
and a major cause of absenteeism. Most headaches have an
emotional basis and even headaches with neurological basis
have significant psychiatric comorbidity. All headache types
are reported to be more prevalent in depressed patients;
the strongest association being between depression and
migraine with aura[45] Elevated one-year prevalence rates
for a wide range ofpsychiatric disorders (Anxiety spectrum
disorder, depression, bipolar affective disorder) in people
with migraine has been reported[46] Dysregulation of
serotonergic neurotransmission has been postulated to have
a key role in the pathogenesis of both major depressionand
migraine.
Epilepsy
At least a two-fold, overall increase in psychiatric morbidity in
patients with epilepsy has been noted. In the pre-ictal state,
prodromal states and mood disturbances are commonly
seen. During the ictal state of complex partial seizures,
the disturbances often seen are affective disturbances,
hallucinations, experiential phenomenon, and automatisms.
Impaired consciousness, delirium, psychosis, and Todds
paresis are usually seen in the post-ictal phase. During the
inter-ictal stage, the commonly seen disturbances include
cognitive, psychoses, sexual behavior, depression, suicide,
crime, antisocial behavior, and personality change.
216
Latest evidence shows a significant association between
the prevalence of depressive symptoms and non-lesional
focal epilepsy[47] Simple causal links between epilepsies and
psychoses appear increasingly tenuous, despite indications
that somepsychotic symptoms and some localized structural
changes are linked
In a study of 204 patients, Guerje et al. found that 37%
emerged as psychiatric cases, almost a third of these being
cases of psychosis. Patients with partial seizure of the
temporal lobe origin were the most psychiatrically impaired.
Self-poisoning is a common complication of epilepsy.
Epilpeptics have been found to have less alcohol excess, but
significantly more psychopathy[48] Purohit and Satija (1984),
reported that psychiatric manifestations were present in
35% of the cases of chronic epilepsy and they were more
common in temporal lobe epilepsy. (Study conducted at
PCJ)[49]
Stroke
Overall 31.835.5% of the stroke patients have depression.
They are likely to be underestimated due to under reporting
of unusual mood, difficulties in assessment of depression in
neurologically impaired individuals, and variability in the
methods used to assess and define depression.[50]
Alzheimers disease
At the initial evaluation, 19% of the Alzheimersdisease
patients had major depression and 34% had dysthymia,
after a mean follow-up of 16 months; 58% of the patients
with major depression at the initial evaluation were
stilldepressed, whereas, only 28% of the patients with initial
dysthymia and 21% of the non-depressed patients were
depressed at follow-up. All three groups showed similar
declines in cognitivestatus and activities of daily living.[51]
Parkinsons disease
The association of depression with Parkinsons disease
is well-established, with a prevalence of 40%. Psychotic
symptoms occur at some stage in 20% of the patients
and excessive somnolence, day-time sleepiness, and
sleep attacks are also common. Research has suggested
that high levels of depression and anxiety observed
in Parkinsons disease are a primary consequence of
its pathophysiology. However, people with a specific
metacognitivestyle had an increased vulnerability to distress
over and abovethe previously identifieddiseasefactors[52]
Head injury
Psychiatric disability has been found to correlate to a
statistically significant extent with the depth and quantity of
brain damage. The duration of post-traumatic amnesia and
the incidence of post-traumatic epilepsy show significant
correlation. Similarly, the development of epilepsy,
especially if within one year of injury, is associated with
increased psychiatricdisability. Left hemisphere lesions and
Indian Journal of Psychiatry 52(3), Jul-Sep 2010
 Gautam: Fourth revolution Addressing psych. comorbidities
temporal lobe wounds are more closely associated with
psychiatric disability.[53]
Other accidents
Bhojak and Gehlot, (1982) reported that 93.33% of limb
amputees reported phantom limb phenomenon, 63.33%
of the patients were depressed, and 46.66% were suicidal
(n=30)[54] Mordia and Gautam (2000), found that there is a
significant psychiatric morbidity post- burn (62.86%), which
includes depression (21.43%), adjustment disorder (21.43%),
PTSD (15.71%), and post-schizophrenic depression (4.26%)
(Studies conducted at PCJ)[55]
AIDS
Psychiatric disorders in populations of people with HIV
exceed the general population estimates significantly.
Rates of depression range from 20 to 37% in people with
HIV. Cognitive impairment increases as the immune
system worsens and HIV progresses. Furthermore, the
prevalence of minor HIV-associated cognitive impairment
is rising among patients on HAART (highly active anti-viral
therapy) as a result of increased survival time.[56] Youths
with major mental disorders had a high prevalence of
most HIV-AIDS risk behaviors. Comorbid substance use
disorders substantially increased the risk.[57] HIV-associated
neurocognitive disorders (HAND) are common among HIV
patients, and HIV-associated dementia (HAD) is a serious
condition. The introduction of HAART has resulted in a
significant decrease in morbidity and mortality in HIV-
infected patients. HAART has also decreased the incidence
of HAD, but does not give complete protection. The utility
of psychotropic medications in HIV patients has not been
studied sufficiently. Mandal and Bhojak (2005), reported
that a prevalence of depression and anxiety in HIV-positive
patients was 26 and 16%, respectively. (Study carried out at
PCJ)[58]
Cancer
Comorbidity in cancer is due to the response to the
diagnosis anxiety, shock, denial, depression, adjustment
disorder, suicide. Major depression occurs in 1020% of
the patients in the course of the disease. Progression and
recurrence are often associated with increased psychiatric
disturbance. Para-neoplasia metastasis and style of coping
predicts survival in lung cancer.[59] Cancer patients with
depression have markedly higher plasma concentrations of
IL-6 than healthy comparison subjects and cancer patients
without depression.[60] The treatment of penile cancer
results in negative effects on the well-being in up to 40%,
with psychiatric symptoms in approximately 50%. Up to
two-thirds of the patients report a reduction in sexual
function[61] Nijhawan and Gehlot (1982), reported that 78% of
cancer patients suffered from psychiatric symptomatology
and more than two-thirds of these patients suffered from
depression.[62] Gautam and Nijhawan (1983), found that
there was no significant difference in psychiatric morbidity
Indian Journal of Psychiatry 52(3), Jul-Sep 2010
between cancer patients and patients with chronic lung
disease. (Studies conducted at PCJ).[63]
Dermatology
Psychocutaneous disorders encompass a wide variety
of dermatological diseases that may be affected by the
presence of psychiatric symptoms or stress and psychiatric
illness in which the skin is the target of disordered thinking,
behavior or perceptions. Atopic dermatitis, psoariasis,
psychogenic excoriation, pruritis ani, pruritis vulvae,
hyperhidrosis, urticaria, leprosy, and so on, have a large
psychiatric overlap. Meel and Gautam (1988), found that
patients of dermatitis perceived more stressful life events,
had schizothymic traits, and had lower scholastic mental
capacity and lower ego strength. They scored high on the
Toronto-Alexithymia scale. (Study carried out at PCJ).[64]
Strategies to address psychiatric comorbidities with
chronic physical disorders:
1. Training of general practitioners (GPs) and physicians
in the identification and management of psychiatric
comorbidities in rural and urban areas.
2. Sensitization of physicians working in different
specialities in secondary and tertiary care hospitals.
3. Presentation of success stories of outcomes in medical
and other outpatient departments.
4. Creating public awareness about psychiatric
comorbidities with chronic physical disorders.
In a large number of patients suffering from psychiatric
comorbidity with chronic physical disorders, the
management of emotional problems remain neglected.
Therefore, if a dent can be made in the management of the
psychiatric comorbidities with chronic physical disorders,
it would not only give a due status to the speciality of
psychiatry, but would also change the quality of life of
millions of patients.
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Source of Support: Nil, Conflict of Interest: None declared

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