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
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
or more diseases is undoubtedly one of the most
important challenges to medicine of the 21st cen-
tury. Our success in prolonging life expectancy did
not greatly increase the number of disease-free
years: the years gained are years in which people
tend to suffer from a variety of chronic diseases,
impairments and disabilities. The survival into
higher age brought with it also a true, still not suffi-
ciently well recognized, epidemic of comorbidity.
The comorbidity of two or more somatic dis-
eases – for example cardiovascular disease and dia-
betes – is generally recognized as being frequent
and requiring simultaneous attention to both dis-
eases. The situation is different when it comes to
the comorbidity of mental and physical illness.
Psychiatry has grown and developed without much
linkage to general medicine or any of the other
medical specialties. Oncologists and other special-
ists who deal with particularly lethal diseases are
perhaps an exception – although even there, the
co-existence of cancer and a mental disorder such
as depression led to the development of a subspe-
cialty – that of psycho-oncology – rather than to a
close collaboration between oncology and main-
stream psychiatry.
In the late 19th century when many countries
constructed mental hospitals, it was normal and
expected that one of the departments or a pavilion
will be reserved for the treatment of somatic illness
of the in-patients. Frequently, the reason for plac-
ing a mentally ill person in such a ward was tuber-
culosis, but there were many who were suffering
from other communicable or non-communicable
disorders. Many of the mentally ill had a short life
expectancy, died early because of neglect, physical
hardships, poor access to medical care, and thus,
there were not all too many people with mental
and a physical illness. The ward for patients with
comorbid physical illness were therefore usually of
a modest size and rarely had more than 10% of the
institution’s beds.
ACTA PSYCHIATRICA SCANDINAVICA
Gradually, the situation changed and medical
departments in mental hospitals vanished. Better
transport made it easier for medical specialists to
come to the mental hospitals, and patients could
be transported to the general hospitals for exami-
nations and care. The diagnostic apparatus in
mental hospitals, for example, for radiography
grew obsolete and usually left to decay. At the
same time, departments of psychiatry in general
hospitals became more frequent. The public in
many countries – and health administrators –
increasingly perceived psychiatry as being distant
from classical medicine. Psychoanalysis became
better known and entered the public mind replac-
ing previous images of psychiatry. Psychiatrists no
longer made physical examinations at the begin-
ning of their acquaintance with the patient. The
psychiatry of the asylum with its inhabitants, for-
gotten by all miles away from other medical insti-
tutions, was not seen as dealing with the same kind
of people as other medical institutions or for that
matter with people with common mental disorders
such as depression or anxiety treated in the psychi-
atric departments of the general hospital. Some
psychiatrists still saw themselves as doctors and
emerged as a subdiscipline of ‘liaison psychiatry’
indicating that they are linked with general medi-
cine – a sad admission by the majority of psychia-
trists (who did not claim to be liaison psychiatrists)
that they did not feel interested nor competent to
deal with mental health issues presented by
patients who were treated for a physical illness.
The situation is perhaps gradually improving.
The excellent studies of mortality of people with
mental illness undertaken in Scandinavia, Aus-
tralia and elsewhere (1–4) made it gradually obvi-
ous that comorbidity of mental and physical
disorders is frequent, deadly and growing.
Physical diseases do not only kill people who
suffer from mental illness: they also make their life
even more difficult. The comorbidity does not only
produce suffering. It also makes the cost of
369
Editorial
treatment of the participating diseases much higher
than it would have been had these diseases
appeared alone (5). Mental disorders still carry
stigma, which makes access to care less easy and
the quality of care less good – both of which con-
tribute to the probability of complications of phys-
ical illnesses such as diabetes. It is still uncertain
whether stigma and discrimination in health care
and self-neglect often present in depressive and
other mental disorders is the main reason for the
higher likelihood of complications: recent findings
of immunologists open the door to thinking that
mental disorders such as depression perhaps share
some of the aetiopathogenetic pathways with
disorders such as diabetes affecting not only the
likelihood of comorbidity but also that of
complications.
For all these reasons, it is of great importance to
promote research into comorbidity and think of
ways in which health care could be reorganized so
as to facilitate treatment and recovery of people
struck by comorbid mental and physical disorders.
An important support to this effort is publications
about comorbidity – such as that by Dickerson
et al. (6) in this issue of Acta. Such publications
will not only help to move research forward and
towards new goals: they might also in time – and I
hope soon – influences the education of health
workers at undergraduate and postgraduate level.
370
The current fragmentation of medicine into ever
finer specialties makes the management of comor-
bidity ever more difficult: a reorientation of post-
graduate training might improve the situation.
N. Sartorius
Association for the Improvement of Mental Health Programmes
(AMH), Geneva, Switzerland
E-mail: sartorius@normansartorius.com
References
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Psychiatry 2010;196:116–121.
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