comorbidity, prevalance and trends. general definition of comorbidity historical origins...

Comorbidity, Comorbidity, Prevalance and Prevalance and TrendsTrends

General Definition of General Definition of ComorbidityComorbidity

Historical Origins (Feinstein, 1970)Historical Origins (Feinstein, 1970) General Definition: Two or more physical General Definition: Two or more physical

illnesses, psychological conditions or a illnesses, psychological conditions or a mix of the twomix of the two

Rule rather than the exceptionRule rather than the exception Distinguish:Distinguish:

CovariationCovariation Co-occurrenceCo-occurrence

Overview of the NCS, Overview of the NCS, NCS-RNCS-R

http://www.hcp.med.harvard.edu/ncs National Comorbidity Survey (1990-1992), First National Comorbidity Survey (1990-1992), First

nationally representative survey of mental nationally representative survey of mental disorders using research diagnostic interviews disorders using research diagnostic interviews using DSM-III-R criteriausing DSM-III-R criteria

National Comorbidity Survey-ReplicationNational Comorbidity Survey-Replication(2001-2003), N = 10,000, used DSM-IV criteria(2001-2003), N = 10,000, used DSM-IV criteria Follow up on disorders from the first NCS and Follow up on disorders from the first NCS and

to explore particular questions in further depthto explore particular questions in further depth

Rates of ComorbidityRates of Comorbidity

Nearly half of all people with a mental disorder Nearly half of all people with a mental disorder have two or more disordershave two or more disorders

More than half of people with a substance use More than half of people with a substance use disorder and more than 75% of those within disorder and more than 75% of those within treatment for substance abuse or dependence treatment for substance abuse or dependence als meet criteria for a mental disorderals meet criteria for a mental disorder

Individuals frequently meet criteria for three or Individuals frequently meet criteria for three or more disordersmore disorders

Disorders may have indirect or direct causes—Disorders may have indirect or direct causes—more on this latermore on this later

Modeling Comorbidity:Modeling Comorbidity:Krueger and MarkonKrueger and Markon

Associated Liabilities Models: A liability Associated Liabilities Models: A liability is an indirectly observed or latent is an indirectly observed or latent propensity to develop directly observed propensity to develop directly observed or manifest disordersor manifest disorders What are some examples of liabilities?What are some examples of liabilities?


Associated Liabilities ModelAssociated Liabilities Model


Multiformity ModelMultiformity Model


Causation ModelCausation Model


Independence ModelIndependence Model


Hypothetical Multivariate ModelHypothetical Multivariate Model

Dual Diagnosis: An Dual Diagnosis: An application of application of ComorbidityComorbidity

Berken’s Fallacy: Individuals with Berken’s Fallacy: Individuals with multiple disorders are more likely to seek multiple disorders are more likely to seek treatment so that estimates of the treatment so that estimates of the prevalence of comorbid disorders will be prevalence of comorbid disorders will be higher in clinical sampleshigher in clinical samples

Inpatient vs Outpatient statusInpatient vs Outpatient status Chronicity of IllnessChronicity of Illness Severity of IllnessSeverity of Illness

Methodological issues Methodological issues contdcontd

Definitional issues vary from problem use Definitional issues vary from problem use of a substance to abuse or dependenceof a substance to abuse or dependence

Which substances are included in the Which substances are included in the definition makes a differencedefinition makes a difference

Disconnected areas of studyDisconnected areas of study

Effect of ComorbidityEffect of Comorbidity

Comorbidity affects a disorder’s course Comorbidity affects a disorder’s course prognosis, assessment, treatment and prognosis, assessment, treatment and outcomeoutcome

Dual diagnosis: When a person meets criteria Dual diagnosis: When a person meets criteria for one or more Axis I or Axis II mental for one or more Axis I or Axis II mental disorders and meet criteria for one or more disorders and meet criteria for one or more substance use disorderssubstance use disorders

Individuals with a lifetime history of a mental Individuals with a lifetime history of a mental illness are 2.3 times more likely to have lifetime illness are 2.3 times more likely to have lifetime alcohol use disorder and 4.5 times more likely alcohol use disorder and 4.5 times more likely to have a substance use disorderto have a substance use disorder

Disorders with Highest Disorders with Highest ComorbiditiesComorbidities

ASP (84%)ASP (84%) Bipolar Disorder (61%)Bipolar Disorder (61%) Schizophrenia (47%)Schizophrenia (47%) Panic (36%)Panic (36%) OCD (33%)OCD (33%) MDD (27.2%)MDD (27.2%) Men and women with PTSD were 5 and 1.4 times more Men and women with PTSD were 5 and 1.4 times more

likely to have a drug use disorder than those withoutlikely to have a drug use disorder than those without Overall mental disorders yield at least double the risk Overall mental disorders yield at least double the risk

of a lifetime alcohol or drug use disorderof a lifetime alcohol or drug use disorder

Impact of Dual DiagnosisImpact of Dual Diagnosis

How are patients affected?How are patients affected? Assessment issuesAssessment issues

Underlying theoriesUnderlying theories

Common FactorsCommon Factors Secondary Substance AbuseSecondary Substance Abuse Secondary Psychiatric DisorderSecondary Psychiatric Disorder Bidirectional ModelsBidirectional Models

Prevalence and Prevalence and Treatment of Disorders Treatment of Disorders 1990-20031990-2003

No notable change in the prevalence or No notable change in the prevalence or severity of mental disorder in the United States severity of mental disorder in the United States between 1990-1992 or between 2001-2003between 1990-1992 or between 2001-2003

Most treatment for disorders falls below the Most treatment for disorders falls below the minimal standards of qualityminimal standards of quality

Treatment typically brief (affects duration of Treatment typically brief (affects duration of particular disorder more than prevalence of particular disorder more than prevalence of mental disordermental disorder

Most treatment delivered in the medical sector Most treatment delivered in the medical sector for disorders below clinical threshold.for disorders below clinical threshold.

Overall Rates of Overall Rates of MultimorbidityMultimorbidity

It is not uncommon for patients to have 3 It is not uncommon for patients to have 3 or more disorders: 14% of the NCS or more disorders: 14% of the NCS sample had 3 or more diagnoses and sample had 3 or more diagnoses and these respondents accounted for almost these respondents accounted for almost 90% of the severe 12 month disorders 90% of the severe 12 month disorders and well over half of the lifetime and 12 and well over half of the lifetime and 12 month diagnoses in the sample.month diagnoses in the sample.

comorbidity, prevalance and trends. general definition of comorbidity historical origins...

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