Mental and physical comorbidity in an Arab national primary health care setting Dr. Muhammad Ajmal Zahid Chairman, Department of Psychiatry, Faculty of Medicine, Kuwait University.

Background Comorbidity is defined as the co-occurrence of mental and physical disorders in the same person, regardless of the chronological order in which they occurred or the causal pathway linking them Comorbidity is an important topic because it is one of the commonest relationships among medical illnesses, with a significant impact on the mode of presentation, clinical severity, response to treatment and psychosocial burden of illness. The pathways causing comorbidity of mental and medical disorders are complex and bidirectional, such that, while medical disorders may lead to mental ones, mental conditions may place a person at risk for medical disorders, and mental and medical disorders may share common risk factors

Objectives Estimate the prevalence of the comorbidity between common mental disorders (anxiety/ depression / somatization) and chronic physical illnesses (diabetes mellitus, hypertension, heart disease and bronchial asthma) in a national random sample of primary health care attendees Explore the relationship of comorbidity with type of illness and socio- demographic characteristics.

Sampling Out of the total number of 87 primary health centers in all the five state Governorates, sixteen centers were blindly selected from the random table. The sample size was calculated to significance level set at 0.05% and a precision of 2%, for an estimated 16% prevalence of psychiatric disorders. An adequate sample size (using power curve) was estimated to be 1000 participants. As a result, a total number of 1046 consenting subjects were recruited so as to allow for 5% of the missing data cases.

Procedures Sixteen physicians administered the PHQ's to all the consenting primary clinic attendees, and their demographic characteristics recorded while they waited for consultation with the physician. Both the English and the Arabic versions of the questionnaires were made available. The treating physicians were requested to refer any patient found to be mentally ill. The patients were recruited on alternative working days during the 5- month period from 1st May to 30th September, 2012.

Measures The Patient Health Questionnaire -Somatic/Anxiety/Depression (PHQ- SAD) is an easy-to administer, brief diagnostic assessment tool, designed to measure probable rates of psychiatric morbidity in the primary care settings. The physical diagnoses, based on the International Classification of Diseases, 10th edition (ICD-10), were assigned by the primary care physicians. All the physically ill patients were receiving treatment for their respective ailments which had been confirmed, where necessary, with by further investigations and the hospital doctor consultation.

Association of demographics Physical illnesses Mental illnesses Physical illnesses Older Divorce Poor living conditions Illiteracy Mental illnesses Older Female Kuwaitis Lower levels of education

Relationship of mental illnesses to physical morbidity Higher prevalence of mental illnesses Higher psychopathology scores Increasing number of physical illnesses

Association of physical and mental morbidity

Association of (number) physical illnesses with (types) mental disorders

Severity of psychopathology with number of physical illnesses

Severity of psychopathology with type of physical illnesses

Results (1) Total number of patients = 1046 275 (26.3%) had only physical condition 148 (14.1%) had 2 physical conditions 33 (3.2) had at least 3 physical conditions 670/360 (53%) had physical-mental comorbidity while mental illness in those without physical illness was 21.8% (376/82) (OR = 4.1, P < 0.001) Subjects with heart diseases and asthma consistently had higher psychopathology scores.

Results (2) 670/1046 (64%) had at least one medical illness diabetes mellitus (37.01%), hypertension (34.18%), heart diseases (7.2%) and non-chronic physical illnesses (9.4%) 442/1056 (42%) had at least one mental disorder Somatization Depression anxiety disorder 442/223 (50%) had mental-physical comorbidity

Weaknesses and strengths Cross-sectional design Cut-off scores used to ascertain caseness Limited range of medical illnesses Sample large and representative Standardized instruments Limited range of illnesses reflect service delivery system with ready availability of specialist centers

Conclusions The findings call for the primary care physicians to be sensitive to the psychosocial context of patients who present primarily with physical conditions; more so for patients with multiple medical illnesses and social disadvantage. The primary clinic physicians need to be trained to adopt holistic (bio- psycho-social) approach to assess the primary clinic attendees. The primary clinic physicians need to be trained to treat the common psychiatric disorders (anxiety, depression, somatization) at the primary care level.

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