标题：Association Between Nonspecific Severe Psychological Distress as an Indicator of Serious Mental Illness and Increasing Levels of Medical Multimorbidity
摘要：Objectives. We sought to determine whether severe psychological distress (SPD) and serious mental illnesses (SMIs) are associated with a specific set of chronic medical conditions (CMCs) and the association between SPD–SMIs and increasing levels of medical multimorbidity and complexity (i.e., from 1 to 3 or more CMCs). Methods. We used data from 3 administrations (2008–2010) of the National Survey on Drug Use and Health collected from 110 455 adult participants. We used binary and ordinal logistic regressions adjusting for sociodemographics and substance abuse to examine the associations between SPD–SMIs and increasing levels of multimorbidity. Results. SPD–SMI was associated with higher probabilities for many CMCs generally, but we found no specific pattern for any class of conditions for SPD–SMIs and multimorbidity. The association between SPD–SMIs and multimorbidity strengthened as the number of CMCs increased. Conclusions. The finding of no discernible risk pattern for any specific CMC grouping supports broad medical assessment strategies and closely coordinated primary and behavioral health care for those with SPD–SMIs, as called for in the Patient Protection and Affordable Care Act. Medical multimorbidity, most commonly defined as having 2 or more chronic medical conditions (CMCs), is of increasing importance for health care practice, policy, and research. 1,2 Several potential reasons motivate this interest. When multimorbidity is present, provision of care is difficult and expensive. Medical care tends to focus on treatment of single conditions. 3 This focus may result in unnecessary or poorly coordinated care, both of which potentially inflate costs. 4–6 Evidence-based clinical practice guidelines have started to address care in the presence of comorbidity, especially when disorders have similar pathogenesis and care requirements. 7 There is a dearth of sound guidance, however, when pathogenesis is discordant or when there are multiple co-occurring conditions. 8 Medical multimorbidity is relatively common. Recent general population surveys have estimated a prevalence between 10% and 20%. 9,10 Within specific subpopulations, the prevalence is much higher. For instance, studies of patients in general medical practice and of older adults have reported multimorbidity prevalence rates of 29% and as high as 55%. 11–13 Because of treatment complexity and high prevalence rates, identification of risk factors for medical multimorbidity has become increasingly emphasized. One cofactor consistently linked to medical multimorbidity is serious mental illnesses (SMIs) such as bipolar disorder, major depressive disorder, or schizophrenia. 13,14 This association has important repercussions, one of which is that the increased rate of medical multimorbidity among those with SMIs results in a substantially diminished life expectancy. Individuals with SMIs are estimated to live 13 to 30 years less than those who do not have SMIs. 15 The higher mortality rates owing to the co-occurrence of SMIs and medical multimorbidity are attributable to a number of factors. People with SMIs tend to lead unhealthy lifestyles characterized by substance use, poor diet, and physical inactivity. 16 They are disproportionately more likely to commit suicide, be victims of violence, and engage more frequently in risky sexual behavior, increasing the likelihood of sexually transmitted infections. 17–19 In addition, some psychiatric medications, most notably atypical antipsychotics, are associated with iatrogenic medical complications such as type 2 diabetes, hyperglycemia, and obesity. 20 As a result of these and lifestyle factors, heart disease is of particular concern among those with an SMI. If multimorbidity develops, diminished access to financial resources and health insurance reduce the likelihood that those with an SMI will obtain medical care, potentially compounding the deleterious effects of multimorbidity. 21 Even when people with SMIs obtain medical care, it is often inadequate. 22 Moreover, people with SMIs who have cognitive and emotional impairments have difficulty adhering to complex, often poorly coordinated medical care and complicated medication regimens, vitiating the benefits of clinical intervention. 15 Because of the widely recognized importance of SMI as a risk factor for multimorbidity and the need to develop better-coordinated treatment strategies, we sought to study the relationship between medical multimorbidity and SMIs further. For the purposes of this study, we used nonspecific severe psychological distress (SPD) as a proxy indicator of a probable SMI. First, we examined associations between SPD–SMI and the individual prevalences of 14 CMCs in a general population sample. 22 We also attempted to determine whether those with medical multimorbidity and SPD–SMI had higher prevalence rates of specific clusters of CMCs than those with multimorbidity but no SPD–SMI. Last, we examined the association of SPD–SMI with multimorbidity across increasing levels of multimorbidity. To date, most research has assumed that the relationship between SPD–SMI and multimorbidity is constant as medical conditions accumulate. 23 We tested that assumption to determine whether people with SPD–SMI are at increasing risk for experiencing a higher number of concurrent CMCs relative to the risk of fewer CMCs.
