Introduction: The Integrated Approach to Addressing Comorbidities—Part 1

Introduction: The Integrated Approach to Addressing Comorbidities—Part 1

It is increasingly appreciated that comorbidity in psychiatric illness is an important consideration in clinical practice; it has also become a topic of research interest. Many recent articles highlight the complexity of psychiatric and systemic illness, both in terms of overlapping clinical presentation and in the degrees to which systemic illness and psychiatric illness affect each other. (A literature review that offers a sample of these articles can be viewed in the online version of this article here.)

When one speaks of psychiatric comorbidity, 2 constructs come to mind. The first is psychiatric illness that is comorbid with systemic medical illness. Whether the onset of the psychiatric illness is temporally associated with the systemic illness, whether the psychiatric illness comorbidity can be explained by the patient not coping well with the systemic illness, or whether both are referable to a common source is often elusive and ambiguous. What matters is that the patient has 2 (or more) medical problems (that affect different organ systems) that need to be addressed by evidence-based clinical interventions in an integrated approach.

The other “psychiatric comorbidity” refers to more than one psychiatric illness in the same patient. Examples include dementia with episodic delirium, depression with concurrent substance abuse, and personality disorder comorbid with PTSD. Indeed, for some particularly complex psychiatric patients, one may speak of “trimorbidity” (eg, mood disorder, personality disorder, and substance abuse), even in the absence of significant systemic illness. Of course, physicians are quite familiar with patients who are “multiply comorbid” on 2 dimensions (ie, 2 or more chronic systemic illnesses and 2 or more psychiatric illnesses) simultaneously.

The semantics of all of this can be daunting and less than precise. What is important, for psychiatrists and other specialty physicians, is to be vigilant for comorbidity within the category of psychiatric illness and to look for psychiatric and systemic comorbidity simultaneously. Care for these various conditions should be integrated and balanced, so that various medical interventions do not work at cross purposes. Comorbidity can serve as the illnesses’ “substrate” that encourages the patient’s various specialty physicians to thoughtfully collaborate and complement their respective interventions.

The authors of this Special Report—which will appear in this issue and also in February and which can now be read online at—have chosen a compelling series of topics. In her article, Eleanor Stein, MD, addresses the psychiat-ric comorbidity of painful and life-limiting illnesses. She emphasizes that these systemic conditions both mimic primary psychiatric illnesses and are frequently comorbid with them. The inclusion of the Fukuda and Canadian criteria is a timely addition. Dr Stein specifies which symptoms of myalgic encephalomyelitis and fibromyalgia overlap with psychiatric illness and which do not, adding diagnostic and attributional specificity. She suggests that conventional psychiatric interventions such as psychotropic medication and psychotherapy may be indicated for the “non-psychiatric” systemic illnesses as well as for their comorbid psychiatric conditions. The specification of cognitive-behavioral therapy as the chosen psychotherapy model for pain conditions is especially important.

Shane Coleman, MD, and Wayne Katon, MD, describe the synergistic and often “reciprocal” relationship between depression and diabetes. Because these two illnesses are, independent of each other, major public health problems worldwide, thoughtful management of their commonly overlapping presentations is especially crucial for patient outcomes. The authors describe the pervasive effects diabetes and depression each have on the other. Their guidance on attributional interpretation of symptoms is particularly helpful.

Gregory Pontone, MD, straddles the neuropsychiatric borderland in his article. It is often best to think of many CNS phenomena as neither exclusively psychiatric nor exclusively neurological, but as both. He provides concise and clinically utilitarian descriptions of the various movement disorders encountered in psychiatric practice and offers useful management approaches.

Todd Smitherman, PhD, Donald B. Penzien, PhD, and Jeanetta C. Rains, PhD, review a common clinical relationship between migraine and psychiatric illness. Because psychiatric comorbidity is both common and complicating, physicians are reminded to consider migraine and its psychiatric comorbidity in an integrated fashion. Both psychopharmacological and nonpsychopharmacological treatment should be actively considered.

Robert Biskin, MDCM, and Joel Paris, MD, describe the complex and often multiple psychiatric comorbidities that affect patients with borderline personality disorder, one of the more complex and common patient presentations in clinical practice. The authors remind us that simultaneous attention to these comorbidities is crucial in the clinical management and treatment outcomes for these patients.

These articles illustrate the variety and complexity of problems associated with comorbidity in psychiatric disorder. We hope that physicians who daily face the challenges of often multiple psychiatric illnesses in patients with significant comorbidity will find these articles useful.


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