Vol 7, No 3 Printed in Great Britain
International Journal of Epidemiology ©Oxford University Preo 1978
Epidemiological Perspective Psychosomatic Medicine 'psychosomatic paradox'. This consists essentially in the two uses of the adjective 'psychosomatic': the one covering no more than a holistic approach to medicine which takes account of both biological and psycho—social factors; the other referring to particular disorders, such as hypertension, peptic ulcer and asthma 'in which psychological factors are supposed to play a major role'. The report referred pointedly to the lack of established evidence for the psychogenic theories in vogue, the ambiguity of the notion of stress and the uncertainty of the basic concept of specificity in the relationship between the nature of a psychological stressor and a particular organ system. It also drew attention to the research potential of epidemiological techniques, since the scientific study of 'psychosomatic medicine' was seen as being closely allied to the investigation of the psycho—social associations — antecedent, concurrent and subsequent — of somatic disease, and so coming within the orbit of general epidemiology. Unfortunately the pretensions of psychosomatic apologists (5) have not only proved sterile in their own right; they have also obstructed the application of the epidemiological perspective by deflecting interest away from the wider implications of the mind—body nexus in the various forms of recognised mental disease. Within this framework a psychogenic factor is only one link in a multifactorial chain, whether it be related to the physical dysfunctions of the eating disorders or to the mental states of the depressive reactions. Furthermore, by the same token the somatic factors in the aetiology of mental illness call for as much consideration as the psychogenesis of organic disease. Indeed, it may be contended that the preoccupation with the shadowy issues of 'psychosomatics' has obscured the more substantial problem of 'somatopsychics'. Within the categories of Section V of the International Classification of Diseases, for example, only category 305, 'Physical Disorders of Presumably Psychogenic Origin', would qualify for inclusion as a 'psychosomatic' category
In 1964 the World Health Organization published a technical report on 'Psychosomatic Disorders' (4), drawing attention to what it called the 'Based on a paper delivered at the 8th International Scientific Meeting of the International Epidemiological Association Puerto Rico, 1977
201
Downloaded from http://ije.oxfordjournals.org/ at University of Michigan on June 23, 2015
No discussion of the relationships between physical and mental illness can escape some mention of the term 'psychosomatic', a word which assumed increasing popularity in the mid-1940's, when it developed from the interest in the emergent concept of stress. Flanders Dunbars' two self-styled 'laws of emotional thermodynamics' summarize the thinking of the times (1). The first 'law' stated that psychic energy, when not expressed through higher levels, obtained its outlet through physical symptoms; the second postulated that if such symptoms were the result of permanent structural damage, energy would be correspondingly dissipated and made unavailable. Somatic dysfunction was thus equated with 'a waste or dissipation of energy due to the faulty design of the personality' which led in turn to the quest for 'psychological profiles characteristic of specific disease syndromes' and to the view that many somatic diseases were psychogenic in origin and reactive to an omnipresent group of ill-defined 'stressors'. So cavalier a disregard for the complexities of the mind—body relationship and the nature of causality could only have been taken seriously in the climate of opinion then prevailing. In retrospect it is apparent that much of what passed for psychosomatic medicine was little more than a scientifically naive attempt to impose psychoanalytical theorizing on physical illness in an attempt to demonstrate psychological causation. Since then the undermining of these high hopes by intensive clinical and experimental investigation has led Grinker to conclude that The concept of a psychosomatic disorder is fast becoming obsolete . . .' (2) and Lewis to remark that the term 'reflects only a rather muddled phase of specialized ignorance' (3).
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Population Censuses and Surveys, which provides figures based on a one-in-ten sample of in-patient discharge and death records from NHS general hospitals in England and Wales, excluding institutions confined to the treatment of psychiatric diseases and the psychiatric departments of general hospitals (8). It emerges that of more than 40 000 cases registered in 1972 as suffering from all the forms of mental disorder coded in Section V of the LCD. about 5 000 were diagnosed as being associated with alcohol, only 300 of whom were psychotic. However, even though three quarters of the patients were treated in departments of general medicine the figures take no account of the various physical conditions related to excessive drinking — such as malnutrition, polyneuritis, myocarditis, accidents, gastro-intestinal disorders and, above all, the several thousand cases of hepatic cirrhosis. This lacuna is attributable to the policy adopted in general hospitals which is to classify data primarily by the physical condition leading to admission so that the category, 'mental disorders not classified as psychotic associated with physical conditions', claims virtually no cases at all. Such niggardly material contrasts sharply with the findings obtained from studies of somatic illness in which the psychiatric phenomena have been assessed separately. With this approach probably the best-established psychiatric correlate of physical disease is depression. One of the earliest studies conducted some years ago demonstrated this association in general hospital patients with both medical and surgical conditions (9), and more recent studies have shown that no fewer than 25% of hospital in-patients with medical disorders were morbidly depressed (10). This reaction is not linked to any particular group of diseases from the results obtained so far and part, at least, of the explanation would seem to reside in an understandable depressive reaction to physical sickness and its significance to the patient. Patients who come to health care agencies, however, represent only a segment of morbidity for epidemiological enquiry. During the past 30 years various studies have suggested that there is an association between physical and psychiatric illness in the population at large. These studies have ranged from health surveys, such as those of Downes and Simon (11) to the examination of individual medical records (12, 13). In our own studies of psychiatric illness in general practice (14), we attempted to examine this association indirectly by identifying from among a large, representative group of general practice attenders a control group of
Downloaded from http://ije.oxfordjournals.org/ at University of Michigan on June 23, 2015
in the narrow sense of the term. However, to restrict the concept in this way is to exclude large parts of Section V. Thus about one half of the sub-categories of psychosis in LCD. 8 specify or imply a physical factor of causation, whether this be cerebral senile changes, alcohol, intracranial infection, or other cerebral and other non cerebral conditions. The list of non-psychotic disorders takes in alcoholism, drug dependence and 'mental disorders not specified as psychotic associated with physical conditions'. In addition, several forms of mental retardation are listed with such fourth digits as infection, trauma, metabolic disorder, brain disease, congenital disorder or chromosomal anomaly. The situation is acknowledged in the notes on the use of the glossary to LCD. 8 which recommends that 'whenever an associated physical condition appears in the diagnosis of a mental disorder, it be specified and coded separately' (6). This practice is intended to pave the way for LCD. 9 in which combination categories are to be eliminated and the individual conditions coded separately. The observation of this principle is imperative for the epidemiological study of possible associations between physical factors and 'mental' phenomena. At present, unfortunately, the value of large-scale data relating to this issue is limited even where, as in the United Kingdom, national hospital statistics are routinely collected and classified in terms of the LCD. An instructive illustration is furnished by the determination of the amount and nature of psychiatric morbidity associated with the physical agent, alcohol, which comes to the attention of the hospital services. On the psychiatric side the Mental Health Enquiry of the British Department of Health and Social Security has presented the statistical returns from most psychiatric institutions in England and Wales for almost 30 years. (7). In 1949 fewer than 500 alcoholic patients were admitted to National Health Service Hospitals and units, about one half recorded as suffering from an 'alcoholic psychosis', the other half from 'alcoholism'. In the subsequent twenty-five years the number of admissions has risen to more than 12 000, but while the ratio of recorded alcoholism to alcoholic psychosis had increased to 6:1, alcoholism itself was entered as a secondary diagnosis in a quarter of the cases, most of which were diagnosed as primarily depressive. Meanwhile it has also become possible to approach the problem from another direction by means of the data obtainable from the Hospital In-patient Enquiry, conducted by the Department of Health and Social Security and the Office of
EPIDEMIOLOGICAL PERSPECTIVE
Even so, we felt it unwise to rely exclusively on inferences drawn from data collected for other purposes. Further, a review of the relevant epidemiological literature revealed a picture of some confusion, largely arising from four methodological issues, namely: (1) differences in the patterns of consultation and presentation of symptoms by patients in different settings; (2) marked variations in the diagnostic habits and methods of record-keeping by medical practitioners; (3) the tendency of research workers to employ different techniques of case-identification and data collec-
tion; (4) the lack of comparability between the criteria of measurement of morbidity. We felt, nonetheless, that our data seemed promising enough to warrant an independent inquiry (16). Its aim was to determine directly whether individuals with psychiatric illness did nor did not suffer from more physical illness than mentally healthy people. The relevant information was obtained by collaborating with a group of general practitioners who were working on a survey of health-screening. From this population subjects between the ages of 40 and 64 were randomly chosen and assessed in four stages: (1) the completion of a self-administered questionnaire; (2) a standardized psychiatric interview; (3) physical screening-tests carried out by trained ancillary staff; (4) a physical examination by an independent physician. The subjects with psychiatric disorders were compared with a control group from the same population, matched for age, sex, marital status and social class. It should be emphasized that the study was cross-sectional, without regard to previous history of illness or surgery attendances. The results showed strong presumptive evidence of an association between physical and mental illness in this population, the links being most marked with subjects suffering from cardiovascular and respiratory disease. In an independent study of patients with chronic airways obstruction Rutter has reached the same conclusion. (17). What are the practical implications of such findings? While in themselves they can shed little light on aetiology they do bear on the important issue of outcome. A number of studies have already shown that an understanding of prognosis in a variety of physical conditions, varying from surgical trauma to peptic ulcer, must take account of psycho-social factors as well as of pathology. (18) How outcome may be specifically related to environment is suggested by the findings of Shaffer ct al who have studied a population for disability benefits under the US Social Security Administration's disability programme (19). These workers made psychiatric assessments of such patients suffering from physical disorders and administered the MMPI to more than 1 000 individuals, matched with 14 000 patients in a medical clinic. The results demonstrated a marked difference between the two groups, furnishing an estimate of up to 44% of individuals with moderate to severe psychoneuroses or personality disorders among the applicants for disability benefit. From outcome it is merely a step to intervention, covering not only the obvious importance of paying
Downloaded from http://ije.oxfordjournals.org/ at University of Michigan on June 23, 2015
cases reported as being free from any psychiatric disturbance for comparison with patients diagnosed as suffering from psychiatric disorders. Emotional disorder in the survey sample proved to be associated with a high demand for medical care; the patients attended more frequently, exhibiting higher rates of general morbidity and more categories of illness per head. In particular, the reported prevalence rates for chronic disease were higher among psychiatric patients for every category of illness except neoplasia and orthopaedic disorders. It might, of course, be argued that these findings were largely manifestations of a high demand for medical care attributable to the patients' attitude to health and that the patients were labelled as neurotic largely because of the frequency of attendances and multiplicity of ailments. Independent data were therefore sought by examining for physical disease a"mong groups scoring high and low on the psychiatric section of the Cornell Medical Index questionnaire, a procedure which yielded similar findings. Evidence from other of our studies pointed in the same direction. First, there were the data indicating that patients who did not attend their general practitioners at all for prolonged periods were physically healthier than average and carried a low risk for mental disorder. Secondly, a detailed, clinical sub-study of a sample of the chronic physical symptoms and disabilities. Thirdly, a group of chronic neurotic females who kept specially constructed health diaries on the health of themselves and their families over a 12-month period reported significantly more episodes of physical ill health among the index patients than in a control group. Our interpretation of these findings was that they lent support to the concept of a true association between chronic psychiatric disorder and other forms of chronic ill health, a view in line with the conclusions of Hinkle and Wolff that 'clustering of illness occurs in some individuals, with all forms of morbidity being involved'. (15)
203
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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
The problems of method involved in an epidemiological inquiry of this sort call for detailed consideration. The plan of the study is depicted in figure 1. Essentially, the subjects were asked to attend a screening centre for blood pressure measurements. If the diastolic pressure were found to be above 90mm Hg the subject was asked to attend again. On the second screening occasion, should the pressure not have settled, the subject was considered for inclusion in the trial. If at a third visit, when a medical examination was carried out Subjects (.15-64 years) attending MRC clinics for BP check
Result of BP check
Result of recall
Trial participants matched with controls for psvchiatric study
3-month follow-up
1-ycar follow-up
Severely hypertensive Normal controls
Normal controls
Normal controls
Pressure below 90 mmHg
Recalled controls
Recalled controls
Recalled controls
Suitable for trial. 90-109 mmHg
Trial participants
Trial participants
Trial participants
BP below 90mmHg
/
For recall BPyO-109 \ mmHg
GHQ: (A)
(B)
(C>
(DJ
Psychiatric interview conducted
X
X
X
Fio. 1.
Downloaded from http://ije.oxfordjournals.org/ at University of Michigan on June 23, 2015
and the blood pressure elevation confirmed, there were no reasons for exclusion from the trial and the general practitioner had given permission, the subject was invited to participate in the trial. Those who consented were randomly allocated to either a pharmacologically active treatment or a placebo regime. The participant was unaware of which regime had been prescribed. For 5 years after entry into the trial, the subjects are followed up at their clinic so that the health of those on active and placebo tablets can be compared in this period. With regard to their mental health, all subjects attending the blood-pressure clinics were first asked to complete the General Health Questionnaire (21) before examination. Each individual entering the trial was matched by age, sex, area of residence and response to the questionnaire with two control subjects: one of these was randomly selected by computer from screened subjects with a normal blood-pressure, the other from subjects whose pressure was initially raised but had fallen on recall. On entry into the trial each subject and the two controls were given the questionnaire for a second , time, and again after 3 and 12 months. Comparison of the changes from first to second response between the normal control group and those recalled allowed of an assessment of the effect of informing people of their raised pressure. Comparison of the responses between the recalled control group and the trial participants enabled the effect of recruitment into the trial to be assessed. Comparison of the responses of the trial group and the control groups after 3 and 12 months made it possible to assess the effect of participating in the trial over time. Further, since both the psychiatrist and the subject were ignorant of the prescribed regime the study also incorporated a double blind investigation into the psychological side effects of
due regard to both physical and non-physical factors in therapeutics but also an issue which has assumed increasing significance from the epidemiological standpoint. This concerns the possible mental health implications of the much-debated programmes for the prescriptive community screening of physical disease. The question turns on what, if any, are the effects on the so-called quality of life' of the detection and treatment of asymptomatic or pre-symptomatic disease? It has recently been raised acutely in the United Kingdom by the large-scale clinical trial of the treatment of patients with mild to moderate hypertension conducted under the aegis of the British Medical Research Council (20). The aim of the inquiry was to assess whether drug-therapy for men and women between the ages of 35 and 64 and with diastolic blood-pressures between 90— 109mm.Hg. can reduce mortality or morbidity from the sequelae of hypertension, especially fatal and non-fatal strokes. During the pilot phase of this inquiry it became apparent that it would be necessary to study the possibly deleterious impact on asymptomatic subjects (a) of their becoming aware of their raised blood-pressure, (b) of being recruited into a long-term pattern of clinic-attendance and (c) of receiving medication over a period of months or years.
EPIDEMIOLOCICAL PERSPECTIVE
MICHAEL SHEPHERD REFERENCES (l)DunbarHF. Psychosomatic Diagnosis. Heober, New York. 1943. (2) Grinker R R. Psychosomatic Concepts. Aronson, New York: 1973. (3) Lewis A. (1967) 'Aspects of psychosomatic medicine', in Inquiries in Psychiatry. London: Routledge and Kegan Paul, p. 193.
(4) Psychosomatic Disorders. Technical Report Series No 275, World Health Organization, Geneva, 1964. (5) Lipowski Z J. Psychosomatic medicine in the seventies: an overview. American Journal of Psychiatry 134i 233, 1977. (6) Glossary of mental disorders and guide to their classification. World Health Organization, Geneva. 1974. (7) Psychiatric units in England and Wales. In-patient statistics from the Mental Health Enquiry for the year 1971. Department of Health & Social Security. Statistical & Research Report Scries No 6 HMSO, London. 1973. (8) Hospital In-patient Enquiry, 1972. Office of Population and Censuses and Surveys. HMSO, London. 1974. (9) Shepherd M, Davies B and Culpan R H. Psychiatric illness in the general hospital. Acta Psycbiatrica et Neurologica Scandinavica 35i 518, 1960. (10) Mofficc H S and Paykel E S. Depression in medical in-patients. British Journal of Psychiatry 126i 346, 1975. (ll)DownesJ and Simon K. Characteristics of psychoneurotic patients and their families as revealed in a general morbidity study. Psychosomatic Medicine 15t 463, 1953. (12) Lovett Doust J W. Psychiatric aspects of social immunity. British Journal of Preventive and Social Medicine, 6: 49, 1952. (13) Rocssler R and Greenfield N S. Incidence of somatic disease in psychiatric patients. Psychosomatic Medicine 23. 413, 1961 (14) Shepherd M, Cooper B, Brown A C and Kalton G W. Psychiatric illness in general practice. Oxford University Press, London. 1966. (15)HinkleLE and Wolff H G. The natures of man's adaptation to his total environment and the relation of this to illness. Archives of Internal Medicine 99i 442, 1957. (16) Eastwood M R. The relation between physical and mental illness. Clarke Institute of Psychiatry Monograph No 4, University of Toronto Press. 1975. (17) Rutter B M. Some psychological concomitants of chronic bronchitis. Psychological Medicine 7i 459, 1977. (18) Shepherd M. Clinical and social factors relevant to outcome In The epidemiology of mental illness. Oxford University Press for the Nuffield Provincial Hospitals'Trust. 1962 (19) Shaffer J W, Nussbaum K and Little J M. MMPI profiles of disability insurance claimants. American Journal of Psychiatry 129. 403, 1972. (20) Mann A H. The psychological effect of a screening programme and clinical trial for hypertension upon the participants. Psychological Medicine 7. 431, 1977. (21) Goldberg D P. The detection of psychiatric illness by questionnaire. Maudsley Monograph, No 21. Oxford University Press, London. 1972. (22) Goldberg D P, Cooper B, Eastwood M R, Kedward H B and Shepherd M. A standardized psychiatric interview suitable for use in community surveys. British Journal of Preventive and Social Medicine 24. 18, 1970.
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some anti-hypertensive agents. Finally, to provide more detailed psychiatric information, those subjects responding positively at the outset of the follow-up were assessed clinically by means of a standardized psychiatric interview (22), as were those patients whose response became positive 3 months and a year after the follow-up. The information obtained from these interviews enabled the trial participants to be compared with the control groups in respect of both the progress of psychiatric cases diagnosed at outset and the incidence of new psychiatric episodes during the follow-up. A comparison between trial participants and controls can therefore be made in terms of both the distribution of questionnaire response and of diagnosed psychiatric cases among the groups. In this way it has been possible to assemble several hundred cases within the framework of the study. In the event there was no evidence from any of these measures to suggest that participation in the study impaired the psychological well-being of the participants, but perhaps the most important aspect of the model resides in its potential application to other physical disorders and their treatment. The current WHO Mental Health Programme, 1975—1982, sets out as one of its approaches, that of 'Promoting integration of mental health elements into general and primary health care and collaboration between mental health services and general health services' with the stated objective to 'increase effectiveness of general health services through appropriate utilization of mental health skills and knowledge'. It can be maintained that epidemiological investigation in this sphere may elucidate issues of aetiology, prevalence, demographic and social correlates, out-come and response to treatment. The findings to date make it clear that a substantial segment of morbidity is involved and that attention could be directed profitably to the relationships rather than to the differences between physical and mental disorder.
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International Journal of Epidemiology ©Oxford University Preo 1978
Epidemiological Perspective Psychosomatic Medicine 'psychosomatic paradox'. This consists essentially in the two uses of the adjective 'psychosomatic': the one covering no more than a holistic approach to medicine which takes account of both biological and psycho—social factors; the other referring to particular disorders, such as hypertension, peptic ulcer and asthma 'in which psychological factors are supposed to play a major role'. The report referred pointedly to the lack of established evidence for the psychogenic theories in vogue, the ambiguity of the notion of stress and the uncertainty of the basic concept of specificity in the relationship between the nature of a psychological stressor and a particular organ system. It also drew attention to the research potential of epidemiological techniques, since the scientific study of 'psychosomatic medicine' was seen as being closely allied to the investigation of the psycho—social associations — antecedent, concurrent and subsequent — of somatic disease, and so coming within the orbit of general epidemiology. Unfortunately the pretensions of psychosomatic apologists (5) have not only proved sterile in their own right; they have also obstructed the application of the epidemiological perspective by deflecting interest away from the wider implications of the mind—body nexus in the various forms of recognised mental disease. Within this framework a psychogenic factor is only one link in a multifactorial chain, whether it be related to the physical dysfunctions of the eating disorders or to the mental states of the depressive reactions. Furthermore, by the same token the somatic factors in the aetiology of mental illness call for as much consideration as the psychogenesis of organic disease. Indeed, it may be contended that the preoccupation with the shadowy issues of 'psychosomatics' has obscured the more substantial problem of 'somatopsychics'. Within the categories of Section V of the International Classification of Diseases, for example, only category 305, 'Physical Disorders of Presumably Psychogenic Origin', would qualify for inclusion as a 'psychosomatic' category
In 1964 the World Health Organization published a technical report on 'Psychosomatic Disorders' (4), drawing attention to what it called the 'Based on a paper delivered at the 8th International Scientific Meeting of the International Epidemiological Association Puerto Rico, 1977
201
Downloaded from http://ije.oxfordjournals.org/ at University of Michigan on June 23, 2015
No discussion of the relationships between physical and mental illness can escape some mention of the term 'psychosomatic', a word which assumed increasing popularity in the mid-1940's, when it developed from the interest in the emergent concept of stress. Flanders Dunbars' two self-styled 'laws of emotional thermodynamics' summarize the thinking of the times (1). The first 'law' stated that psychic energy, when not expressed through higher levels, obtained its outlet through physical symptoms; the second postulated that if such symptoms were the result of permanent structural damage, energy would be correspondingly dissipated and made unavailable. Somatic dysfunction was thus equated with 'a waste or dissipation of energy due to the faulty design of the personality' which led in turn to the quest for 'psychological profiles characteristic of specific disease syndromes' and to the view that many somatic diseases were psychogenic in origin and reactive to an omnipresent group of ill-defined 'stressors'. So cavalier a disregard for the complexities of the mind—body relationship and the nature of causality could only have been taken seriously in the climate of opinion then prevailing. In retrospect it is apparent that much of what passed for psychosomatic medicine was little more than a scientifically naive attempt to impose psychoanalytical theorizing on physical illness in an attempt to demonstrate psychological causation. Since then the undermining of these high hopes by intensive clinical and experimental investigation has led Grinker to conclude that The concept of a psychosomatic disorder is fast becoming obsolete . . .' (2) and Lewis to remark that the term 'reflects only a rather muddled phase of specialized ignorance' (3).
202
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Population Censuses and Surveys, which provides figures based on a one-in-ten sample of in-patient discharge and death records from NHS general hospitals in England and Wales, excluding institutions confined to the treatment of psychiatric diseases and the psychiatric departments of general hospitals (8). It emerges that of more than 40 000 cases registered in 1972 as suffering from all the forms of mental disorder coded in Section V of the LCD. about 5 000 were diagnosed as being associated with alcohol, only 300 of whom were psychotic. However, even though three quarters of the patients were treated in departments of general medicine the figures take no account of the various physical conditions related to excessive drinking — such as malnutrition, polyneuritis, myocarditis, accidents, gastro-intestinal disorders and, above all, the several thousand cases of hepatic cirrhosis. This lacuna is attributable to the policy adopted in general hospitals which is to classify data primarily by the physical condition leading to admission so that the category, 'mental disorders not classified as psychotic associated with physical conditions', claims virtually no cases at all. Such niggardly material contrasts sharply with the findings obtained from studies of somatic illness in which the psychiatric phenomena have been assessed separately. With this approach probably the best-established psychiatric correlate of physical disease is depression. One of the earliest studies conducted some years ago demonstrated this association in general hospital patients with both medical and surgical conditions (9), and more recent studies have shown that no fewer than 25% of hospital in-patients with medical disorders were morbidly depressed (10). This reaction is not linked to any particular group of diseases from the results obtained so far and part, at least, of the explanation would seem to reside in an understandable depressive reaction to physical sickness and its significance to the patient. Patients who come to health care agencies, however, represent only a segment of morbidity for epidemiological enquiry. During the past 30 years various studies have suggested that there is an association between physical and psychiatric illness in the population at large. These studies have ranged from health surveys, such as those of Downes and Simon (11) to the examination of individual medical records (12, 13). In our own studies of psychiatric illness in general practice (14), we attempted to examine this association indirectly by identifying from among a large, representative group of general practice attenders a control group of
Downloaded from http://ije.oxfordjournals.org/ at University of Michigan on June 23, 2015
in the narrow sense of the term. However, to restrict the concept in this way is to exclude large parts of Section V. Thus about one half of the sub-categories of psychosis in LCD. 8 specify or imply a physical factor of causation, whether this be cerebral senile changes, alcohol, intracranial infection, or other cerebral and other non cerebral conditions. The list of non-psychotic disorders takes in alcoholism, drug dependence and 'mental disorders not specified as psychotic associated with physical conditions'. In addition, several forms of mental retardation are listed with such fourth digits as infection, trauma, metabolic disorder, brain disease, congenital disorder or chromosomal anomaly. The situation is acknowledged in the notes on the use of the glossary to LCD. 8 which recommends that 'whenever an associated physical condition appears in the diagnosis of a mental disorder, it be specified and coded separately' (6). This practice is intended to pave the way for LCD. 9 in which combination categories are to be eliminated and the individual conditions coded separately. The observation of this principle is imperative for the epidemiological study of possible associations between physical factors and 'mental' phenomena. At present, unfortunately, the value of large-scale data relating to this issue is limited even where, as in the United Kingdom, national hospital statistics are routinely collected and classified in terms of the LCD. An instructive illustration is furnished by the determination of the amount and nature of psychiatric morbidity associated with the physical agent, alcohol, which comes to the attention of the hospital services. On the psychiatric side the Mental Health Enquiry of the British Department of Health and Social Security has presented the statistical returns from most psychiatric institutions in England and Wales for almost 30 years. (7). In 1949 fewer than 500 alcoholic patients were admitted to National Health Service Hospitals and units, about one half recorded as suffering from an 'alcoholic psychosis', the other half from 'alcoholism'. In the subsequent twenty-five years the number of admissions has risen to more than 12 000, but while the ratio of recorded alcoholism to alcoholic psychosis had increased to 6:1, alcoholism itself was entered as a secondary diagnosis in a quarter of the cases, most of which were diagnosed as primarily depressive. Meanwhile it has also become possible to approach the problem from another direction by means of the data obtainable from the Hospital In-patient Enquiry, conducted by the Department of Health and Social Security and the Office of
EPIDEMIOLOGICAL PERSPECTIVE
Even so, we felt it unwise to rely exclusively on inferences drawn from data collected for other purposes. Further, a review of the relevant epidemiological literature revealed a picture of some confusion, largely arising from four methodological issues, namely: (1) differences in the patterns of consultation and presentation of symptoms by patients in different settings; (2) marked variations in the diagnostic habits and methods of record-keeping by medical practitioners; (3) the tendency of research workers to employ different techniques of case-identification and data collec-
tion; (4) the lack of comparability between the criteria of measurement of morbidity. We felt, nonetheless, that our data seemed promising enough to warrant an independent inquiry (16). Its aim was to determine directly whether individuals with psychiatric illness did nor did not suffer from more physical illness than mentally healthy people. The relevant information was obtained by collaborating with a group of general practitioners who were working on a survey of health-screening. From this population subjects between the ages of 40 and 64 were randomly chosen and assessed in four stages: (1) the completion of a self-administered questionnaire; (2) a standardized psychiatric interview; (3) physical screening-tests carried out by trained ancillary staff; (4) a physical examination by an independent physician. The subjects with psychiatric disorders were compared with a control group from the same population, matched for age, sex, marital status and social class. It should be emphasized that the study was cross-sectional, without regard to previous history of illness or surgery attendances. The results showed strong presumptive evidence of an association between physical and mental illness in this population, the links being most marked with subjects suffering from cardiovascular and respiratory disease. In an independent study of patients with chronic airways obstruction Rutter has reached the same conclusion. (17). What are the practical implications of such findings? While in themselves they can shed little light on aetiology they do bear on the important issue of outcome. A number of studies have already shown that an understanding of prognosis in a variety of physical conditions, varying from surgical trauma to peptic ulcer, must take account of psycho-social factors as well as of pathology. (18) How outcome may be specifically related to environment is suggested by the findings of Shaffer ct al who have studied a population for disability benefits under the US Social Security Administration's disability programme (19). These workers made psychiatric assessments of such patients suffering from physical disorders and administered the MMPI to more than 1 000 individuals, matched with 14 000 patients in a medical clinic. The results demonstrated a marked difference between the two groups, furnishing an estimate of up to 44% of individuals with moderate to severe psychoneuroses or personality disorders among the applicants for disability benefit. From outcome it is merely a step to intervention, covering not only the obvious importance of paying
Downloaded from http://ije.oxfordjournals.org/ at University of Michigan on June 23, 2015
cases reported as being free from any psychiatric disturbance for comparison with patients diagnosed as suffering from psychiatric disorders. Emotional disorder in the survey sample proved to be associated with a high demand for medical care; the patients attended more frequently, exhibiting higher rates of general morbidity and more categories of illness per head. In particular, the reported prevalence rates for chronic disease were higher among psychiatric patients for every category of illness except neoplasia and orthopaedic disorders. It might, of course, be argued that these findings were largely manifestations of a high demand for medical care attributable to the patients' attitude to health and that the patients were labelled as neurotic largely because of the frequency of attendances and multiplicity of ailments. Independent data were therefore sought by examining for physical disease a"mong groups scoring high and low on the psychiatric section of the Cornell Medical Index questionnaire, a procedure which yielded similar findings. Evidence from other of our studies pointed in the same direction. First, there were the data indicating that patients who did not attend their general practitioners at all for prolonged periods were physically healthier than average and carried a low risk for mental disorder. Secondly, a detailed, clinical sub-study of a sample of the chronic physical symptoms and disabilities. Thirdly, a group of chronic neurotic females who kept specially constructed health diaries on the health of themselves and their families over a 12-month period reported significantly more episodes of physical ill health among the index patients than in a control group. Our interpretation of these findings was that they lent support to the concept of a true association between chronic psychiatric disorder and other forms of chronic ill health, a view in line with the conclusions of Hinkle and Wolff that 'clustering of illness occurs in some individuals, with all forms of morbidity being involved'. (15)
203
204
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
The problems of method involved in an epidemiological inquiry of this sort call for detailed consideration. The plan of the study is depicted in figure 1. Essentially, the subjects were asked to attend a screening centre for blood pressure measurements. If the diastolic pressure were found to be above 90mm Hg the subject was asked to attend again. On the second screening occasion, should the pressure not have settled, the subject was considered for inclusion in the trial. If at a third visit, when a medical examination was carried out Subjects (.15-64 years) attending MRC clinics for BP check
Result of BP check
Result of recall
Trial participants matched with controls for psvchiatric study
3-month follow-up
1-ycar follow-up
Severely hypertensive Normal controls
Normal controls
Normal controls
Pressure below 90 mmHg
Recalled controls
Recalled controls
Recalled controls
Suitable for trial. 90-109 mmHg
Trial participants
Trial participants
Trial participants
BP below 90mmHg
/
For recall BPyO-109 \ mmHg
GHQ: (A)
(B)
(C>
(DJ
Psychiatric interview conducted
X
X
X
Fio. 1.
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and the blood pressure elevation confirmed, there were no reasons for exclusion from the trial and the general practitioner had given permission, the subject was invited to participate in the trial. Those who consented were randomly allocated to either a pharmacologically active treatment or a placebo regime. The participant was unaware of which regime had been prescribed. For 5 years after entry into the trial, the subjects are followed up at their clinic so that the health of those on active and placebo tablets can be compared in this period. With regard to their mental health, all subjects attending the blood-pressure clinics were first asked to complete the General Health Questionnaire (21) before examination. Each individual entering the trial was matched by age, sex, area of residence and response to the questionnaire with two control subjects: one of these was randomly selected by computer from screened subjects with a normal blood-pressure, the other from subjects whose pressure was initially raised but had fallen on recall. On entry into the trial each subject and the two controls were given the questionnaire for a second , time, and again after 3 and 12 months. Comparison of the changes from first to second response between the normal control group and those recalled allowed of an assessment of the effect of informing people of their raised pressure. Comparison of the responses between the recalled control group and the trial participants enabled the effect of recruitment into the trial to be assessed. Comparison of the responses of the trial group and the control groups after 3 and 12 months made it possible to assess the effect of participating in the trial over time. Further, since both the psychiatrist and the subject were ignorant of the prescribed regime the study also incorporated a double blind investigation into the psychological side effects of
due regard to both physical and non-physical factors in therapeutics but also an issue which has assumed increasing significance from the epidemiological standpoint. This concerns the possible mental health implications of the much-debated programmes for the prescriptive community screening of physical disease. The question turns on what, if any, are the effects on the so-called quality of life' of the detection and treatment of asymptomatic or pre-symptomatic disease? It has recently been raised acutely in the United Kingdom by the large-scale clinical trial of the treatment of patients with mild to moderate hypertension conducted under the aegis of the British Medical Research Council (20). The aim of the inquiry was to assess whether drug-therapy for men and women between the ages of 35 and 64 and with diastolic blood-pressures between 90— 109mm.Hg. can reduce mortality or morbidity from the sequelae of hypertension, especially fatal and non-fatal strokes. During the pilot phase of this inquiry it became apparent that it would be necessary to study the possibly deleterious impact on asymptomatic subjects (a) of their becoming aware of their raised blood-pressure, (b) of being recruited into a long-term pattern of clinic-attendance and (c) of receiving medication over a period of months or years.
EPIDEMIOLOCICAL PERSPECTIVE
MICHAEL SHEPHERD REFERENCES (l)DunbarHF. Psychosomatic Diagnosis. Heober, New York. 1943. (2) Grinker R R. Psychosomatic Concepts. Aronson, New York: 1973. (3) Lewis A. (1967) 'Aspects of psychosomatic medicine', in Inquiries in Psychiatry. London: Routledge and Kegan Paul, p. 193.
(4) Psychosomatic Disorders. Technical Report Series No 275, World Health Organization, Geneva, 1964. (5) Lipowski Z J. Psychosomatic medicine in the seventies: an overview. American Journal of Psychiatry 134i 233, 1977. (6) Glossary of mental disorders and guide to their classification. World Health Organization, Geneva. 1974. (7) Psychiatric units in England and Wales. In-patient statistics from the Mental Health Enquiry for the year 1971. Department of Health & Social Security. Statistical & Research Report Scries No 6 HMSO, London. 1973. (8) Hospital In-patient Enquiry, 1972. Office of Population and Censuses and Surveys. HMSO, London. 1974. (9) Shepherd M, Davies B and Culpan R H. Psychiatric illness in the general hospital. Acta Psycbiatrica et Neurologica Scandinavica 35i 518, 1960. (10) Mofficc H S and Paykel E S. Depression in medical in-patients. British Journal of Psychiatry 126i 346, 1975. (ll)DownesJ and Simon K. Characteristics of psychoneurotic patients and their families as revealed in a general morbidity study. Psychosomatic Medicine 15t 463, 1953. (12) Lovett Doust J W. Psychiatric aspects of social immunity. British Journal of Preventive and Social Medicine, 6: 49, 1952. (13) Rocssler R and Greenfield N S. Incidence of somatic disease in psychiatric patients. Psychosomatic Medicine 23. 413, 1961 (14) Shepherd M, Cooper B, Brown A C and Kalton G W. Psychiatric illness in general practice. Oxford University Press, London. 1966. (15)HinkleLE and Wolff H G. The natures of man's adaptation to his total environment and the relation of this to illness. Archives of Internal Medicine 99i 442, 1957. (16) Eastwood M R. The relation between physical and mental illness. Clarke Institute of Psychiatry Monograph No 4, University of Toronto Press. 1975. (17) Rutter B M. Some psychological concomitants of chronic bronchitis. Psychological Medicine 7i 459, 1977. (18) Shepherd M. Clinical and social factors relevant to outcome In The epidemiology of mental illness. Oxford University Press for the Nuffield Provincial Hospitals'Trust. 1962 (19) Shaffer J W, Nussbaum K and Little J M. MMPI profiles of disability insurance claimants. American Journal of Psychiatry 129. 403, 1972. (20) Mann A H. The psychological effect of a screening programme and clinical trial for hypertension upon the participants. Psychological Medicine 7. 431, 1977. (21) Goldberg D P. The detection of psychiatric illness by questionnaire. Maudsley Monograph, No 21. Oxford University Press, London. 1972. (22) Goldberg D P, Cooper B, Eastwood M R, Kedward H B and Shepherd M. A standardized psychiatric interview suitable for use in community surveys. British Journal of Preventive and Social Medicine 24. 18, 1970.
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some anti-hypertensive agents. Finally, to provide more detailed psychiatric information, those subjects responding positively at the outset of the follow-up were assessed clinically by means of a standardized psychiatric interview (22), as were those patients whose response became positive 3 months and a year after the follow-up. The information obtained from these interviews enabled the trial participants to be compared with the control groups in respect of both the progress of psychiatric cases diagnosed at outset and the incidence of new psychiatric episodes during the follow-up. A comparison between trial participants and controls can therefore be made in terms of both the distribution of questionnaire response and of diagnosed psychiatric cases among the groups. In this way it has been possible to assemble several hundred cases within the framework of the study. In the event there was no evidence from any of these measures to suggest that participation in the study impaired the psychological well-being of the participants, but perhaps the most important aspect of the model resides in its potential application to other physical disorders and their treatment. The current WHO Mental Health Programme, 1975—1982, sets out as one of its approaches, that of 'Promoting integration of mental health elements into general and primary health care and collaboration between mental health services and general health services' with the stated objective to 'increase effectiveness of general health services through appropriate utilization of mental health skills and knowledge'. It can be maintained that epidemiological investigation in this sphere may elucidate issues of aetiology, prevalence, demographic and social correlates, out-come and response to treatment. The findings to date make it clear that a substantial segment of morbidity is involved and that attention could be directed profitably to the relationships rather than to the differences between physical and mental disorder.
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