Medical Co-Morbidity in Schizophrenia from Rural Region of Central India: A Cross-Sectional Study

Transcription

1 It J Med. Public Health. 2017; 7(4): A Multifaceted Peer Reviewed Joural i the field of Medicie ad Public Health Origial Article Medical Co-Morbidity i Schizophreia from Rural Regio of Cetral Idia: A Cross-Sectioal Study Siddharth Kalucha 1, Sachi Rata Gedam 2, Prakash Behere 3 Siddharth Kalucha 1, Sachi Rata Gedam 2, Prakash Behere 3 1 Residet, Departmet of Psychiatry, Jawaharlal Nehru Medical College, Sawagi (Meghe), Wardha, Maharashtra, INDIA. 2 Assistat Professor, Departmet of Psychiatry, Mahatma Gadhi Istitute of Medical Scieces Sevagram, Wardha, Maharashtra, INDIA. 3 Professor of Psychiatry, Vice Chacellor, D Y Patil Educatio Society (Deemed Uiversity) Kolhapur, Maharashtra, INDIA. Correspodece Dr. Sachi Rata Gedam, MD Assistat Professor, Departmet of Psychiatry, Mahatma Gadhi Istitute of Medical Scieces Sevagram, Wardha, Maharashtra, INDIA. Mobile o: ; sachirgedam@gmail.com History Submissio Date: Revised Date: Accepted Date: DOI : /ijmedph Article Available olie Copyright 2017 Phcog.Net. This is a opeaccess article distributed uder the terms of the Creative Commos Attributio 4.0 Iteratioal licese. ABSTRACT Backgroud: The patiets with schizophreia have higher mortality rates ad shorteed life spa. The major causes of this excess mortality are medical disease, uhealthy lifestyle, substace misuse, poor compliace or treatmet refusal, ad suicide amog uatural causes. The peoples diagosed with schizophreia expect to live 9-12 years lesser tha those i the geeral populatio o average. Objectives: To study the prevalece of medical co-morbidities; associatio of medical co-morbidities with socio-demographic ad cliical variables amog schizophreia patiets; ad to determie the associatio of I.C.D. -10 subtypes of schizophreia with medical co-morbidities. Materials ad methods: The cross-sectioal study was coducted o 100 patiets over a period of 4 moths as per defied iclusio ad exclusio criteria at tertiary care ceter. A semi-structured proforma, desiged for the study was used to collect the sociodemographic ad cliical details. Results: Co-morbid medical illess was reported i 22% of patiets. The most commo physical illess was edocriological disorders (31.82%). The patiets who had higher age ad exposure to psychotropic medicatios were sigificatly associated with medical co-morbidities (p<0.05). The co morbid medical illesses were ot sigificatly associated with type of medicatio used, subtype of schizophreia ad family history of metal illess (p>0.05) whereas reported sigificat associatio with history of substace use (p<0.05). Coclusio: The prevalece of medical co-morbidities was foud to be 22%, lower tha that i previous literature. Sometimes the physical illesses remai urecogized i such patiets so itegrated approaches require for prevetio ad treatmet modalities. Key words: Medical illess, Co-morbidities, Schizophreia, Chroic illess. INTRODUCTION The patiets with schizophreia have higher mortality rates ad shorteed life spa as compared to the geeral populatio. 1,2 The literature reported that the major causes of this excess mortality are medical disease, uhealthy lifestyle, substace misuse, poor compliace or treatmet refusal, ad suicide amog uatural causes. 3 This vulerable group of patiets does ot receive the physical health care because of physical symptoms beig misiterpreted as part of physical illess by professioals, lack of motivatio, social isolatio, poor social skills ad cogitive impairmet makig them less likely to adhere to treatmet. 4 The peoples diagosed with schizophreia ca expect to live 9-12 years fewer tha those i the geeral populatio o average. 5 Recet literature showed that me with schizophreia die 20 years earlier ad wome die 15 years earlier tha people without major metal illess. 6 The commo physical coditios foud i patiets with metal illess iclude diabetes, hyperlipidaemia, cardiovascular disease (hypertesio, cardiac arrhythmias), obesity, maligat eoplasm, HIV/ AIDS, Hepatitis C, osteoporosis, hyperprolactiaemia ad other physical illesses. 7 A study by Sokal et al reported greater odds of respiratory illesses for persos with schizophreia eve after cotrollig for smokig ad medical illesses foud to be more severe amog them. 8,9 Mortese ad Juel oted that some proportio of mortality i schizophreia may be directly associated with side effects of euroleptic medicatios. 10 Several factors are kow to icrease the risk of medical disorders amog metal illess. Amog them are use of medicatios that cotribute to weight gai, which is associated with diabetes ad hypertesio; poor attetio to persoal hygiee, which is associated with ski ifectios; high rates of smokig, which cotributes to asthma, acute respiratory disease, heart disease, ad lug cacer; reduced physical activity ad fitess, which cotributes to hypertesio ad heart disease; ad use of medicatios with adverse gastroitestial effects. 9 Some variaces associated with metal illess may remai uexplaied. I our coutry, the study has ot received much attetio. Hece this study was udertake to kow the preset sceario i the rural regio. Cite this article : Kalucha S, Gedam SR, Behere P. Medical Co-Morbidity i Schizophreia from Rural Regio of Cetral Idia: A Cross-Sectioal Study. It J Med Public Health. 2017;7(4): Iteratioal Joural of Medicie ad Public Health, Vol 7, Issue 4, Oct-Dec,

2 The aims ad objectives of the preset study are as follows: 1. To determie the prevalece of medical co-morbidities i schizophreia patiets. 2. To study the associatio of medical co-morbidities with sociodemographic ad cliical variables. 3. To determie the associatio of I.C.D. -10 subtypes of schizophreia with medical co-morbidities. MATERIAL AND METHOD Study desig ad sample The cross-sectioal study was coducted at Departmet of Psychiatry, Jawaharlal Nehru Medical College, Sawagi (M) Wardha, Maharashtra, Idia. The approval from Istitutioal ethics committee was obtaied prior to the study. Total 100 patiets diagosed as schizophreia as per Iteratioal Classificatio of Diseases 10 th revisio of WHO (ICD-10) diagostic criteria fulfillig the iclusio ad exclusio criteria betwee Ja to Apr 2013 were icluded i the study. The majority of the physical illesses were diagosed by medical specialists withi our hospital setup ad documeted i the medical records of the patiets. Iclusio criteria 1. Patiets i the age group of more tha 18 ad less tha 55 years of age (due to icrease risk of cogitive deficits i the patiets). 2. Patiets diagosed to be sufferig from Schizophreia accordig to ICD 10 criteria. 3. Patiets who were stable o medicatios sice at least past three moths. 4. Both ipatiets ad out patiets. Exclusio criteria 1. Patiets who were violet ad ucooperative. 2. Patiets who have ay cogitive deficits ad metally subormal patiets. 3. Patiets with ay other psychiatric co-morbidity. 4. Patiets ot accompaied with reliable relative, previous medical record or documets. Tools A semi-structured proforma, desiged for the study was used to collect the socio-demographic ad cliical details. ICD-10 diagostic criteria were used to validate the diagosis of schizophreia. Procedure The patiet ad close relative were explaied the ature of the study. The writte coset obtaied from the patiet. The patiet was the iterviewed usig the available tools. The relative was subsequetly iterviewed to obtai other relevat details alog with previous medical records or documets. Wheever patiet preseted with ay physical complait he/she was referred to cosultat physicia at our Istitute. The diagosis ad treatmet give by physicia was etered ito the record. Those patiets who were already havig co-morbid physical illess were etered i proforma. Thus preseces of medical co morbidities were assessed usig family member report, patiet self-report or previous medical records. Statistical aalysis The data was collected ad etries were doe usig SPSS versio 17.0 ad Epi Ifo software. Aalysis was studied usig Chi square test ad Odds ratio. P value of less tha 0.05 was cosidered statistically sigificat. RESULTS The sample cosisted of 47 male ad 53 female schizophreia patiets (Table 1). The mea age of oset of schizophreia was years (SD 13.07), mea duratio of illess was 8.40 years (SD 8.60) ad 93% patiets had less tha 20 years of duratio of schizophreia (Table 2). The result reported, 69% patiets were exposed to psychotropic medicatios for less tha 5 years while 23% were exposed for 6 to 10 years; 22.73% of patiets had medical illess before oset of schizophreia ad 77.27% had developed medical illess after the oset of schizophreia (Table 2). Amog them medical illess worseed schizophreia i 27.27% of patiets (Table 2) ad causes may iclude electrolyte disturbaces such as hypocalcaemia, hypoatremia, hyperatremia, hypokalemia, hypomagesemia; disorders causig the delirious state ad edocrie disorders causig hormoal chages. It was foud that schizophreia patiets who had higher age ad exposure to psychotropic medicatios were sigificatly associated with medical co-morbidities (Table 3). The patiets with schizophreia developig medical illess were ot sigificatly associated with duratio of illess (Table 3). The co morbid medical illesses were ot associated with type of medicatio used, subtype of schizophreia ad family history of metal illess whereas reported sigificat associatio with history of substace use (Table 4). As show i Figure 1, prevalece of medical co morbidities foud to be 22%. The edocrie disorders were foud to be highest (32%) followed by disorders of respiratory system (Figure 2). Figure 3 showed, 67% were exposed to atypical ati psychotics, 11% were exposed to typical ati psychotics while 22% were exposed to combiatio of both typical ad atypical ati psychotic. Out of total patiets, 78% were diagosed as sufferig from paraoid schizophreia, 12% from udifferetiated schizophreia, 3% from hebephreic schizophreia, 2% from catatoic schizophreia ad 5% from other types (Figure 4). DISCUSSION Schizophreia has bee described as a life-shorteig disease. People with schizophreia ad other metal illesses have high rates of prevetable risk factors ad physical co morbidity accouts for 60% of premature deaths. 11 Kora et al estimated that 45% of patiets i Califoria s public metal-health system had physical disease. 12 A study by Korayi et al of psychiatric cliic patiets revealed that 43% of patiets had physical illesses. 13 Hall et al foud that 46% of patiets admitted had a urecogized physical illess that either caused or exacerbated their psychiatric illess. 14 I our study we foud 22% of medical co morbidity i schizophreia patiets. It is lower tha that foud i other studies. This disparity may be due to the fact that the preset study settig was i rural area ad low socio-ecoomic strata, may people were ot affordig thorough medical ivestigatios; brigig the percetage of medical co morbidity to lower levels. A study by Holt ad Pevler reported that diabetes occurred i 15% patiets with schizophreia lower as compared to preset study. 15 Table 1: Age ad Geder wise distributio of the patiets Age (years) Male (%) Female (%) Total (%) < 20 4(4%) 3(3%) 7(7%) (30%) 33(33%) 63(63%) (11%) 15(15%) 26(26%) (2%) 2(2%) 4(4%) Total 47(47%) 53(53%) 100(100%) Mea SD Iteratioal Joural of Medicie ad Public Health, Vol 7, Issue 4, Oct-Dec, 2017

3 Table 2: Semi structured details of the patiets Age of oset No of patiets Percetage (%) Mea ± SD < ± Duratio of illess(yrs.) No of patiets Percetage (%) < ± Exposure to psychotropic medicatio No of patiets Percetage (%) < 5 years ± years years years 3 3 Distributio of medical illess No of patiets Percetage (%) Before After Effect of medical illess o schizophreia No of patiets Percetage (%) Worse Does ot worse Table 3: Associatio of the cliical variables with medical co-morbidities Mea Age Std. Deviatio Mea Yes No Duratio of metal illess Std. Deviatio Mea Yes No Exposure to psychotropic medicatio Std. Deviatio Mea Yes No Icreased risk i people with schizophreia of developig glucoseregulatio abormalities, isuli resistace ad type 2 diabetes mellitus foud to be due to lifestyle factors (poor diet, sedetary behaviour); ad all atipsychotic agets (atypical more tha typical) icrease the propesity to develop diabetes. 16,17,18 People with severe metal illess have 2-3 times more risk for cardiovascular disorders tha the geeral populatio. People with metal illess have higher rates of cardiovascular ad respiratory disorders tha the geeral populatio; atipsychotic agets cotribute to metabolic sydrome X (hypertesio, hyperlipidaemia, hyperglycaemia, isuli resistace ad obesity); lifestyle factors (smokig, alcoholism, poor diet, ad lack of exercise) cotribute to icreased risk of cardiac problems. Mortality due to ischaemic heart disease, cardiac arrhythmias ad myocardial ifarctio is higher i people with metal illess. 19,20,21,22 The preset study reported prevalece of edocrial abormalities to be higher (31.82% especially diabetes mellitus type -2) tha the cardiovascular morbidity at 9.09% ad the patiets who had higher age were associated with icreased risk of physical illess. Our fidigs are cosistet with a study coducted by Smith DJ et al who reported that people with schizophreia had lower recorded rates of cardiovascular disease as compared to other physical health co morbidities. 23 The variatio as compared to other studies ca be accouted to the fact of differece i sample demographics like variatios i settig, as our study was o rural populatio. It is a well-kow fact that both typical ad atypical atipsychotics though are mai stay of treatmet for schizophreia, are also associated with their side effects. Gupta et al (2003) reported a prevalece rate of 30% for hypertesio, 17% for diabetes ad 43% for lipid abormalities i 208 patiets with psychotic disorders who were receivig ati-psychotic medicatios. 24 Risk of metabolic sydrome also foud to be higher i patiets beig treated with atypical atipsychotics. Heiskae et al (2003) Iteratioal Joural of Medicie ad Public Health, Vol 7, Issue 4, Oct-Dec,

4 Table 4: Associatio of the variables with medical co-morbidities Yes No Total 2-valueא Type of medicatio Atypical Typical ,NS Mixed ICD 10 classificatio of schizophreia Paraoid Udifferetiated Catatoic Hebephreic Other H/O Substace Abuse Yes No Family H/O metal illess Yes No Figure 1: Distributio accordig to presece of medical illess. Figure 3: Distributio accordig to type of medicatio. Figure 2: Distributio of metal illess accordig to medical co morbidities. Figure 4: Distributio accordig to I.C.D. 10 diagosis of schizophreia. 194 Iteratioal Joural of Medicie ad Public Health, Vol 7, Issue 4, Oct-Dec, 2017

5 foud that 37% of patiets with schizophreia receivig atipsychotic medicatios developed metabolic sydrome higher as compared to preset study. 25 Tarricoe et al (2006) foud that patiets treated with atypical atipsychotics had higher mea glycaemia ad triglyceridemia ad a sigificatly higher risk of receivig a diagosis of hyperglycemia ad hypertriglyceridemia tha the referece group. 26 The above fidigs are cosistet with the results reported i preset study that patiets who were exposed to psychotropic medicatios for loger periods of time, were more at risk of developig medical illess (majority of our patiets i.e. 67% were beig treated with atypical atipsychotics). High alcohol use i schizophreia is associated with more severe psychiatric symptoms ad more disturbed behavior. 27 Poor medicatio compliace, higher rates of re hospitalizatio ad poor treatmet respose has bee associated with comorbid drug abuse i schizophreia. 28,29 Smokig rates is foud to be higher i schizophreia subjects tha i ormal populatio. 30 The preset study also foud that history of substace abuse i schizophreia icreased the risk of developig medical co-morbidities. This fidig is i accordace with above metioed studies. Literature is limited for medical co-morbidity see i differet subtypes of schizophreia as described i ICD-10. This study also did ot fid ay differece i subtypes of schizophreia ad prevalece of medical co-morbidity. Similarly literature is very limited o prevalece of medical comorbidity i schizophreia ad its correlatio with family history of metal illess. The preset study foud that havig a family history of metal illess i patiets with schizophreia does ot icrease the likelihood of developmet of physical Illess. CONCLUSION The prevalece of medical co-morbidities was foud to be lower tha that i previous literature. As show by this study schizophreia patiets reported co-morbid diabetes mellitus, C.O.P.D, hypertesio, aaemia amog may others. More the exposure to psychotropic mediatios i term of duratio icreased the chaces of developig medical illess. Sometimes the physical illesses remai urecogized i such patiets so itegrated approaches such as assessmet of medical illess by physicia ad psychiatric diagosis by psychiatrist require to prevet ad treat the co-morbid disorders. Further research is eeded to provide more isight ito the risk factors ad treatmet modalities. CONFLICT OF INTEREST The authors declare o coflict of iterest. ABBREVIATION USED ICD: Iteratioal Classificatio of Diseases; HIV: Huma immuodeficiecy virus; AIDS: Acquired immue deficiecy sydrome; SPSS: Statistical Package for the Social Scieces; COPD: Chroic Obstructive Pulmoary Disease. REFERENCES 1. Saha S, Chat D, mcgrath J. A systematic review of mortality i schizophreia: Is the differetial mortality gap worseig over time?. Arch Ge Psychiatry. 2007; 64(10): Capasso RM, Lieberry TW, Bostwick JM, Decker PA, St Sauver J. Mortality i schizophreia ad schizoaffective disorder: A Olmsted Couty, Miesota cohort: Schizophr Res. 2008;98(1): Brow S, Iskip H, Barraclough B. Causes of the excess mortality of schizophreia. Br J Psychiatry. 2000;177(3): Phela M, Stradis L, Morriso S. Physical health of people with severe metal illess. BMJ. 2001;322(7284): Ruschea D, Mulle PE, Burgess P, et al. Sudde death i psychiatric patiets. Br J Psychiatry. 1998;172: Tiihoe J, Löqvist J, Wahlbeck K, et al. 11-year follow-up of mortality i patiets with schizophreia: a populatio-based cohort study (FIN11 study). Lacet. 2009;374: Timothy JRL, Deis V, Christos P. Medical comorbidity i schizophreia. SUPPLEMENT SCHIZOPHRENIA; MJA. 2003;178:S67-S Sokal J, Messias E, Dickerso FB, et al. Comorbidity of medical illesses amog adults with serious metal illess who are receivig commuity psychiatric services. J Nerv Met Dis. 2004;192(6): Dixo L, Postrado L, Delahaty J, Fischer PJ, Lehma A. The associatio of medical comorbidity i schizophreia with poor physical ad metal health. J Nerv Met Dis. 1999;187(8): Mortese PB, Juel K. Mortality ad causes of death i first admitted schizophreic patiets. British Joural of Psychiatry. 1993;163(2): Lambert TJ, Velakoulis D, Patelis C. Medical comorbidity i schizophreia. Med J Aust. 2003;178 Suppl:S Kora LM, Sox HC, Marto KI, et al. Medical evaluatio of psychiatric patiets. I. Results i a state metal health system. Arch Ge Psychiatry. 1989;46(8): Korayi EK. Morbidity ad rate of udiagosed physical illesses i a psychiatric cliic populatio. Arch Ge Psychiatry. 1979;36(4): Hall RC, Garder ER, Popki MK, et al. Urecogized physical illess promptig psychiatric admissio: a prospective study. Am J Psychiatry. 1981;138(5): Holt RIG, Peveler RC. Associatio betwee atipsychotic drugs ad diabetes. Diabetes Obesity ad Metabolism. 2006;8(2): Dixo L, Weide P, Delahaty J, et al. Prevalece ad correlates of diabetes i atioal schizophreia samples. Schizophr Bull. 2000;26(4): Seryak M, Leslie D, Alarco R, et al. Associatio of diabetes mellitus with use of atypical euroleptics i the treatmet of schizophreia. Am J Psychiatry. 2002;159(4): Felker B, Yazel JJ, Short D. Mortality ad medical comorbidity amog psychiatric patiets: a review. Psychiatr Serv. 1996;47: Lawrece D, Holma C, Jablesky A. Prevetable physical illess i people with metal illess. Perth: Uiversity of Wester Australia, Available at: (accessed Mar 2003). 20. Davidso M. Risk of cardiovascular disease ad sudde death i schizophreia. J Cli Psychiatry. 2002;63:5-11. (Erratum appears i J Cli Psychiatry. 2002; 63:744.) 21. Rya MC, Thakore JH. Physical cosequeces of schizophreia ad its treatmet: the metabolic sydrome. Life Sci. 2002;71: Kedrick T. Cardiovascular ad respiratory risk factors ad symptoms amog geeral practice patiets with log-term metal illess. Br J Psychiatry. 1996;169(6): Smith DJ, Laga J, mclea G, et al. Schizophreia is associated with excess multiple physical-health comorbidities but low levels of recorded cardiovascular disease i primary care: cross-sectioal study. BMJ Ope. 2013;3(4):e Doi: / bmjope Gupta S, Steimeyer C, Frak B, Madhusoodaa S, Lockwood K, Letz B, et al. Hyperglycemia ad hypertriglyceridemia i real world patiets o atipsychotic therapy. Am J Ther. 2003;10: Heiskae T, Niskae L, Lyytikäie R, Saarie PI, Hitikka J. Metabolic sydrome i patiets with schizophreia. J Cli Psychiatry. 2003;64(5): Ilaria T, Michela C, Beatrice FG, Daiela G, Marco M, Alessadro S, et al. Metabolic risk factor profile associated with use of secod geeratio atipsychotics: a cross sectioal study i a commuity metal health cetre. BMC Psychiatry. 2006;6(1): Duke PJ, Patelis C, Bares TR. South Westmister schizophreia survey: Alcohol use ad its relatioship to symptoms, tardive dyskiesia, ad illess oset. British Joural of Psychiatry. 1994;164(5): Drake RE, Osher FC, Wallach MA. Alcohol use ad abuse i schizophreia: A prospective commuity study. Joural of Nervous ad Metal Disease. 1989;177(7): Mueser KT, Bellack AS, Blachard JJ. Comorbidity of schizophreia ad substace abuse: Implicatios for treatmet. Joural of Cosultig ad Cliical Psychology. 1992;60(6): Hughes JR, Hatsukami DK, Mitchell JE, Dahlgre LA. Prevalece of smokig amog psychiatric outpatiets. America Joural of Psychiatry. 1986;143(8): Cite this article : Kalucha S, Gedam SR, Behere P. Medical Co-Morbidity i Schizophreia from Rural Regio of Cetral Idia: A Cross-Sectioal Study. It J Med Public Health. 2017;7(4): Iteratioal Joural of Medicie ad Public Health, Vol 7, Issue 4, Oct-Dec,