Medical comorbidity in geriatric psychiatry.

Received January 3, 2005; accepted January 6, 2005. From the University of California–San Diego (DPF) and Channing Laboratory, Boston, MA (OIO). Send correspondence to Olivia I. Okereke, M.D., Channing Laboratory, 3rd floor, 181 Longwood Avenue, Boston, MA 02115. e-mail: ookereke@partners.org. 2005 American Association for Geriatric Psychiatry This is the first time that The American Journal of Geriatric Psychiatry has published a special section focusing on comorbid medical and psychiatric conditions in older persons. This theme is particularly important, given the fact that, among older patients, comorbid medical conditions are the rule rather than the exception. For example, in the IMPACT study, which was an investigation of collaborative care for older patients with depression treated in primary care, the average patient had more than three comorbid medical conditions. The relationship between mental and physical health may bemore important in geriatric psychiatry and geriatrics than in any other area of medicine. In this month’s Journal, Kilbourne and colleagues address the overall burden of general-medical comorbidity among older patients with serious mental illness (SMI). Using a large Veterans Health Administration-based sample of over 8,000 subjects with schizophrenia, schizoaffective disorder, or bipolar disorder, they contrast the degree of medical comorbidity among those patients age 60 and older with that of young patients. The authors found that the prevalence estimates of cardiovascular morbidity (hypertension and ischemic heart disease were the two most frequent diagnoses) and endocrinemorbidity (diabetes and hyperlipidemia were the two most common) were each about 30% among older patients. Also, older people with SMI were more likely to be diagnosed with pulmonary conditions and cancers and had an overall higher total burden of medical comorbidity (i.e., three or more conditions) than younger individuals. These results stand in contrast to the finding that younger seriously mentally ill persons experience a higher burden of substance-abuse disorders, hepatic illnesses, and accidents or injuries. The authors highlight the need for further development of strategies to treat coexisting serious medical and psychiatric conditions in the geriatric population. Also in this issue, Kilbourne et al. examine the effect that depressive symptoms have on adherence to treatment for a specific chronic condition: diabetes. As the authors point out, diabetes is an excellent example of a chronic disease for assessment to advance our understanding of why patients with depression have worse medical outcomes than those without depression. Diabetes is common, particularly in older patients, and the treatment of diabetes often involves multiple medications. In this investigation, the authors found a relationship between depressive symptoms and some, but not all, measures of adherence to diabetes treatment. This study highlights the complexity of measuring adherence to medications: using pharmacy refill data and patient self-report, there appeared to be a lower rate of medication adherence in patients with greater depressive symptoms; however, when using provider-report and electronic monitoring caps, no relationship was found between adherence and depressive symptoms. As the authors conclude, this report suggests that physicians caring for people with diabetes should be aware that those patients with comorbid depression may have lower medication adherence and may benefit from extra efforts to improve treatment adherence.