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Mental Disorders in Medical Inpatients and the Association to Severity of Illness, Self-Rated Physical Disability, and Health Perception

Received April 7, 2000; revised July 25, 2000; accepted September 6, 2000. From Department of Psychiatric Demography, Psychiatric Hospital in Aarhus, Risskov, Denmark; Research Unit for Functional Disorders, Psychosomatics and C-L Psychiatry, Aarhus University Hospital, Aarhus, Denmark; Department of Biostatistics, University of Aarhus, Aarhus, Denmark; Department of Psychiatric Demography, Psychiatric Hospital in Aarhus, Risskov, Denmark; Department of Psychiatry, Vejle Sygehus, Vejle, Denmark; Department of Psychiatric Demography, Psychiatric Hospital in Aarhus, Aarhus University Hospital, Risskov, Denmark. Address correspondence and reprint requests to Dr. Hansen, Department of Psychiatric Demography, Psychiatric Hospital in Aarhus, Skovagervej 2, DK-8240 Risskov, Denmark.

ABSTRACT

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In a study of 294 consecutive medical inpatients, the authors assessed a subsample of 157 patients for psychiatric diagnoses using an extensive semistructured interview, Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Patients rated their health and physical functioning, and medical consultants assessed them for chronic and life-threatening diseases. A life-threatening condition increased odds for having a psychiatric diagnosis by 3.1 times (95% Confidence Interval (CI): 1.03–9.1), while a chronic medical disease had no such impact (OR=1.1; 95% CI: 0.5–2.3). In women, mental disorders were strongly associated with self-rated disability (OR=6.7; 95% CI: 1.6–27.8) and self-rated health (OR=9.4; 95% CI: 2.7–32.4). This association was absent in men (OR_disability=0.7; 95% CI: 0.2–2.7; OR_health=1.6; 95% CI: 0.6–4.7). Analyses included adjustment for age and gender.

Key Words: Disorders • Self-Report

INTRODUCTION

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Studies have shown that mental disorders are highly prevalent in medical settings and that mental disorders are associated with high health care utilization.^1–10 Several explanations for this association have been introduced. One explanation is a psychological reaction to the distress imposed by a chronic medical condition, by a life-threatening condition, or by the overall severity of the illness. Another is a difference in illness perception and behavior in which mentally disordered patients may consider themselves more troubled by medical conditions and therefore be more likely to seek medical help than mentally healthy patients. A third possible explanation is somatization.⁹

As to the first explanation, which associates illness severity or chronicity to psychiatric morbidity, studies of hospital patients have been contradictory,^4,5,11–15 whereas a positive association has been found in population studies and in family practice.^16–19

Concerning illness/health perception, population studies have shown that people who are depressed consider their general²⁰ and physical²¹ health worse than people who are not depressed. In medical settings, patients with depression²² and anxiety²³ rated their physical functioning worse than mentally healthy patients.

When looking at previous studies, objections may be raised concerning methodology. In studies of physician-reported illness severity, the definition varies and is sometimes not described. Moreover, statistical methods enabling adjustment for age and gender, which are highly associated with psychiatric morbidity, have not always been applied. Studies of self-rated health and disability are prone to bias originating from the fact that low levels of perceived health and functioning in mentally disordered patients may be due to more severe physical illness among these patients.

The first objective of our study is to investigate whether psychiatric morbidity in internal medical inpatients is associated with severity of physical illness, measured as the presence of a chronic physical disease and/or a life-threatening disease. Second, we examine the impact of the presence of a mental disorder on a patient's illness perception, measured by ratings of general health and physical disability. For both objectives, we will control for possible confounders.

METHODS

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Study Population
The study population (n=547) consisted of consecutive inpatients 18 years or older who were admitted to the department of internal medicine at Silkeborg Central Hospital during a 3-month period in 1997. The department provides all medical services for the catchment area. We included each patient only once.

We excluded patients according to the following predefined criteria (for details see Reference 1): patients who were not of Scandinavian origin (n=4) or who did not speak Danish (n=0) and patients who could not be interviewed, either because of too severe a physical illness (n=41), deafness (n=5), disorientation (n=21), or expressive problems, [e.g., aphasia (n=13), or unconsciousness (n=7)]. In addition, 58 patients were discharged, and 6 patients died before they could be interviewed. Ninety-eight patients refused to participate in the study. Hence, a total of 294 patients were included (Figure 1).

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FIGURE 1. Inclusion of patients

We compared the patients who died before inclusion or who were excluded according to predefined criteria (n=97), the patients who refused to participate (n=98), and the patients who were discharged before they were contacted by a research worker (n=58) with the included patients on age and gender. We also obtained data from national patient registers and made comparisons on psychiatric and nonpsychiatric health service utilization. These three groups of patients not included in the study differed significantly from the included patients only in terms of age (Hansen et al., unpublished results).

Procedure and Assessment
All patients were interviewed by one of three research workers. The interview included an 8-item version of the Symptom Checklist (SCL-8),²⁷ detecting anxiety and depression, and the 7-item Whiteley Index,²⁸ detecting hypochondriasis. The scales were dichotomized, and patients with a score of 2 on the SCL-8 and/or 3 on the Whiteley Index were considered high scorers.

A random sample of one-third of all patients were then selected for psychiatric interviews, followed by adding all high scorers from the remaining two-thirds of patients. Thus, a stratified subsample was produced, consisting of all high scorers and approximately one-third of the low scorers. This stratified sample was not representative of the total study population, but this skewness was eliminated in the statistical procedure (see below).

The psychiatric diagnostic interviews were done at discharge using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN, v.2.1).²⁹

Developed by the World Health Organization (WHO), the SCAN includes a newly revised version of the Present State Examination (PSE v.10),³⁰ which is widely considered a gold standard among psychiatric diagnostic instruments.^2,31 The SCAN/PSE is an extensive semistructured interview that requires the interviewer to have psychiatric skills at an academic level and to have received special training at a WHO center. In the SCAN/PSE, all the diagnostic criteria in the ICD-10 are represented as items in the interview, so that diagnoses can be made. Computer algorithms are available for this purpose and were used in the present study.

Eleven patients refused to participate in the interview, and two died before an interview could be arranged. Thus, we interviewed 157 patients with the SCAN.

The SCAN interviewers (two psychiatrists, MSH and LS) had been trained and certified at the WHO-center in Aarhus, Denmark, and were blind to the patients' answers to the interviews at admission. The interrater agreement was high [i.e., there was agreement on 16 of 17 patients (kappa=0.88).]

Information was recorded on sociodemographic variables. The two following questions were asked of the medical consultants responsible for each patient. "Does this patient suffer from a chronic medical disease?" (answers: Yes or No) and "Does the patient have a life threatening disease?" (answers: No, Mild, Moderate, or Severe). For self-rated health, one question was asked of the patients. "How would you say your health has been during the last week?" (answers range from Excellent to Very Poor). Physical disability was rated by the patients by the following three questions: "During the past 2 weeks, which of the following physical activities would you be able to maintain for at least 2 minutes?" (answers range from Fast Running to No Physical Activity At All); "Did you have any walking difficulties during the last 3 months (i.e., were you dependent on others)?" (answers range from No, Independent to Complete Dependence); and "During the last 3 months, have you had problems taking care of yourself, i.e., did you require help from others?" (answers from No, Independent to Complete Dependence). The last three questions were dichotomized for an index variable created by simple addition. The original scores of 2 and 3 were collapsed because of small numbers of answers in these categories. Thus, high scores refer to more disability.

Data Analysis
ICD-10 psychiatric diagnosis was obtained from SCAN interviews by a computer program developed at the WHO center in Aarhus. Some subsequent revision of the output was necessary.

As the SCAN interview was performed only on a stratified subsample, we examined, one at a time, the associations between the psychiatric morbidity and severity variables (the presence of a chronic or life-threatening disease) were examined by weighted logistic regression analyses,^32,33 with the psychiatric diagnosis (present/not present) as the dependent variable and the other variables of interest as independent variables. The weighting procedure eliminates bias introduced by stratified sampling, thus ensuring accurate estimates of prevalences, odds ratios, and confidence intervals representative of the total study population.

As age and gender were significantly associated with the psychiatric morbidity,¹ the model also included gender and age (three age groups: 18–49, 50–69, and 70+) and their interaction, as possible confounders. To study if age or gender modified the association, the interaction terms "severity variablexage" and "severity variablexgender" were tested and were included in the model if their corresponding P value <0.05 (likelihood ratio test). The impact of mental disorders on health perception variables (i.e., self-rated physical disability and health) were analyzed with the dichotomized health perception variable as an outcome (dependent) variable and the presence of a mental disorder as a covariate, together with gender, age, their interaction, and both the severity variables mentioned above, for statistical adjustment.

To reveal differences between psychiatric diagnoses, we repeated both sets of analyses, substituting the overall psychiatric morbidity with the three main groups of psychiatric diagnoses in the sample (i.e., somatoform disorders, substance use disorders, and anxiety and/or depression, for details see Reference 1).

Analysis and testing of associations, not including psychiatric morbidity data, were calculated on the total sample (N=294) without weighting.

SPSS for Windows (v.6.1/8.0) was used for statistical analysis.

RESULTS

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The prevalence of specific mental disorders in the study population and the relation to age and gender have been presented elsewhere.¹ As shown in Table 1, the psychiatric morbidity and prevalence of chronic and life-threatening disease, and self-rated physical disability and health are highly dependent on gender and age. This fact emphasizes the importance of statistical adjustment when analyzing their relationship.

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TABLE 1. Prevalence (%) of mental disorders, chronic and life-threatening disease, and self-rated physical disability and health

The presence of a mental disorder showed neither a statistically significant association with the presence of a mental disorder (Table 2) nor the presence of a mildly life-threatening disease. However, among patients with a moderate or severe life-threatening disease, the odds of having a psychiatric diagnosis were 3.1 times higher than for patients with no life-threatening disease (P=0.04). This statistically significant association appeared only when including age and gender in the model, but the size of the association did not differ significantly among the age and gender groups.

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TABLE 2. Mental disorders versus chronic and life-threatening disease

When we adjusted for age and presence of a chronic and life-threatening disease (see Table 3), odds for reporting poor or very poor health were more than 9 times higher among mentally disordered women than among the mentally healthy women(P<0.001). Women with mental disorders had more than 6 times greater odds of rating themselves as moderately disabled or worse, compared with women without mental disorders (P<0.01). Among men, however, neither self-rated physical disability nor self-rated health showed any statistically significant association with psychiatric morbidity. For both self-rated variables, this gender difference was statistically significant (disability: P=0.02; health: P=0.02).

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TABLE 3. Self-rated disability and health versus mental disorders

The analyses of association between groups of specific psychiatric diagnoses (i.e., somatoform disorders, substance use disorders, and anxiety/depression) and the physicians' and patients' reports confirmed our results described above and did not leave any reason to suspect a difference between the diagnostic groups as to the above-mentioned association figures. However, some of these latter analyses were weakened by the small number of disordered patients.

Finally, the discharge diagnoses (ICD-10, groups A-Z) from the medical department were included in the analyses in order to test for associations with psychiatric morbidity and for possible contribution to the above-mentioned significant associations. Neither of these was the case.

DISCUSSION

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Problems concerning the exclusion of certain patient groups are discussed elsewhere.¹

We studied important aspects of physician-reported illness severity. Concerning disease chronicity, our results indicate that among consecutive hospital admissions, mental illness is no more frequent in patients with chronic physical diseases than in patients without a chronic physical disease. This is consistent with the results from an outpatient clinic reported by Cassileth et al.¹⁵ but is in contrast to the population studies.^16–18 These latter studies, though, used either lay interviewers (using Diagnostic Interview Schedule, CIS, etc.) or self-rating questionnaires for psychiatric assessment—methods that might cause problems when identifying cases.³¹ Thus, our present study confirms that within the hospital, unlike what seems to be the case in the general population, the presence of a chronic physical disease is not associated with elevated prevalence of mental illness.

The presence of a life-threatening disease, as reported by the medical consultants, was associated with a 3 times greater odds for having a mental disorder. Two recent studies^4,12 did not find any association between illness severity and mental illness. Silverstone's⁴ study is similar to our present study by studying medical patients using SCAN, applying a definition of illness severity mainly based on life threat, and excluding cognitive disorders. A discrepancy between the two may be because of the statistical adjustment for age and gender, which was done only in our study. A direct comparison is not possible because the statistical methods are different.

Schwab et al.¹³ reported contrasting results, but they did not define illness severity and only studied depression and not other types of psychopathology. Our study, though, shows results concerning depression quite similar to the results concerning overall psychiatric morbidity. Arolt et al.⁵ and Feldman et al.¹⁴ found similar results to our study, with the latter presenting a trend that was not statistically significant. Again, in these studies no adjustment was performed for possible confounders, such as age and gender.

It thus seems that "objective" (i.e., physician-reported severity of physical illness) is somewhat associated with mental illness, irrespective of the gender of patients. This result suggests that severe medical illness can trigger mental illness, psychologically and/or biologically and that mental illness and the associated life style also enhance the risk for medical illness.

As to the impact of mental disorders on self-rated health and physical disability, it was expected that these indicators of health perception, should be affected by present mental disorders. The results concerning women supported that idea. However, it is remarkable that, in this study, men's health reports are apparently not linked with their mental health status. Other researchers did not find this gender difference.^20–23,34 The difference might have been because of the difference in the distribution of psychiatric diagnoses among male and female patients found in our study,¹ but it remained unchanged also when examining different psychiatric diagnoses separately. Although different statistical methods and sparse information in the above-mentioned articles make comparison difficult, it may be important that we studied internal medical inpatients, whereas the other researchers used either with general population samples^20,21 or patients in other clinical settings.^22,23,34 However, it is likely that our result reflect a genuine difference in men's and women's perception of health and illness.

Our present study indicates that, in a medical department like the one studied here, patients are more likely to be psychiatrically ill if they suffer from a life-threatening physical disease, which contributes to the idea that psychological distress explains part of the medical-psychiatric comorbidity. The presence of a chronic physical disease has no impact.

Mental illness had a significant impact on women's health perception. This may contribute to a more help-seeking illness behavior in mentally disordered women, and thus, to a high utilization of health care resources and to comorbidity. It also indicates that increased focus on diagnosing and treating mental disorders in hospitals would be of value to the patients. Finally, our study illustrates the difference between the doctors' view of the disease and the patients' perception of their illness, a difference one should be aware of when doing research in this field.

ACKNOWLEDGMENTS

 
The authors thank Dr. Aksel Bertelsen from the WHO Center at Psychiatric Hospital in Aarhus, for his help concerning the SCAN, and Erik Kristensen, Dr.Med.Sc., chief consultant, Ulla Nielsen, head nurse and research worker, and Åse Thøgersen, head secretary, all from the Department of Internal Medicine, Silkeborg Central Hospital. The authors also thank all staff members at the department for their help in the data collection. Also thanks to Søren Skadhede, computer programmer at the Department of Psychiatric Demography, Psychiatric Hospital in Aarhus. In addition to the authors, contributions to the design of the study have been made by F J. Huyse (The Netherlands), Thomas Herzog (Germany), Antonio Lobo (Spain), J.P.J Slaets (The Netherlands), Peter de Jonge (The Netherlands), Graca Cardoso (Portugal) and Marco Rigatelli (Italy).

This study is part of the Biomed1 Risk Factor Study (European Consultation Liaison Workgroup, ECLW).^24–26 This study was supported by The Danish Medical Research Council (Grant 9601898), The Danish Health Insurance Fund, The Hede Nielsen Foundation, the fund "Puljen til Styrkelse af Psykiatrisk Forskning," and by Biomed1 Grant BMH1-CT93–1180.³⁵

REFERENCES

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