studies have documented high rates of co- morbid medical illness in psychiatric
patients.1,2 Medical co-morbidity in psychiatric
in-patients has also been found to be a significant factor determining the
psychiatric outcomes and in some cases hospital stay.3,4Hhaving a psychiatric illness
unfortunately creates a barrier to effective medical care as psychiatric symptoms
often impair patient’s capacity to care for themselves. There is high likelihood of medical co -morbidity
in this patient population remaining under diagnosed and untreated.
Modest associations have been found
between BMI and psychiatric disorders.5 It is also well known that higher
BMI is a significant risk factor for diabetes, hypertension and dyslipidemia.6,7
There have been hardly any studies in India which have assessed medical co
morbidity and Body Mass Index (BMI) in psychiatric in-patients.
was a cross-sectional, observational study. The research received approval from
the institution’s ethics committee and written informed consent was obtained
from all subjects.
of 78 in-patients of a psychiatric ward in the teaching hospital were enrolled
for the study over a period of one month through consecutive sampling method.
Inclusion criteria were: Age 18 years and above, and in-patient status in
general psychiatry ward. Having severe psychiatric symptoms, resulting in
patient being uncooperative was the exclusion criterion. Patients were
interviewed during first week of admission to the psychiatry ward. Height and
weight measurements were taken during the same time period. A specially
designed semi-structured questionnaire was used to interview both the subject
and a reliable informant to obtain the socio-demographic, medical and
psychiatric data. The attending psychiatrist’s diagnosis (ICD 10 diagnostic
criteria) at discharge of the patient was documented.
variables were studied and compared across groups using mean, standard
deviation and student’s t test. Chi-Square analysis was used for categorical
Tables and Figures
Table I. Comparison of Mean BMI and distribution of
male and female psychiatric in-patients into BMI categories
Mean BMI (SD)
21.16 ( 3.44)
II. Psychiatric diagnoses of the study subjects, BMI and medical disorders
mood disorder (30)
Nonorganic Psychosis (17)
dependence syndrome (12)
mental disorder (3)
retardation with behavioural problem (1)
the subjects ranged from 18 to 65 years (Mean 36.13 years, SD 11.42). There
were 58 male (Mean age 34.38 yrs) and 20 female (Mean age 41.20 yrs) subjects.
All the subjects were from rural areas. Most of them (71.80%) were from nuclear
families. About 43.5% were married and living with their spouses, and 25.6%
were single (never married). The remaining 30.9% were either divorcees or
separated from the spouse. About 22% of the subjects belonged to BPL (Below
Poverty Line) category of socio-economic status. 8 The
remaining belonged to either low (36%) or lower middle (42.1%) socioeconomic
BMI9 of the subjects was 21.67 (SD 4.65). Although the
average BMI in males [21.16, SD 3.44] and females [23.13, SD 7.02]
did not differ significantly, males and females showed significant group
differences when different BMI categories were compared across two groups (p<0.0005).
Female subjects had higher rates of obesity (30%) compared to male subjects
(nil). Under-weight individuals also constituted 30% of female subjects
compared to 10% in males. (Table I)
There was mild positive correlation
between age and BMI but it was not statistically significant (p=0.643). Socioeconomic
groups did not show statistically significant differences when the mean BMIs of
these groups were compared (p=0.053).
with schizophrenia (Mean-23.08, SD 3.39) had the highest BMI, followed by
bipolar mood disorder (Mean 22.89, SD 6.21), alcohol dependence syndrome (Mean
21.70, SD 2.12), depressive disorder (Mean 21.23, SD 3.43), unspecified
nonorganic psychosis (Mean 20.83, SD 4.61), and delusional disorder (Mean
20.48, SD 3.21). There were no significant differences between the mean BMIs of
these diagnostic groups. (TableII)
affective disorder was the most common psychiatric illness, being present in 30
subjects (38.5%), followed by unspecified nonorganic psychosis (21.8%), alcohol
dependence syndrome (15.4%), paranoid schizophrenia (7.7%), depressive disorder
(6.4%), delusional disorder (5.1%), organic mental disorders (3.8%), and mental
retardation with behavioral problems (1.2%). Four of the 12 patients with
alcohol dependence syndrome also had alcohol related psychotic disorder.
23.1% of the subjects had significant medical disorders. Diabetes mellitus Type
II (12.8%) was most common, followed by essential hypertension (6.4%), epilepsy
(2.5%) and hyperthyroidism (1.2%). Only 50% of them were on regular medication
for the medical disorders. Psychiatric illness interfering the patients’
motivation to comply with the treatment was the main reason for poor
compliance. Medical problem in every case required clinical attention and
physician’s opinion was sought.
with diabetes mellitus and hypertension had significantly higher BMI
(Mean-25.46, SD 6.19) compared to subjects without these conditions
(Mean-20.97, SD 3.93), which was statistically significant (P=0.016). Females
had higher rates of medical disorders (30%) compared to males (20.7%). Medical
co-morbidity was highest among patients with bipolar disorder and alcohol
dependence syndrome (both 40%) followed by schizophrenia (33%) and unspecified
nonorganic psychosis (11%). Among 30 bipolar patients, eight (26.6%) were
diabetic, and 3(10%) were hypertensive.
Numerous studies have shown
significant medical co-morbidity in psychiatric in-patients. 3-6, 11 However
there has been paucity of studies that have assessed medical comorbidity in
psychiatric in-patients of general hospitals in Indian setting. We assessed
body mass index, medical comorbidity and other relevant variables in
Although our males and female
subjects did not differ significantly in terms of age, distribution of subjects
into different BMI categories differed significantly between genders
psychiatry in-patients had considerably higher rates of obesity (30%) compared
to male counterparts (nil). Not surprisingly,
about 30% of females were affected by medical disorders compared to 20.7% of
males. No specific psychiatric diagnostic category stood out when BMI
was compared across various diagnostic groups.
was significant medical comorbidity (23.1%) among the subjects. Only half of
them were on regular medication for the medical disorders. The main reason for
poor compliance was the interference by the symptoms of psychiatric disorder.
Diabetes mellitus (12.8%) and essential hypertension (6.4%) were most common
medical disorders. Medical comorbidity was highest in patients with bipolar
mood disorder and alcohol dependence syndrome. About 40% from both these
diagnostic categories were affected by medical disorders. Medical disorders did not appear to
be influenced by age or socio-economic status. However subjects with diabetes mellitus and/or hypertension had
significantly higher BMI (Mean-25.46,) compared to subjects without these
conditions (Mean-20.97), which was statistically significant (P<0.05).
frequency of medical comorbidity in this patient population is consistent with
the similar studies done in the western countries.1-3 Our findings
are in line with those of Lyketsos et al,3 who reported that for
20.6% of the psychiatric in-patients, medical comorbidity had been a focus of
care during the hospitalization. They are also in line with those of Levine et
al who found that female psychiatric subjects had considerably higher
rates of being either overweight or obese as compared to women in the general
U.S. population.4 we found 30% rate of obesity in our female
subjects. Although this rate of obesity was much lower compared to the U.S
counterparts (69%), it was much higher compared to the obesity rates (7%) in
rural Indian women,8 considering that all our subjects were from
rural areas. The dual burden of malnutrition reported in the national family
health survey sponsored by government of India was true for the female subjects
in our study as well.10 Almost 30% of them were underweight. Male
psychiatric subjects did not differ significantly from their counterparts in
the general population in being overweight or obese (6.9%).
Bipolar mood disorder
patients formed a major diagnostic category in our study. Our study found
elevated frequency of type II diabetes mellitus in
these patients. Eight out of 30 (26.6%) bipolar
patients had diabetes. The association between bipolar disorder and diabetes is
well documented. During past decades, several studies have reported
elevated frequency of diabetes among patients with bipolar disorder. The prevalence of type II diabetes mellitus in patients
with bipolar disorder has been reported to range from 10% to 26%, as much as
threefold higher than the estimates in the general population.12-14 Cassidy
et al found that 9.9% of the hospitalized bipolar patients (aged 20-74 years)
had diabetes mellitus. The frequency of diabetes in our bipolar patients (aged
25-65 years) was much higher.
Our study confirms the findings of earlier studies done in other parts
of the world that showed high medical comorbidity in psychiatric in-patients.
As this was a cross-sectional study, associations between psychotropic drug
classes and specific medical conditions could not be deduced.
We found high medical comorbidity in our psychiatric in-patients.
Diabetes and hypertension were the most common medical disorders in this
patient population. Female psychiatric in-patients are more likely to have
higher BMI, higher obesity rates, and higher medical comorbidity. Patients with
bipolar mood disorder and alcohol dependence syndrome are at high risk of
having medical problems. A large number of psychiatric patients with medical
illness do not comply with the treatment of medical disorders due to the nature
of psychiatric illness. All medical professionals involved in the care of
mentally ill must actively screen them for the presence of cardiovascular,
medical and metabolic disorders and enhance clinical surveillance.
B, Yazel JJ, and Short D: Mortality and medical comorbidity among psychiatric
patients: a review. Psychiatr Serv 1996; 47:1356–1363.
LS: Comorbid medical illness in psychiatric patients. Curr Psychiatry Rep 2000;
Lyketsos CG, Dunn G, Kaminsky MJ, Breakey WR.
Medical comorbidity in psychiatric inpatients: relation to clinical outcomes
and hospital length of stay.
Chengappa, KNR, Patel A, Vagnucci A, John V,
Brar JS.Obesity and Medical Illnesses in Psychiatric Patients Admitted
to a Long-term Psychiatric Facility. Journal of Psychiatric Practice:
Bruffaerts R, Simon GE, Alonso J,Angermeyer M,de Girolamo G et
al. Obesity and mental disorders in the general population: results from the world mental health surveys. Int J of Obes.2008;
Narayan K.M.V , Boyle JP, Thompson TJ, Gregg EW,
Williamson DF. Effect of BMI on Lifetime Risk for Diabetes in the U.S. Diabetes Care 30:1562–1566, 2007.
CD, Higgins M, Donato KA,Rohde FC,Garrison R, Obarzanek E et
al.Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obesity Research. 2000; 8:605–619.
Agarwal AK . Social
Classification: The Need to Update in the Present Scenario. Indian Journal of Community Medicine.
2008: 33(1): 50-51.
WHO expert consultation.
Appropriate body-mass index for Asian populations and its implications for
policy and intervention strategies. The Lancet, 2004; 157-163.
Institute for Population Sciences (IIPS) and Macro International. 2007.
National Family Health Survey (NFHS-3), 2005-06, India: Key Findings. Mumbai:
Meyer JM, Goff DC McEvoy
JP, Davis SM, Stroup TS et al. Low rates of treatment for
hypertension, dyslipidemia and diabetes in schizophrenia: Data from the SCATIE
schizophrenia trial sample at baseline. Schizophrenia Research.2006; 86:15 –
Cassidy F, Ahearn E, Carroll J. Elevated Frequency of Diabetes
Mellitus in Hospitalized Manic-Depressive Patients. Am J Psychiatry. 1999;
SL. Prevalence of diabetes in a manic-depressive population. Compr
WT, Thapar RK, Marano C, Gavirneni S, Kondapavuluru PV. Increased prevalence of
type 2 diabetes mellitus among psychiatric inpatients with bipolar I affective
and schizoaffective disorders independent of psychotropic drug use. J Affect
Disord. 2002; 70:19–26.