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Medical Co-Morbidity and Body Ma

Medical Co-Morbidity and Body Mass Index among Psychiatric Inpatients of a Medical College Hospital in Southern India

Rohan Mendonsa,* Safeekh A T,** Neevan D’souza,***  P.John Mathai,****

*Assistant Professor,Department of Psychiatry,Yenepoya Medical College,Mangalore.

**Associate Professor,Department of Psychiatry,Fr Muller Medical College,Mangalore

***Assistant Professor,Department of Community Medicine,Yenepoya Medical College,Mangalore.

****Professor and HOD.Department of Psychiatry,Fr Muller Medical College,Mangalore.

Abstract


Objective: To study the medical comorbidity and to evaluate the association between BMI and other variables including medical co morbidity, psychiatric diagnosis and socio-demographic factors in psychiatric in-patients.

Method: It was a cross-sectional, observational study comprising 78 psychiatric in-patients, recruited through consecutive sampling method.

Results: Significant medical disorders were present in 18 subjects (23%). Only 50% of among these were on regular medication for the medical disorders. Forty percent of patients with bipolar mood disorder and alcohol dependence syndrome had significant medical comorbidity. Diabetes mellitus Type II was the most common medical disorder, followed by essential hypertension. Subjects with diabetes mellitus and hypertension had significantly higher BMI (Mean-25.46,) compared to subjects without these conditions (Mean-20.97), which was statistically significant (P<0.05). Compared to male counterparts, female psychiatric in-patients had higher mean BMI (23.13 Vs 21.67), were more likely to be obese (30% Vs Nil) and to have higher rates of related medical problems (30% Vs 20.7%).

Conclusions: Significantly higher medical co morbidity found in our psychiatric in-patients is comparable to their counterparts from other parts of the world. Female psychiatric in-patients appear to have higher BMI, higher rates of obesity, and higher rates of medical disorders than male patients.


Introduction


Several 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.

Methods

This 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.

A total 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.

Statistics: Continuous variables were studied and compared across groups using mean, standard deviation and student’s t test. Chi-Square analysis was used for categorical grouped data

Tables and Figures

Table I. Comparison of Mean BMI and distribution of male and female psychiatric in-patients into BMI categories

 

Males
 n=58,

Females
n=20

Overall
N=78

Mean BMI (SD)

21.16 ( 3.44)

23.13 (7.02)

21.67 (4.65)

BMI Categories

 

 

 

Underweight
<18.50

10.3%

30%

23.1%

Normal range
18.50-24.99

65.5%

40%

59%

Overweight
≥25

6.9%

30%

18%

Obese
≥30

Nil

30%

7.7%

P<.0005

Table II. Psychiatric diagnoses of the study subjects, BMI and medical disorders

Psychiatric diagnosis (no)

Mean BMI (SD)

Medical comorbidity

Bipolar mood disorder (30)

22.89 (6.21)

Diabetes-8
Hypetension-3
Hyerthyroidism-1

Unspecified Nonorganic Psychosis (17)

20.83 (4.61)

Diabetes-1
Hypertension-1

Alcohol dependence syndrome (12)

21.70 (2.12)

Diabetes-2
Hypertension-2

Schizophrenia (6)

23.08(3.39)

Diabetes-2

Depressive disorder (5)

21.23(3.43)

Nil

Delusional disorder (4)

20.48(3.21)

Nil

Organic mental disorder (3)

18.89 (2.97)

Epilepsy-2

Mental retardation with behavioural problem (1)

15.02 (NA)

Nil

 

Results

Age of 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 status.

Average 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).

Patients 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)

Bipolar 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.

About 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.

Subjects 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.

Discussion

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 psychiatric in-patients.

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 (p<0.0005). Female 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.

There 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).

The high 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.

References

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