Somatopsychic comorbidities occur frequently

For Prof. Hans Christoph Friedrich somatopsychic comorbidities are common. They lead to increased morbidity and mortality, especially in cardiometabolic and pulmonary diseases.

Tackling physical illness with psychotherapy 

As Prof. Hans Christoph Friedrich, (Department of Psychosomatic and General Clinical Medicine, Heidelberg University Hospital / Klinik für Psychosomatische und Allgemeine Klinische Medizin, Universitätsklinikum Heidelberg), made clear at the DGIM Congress, somatopsychic comorbidities occur frequently. They lead to increased morbidity and mortality, especially in cardiometabolic and pulmonary diseases.

Somatopsychic comorbidity occurs when patients have somatic diseases and mental disorders. As Prof. Hans Christoph Friedrich made clear at the German Society for Internal Medicine (DGIM) digital congress, somatopsychic comorbidities occur frequently and to increased morbidity and mortality, especially in cardiometabolic diseases and lung diseases. The interactions are complex: early programming through childhood trauma (maltreatment, abuse, neglect) increases disease vulnerability for both mental and physical illnesses.

Prof. Friedrich emphasised that psychotherapy is effective for comorbid mental disorders in physically ill patients. However, it should always take health behaviour into account and promote the patient's self-management.

What can psychotherapy achieve?

The price to pay due to bad behavioural practices related to health is high. And it has a direct effect in lost years of life. As some examples, Prof. Dr. Holger Köllner, Department of Behavioural Therapy and Psychosomatics at the Rehazentrum Seehof in Teltow/Berlin reminded us that heavy smoking has an even higher influence than high alcohol consumption, obesity, high meat consumption and too few fruits and vegetables. But how can patients be motivated to change their health behaviour?

According to Prof. Köllner, education and information should initially dominate: "Why is it important that I change my health behaviour now?" It is good if the patient has several decision options, e.g. medication, weight reduction, dietary changes or more exercise to lower blood pressure. It is also important that it is not the physician who decides, but that the patient is asked to decide. A good physician-patient relationship leads to better adherence and effectiveness of a given medication.

Prof. Köllner reminded us that it is what is said, not what is heard, that has the greatest effect on behaviour. If the physician constantly argues for change, he pushes the patient into the opposite position (a sort of "yes, but..." trap). An alternative is to get the patient to provide the arguments for the specific necessary change. A motivational interview can make an important contribution to this.

The motivational interview and its 5Rs: a“quitting smoking” example

Prof. Köllner reported that adverse life events in childhood and adolescence (sexual and violent abuse, severe neglect, addiction of a parent...) are strong predictors of type 2 diabetes, coronary heart disease (CHD), obesity, COPD, bronchial carcinoma, serious accidents and other behavioural diseases in adulthood. The strongest mediating factor is health behaviour. If little care was experienced in childhood and adolescence, it is difficult to develop a self-caring approach to oneself as an adult.

Comorbid depression significantly increases mortality in diabetes and CHD

Depression, along with anxiety disorders, is one of the most common mental illnesses. Comorbid depression significantly increases mortality, e.g. in CHD and type 2 diabetes. Depressed patients have significantly worse chances of quitting smoking, losing weight or starting exercise (due to the illness-related lack of drive). Therefore, it is important to treat an existing depression and then make a second attempt to change the health behaviour.

Hypochondria and generalised anxiety disorder are particularly relevant for adherence. Behaviour is controlled by an imminent danger (such as the side effects printed on a cigarette package) and not an event in the distant future (stroke). Fear leads to avoidance and to closing one's eyes to the disease. Again, treating the anxiety disorder can make the path to adherence much easier.

Post-traumatic stress disorder (PTSD) related to the disease is also associated with significantly increased mortality after heart or lung transplantation or after an Implantable cardioverter-defibrillator (ICD) implantation. A major cause is adherence problems due to avoidance behaviour. Everything that can remind people of the disease is avoided, e.g. heart palpitations during sporting activity. In addition, dysfunctional health behaviours (nicotine, alcohol) are used to cope with stress. With trauma confrontation and Eye Movement Desensitization and Reprocessing (EMDR) therapy, highly effective evidence-based treatment strategies are available.

Recommendations for improving medication adherence

A therapy is only as effective as the patient's adherence to it or taking the medication. And that is exactly what is often wrong. How can drug adherence be improved? Between 6% and 28% of primary care prescriptions are not filled at the pharmacy. Which interventions can improve medication adherence? A meta-analysis in JAMA (Kini V et al. JAMA, 2018;320(23) examined 48 studies in this regard and shows that three interventions are suitable for this purpose:

127th Annual Conference of the German Society for Internal Medicine e.V. (DGIM), Session: Psychosomatics in a nutshell, 19 April 2021

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