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EDITORIAL |
Department of Psychiatry, University of California, San Diego 9500 Gilman Drive La Jolla, CA 92093-0804
"When sorrows come, they come not single spies, but in battalions!"—William Shakespeare, Hamlet, act IV, scene V
King Claudius utters these lines to the Queen after beholding Ophelia raving mad. As usual Shakespeare has it right. Two lines earlier the King attributes Ophelia’s madness to "the poison of deep grief," namely Polonius’ murder, Hamlet’s flight, and the disorder in the realm. The reverberations of sorrow permeate the play. One scene later we receive the news of Ophelia’s suicide, and three scenes later we are staggered by a crescendo of four deaths (the Queen, Laertes, the King, and Hamlet), all within one page. Talk about battalions of sorrows!
This issue of Psychosomatic Medicine does not tell such tragic tales, but it contains a special section of articles that address the phenomenon of "battalions of illness" that follow in the wake of distress. Although it is esthetically satisfying to diagnose one disease that accounts for all the patient’s signs and symptoms, frequently one disease sets in play vulnerabilities to battalions of other diseases (eg, hypertension leading to renal failure). Increasingly we are coming to recognize that psychiatric illnesses carry in their wake not just emotional suffering but also a host of other medical illnesses. Although the mechanisms for such links are uncertain, their existence is increasingly recognized. The study of such links has come to be known as research on "comorbidity," and this area is a natural topic for psychosomatic research.
This issue includes eight articles dealing with the comorbidity between depression and anxiety on one hand and illnesses such as myocardial infarction and stroke on the other. The bulk of the articles relate to cardiovascular disease, but the approaches taken are vastly different.
Using data from a union-sponsored hypertension control program, Cohen et al. (1) found that a history of treatment for depression was significantly related to development of subsequent myocardial infarction during a 5-year follow-up interval. Lane et al. (2) examined the potential impact of symptoms of depression and anxiety on mortality and quality of life in patients hospitalized for myocardial infarction. Anxiety and depressive symptoms did not presage mortality in a 2-year follow-up; however, these symptoms at the time of myocardial infarction were strongly predictive of patients’ quality of life during the follow-up interval. The comorbidity links between depression and cardiovascular disease also pertain to stroke. Ostir et al. (3) found that increasing scores on a self-rated depression scale were prospectively related to the incidence of stroke over a 6-year follow-up interval. Cossette et al. (4) studied the ability of a therapeutic intervention to reduce psychological distress and improve cardiac prognosis in a series of post–myocardial infarction patients.
Sullivan et al. (5) examined how potential mediators and moderators, such as symptoms of angina, personality style, and social support, affect the links between depression and self-reported physical health. Godemann et al. (6) chose a slightly different tack, studying how an invasive cardiovascular intervention was related to subsequent emotional functioning. The investigators found that >15% of patients developed an anxiety disorder after receiving an implantable defibrillator.
Comorbidity is of course not confined to the cardiovascular system. A large Dutch study by Neeleman et al. (7) examined how personality variables were linked to various medical disorders. The authors reported that "multiple morbidities" are indeed surprisingly common and not attributable to disorder-specific risks but rather to generic factors such as levels of neuroticism. Finally, Cole-King and Harding (8) examined in fine detail the effects of depression and anxiety on wound healing. The succinct message: Wound healing was slower in individuals with high scores on depression and anxiety inventories.
Comorbidity studies embody the recognition that psychological distress carries with it additional medical perils (and vice versa). This recognition comes at a good time for the field of psychosomatic medicine. Recent observers of psychiatry would have to conclude from an analysis of psychiatric textbooks and diagnostic nomenclature that psychosomatic medicine is no longer at the "core" of psychiatry. That core has shifted to emphasize diagnostic reliability (D), neuroscience (N), and psychopharmacology (P). The DNP approach has, of course, had many benefits, including strengthening the legitimacy of mental health services, but DNP has not been an unmixed mixed blessing because it gives psychotherapy less emphasis and it marginalizes research that is not tightly linked to standard clinical practice and the DNP emphasis.
The clinical arm of psychosomatic medicine is usually found in consultation psychiatry and behavioral medicine settings, a locale where axis I diagnoses according to DSM-IV are murky at best. The "basic research" embodiment of psychosomatic medicine is typically found in studies of the physiology of emotional arousal or in epidemiological studies of various emotional symptoms and illnesses. What has been relatively missing in psychosomatic research has been an examination of the effects of axis I disorders per se on other medical illnesses. This sort of focus links the clinician, the physiologist, and the epidemiologist and joins them with the DNP advocates. When such linkages are established, psychosomatic research is immeasurably enriched.
Because of the comorbidity approach, psychosomatic connections are increasingly being recognized as palpably real, with demonstrable physiology and epidemiology and logical clinical interventions. As a result, psychosomatic medicine is returning to the mainstream of medical research. It is no accident that in recent years our pages have included editorials by the director of the National Heart, Lung, and Blood Institute (9) and the former director of the National Institutes of Mental Health (10). Psychosomatic medicine is increasingly seen as a research discipline that offers an invaluable set of clinical and research skills connecting psychiatry, psychology, medicine, physiology, and epidemiology. We have read our Shakespeare. Indeed, there is a toll of emotional suffering: Whole battalions of other illnesses follow in the wake of anguish.
REFERENCES
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