Research paperDual burden of chronic physical diseases and anxiety/mood disorders among São Paulo Megacity Mental Health Survey Sample, Brazil
Introduction
As the largest cause of death in the world, chronic physical conditions remain a major global priority (Yach et al., 2004). In 2005, 50% of global burden of disease, or disability-adjusted life years (DALYs), among all ages were attributable to chronic disease (World Health Organization, 2005). Later, in 2012, chronic disease was responsible for 68% (38 million) of total global deaths (World Health Organization, 2014). In 2015, chronic disease caused 71.3% of all global deaths according to the Global Disease Burden study. From 2005–2015, total deaths due to non-communicable disease increased by 14.3% (Collaborators, 2016). According to the World Health Organization (WHO) (2014), 82% of chronic disease deaths occur in low and middle-income countries. Despite this statistic, insufficient resources are allocated to these high-risk locations, making it difficult to combat severe mortality rates.
Chronic physical conditions lead to premature mortality (World Health Organization, 2005; National Center for Chronic Disease Prevention and Health Promotion, 2016) and their comorbidity with mental disorders, such as mood and anxiety disorders (Watch, 2008; Simon, 2001) negatively impacts quality of life. In 2010, the WHO estimated 7.4% of global DALYs estimated were attributable to mental health disorders, and major depressive disorders were responsible for the highest percentage of total global DALYs (2.54%) of any mental and behavioral disorder (Murray et al., 2012). The 2000–2007 World Mental Health (WMH) Survey estimated lifetime anxiety disorders to be the most prevalent mental disorder (25%) (Kessler and Greenberg, 2002). However, as identified by WMH Survey, 76.3–85.4% of serious mental disorder cases in low and middle income countries did not receive any treatment 12 months prior to the survey (Consortium, 2004). There is a clear need to make mental health diagnosis and treatment a priority within these settings (Wang et al., 2016; Campanha et al., 2015; Filho et al., 2013). In Brazil, for example, the 2005 Global Burden of Disease Project estimated mental health burden to be substantial, with neuropsychiatric conditions accounting for 21.5% of DALYs (World Health Organization, 2010). The prevalence of mental health disorders among adults from the São Paulo metropolitan area was higher than other studies within the World Mental Health Initiative in other global megacities (Andrade et al., 2012) Migratory streams from rural areas to the São Paulo urban area and social deprivation has increased social isolation and broken up family ties, having considerable negative consequences on mental health (Andrade et al., 2012). Brazil's population is rapidly aging (Minayo, 2012), increasing the exposure time to chronic disease risk factors and thus impact of chronic disease.
Patients often suffer from chronic physical conditions in tandem with other health issues, making them especially dangerous. Patients with mood and anxiety disorders have increased risk of developing chronic disease, more severe symptoms, heightened economic burden due to disease, and increased risk of mortality when developing disease (Watch, 2008). Previous mental and physical health comorbidity studies are prominently conducted from high-income nations. A nationally representative study in the United States showed higher occurrence of mental disorders among patients from primary care clinics with chronic diseases with an OR of 1.37 (Gili et al., 2010). The study also found an increase in prevalence of mental disorders according to a patient's number of chronic diseases (Gili et al., 2010).
Studies indicate that chronic physical conditions are consistently associated with elevated prevalence of mood disorders, such as depressive disorder (Simon, 2001; Worksite, 2012). This comorbidity may be explained by behavioral limitations on activity due to physical illness, which further restricts an individual from engaging in gratifying activities (Simon, 2001). Depression increases burden of physical chronic illness, as depressed chronic disease patients experienced two times as many missed work days or days with limited activity due to physical illness (Ormel et al., 1994). Depression is also associated with quicker advancement of chronic diseases, such as ischemic heart disease (Glassman, 1998) and diabetes (de Groot et al., 2001).
In addition to mood disorders, anxiety disorders have significant comorbidity with chronic physical conditions (Watch, 2008). Anxiety disorders affect the sympathetic nervous system and result in heart and breath rate increases, muscles tensing, and blood flow being drawn away from abdominal organs towards the brain (Watch, 2008). A Nurses' Health Study found that women with severe phobic anxiety were 59% more likely to have a heart attack and 31% more likely to die from a heart attack (Watch, 2008). Two studies from Harvard Medical School and the Lown Cardiovascular Research Institute found that patients that had ever been diagnosed with an anxiety disorder were twice as likely to have a heart attack compared to those without previous anxiety disorder histories (Watch, 2008). Previous studies have also found associations between anxiety disorders and chronic respiratory disorders (Watch, 2008).
Chronic disease risk factors, such as obesity, tend to be more complex. The association between obesity and depression likely involves multiple pathways of associations (Faith et al. 2002). More longitudinal studies are needed to examine the causal pathways of this association (Faith et al., 2002, Luppino et al., 2010) However, some theories have been established about this relationship. One theory claims that depressed individuals may have inadequate stress systems, or practice unhealthy lifestyle behaviors, increasing their chances of developing obesity (Luppino et al., 2010). A second theory claims that obesity has negative implications on self-efficacy, leading to development of depression over time (Luppino et al., 2010). For example, environmental influences such as adverse childhood experiences encourage the initiation of depression and obesity, and thus, their comorbidity (Stunkard et al., 2003).
Various nationally representative epidemiological studies from the United States, New Zealand, Germany, France, the Netherlands, and Norway have found significant comorbidity of depression/anxiety disorders and obesity among adult populations (Brumpton et al., 2013; Simon et al., 2006a; Barry and Petry, 2009). A New Zealand study found obesity to be significantly associated with any mood disorder (OR: 1.23) and any anxiety disorder (OR: 1.46) (Scott et al., 2008). According to a study on a nationally representative sample of Americans, obesity was associated with a 25% increase in odds of mood and anxiety disorders; thus, differences in this association among demographic sub-populations indicates that social factors may moderate or mediate this association (Simon et al., 2006b).
The São Paulo Megacity study was part of the WMH Surveys Initiative. Among eighteen nationally representative WMH adult population surveys conducted in 17 countries (N=42,249), all physical disorders were associated with depressive and/or anxiety disorders; however, there was substantial variation in the strength of association across countries (ORs 1.2–4.5) (Scott et al., 2007). Literature is scarce on these associations in South America, though one WHO multi-center study conducted in outpatient primary care clinics in Chile found that 66% of Chilean adult patients with a chronic medical condition had coexisting psychiatric diagnoses as compared to 31% in the overall global study group (Fullerton et al., 2000). These associations have yet to be examined among the São Paulo Megacity population. Thus, in this study, we aim to examine the comorbidity of chronic disease/chronic disease risk factors and mood/anxiety disorders.
Section snippets
Sample
The São Paulo Megacity Mental Health Survey was a cross-sectional study of psychiatric morbidity including 5037 residents in the São Paulo metropolitan area of 18 years or older (Viana et al., 2009). The São Paulo metropolitan area is comprised of the state's capital city of São Paulo and its 38 surrounding municipalities, encompassing a total geographic area of 8051 km2 (Carmen Viana et al., 2009, Istica, 2001). Data was collected between May of 2005 and May of 2007. The mean age of the study
Results
Table 1 presents the descriptive analysis of the sample in which 56.6% were female, mean age was 41.5 years, 26.7% had low education levels, 48.0% lived in neighborhoods with high-income inequality (deprivation scale), and 64.5% were married. Table 1 also presents Chi-square measures of association for the comorbidity between any mood/any anxiety disorders and various chronic diseases (diabetes, cancer, respiratory, neurological, chronic pain disorder, arthritis, and cardiovascular disease).
Discussion
The results reveal that comorbidity between mental and physical illness is a widespread phenomenon among residents of the São Paulo megacity area. This study provides the first data on the prevalence of mood/anxiety disorders and associated comorbidity with chronic disease in the adult population living in households within Brazil's most highly populated metropolitan area. Thus, this study may serve as a model of mental and physical comorbidity patterns that might be seen in other megacities
Conclusion
This epidemiological study of comorbidity of any mood/anxiety disorders and chronic disease experienced by adults living in a diverse heterogeneous megacity has presented significant findings that may help refocus health priorities within dynamic Brazilian health systems. The dual burden of chronic diseases and psychiatric disorders in low- and middle-income countries is a pressing issue that health providers and stakeholders should consider. The heavy mental health burden experienced by those
Funding
The São Paulo Megacity Mental Health (SPMH) Survey was funded by the São Paulo Research Foundation, Brazil (FAPESP Grants # 2003/00204-3 and 2011/50517-4). Funding was also provided by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, grant number 14/05363-7). Instrument development was supported by the Foundation for Science and Technology of Vitória, Espírito Santo, Brazil (Fundo de Apoio à Ciência e Tecnologia do Município de Vitória – FACITEC 002/2003). The SPMH Survey is
Competing interests
The authors have read the journal's policy and have the following conflicts: The main coordination center activities, at Harvard University, were supported by the United States National Institutes of Mental Health (R01MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, the Eli Lilly and Company
Acknowledgements
The São Paulo Megacity Mental Health Survey was conducted as part of the World Health Organization World Mental Health (WMH) Survey Initiative. A comprehensive list of WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/.
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Current affiliation is the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene.