EABCT 2002, Maastricht Comorbidity as a challenge for treatment guidelines Frank Jacobi

1. EABCT 2002, Maastricht Comorbidity as a challenge for treatment guidelines Frank Jacobi Jürgen Hoyer Hans-Ulrich Wittchen Dresden University of Technology, Germany Clinical Psychology and Psychotherapy Epidemiology and Health Care Service Research

2. Focus on treatment guidelines in... • Therapies in controlled studies: Methodologic demands in etiologic and psychotherapy research: (“integrity” of tested intervention) • Health care politics: quality control, allocation of treatment funding, cost-benefit calculations • Practitioners: “evidence based” help for diagnosis, (differential) indication, and application (effectiveness and efficiency)

3. Limitations of disorder-specific guidelines and treatment manuals: Comorbidity is a fact (in the “DSM world”) • High comorbidity found in epidemiological studies (high sensitivity of standardized interviews) • High comorbidity seen in clinical settings (comorbidity as a strong risk factor of impairent and helpseeking)

4. Limitations of disorder-specific guidelines and treatment manuals: Comorbidity is a fact (in the “DSM world”) • High comorbidity found in epidemiological studies (high sensitivity of standardized interviews) • High comorbidity seen in clinical settings (comorbidity as a strong risk factor of impairent and helpseeking) • and: substantial association mental vs. somatic disorders (e.g. Hoyer, Jacobi, Höfler & Wittchen, 2002); particular importance in GP and inpatient settings

5. Comorbidity of mental disordersin the general population: Prevalence Cross sectional (12 month) comorbidity very common in many diagnoses (GHS-MHS, N=4181; Jacobi, Wittchen etal., 2002; Jacobi, Wittchen et al., submitted): • Comorbidity by subjects: 40% with a DSM-IV mental disorder received more than one, and 10% more than three diagnoses • Comorbidity by disorders: ranging from 44% (alcohol abuse/dependence) to 94% (GAD); mean: 66%

6. Comorbidity of mental disordersin the general population: Prevalence Cross sectional (12 month) comorbidity very common in many diagnoses (GHS-MHS; Jacobi, Wittchen et al., submitted): • Comorbidity by subjects: 40% with a DSM-IV mental disorder received more than one, and 10% more than three diagnoses • Comorbidity by disorders: ranging from 46% (alcohol dependence) to 94% (GAD); mean: 66% #grafik • Even more comorbidity when taking into account lifetime and subthreshold diagnoses (+ interpersonal problems, Axis II disorders etc.)

7. comorbidity mood disorders: 39%-82% comorbidity anxiety disorders: 38%-94% comorbidity substance disorders: 41%-83% comorbidity somatoform disorders: 39%-75%

8. Comorbidity of mental disordersin the general population: Correlates 1. Sociodemographic variables: no therapeutic heuristics • Females 15% more disorders (if at least one disorder) than males • Low social class (Winkler-Index) 25% more disorders (if at least one disorder) than high social class 2. Comorbidity as a predictor for impairment and health care utilization • Highly comorbid (>3 disorders) 15x more impairment days due to mental health problems than in “pure” cases • 75% of highly comorbid (>3 disorders) have received at least minimal health care intervention due to mental health problems vs. 30% of the “pure” cases

9. Comorbidity of mental disordersin the general population: Correlates 3. Associations mental and somatic health • Highly comorbid (>3 disorders) elevated risk to have poor somatic health status compared to “pure” cases (OR=4.1; 95%ci: 2.2-7.7) • Subjects with somatic conditions had 80% more mental comorbidity than physically healthy subjects 4. Specific comorbidity patterns: elevated risk of developing secondary mental disorders • Example: Anxiety and depressive disorders

10. Cumulative hazard rate for (comorbid) anxiety and depressive disorders (NCS data) Anxiety % age

11. Cumulative hazard rate for (comorbid) anxiety and depressive disorders (NCS data) Anxiety MDD-total % age

12. Cumulative hazard rate for (comorbid) anxiety and depressive disorders (NCS data) Anxiety MDD-total % MDD-pure/primary age

13. Disorder specific manuals: Do they ever fit? Sceptical conclusions • It doesn´t make sense to use disorder-specific manuals if I never see a “pure” patient • Comorbidity is too complex to be include into decision making • Variety of comorbidity patterns underline that patients are individuals and therefore shouldn´t be treated standardized • and: Reservation towards manuals designed by scientists (“Lack of external validity in controlled studies”)

14. Optimistic conclusions:Strenghts of evidence based heuristics • Manuals that contain information about comorbidity can be helpful in generating hypotheses about concrete patients • Even in highly comorbid patients at least parts/modules of manuals can be applied • Prevention of negative therapy outcome

15. Using manuals in clinical practice: How to deal with comorbidity • Pure diagnosis: use manual • Comorbidity of “similar” conditions: use rational of manual(s) • Comorbidity of “dissimilar” conditions: • rationals different but not incompatible: consecutive use of respective manuals (e.g. primary first) • rationals incompatible: decision for one of the conflicting rationals in order to at least reduce comorbidity, or completely nonmanualized case formulation • “diffuse” multimorbidity or unclear interpersonal problems: don´t use manuals

16. Using manuals in clinical practice: Examples for “comorbidity rules” • Don´t neglect (lifetime) comorbidity assessment and prediction • Comorbidity is a risk factor of impairment and further negative development ( measure for severity) • Knowledge about risk factors should have consequences for prognosis even when potential secondary condition not currently present • Even “non-severe” comorbid conditions (e.g. panic attack without diagnosis of panic disorder, specific phobia) can be vulnerability markers for future problems • Treat primary anxiety disorders first (Caveat: Exceptions; e.g. substance related disorders, severe depression) • Assess comorbidity systematically as a check for counter- indication of certain manual interventions (e.g. suicidality, psychosis)

17. Developing empirically based guidelines for comorbidity treatment • Identification of common/significant comorbidity patterns that potentially conflict with disorder specific manualized treatment • Test of epidemiologically found possibly significant comorbidity patterns in clinical treatment datasets • Refinement of diagnostic features in disorder specific manuals with differential suggestions for interventions (e.g. severity/amount of comorbidity, functional vs. interpersonal, personality/Axis II features, course, primary vs. secondary etc.)

18. Developing empirically based guidelines: General perspectives • Developing guidelines for the management of common/significant comorbid conditions • Developing process guidelines in addition to disorder-specific manualized techniques • Caspar (1997): “What goes on in a psychotherapist´s mind?”: How to teach “intuition vs. cook-book” in comorbid cases • Lutz (2002): “Patient focused psychotherapy research”: Taking comorbidity-process-interactions into account when predicting treatment outcome

19. Developing empirically based guidelines: General perspectives • Consensus on “good” guidelines possible? • “Guidelines on guideline development” • Local adaptations but not idiosyncratic manuals for every country or profession • manualizing goals rather than techniques • Still a long way to go: The fine line between simplifying vs. being sophisticated • e.g. some psychiatric guidelines: ”first line=SSRI, second line=adding CBT” very vague • determined by empirical base, practical application, politics, scientific community...