Mood disorder

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Mood_disorder 

 

Mood disorder
Other names	mental disorder
A depressive man standing by a country pond in the pouring rain
Specialty	Psychiatry
Types	Bipolar disorder, cyclothymia, disruptive mood dysregulation disorder, dysthymia, major depressive disorder, premenstrual dysphoric disorder, seasonal affective disorder
Causes	Family history, previous diagnosis of a mood disorder, trauma, stress or major life changes in the case of depression, physical illness or use of certain medications. Depression has been linked to major diseases such as cancer, diabetes, Parkinson’s disease and heart disease, Brain structure and function in the case of bipolar disorder.
Medication	Antidepressants, mood stabilizers, antipsychotics

A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Mood disorders fall into seven groups, including; abnormally elevated mood, such as mania or hypomania; depressed mood, of which the best-known and most researched is major depressive disorder (MDD) (alternatively known as clinical depression, unipolar depression, or major depression); and moods which cycle between mania and depression, known as bipolar disorder (BD) (formerly known as manic depression). There are several sub-types of depressive disorders or psychiatric syndromes featuring less severe symptoms such as dysthymic disorder (similar to MDD, but longer lasting and more persistent, though often milder) and cyclothymic disorder (similar to but milder than BD).

In some cases, more than one mood disorder can be present in an individual, like bipolar disorder and depressive disorder. If a mood disorder and schizophrenia are both present in an individual, this is known as schizoaffective disorder. Mood disorders may also be substance induced, or occur in response to a medical condition.

English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.

Classification

Depressive disorders

• Major depressive disorder (MDD), commonly called major depression, unipolar depression, or clinical depression, wherein a person has one or more major depressive episodes. After a single episode, Major Depressive Disorder (single episode) would be diagnosed. After more than one episode, the diagnosis becomes Major Depressive Disorder (Recurrent). Depression without periods of mania is sometimes referred to as unipolar depression because the mood remains at the bottom "pole" and does not climb to the higher, manic "pole" as in bipolar disorder.

Individuals with a major depressive episode or major depressive disorder are at increased risk for suicide. Seeking help and treatment from a health professional dramatically reduces the individual's risk for suicide. Studies have demonstrated that asking if a depressed friend or family member has thought of committing suicide is an effective way of identifying those at risk, and it does not "plant" the idea or increase an individual's risk for suicide in any way. Epidemiological studies carried out in Europe suggest that, at this moment, roughly 8.5 percent of the world's population have a depressive disorder. No age group seems to be exempt from depression, and studies have found that depression appears in infants as young as 6 months old who have been separated from their mothers.

• Depressive disorder is frequent in primary care and general hospital practice but is often undetected. Unrecognized depressive disorder may slow recovery and worsen prognosis in physical illness, therefore it is important that all doctors be able to recognize the condition, treat the less severe cases, and identify those requiring specialist care.

Diagnosticians recognize several subtypes or course specifiers:

• Atypical depression (AD) is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite ("comfort eating"), excessive sleep or somnolence (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection. Difficulties in measuring this subtype have led to questions of its validity and prevalence.

• Melancholic depression is characterized by a loss of pleasure (anhedonia) in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.

• Psychotic major depression (PMD), or simply psychotic depression, is the term for a major depressive episode, in particular of melancholic nature, wherein the patient experiences psychotic symptoms such as delusions or, less commonly, hallucinations. These are most commonly mood-congruent (content coincident with depressive themes).

• Catatonic depression is a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here, the person is mute and almost stuporous, and either is immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms can also occur in schizophrenia or a manic episode, or can be due to neuroleptic malignant syndrome.

• Postpartum depression (PPD) is listed as a course specifier in DSM-IV-TR; it refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which affects 10–15% of women, typically sets in within three months of labor, and lasts as long as three months. It is quite common for women to experience a short-term feeling of tiredness and sadness in the first few weeks after giving birth; however, postpartum depression is different because it can cause significant hardship and impaired functioning at home, work, or school as well as, possibly, difficulty in relationships with family members, spouses, or friends, or even problems bonding with the newborn. In the treatment of postpartum major depressive disorders and other unipolar depressions in women who are breastfeeding, nortriptyline, paroxetine (Paxil), and sertraline (Zoloft) are in general considered to be the preferred medications. Women with personal or family histories of mood disorders are at particularly high risk of developing postpartum depression.

• Premenstrual dysphoric disorder (PMDD) is a severe and disabling form of premenstrual syndrome affecting 3–8% of menstruating women. The disorder consists of a "cluster of affective, behavioral and somatic symptoms" that recur monthly during the luteal phase of the menstrual cycle. PMDD was added to the list of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders in 2013. The exact pathogenesis of the disorder is still unclear and is an active research topic. Treatment of PMDD relies largely on antidepressants that modulate serotonin levels in the brain via serotonin reuptake inhibitors as well as ovulation suppression using contraception.

• Seasonal affective disorder (SAD), also known as "winter depression" or "winter blues", is a specifier. Some people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and resolving in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times over a two-year period or longer. It is commonly hypothesised that people who live at higher latitudes tend to have less sunlight exposure in the winter and therefore experience higher rates of SAD, but the epidemiological support for this proposition is not strong (and latitude is not the only determinant of the amount of sunlight reaching the eyes in winter). It is said that this disorder can be treated by light therapy. SAD is also more prevalent in people who are younger and typically affects more females than males.

• Dysthymia is a condition related to unipolar depression, where the same physical and cognitive problems are evident, but they are not as severe and tend to last longer (usually at least 2 years). The treatment of dysthymia is largely the same as for major depression, including antidepressant medications and psychotherapy.

• Double depression can be defined as a fairly depressed mood (dysthymia) that lasts for at least two years and is punctuated by periods of major depression.

• Unspecified Depressive Disorder is designated by the code 311 for depressive disorders. In the DSM-5, Unspecified Depressive Disorder encompasses symptoms that are characteristic of depressive disorders and cause significant impairment in functioning, but do not meet the criteria for the diagnosis of any specified depressive disorders. In the DSM-IV, this was called Depressive Disorder Not Otherwise Specified.

• Depressive personality disorder (DPD) is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features. Originally included in the DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R. Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study.

• Recurrent brief depression (RBD), distinguished from major depressive disorder primarily by differences in duration. People with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 2–3 days. Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of the menstrual cycle. People with clinical depression can develop RBD, and vice versa and both illnesses have similar risks.

• Minor depressive disorder, or simply minor depression, which refers to a depression that does not meet full criteria for major depression but in which at least two symptoms are present for two weeks.

Bipolar disorders

• Bipolar disorder (BD) (also called "manic depression" or "manic-depressive disorder"), an unstable emotional condition characterized by cycles of abnormal, persistent high mood (mania) and low mood (depression), which was formerly known as "manic depression" (and in some cases rapid cycling, mixed states, and psychotic symptoms). Subtypes include:

• Bipolar I is distinguished by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes. A depressive episode is not required for the diagnosis of Bipolar I Disorder, but depressive episodes are usually part of the course of the illness.
• Bipolar II consisting of recurrent intermittent hypomanic and depressive episodes or mixed episodes.
• Cyclothymia is a form of bipolar disorder, consisting of recurrent hypomanic and dysthymic episodes, but no full manic episodes or full major depressive episodes.
• Bipolar disorder not otherwise specified (BD-NOS), sometimes called "sub-threshold" bipolar, indicates that the patient has some symptoms in the bipolar spectrum (e.g., manic and depressive symptoms) but does not fully qualify for any of the three formal bipolar DSM-IV diagnoses mentioned above.

It is estimated that roughly 1% of the adult population has bipolar I, a further 1% has bipolar II or cyclothymia, and somewhere between 2% and 5% percent have "sub-threshold" forms of bipolar disorder. Furthermore, the possibility of getting bipolar disorder when one parent is diagnosed with it is 15–30%. Risk, when both parents have it, is 50–75%. Also, while with bipolar siblings the risk is 15–25%, with identical twins it is about 70%.

Substance-induced

A mood disorder can be classified as substance-induced if its etiology can be traced to the direct physiologic effects of a psychoactive drug or other chemical substance, or if the development of the mood disorder occurred contemporaneously with substance intoxication or withdrawal. Also, an individual may have a mood disorder coexisting with a substance abuse disorder. Substance-induced mood disorders can have features of a manic, hypomanic, mixed, or depressive episode. Most substances can induce a variety of mood disorders. For example, stimulants such as amphetamine, methamphetamine, and cocaine can cause manic, hypomanic, mixed, and depressive episodes.

Alcohol-induced

High rates of major depressive disorder occur in heavy drinkers and those with alcoholism. Controversy has previously surrounded whether those who abused alcohol and developed depression were self-medicating their pre-existing depression. Recent research has concluded that, while this may be true in some cases, alcohol misuse directly causes the development of depression in a significant number of heavy drinkers. Participants studied were also assessed during stressful events in their lives and measured on a Feeling Bad Scale. Likewise, they were also assessed on their affiliation with deviant peers, unemployment, and their partner's substance use and criminal offending. High rates of suicide also occur in those who have alcohol-related problems. It is usually possible to differentiate between alcohol-related depression and depression that is not related to alcohol intake by taking a careful history of the patient. Depression and other mental health problems associated with alcohol misuse may be due to distortion of brain chemistry, as they tend to improve on their own after a period of abstinence.

Benzodiazepine-induced

Benzodiazepines, such as alprazolam, clonazepam, lorazepam and diazepam, can cause both depression and mania.

Benzodiazepines are a class of medication commonly used to treat anxiety, panic attacks and insomnia, and are also commonly misused and abused. Those with anxiety, panic and sleep problems commonly have negative emotions and thoughts, depression, suicidal ideations, and often have comorbid depressive disorders. While the anxiolytic and hypnotic effects of benzodiazepines may disappear as tolerance develops, depression and impulsivity with high suicidal risk commonly persist. These symptoms are "often interpreted as an exacerbation or as a natural evolution of previous disorders and the chronic use of sedatives is overlooked". Benzodiazepines do not prevent the development of depression, can exacerbate preexisting depression, can cause depression in those with no history of it, and can lead to suicide attempts. Risk factors for suicide and suicide attempts while using benzodiazepines include high dose prescriptions (even in those not misusing the medications), benzodiazepine intoxication, and underlying depression.

The long-term use of benzodiazepines may have a similar effect on the brain as alcohol, and are also implicated in depression. As with alcohol, the effects of benzodiazepine on neurochemistry, such as decreased levels of serotonin and norepinephrine, are believed to be responsible for the increased depression. Additionally, benzodiazepines can indirectly worsen mood by worsening sleep (i.e., benzodiazepine-induced sleep disorder). Like alcohol, benzodiazepines can put people to sleep but, while asleep, they disrupt sleep architecture: decreasing sleep time, delaying time to REM sleep, and decreasing deep sleep (the most restorative part of sleep for both energy and mood). Just as some antidepressants can cause or worsen anxiety in some patients due to being activating, benzodiazepines can cause or worsen depression due to being a central nervous system depressant—worsening thinking, concentration and problem solving (i.e., benzodiazepine-induced neurocognitive disorder). However, unlike antidepressants, in which the activating effects usually improve with continued treatment, benzodiazepine-induced depression is unlikely to improve until after stopping the medication.

In a long-term follow-up study of patients dependent on benzodiazepines, it was found that 10 people (20%) had taken drug overdoses while on chronic benzodiazepine medication despite only two people ever having had any pre-existing depressive disorder. A year after a gradual withdrawal program, no patients had taken any further overdoses.

Just as with intoxication and chronic use, benzodiazepine withdrawal can also cause depression. While benzodiazepine-induced depressive disorder may be exacerbated immediately after discontinuation of benzodiazepines, evidence suggests that mood significantly improves after the acute withdrawal period to levels better than during use. Depression resulting from withdrawal from benzodiazepines usually subsides after a few months but in some cases may persist for 6–12 months.

Due to another medical condition

"Mood disorder due to a general medical condition" is used to describe manic or depressive episodes which occur secondary to a medical condition. There are many medical conditions that can trigger mood episodes, including neurological disorders (e.g. dementias), hearing loss and associated disorders (e.g. tinnitus or hyperacusis), metabolic disorders (e.g. electrolyte disturbances), gastrointestinal diseases (e.g. cirrhosis), endocrine disease (e.g. thyroid abnormalities), cardiovascular disease (e.g. heart attack), pulmonary disease (e.g. chronic obstructive pulmonary disease), cancer, and autoimmune diseases (e.g. multiple sclerosis). Pregnancy

Not otherwise specified

See also: DSM-IV codes

Mood disorder not otherwise specified (MD-NOS) is a mood disorder that is impairing but does not fit in with any of the other officially specified diagnoses. In the DSM-IV MD-NOS is described as "any mood disorder that does not meet the criteria for a specific disorder." MD-NOS is not used as a clinical description but as a statistical concept for filing purposes. The diagnosis of MD-NOS does not exist in the DSM-5, however the diagnoses of unspecified depressive disorder and unspecified bipolar disorder are in the DSM-5.

Most cases of MD-NOS represent hybrids between mood and anxiety disorders, such as mixed anxiety-depressive disorder or atypical depression. An example of an instance of MD-NOS is being in minor depression frequently during various intervals, such as once every month or once in three days. There is a risk for MD-NOS not to get noticed, and for that reason not to get treated.

Causes

Meta-analyses show that high scores on the personality domain neuroticism are a strong predictor for the development of mood disorders. A number of authors have also suggested that mood disorders are an evolutionary adaptation (see also evolutionary psychiatry). A low or depressed mood can increase an individual's ability to cope with situations in which the effort to pursue a major goal could result in danger, loss, or wasted effort. In such situations, low motivation may give an advantage by inhibiting certain actions. This theory helps to explain why negative life incidents precede depression in around 80 percent of cases, and why they so often strike people during their peak reproductive years. These characteristics would be difficult to understand if depression were a dysfunction.

A depressed mood is a predictable response to certain types of life occurrences, such as loss of status, divorce, or death of a child or spouse. These are events that signal a loss of reproductive ability or potential, or that did so in humans' ancestral environment. A depressed mood can be seen as an adaptive response, in the sense that it causes an individual to turn away from the earlier (and reproductively unsuccessful) modes of behavior.

A depressed mood is common during illnesses, such as influenza. It has been argued that this is an evolved mechanism that assists the individual in recovering by limiting their physical activity. The occurrence of low-level depression during the winter months, or seasonal affective disorder, may have been adaptive in the past, by limiting physical activity at times when food was scarce. It is argued that humans have retained the instinct to experience low mood during the winter months, even if the availability of food is no longer determined by the weather.

Much of what is known about the genetic influence of clinical depression is based upon research that has been done with identical twins. Identical twins have exactly the same genetic code. It has been found that when one identical twin becomes depressed the other will also develop clinical depression approximately 76% of the time. When identical twins are raised apart from each other, they will both become depressed about 67% of the time. Because both twins become depressed at such a high rate, the implication is that there is a strong genetic influence. If it happened that when one twin becomes clinically depressed the other always develops depression, then clinical depression would likely be entirely genetic.

Bipolar disorder is also considered a mood disorder and it is hypothesized that it might be caused by mitochondrial dysfunction.

Sex differences

Mood disorders, specifically stress-related mood disorders such as anxiety and depression, have been shown to have differing rates of diagnosis based on sex. In the United States, women are two times more likely than men to be diagnosed with a stress-related mood disorder. Underlying these sex differences, studies have shown a dysregulation of stress-responsive neuroendocrine function causing an increase in the likelihood of developing these affective disorders. Overactivation of the hypothalamic-pituitary-adrenal (HPA) axis could provide potential insight into how these sex differences arise. Neuropeptide corticotropin-releasing factor (CRF) is released from the paraventricular nucleus (PVN) of the hypothalamus, stimulating adrenocorticotropic hormone (ACTH) release into the blood stream. From here ACTH triggers the release of glucocorticoids such as cortisol from the adrenal cortex. Cortisol, known as the main stress hormone, creates a negative feedback loop back to the hypothalamus to deactivate the stress response. When a constant stressor is present, the HPA axis remains overactivated and cortisol is constantly produced. This chronic stress is associated with sustained CRF release, resulting in the increased production of anxiety- and depressive-like behaviors and serving as a potential mechanism for differences in prevalence between men and women.

Diagnosis

DSM-5

The DSM-5, released in May 2013, separates the mood disorder chapter from the DSM-TR-IV into two sections: Depressive and related disorders and bipolar and related disorders. Bipolar disorders fall in between depressive disorders and schizophrenia spectrum and related disorders "in recognition of their place as a bridge between the two diagnostic classes in terms of symptomatology, family history and genetics" (Ref. 1, p 123). Bipolar disorders underwent a few changes in the DSM-5, most notably the addition of more specific symptomology related to hypomanic and mixed manic states. Depressive disorders underwent the most changes, the addition of three new disorders: disruptive mood dysregulation disorder, persistent depressive disorder (previously dysthymia), and premenstrual dysphoric disorder (previously in appendix B, the section for disorders needing further research). Disruptive mood dysregulation disorder is meant as a diagnosis for children and adolescents who would normally be diagnosed with bipolar disorder as a way to limit the bipolar diagnosis in this age cohort. Major depressive disorder (MDD) also underwent a notable change, in that the bereavement clause has been removed. Those previously exempt from a diagnosis of MDD due to bereavement are now candidates for the MDD diagnosis.

Treatment

There are different types of treatments available for mood disorders, such as therapy and medications. Behaviour therapy, cognitive behaviour therapy and interpersonal therapy have all shown to be potentially beneficial in depression. Major depressive disorder medications usually include antidepressants; a combination of antidepressants and cognitive behavioral therapy has shown to be more effective than one treatment alone. Bipolar disorder medications can consist of antipsychotics, mood stabilizers, anticonvulsants and/or lithium. Lithium specifically has been proven to reduce suicide and all causes of mortality in people with mood disorders. If mitochondrial dysfunction or mitochondrial diseases are the cause of mood disorders like bipolar disorder, then it has been hypothesized that N-acetyl-cysteine (NAC), acetyl-L-carnitine (ALCAR), S-adenosylmethionine (SAMe), coenzyme Q10 (CoQ10), alpha-lipoic acid (ALA), creatine monohydrate (CM), and melatonin could be potential treatment options. In determining treatment, there are many types of depression scales that are used. One of the depression scales is a self-report scale called Beck Depression Inventory (BDI). Another scale is the Hamilton Depression Rating Scale (HAMD). HAMD is a clinical rating scale in which the patient is rated based on clinician observation. The Center for Epidemiologic Studies Depression Scale (CES-D) is a scale for depression symptoms that applies to the general population. This scale is typically used in research and not for self-reports. The PHQ-9 which stands for Patient-Health Questionnaire-9 questions, is a self-report as well. Finally, the Mood Disorder Questionnaire (MDQ) evaluates bipolar disorder.

Epidemiology

According to a substantial number of epidemiology studies conducted, women are twice as likely to develop certain mood disorders, such as major depression. Although there is an equal number of men and women diagnosed with bipolar II disorder, women have a slightly higher frequency of the disorder.

In 2011, mood disorders were the most common reason for hospitalization among children aged 1–17 years in the United States, with approximately 112,000 stays. Mood disorders were top principal diagnosis for Medicaid super-utilizers in the United States in 2012. Further, a study of 18 states found that mood disorders accounted for the highest number of hospital readmissions among Medicaid patients and the uninsured, with 41,600 Medicaid patients and 12,200 uninsured patients being readmitted within 30 days of their index stay—a readmission rate of 19.8 per 100 admissions and 12.7 per 100 admissions, respectively. In 2012, mood and other behavioral health disorders were the most common diagnoses for Medicaid-covered and uninsured hospital stays in the United States (6.1% of Medicaid stays and 5.2% of uninsured stays).

A study conducted in 1988 to 1994 amongst young American adults involved a selection of demographic and health characteristics. A population-based sample of 8,602 men and women ages 17–39 years participated. Lifetime prevalence were estimated based on six mood measures:

• major depressive episode (MDE) 8.6%,
• major depressive disorder with severity (MDE-s) 7.7%,
• dysthymia 6.2%,
• MDE-s with dysthymia 3.4%,
• any bipolar disorder 1.6%, and
• any mood disorder 11.5%.

Research

Kay Redfield Jamison and others have explored the possible links between mood disorders – especially bipolar disorder – and creativity. It has been proposed that a "ruminating personality type may contribute to both [mood disorders] and art."

Jane Collingwood notes an Oregon State University study that:

looked at the occupational status of a large group of typical patients and found that 'those with bipolar illness appear to be disproportionately concentrated in the most creative occupational category.' They also found that the likelihood of 'engaging in creative activities on the job' is significantly higher for bipolar than nonbipolar workers.

In Liz Paterek's article "Bipolar Disorder and the Creative Mind" she wrote:

Memory and creativity are related to mania. Clinical studies have shown that those in a manic state will rhyme, find synonyms, and use alliteration more than controls. This mental fluidity could contribute to an increase in creativity. Moreover, mania creates increases in productivity and energy. Those in a manic state are more emotionally sensitive and show less inhibition about attitudes, which could create greater expression. Studies performed at Harvard looked into the amount of original thinking in solving creative tasks. Bipolar individuals, whose disorder was not severe, tended to show greater degrees of creativity.

The relationship between depression and creativity appears to be especially strong among poets.

Campaigns against corporal punishment

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Campaigns_against_corporal_punishment 

Legal status of corporal punishment of children as of 2019:

  Illegal

  Legal (at least partially)

Campaigns against corporal punishment aim to reduce or eliminate corporal punishment of minors by instigating legal and cultural changes in the areas where such punishments are practiced. Such campaigns date mostly from the late 20th century, although occasional voices in opposition to corporal punishment existed from ancient times through to the modern era.

The UN Committee on the Rights of the Child defines "corporal punishment" as:

any punishment in which physical force is used and intended to cause some degree of pain or discomfort, however light. Most involves hitting ("smacking", "slapping", "spanking") children, with the hand or with an implement – whip, stick, belt, shoe, wooden spoon, etc. But it can also involve, for example, kicking, shaking or throwing children, scratching, pinching, biting, pulling hair or boxing ears, forcing children to stay in uncomfortable positions, burning, scalding or forced ingestion.

History

See also: Corporal punishment § History

Quintilian and Plutarch, both writing in the 1st century A.D., expressed the opinion that corporal punishment was demeaning to those who were not slaves, meaning the children of the freeborn. In contrast, according to the classicist Otto Kiefer, Seneca remarked to his friend Lucilius, "Fear and love cannot live together. You seem to me to do right in refusing to be feared by your slaves and chastising them with words alone. Blows are used to correct brute beasts".

However, according to Robert McCole Wilson, "it is only in the last two hundred years that there has been a growing body of opinion" opposed to corporal punishment.

Australia

Jordan Riak began working against corporal punishment when he was residing with his children in Sydney, Australia. Corporal punishment was eventually banned in the public schools of all Australian states, and the private schools of all states except Queensland.

United Kingdom

In the United Kingdom, one of the earliest organised campaigns was that of the Humanitarian League, with its regular magazine The Humanitarian, which campaigned for several years for the abolition of the chastisement of young seamen in the Royal Navy, a goal partially achieved in 1906 when naval birching was abandoned as a summary punishment. However, it did not manage to get the Navy to abolish caning as a punishment, which continued at Naval training establishments until 1967.

The Howard League for Penal Reform campaigned in the 1930s for, among many other things, the abolition of judicial corporal punishment by cat-o'-nine-tails or birching. This was eventually achieved in the U.K. in 1948.

The Society of Teachers Opposed to Physical Punishment (STOPP) was set up in the U.K. in 1968 to campaign for the abolition of corporal punishment in UK schools.

STOPP was a very small pressure group that lobbied government, local authorities and other official institutions. It also investigated individual cases of corporal punishment and aided families wishing to pursue their cases through the UK and European courts.

The UK Parliament abolished corporal punishment in state schools in 1986. STOPP then wound itself up and ceased to exist, though some of the same individuals went on to form EPOCH to campaign to outlaw spanking, and spanking in the domestic setting.

A campaign by the name of Children Are Unbeatable! involves more than 350 separate groups, including the National Society for the Prevention of Cruelty to Children, Barnardo's, Save the Children, Action for Children (formerly NCH), and the National Children's Bureau.

Canada

In CFCYL v. Canada, the Supreme Court of Canada upheld section 43 of the Criminal Code, which allows for a defence of reasonable use of force by way of correction towards children.

United States

An early U.S. activist against corporal punishment was Horace Mann, who in the 19th century unsuccessfully opposed its use in schools.

Several organizations have been formed in the United States to advocate abolishing corporal punishment in homes and/or schools, including:

• Parents and Teachers Against Violence in Education (PTAVE), based in California
• The Center for Effective Discipline, now part of the Gundersen National Child Protection Training Center (NCPTC) of Winona (MN) State University
• The U.S. Alliance to End the Hitting of Children
• People Opposed to Paddling Students (POPS), based in Texas
• Floridians Against Corporal Punishment in Public School, based in Florida
• The Alliance Against Corporal Punishment
• The National Youth Rights Association
• We the Children Foundation

Individuals who have directly advocated against corporal punishment include, but are not limited to:

• Kirstie Alley (born 1955), Actress - has stated her opposition to corporal punishment on numerous occasions, most notably on the Howard Stern Show
• Nadine Block, wrote the bill which banned corporal punishment from public schools in Ohio in 2009
• Blythe and David Daniel, Professors - advocate and teach children's rights and work for laws against corporal punishment
• Blake Hutchison (born 1980), writer of Nobody's Property, independent filmmaker and videographer from Ohio who has made several often-controversial children's rights and anti-spanking videos on his YouTube channel. including one titled "Children's Rights Pyrotechnic Practice" where he sets fire to a copy of Michael and Debi Pearl's highly controversial book To Train Up A Child (a book which he says is a "training" book to assault kids).
• Horace Mann, campaigned to ban corporal punishment from schools during the 19th century
• Dr. Phil McGraw (born 1950), Television Show Host has had episodes on his show dedicated to showing the harm and/or ineffectiveness of corporal punishment.
• Marcus Lawrence Ward (1812–1884), governor of New Jersey from 1866 to 1869, who signed into law the public and private school corporal punishment ban during his time in office, which is still in effect today.
• Jordan Riak (1935–2016), drafted the bill which banned corporal punishment from public schools in California in the 1980s
• Daniel Vander Ley (born 1982), using the BeatYourChildren.com campaign and the "Fundamentalism - America's Premier Child Abuse Brand" campaign, Vander Ley communicates directly with governments around the world offering their constituents research about the negative effects of corporal punishment and religious extremism.

Worldwide

An organisation called "Global Initiative To End All Corporal Punishment Of Children" was formed in 2001 to campaign for the worldwide prohibition by law of all corporal punishment of children, in homes, schools, penal institutions, and other settings. It seeks to monitor the legal situation in every country of the world. The Global Initiative has received endorsement from UNICEF, UNESCO, the United Nations High Commissioner for Human Rights, the Commissioner for Human Rights of the Council of Europe, the Parliamentary Assembly of the Council of Europe, and the European Network of Ombudsmen for Children.

In 2008, the UN Study on Violence against Children set a target date of 2009 for universal prohibition, including in the home, an aim described by The Economist the same year as "wildly unrealistic".

The Society for Prevention of Injuries & Corporal Punishment [SPIC] is an Indian organization advocating measures to stop corporal punishment in schools by making teachers and students aware of its dangers.

In Austria the White Hand Campaign for a worldwide legal ban on child corporal punishment tries to raise awareness for the topic in the German-speaking countries.

Comorbidity

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Comorbidity

In medicine, comorbidity—from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together)—is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary condition. Comorbidity describes the effect of all other conditions an individual patient might have other than the primary condition of interest, and can be physiological or psychological. In the context of mental health, comorbidity often refers to disorders that are often coexistent with each other, such as depression and anxiety disorders. The concept of multimorbidity is related to comorbidity but presents a different meaning and approach.

Definition

The term "comorbid" has three definitions:

1. to indicate a medical condition existing simultaneously but independently with another condition in a patient.
2. to indicate a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient.
3. to indicate two or more medical conditions existing simultaneously regardless of their causal relationship.

Comorbidity can indicate either a condition existing simultaneously, but independently with another condition or a related derivative medical condition. The latter sense of the term causes some overlap with the concept of complications. For example, in longstanding diabetes mellitus, the extent to which coronary artery disease is an independent comorbidity versus a diabetic complication is not easy to measure, because both diseases are quite multivariate and there are likely aspects of both simultaneity and consequence. The same is true of intercurrent diseases in pregnancy. In other examples, the true independence or relation is not ascertainable because syndromes and associations are often identified long before pathogenetic commonalities are confirmed (and, in some examples, before they are even hypothesized). In psychiatric diagnoses it has been argued in part that this "'use of imprecise language may lead to correspondingly imprecise thinking', [and] this usage of the term 'comorbidity' should probably be avoided." However, in many medical examples, such as comorbid diabetes mellitus and coronary artery disease, it makes little difference which word is used, as long as the medical complexity is duly recognized and addressed.

Difference from multimorbidity

Comorbidity is often referred to as multimorbidity even though the two are considered distinct clinical scenarios.

Comorbidity means that one 'index' condition is the focus of attention, and others are viewed in relation to this. In contrast, multimorbidity describes someone having two or more long-term (chronic) conditions without any of them holding priority over the others. This distinction is important in how the healthcare system treats people and helps making clear the specific settings in which the use of one or the other term can be preferred. Multimorbidity offers a more general and person-centered concept that allows focusing on all of the patient's symptoms and providing a more holistic care. In other settings, for example in pharmaceutical research, comorbidity might often be the more useful term to use.

Mental health

In psychiatry, psychology, and mental health counseling, comorbidity refers to the presence of more than one diagnosis occurring in an individual at the same time. However, in psychiatric classification, comorbidity does not necessarily imply the presence of multiple diseases, but instead can reflect current inability to supply a single diagnosis accounting for all symptoms. On the DSM Axis I, major depressive disorder is a very common comorbid disorder. The Axis II personality disorders are often criticized because their comorbidity rates are excessively high, approaching 60% in some cases. Critics^[who?] assert this indicates these categories of mental illness are too imprecisely distinguished to be usefully valid for diagnostic purposes, impacting treatment and resource allocation. Symptom overlap is a key component against DSM classification and serves as a note towards redefining criteria in disorders that the root cause may not be understood thoroughly. Regardless of criticisms, it stands that, annually, up to 45% of mental health patients fit the criteria for a comorbid diagnosis. A comorbid diagnosis is associated with more severe symptomatic expression and greater chance of dismal prognosis. Certain diagnoses such as ADHD, autism, OCD, and mood disorders have higher rates of co-occurring or being prevalent in separate diagnoses. "Comorbidity in OCD is the rule rather than the exception" with OCD diagnoses facing a lifetime rate of 90%. With overlapping symptoms comes overlap in treatment as well, CBT for example is common for both ADHD and OCD with pediatric onset and can be effective for both in a comorbid diagnosis. OCD and eating disorders have a high rate of occurrence, it is estimated that 20-60% of patients with an eating disorder have OCD. More often, comorbidity complicates and can prevent treatment efficacy on a varying scale depending on the circumstances.

The term 'comorbidity' was introduced in medicine by Feinstein (1970) to describe cases in which a 'distinct additional clinical entity' occurred before or during treatment for the 'index disease', the original or primary diagnosis. Since the terms were coined, meta studies have shown that criteria used to determine the index disease were flawed and subjective, and moreover, trying to identify an index disease as the cause of the others can be counterproductive to understanding and treating interdependent conditions. In response, 'multimorbidity' was introduced to describe concurrent conditions without relativity to or implied dependency on another disease, so that the complex interactions to emerge naturally under analysis of the system as a whole.

Although the term 'comorbidity' has recently become very fashionable in psychiatry, its use to indicate the concomitance of two or more psychiatric diagnoses is said to be incorrect because in most cases it is unclear whether the concomitant diagnoses actually reflect the presence of distinct clinical entities or refer to multiple manifestations of a single clinical entity. It has been argued that because "'the use of imprecise language may lead to correspondingly imprecise thinking', this usage of the term 'comorbidity' should probably be avoided".

Due to its artifactual nature, psychiatric comorbidity has been considered as a Kuhnian anomaly leading the DSM to a scientific crisis and a comprehensive review on the matter considers comorbidity as an epistemological challenge to modern psychiatry. The Hierarchical Taxonomy of Psychopathology is a leading alternative classification system that addresses these concerns about comorbidity.

History

Widespread study of physical and mental pathology found its place in psychiatry. I. Jensen (1975), J.H. Boyd (1984), W.C. Sanderson (1990), Yuri Nuller (1993), D.L. Robins (1994), A. B. Smulevich (1997), C.R. Cloninger (2002) and other psychiatrists discovered a number of comorbid conditions in those with psychiatric disorders.

The influence of comorbidity on the clinical progression of the primary (basic) physical disorder, effectiveness of the medicinal therapy and immediate and long-term prognosis of the patients was researched by physicians and scientists of various medical fields in many countries across the globe. These scientists and physicians included: M. H. Kaplan (1974), T. Pincus (1986), M. E. Charlson (1987), F. G. Schellevis (1993), H. C. Kraemer (1995), M. van den Akker (1996), A. Grimby (1997), S. Greenfield (1999), M. Fortin (2004) & A. Vanasse (2004), C. Hudon (2005), L. B. Lazebnik (2005), A. L. Vertkin (2008), G. E. Caughey (2008), F. I. Belyalov (2009), L. A. Luchikhin (2010) and many others.

Inception of the term

Many centuries ago the doctors propagated the viability of a complex approach in the diagnosis of disease and the treatment of the patient, however, modern medicine, which boasts a wide range of diagnostic methods and a variety of therapeutic procedures, stresses specification. This brought up a question: How to wholly evaluate the state of a patient who has a number of diseases simultaneously, where to start from and which disease(s) require(s) primary and subsequent treatment? For many years this question stood out unanswered, until 1970, when a renowned American doctor epidemiologist and researcher, A.R. Feinstein, who had greatly influenced the methods of clinical diagnosis and particularly methods used in the field of clinical epidemiology, came out with the term of "comorbidity". The appearance of comorbidity was demonstrated by Feinstein using the example of patients physically affected by rheumatic fever, discovering the worst state of the patients, who simultaneously had multiple diseases. In due course of time after its discovery, comorbidity was distinguished as a separate scientific-research discipline in many branches of medicine.

Evolution of the term

Presently there is no agreed-upon terminology of comorbidity. Some authors bring forward different meanings of comorbidity and multi-morbidity, defining the former, as the presence of a number of diseases in a patient, connected to each other through proven pathogenetic mechanisms and the latter, as the presence of a number of diseases in a patient, not having any connection to each other through any of the proven to date pathogenetic mechanisms. Others affirm that multi-morbidity is the combination of a number of chronic or acute diseases and clinical symptoms in a person and do not stress the similarities or differences in their pathogenesis. However the principle clarification of the term was given by H. C. Kraemer and M. van den Akker, determining comorbidity as the combination in a patient of 2 or more chronic diseases (disorders), pathogenetically related to each other or coexisting in a single patient independent of each disease's activity in the patient.

Synonyms

• Polymorbidity
• Multifactorial diseases
• Polypathy
• Dual diagnosis, used for mental health issues
• Pluralpathology

Epidemiology

Comorbidity is widespread among the patients admitted at multidiscipline hospitals. During the phase of initial medical help, the patients having multiple diseases simultaneously are a norm rather than an exception. Prevention and treatment of chronic diseases declared by the World Health Organization, as a priority project for the second decade of the 20th century, are meant to better the quality of the global population. This is the reason for an overall tendency of large-scale epidemiological researches in different medical fields, carried-out using serious statistical data. In most of the carried-out, randomized, clinical researches the authors study patients with single refined pathology, making comorbidity an exclusive criterion. This is why it is hard to relate researches, directed towards the evaluation of the combination of ones or the other separate disorders, to works regarding the sole research of comorbidity. The absence of a single scientific approach to the evaluation of comorbidity leads to omissions in clinical practice. It is hard not to notice the absence of comorbidity in the taxonomy (systematics) of disease, presented in ICD-10.

Clinico-pathological comparisons

All the fundamental researches of medical documentation, directed towards the study of the spread of comorbidity and influence of its structure, were conducted until the 1990s. The sources of information, used by the researchers and scientists, working on the matter of comorbidity, were case histories, hospital records of patients and other medical documentation, kept by family doctors, insurance companies and even in the archives of patients in old houses.

The listed methods of obtaining medical information are mainly based on clinical experience and qualification of the physicians, carrying out clinically, instrumentally and laboratorially confirmed diagnosis. This is why despite their competence, they are highly subjective. No analysis of the results of postmortem of deceased patients was carried out for any of the comorbidity researches.

"It is the duty of the doctor to carry out autopsy of the patients they treat", said once professor M. Y. Mudrov. Autopsy allows you to exactly determine the structure of comorbidity and the direct cause of death of each patient independent of his/her age, gender and gender specific characteristics. Statistical data of comorbid pathology, based on these sections, are mainly devoid of subjectivism.

Research

The analysis of a decade long Australian research based on the study of patients having 6 widespread chronic diseases demonstrated that nearly half of the elderly patients with arthritis also had hypertension, 20% had cardiac disorders and 14% had type 2 diabetes. More than 60% of asthmatic patients complained of concurrent arthritis, 20% complained of cardiac problems and 16% had type 2 diabetes.

In patients with chronic kidney disease (renal insufficiency) the frequency of coronary heart disease is 22% higher and new coronary events 3.4 times higher compared to patients without kidney function disorders. Progression of CKD towards end stage renal disease requiring renal replacement therapy is accompanied by increasing prevalence of Coronary Heart Disease and sudden death from cardiac arrest.

A Canadian research conducted upon 483 obesity patients, it was determined that spread of obesity related accompanying diseases was higher among females than males. The researchers discovered that nearly 75% of obesity patients had accompanying diseases, which mostly included dyslipidemia, hypertension and type 2 diabetes. Among the young obesity patients (from 18 to 29) more than two chronic diseases were found in 22% males and 43% females.

Fibromyalgia is a condition which is comorbid with several others, including but not limited to; depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, rheumatoid arthritis, migraine, and panic disorder.

The number of comorbid diseases increases with age. Comorbidity increases by 10% in ages up to 19 years, up to 80% in people of ages 80 and older. According to data by M. Fortin, based on the analysis of 980 case histories, taken from daily practice of a family doctor, the spread of comorbidity is from 69% in young patients, up to 93% among middle aged people and up to 98% patients of older age groups. At the same time the number of chronic diseases varies from 2.8 in young patients and 6.4 among older patients.

According to Russian data, based on the study of more than three thousand postmortem reports (n=3239) of patients of physical pathologies, admitted at multidisciplinary hospitals for the treatment of chronic disorders (average age 67.8 ± 11.6 years), the frequency of comorbidity is 94.2%. Doctors mostly come across a combination of two to three disorders, but in rare cases (up to 2.7%) a single patient carried a combination of 6–8 diseases simultaneously.

The fourteen-year research conducted on 883 patients of idiopathic thrombocytopenic purpura (Werlhof disease), conducted in Great Britain, shows that the given disease is related to a wide range of physical pathologies. In the comorbid structure of these patients, most frequently present are malignant neoplasms, locomotorium disorders, skin and genitourinary system disorders, as well as haemorrhagic complications and other autoimmune diseases, the risk of whose progression during the first five years of the primary disease exceeds the limit of 5%.

In a research conducted on 196 larynx cancer patients, it was determined that the survival rate of patients at various stages of cancer differs depending upon the presence or absence of comorbidity. At the first stage of cancer the survival rate in the presence of comorbidity is 17% and in its absence it is 83%, in the second stage of cancer the rate of survivability is 14% and 76%, in the third stage it is 28% and 66% and in the fourth stage of cancer it is 0% and 50% respectively. Overall the survivability rate of comorbid larynx cancer patients is 59% lower than the survivability rate of patients without comorbidity.

Except for therapists and general physicians, the problem of comorbidity is also often faced by specialists. Regretfully they seldom pay attention to the coexistence of a whole range of disorders in a single patient and mostly conduct the treatment of specific to their specialization diseases. In current practice urologists, gynecologists, ENT specialists, eye specialists, surgeons and other specialists all too often mention only the diseases related to "own" field of specialization, passing on the discovery of other accompanying pathologies "under the control" of other specialists. It has become an unspoken rule for any specialized department to carry out consultations of the therapist, who feels obliged to carry out symptomatic analysis of the patient, as well as to the form the diagnostic and therapeutic concept, taking in view the potential risks for the patient and his long-term prognosis.

Based on the available clinical and scientific data it is possible to conclude that comorbidity has a range of undoubted properties, which characterize it as a heterogeneous and often encountered event, which enhances the seriousness of the condition and worsens the patient's prospects. The heterogeneous character of comorbidity is due to the wide range of reasons causing it.

Causes

• Anatomic proximity of diseased organs
• Singular pathogenetic mechanism of a number of diseases
• Terminable cause-effect relation between the diseases
• One disease resulting from complications of another
• Pleiotropy

The factors responsible for the development of comorbidity can be chronic infections, inflammations, involutional and systematic metabolic changes, iatrogenesis, social status, ecology and genetic susceptibility.

Types

• Trans-syndromal comorbidity: coexistence, in a single patient, of two and/or more syndromes, pathogenetically related to each other.
• Trans-nosological comorbidity: coexistence, in a single patient, of two and/or more syndromes, pathogenetically not related to each other.

The division of comorbidity as per syndromal and nosological principles is mainly preliminary and inaccurate, however it allows us to understand that comorbidity can be connected to a singular cause or common mechanisms of pathogenesis of the conditions, which sometimes explains the similarity in their clinical aspects, which makes it difficult to differentiate between nosologies.

• Etiological comorbidity: It is caused by concurrent damage to different organs and systems, which is caused by a singular pathological agent (for example due to alcoholism in patients with chronic alcohol intoxication; pathologies associated with smoking; systematic damage due to collagenoses).
• Complicated comorbidity: It is the result of the primary disease and often subsequent after sometime after its destabilization appears in the shape of target lesions (for example chronic nephratony resulting from diabetic nephropathy (Kimmelstiel-Wilson disease) in patients with type 2 diabetes; development of brain infarction resulting from complications due to hypertensive crisis in patients with hypertension).
• Iatrogenic comorbidity: It appears as a result of necessitated negative effect of the doctor on the patient, under the conditions of pre determine danger of one or the other medical procedure (for example, glucocorticosteroid osteoporosis in patients treated for a long time using systematic hormonal agents (preparations); drug-induced hepatitis resulting from chemotherapy against TB, prescribed due to the conversion of tubercular tests).
• Unspecified (NOS) comorbidity: This type assumes the presence of singular pathogenetic mechanisms of development of diseases, comprising this combination, but require a number of tests, proving the hypothesis of the researcher or physician (for example, erectile dysfunction as an early sign of general atherosclerosis (ASVD); occurrence of erosive-ulcerative lesions in the mucous membrane of the upper gastrointestinal tract in "vascular" patients).
• "Arbitrary" comorbidity: initial alogism of the combination of diseases is not proven, but soon can be explained with clinical and scientific point of view (for example, combination of coronary heart disease (CHD) and choledocholithiasis; combination of acquired heart valvular disease and psoriasis).

Structure

There are a number of rules for the formulation of clinical diagnosis for comorbid patients, which must be followed by a practitioner. The main principle is to distinguish in diagnosis the primary and background diseases, as well as their complications and accompanying pathologies.

• Primary disease: This is the nosological form, which itself or as a result of complications calls for the foremost necessity for treatment at the time due to threat to the patient's life and danger of disability. Primary is the disease, which becomes the cause of seeking medical help or the reason for the patient's death. If the patient has several primary diseases it is important to first of all understand the combined primary diseases (rival or concomitant).
• Rival diseases: These are the concurrent nosological forms in a patient, interdependent in etiologies and pathogenesis, but equally sharing the criterion of a primary disease (for example, transmural myocardial infarction and massive thromboembolism of pulmonary artery, caused by phlebemphraxis of lower limbs). For practicing pathologist rival are two or more diseases, exhibited in a single patient, each of which by itself or through its complications could cause the patient's death.
• Polypathia: Diseases with different etiologies and pathogenesis, each of which separately could not cause death, but, concurring during development and reciprocally exacerbating each other, they cause the patient's death (for example, osteoporotic fracture of the surgical neck of the femur and hypostatic pneumonia).
• Background disease: This helps in the occurrence of or adverse development of the primary disease increases its dangers and helps in the development of complications. This disease as well as the primary one requires immediate treatment (for example, type 2 diabetes).
• Complications: Nosologies having pathogenetic relation to the primary disease, supporting the adverse progression of the disorder, causing acute worsening of the patient's conditions (are a part of the complicated comorbidity). In a number of cases the complications of the primary disease and related to it etiological and pathogenetic factors, are indicated as conjugated disease. In this case they must be identified as the cause of comorbidity. Complications are listed in a descending order of prognostic or disabling significance.
• Associating diseases: Nosological units not connected etiologically and pathogenetically with the primary disease (Listed in the order of significance).

Diagnosis

Many tests attempt to standardize the "weight" or value of comorbid conditions, whether they are secondary or tertiary illnesses. Each test attempts to consolidate each individual comorbid condition into a single, predictive variable that measures mortality or other outcomes. Researchers have validated such tests because of their predictive value, but no one test is as yet recognized as a standard.

Charlson Comorbidity Index (CCI)

Main article: Charlson Comorbidity Index

The Charlson Comorbidity Index predicts the mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 17 conditions). Each condition is assigned a score of 1, 2, 3, or 6, depending on the risk of dying associated with each one. Scores are summed to provide a total score to predict mortality. Many variations of the Charlson comorbidity index have been presented, including the Charlson/Deyo, Charlson/Romano, Charlson/Manitoba, and Charlson/D'Hoores comorbidity indices.

For a physician, this score is helpful in deciding how aggressively to treat a condition. For example, a patient may have cancer with comorbid heart disease and diabetes. These comorbidities may be so severe that the costs and risks of cancer treatment would outweigh its short-term benefit.

Since patients often do not know how severe their conditions are, nurses were originally supposed to review a patient's chart and determine whether a particular condition was present in order to calculate the index. Subsequent studies have adapted the comorbidity index into a questionnaire for patients.

The Charlson index, especially the Charlson/Deyo, followed by the Elixhauser have been most commonly referred by the comparative studies of comorbidity and multimorbidity measures.

Comorbidity–Polypharmacy Score (CPS)

Main article: Comorbidity–polypharmacy score

The comorbidity–polypharmacy score (CPS) is a simple measure that consists of the sum of all known comorbid conditions and all associated medications. There is no specific matching between comorbid conditions and corresponding medications. Instead, the number of medications is assumed to be a reflection of the "intensity" of the associated comorbid conditions. This score has been tested and validated extensively in the trauma population, demonstrating good correlation with mortality, morbidity, triage, and hospital readmissions. Of interest, increasing levels of CPS were associated with significantly lower 90-day survival in the original study of the score in trauma population.

Elixhauser Comorbidity Index

Main article: Elixhauser Comorbidity Index

The Elixhauser comorbidity measure was developed using administrative data from a statewide California inpatient database from all non-federal inpatient community hospital stays in California (n = 1,779,167). The Elixhauser comorbidity measure developed a list of 30 comorbidities relying on the ICD-9-CM coding manual. The comorbidities were not simplified as an index because each comorbidity affected outcomes (length of hospital stay, hospital changes, and mortality) differently among different patients groups. The comorbidities identified by the Elixhauser comorbidity measure are significantly associated with in-hospital mortality and include both acute and chronic conditions. van Walraven et al. have derived and validated an Elixhauser comorbidity index that summarizes disease burden and can discriminate for in-hospital mortality. In addition, a systematic review and comparative analysis shows that among various comorbidities indices, Elixhauser index is a better predictor of the risk especially beyond 30 days of hospitalization.

Diagnosis-related group

Patients who are more seriously ill tend to require more hospital resources than patients who are less seriously ill, even though they are admitted to the hospital for the same reason. Recognizing this, the diagnosis-related group (DRG) manually splits certain DRGs based on the presence of secondary diagnoses for specific complications or comorbidities (CC). The same applies to Healthcare Resource Groups (HRGs) in the UK.

Clinical example of evaluation

Patient S., 73 years, called an ambulance because of a sudden pressing pain in the chest. It was known from the case history that the patient had CHD for many years. Such chest pains were experienced by her earlier as well, but they always disappeared after a few minutes of sublingual administration of organic nitrates. This time taking three tablets of nitroglycerine did not kill the pain. It was also known from the case history that the patient had twice had myocardial infarctions during the last ten years, as well as had an Acute Cerebrovascular Event with sinistral hemiplegia more than 15 years ago. Apart from that the patient had hypertension, type 2 diabetes with diabetic nephropathy, hysteromyoma, cholelithiasis, osteoporosis and varicose pedi-vein disease. It was also learned that the patient regularly takes a number of antihypertensive drugs, urinatives and oral antihyperglycemic remedies, as well as statins, antiplatelet and nootropics. In the past the patient had undergone cholecystectomy due to cholelithiasis more than 20 years ago, as well as the extraction of a cataract of the right eye 4 years ago. The patient was admitted to cardiac intensive care unit at a general hospital diagnosed for acute transmural myocardial infarction. During the check-up moderate azotemia, mild erythronormoblastic anemia, proteinuria and lowering of left vascular ejection fraction were also identified.

Methods of evaluation

There are currently several generally accepted methods of evaluating (measuring) comorbidity:

1. Cumulative Illness Rating Scale (CIRS): Developed in 1968 by B. S. Linn, it became a revolutionary discovery, because it gave the practicing doctors a chance to calculate the number and severity of chronic illnesses in the structure of the comorbid state of their patients. The proper use of CIRS means separate cumulative evaluation of each of the biological systems: "0" The selected system corresponds to the absence of disorders, "1": Slight (mild) abnormalities or previously had disorders, "2": Illness requiring the prescription of medicinal therapy, "3": Disease, which caused disability and "4": Acute organ insufficiency requiring emergency therapy. The CIRS system evaluates comorbidity in cumulative score, which can be from 0 to 56. As per its developers, the maximum score is not compatible with the patient's life.
2. Cumulative Illness Rating Scale for Geriatrics (CIRS-G): This system is similar to CIRS, but for aged patients, offered by M. D. Miller in 1991. This system takes into account the age of the patient and the peculiarities of the old age disorders.
3. The Kaplan–Feinstein Index: This index was created in 1973 based on the study of the effect of the associated diseases on patients with type 2 diabetes during a period of 5 years. In this system of comorbidity evaluation all the present (in a patient) diseases and their complications, depending on the level of their damaging effect on body organs, are classified as mild, moderate and severe. In this case the conclusion about cumulative comorbidity is drawn on the basis of the most decompensated biological system. This index gives cumulative, but less detailed as compared to CIRS, assessment of the condition of each of the biological systems: "0": Absence of disease, "1": Mild course of the disease, "2": Moderate disease, "3": Severe disease. The Kaplan–Feinstein Index evaluates comorbidity by cumulative score, which can vary from 0 to 36. Apart from that the notable deficiency of this method of evaluating comorbidity is the excessive generalization of diseases (nosologies) and the absence of a large number of illnesses in the scale, which, probably, should be noted in the "miscellaneous" column, which undermines (decreases) this method's objectivity and productivity of this method. However the indisputable advantage of the Kaplan–Feinstein Index as compared to CIRS is in the capability of independent analysis of malignant neoplasms and their severities. Using this method patient S's, age 73, comorbidity can be evaluated as of moderate severity (16 out of 36 points), however its prognostic value is unclear, because of the absence of the interpretation of the overall score, resulting from the accumulation of the patient's diseases.
4. Charlson Index: This index is meant for the long-term prognosis of comorbid patients and was developed by M. E. Charlson in 1987. This index is based on a point scoring system (from 0 to 40) for the presence of specific associated diseases and is used for prognosis of lethality. For its calculation the points are accumulated, according to associated diseases, as well as the addition of a single point for each 10 years of age for patients of ages above forty years (in 50 years 1 point, 60 years 2 points etc.). The distinguishing feature and undisputed advantage of the Charlson Index is the capability of evaluating the patient's age and determination of the patient's mortality rate, which in the absence of comorbidity is 12%, at 1–2 points it is 26%; at 3–4 points it is 52% and with the accumulation of more than 5 points it is 85%. Regretfully this method has some deficiencies: Evaluating comorbidity severity of many diseases is not considered, as well as the absence of many important for prognosis disorders. Apart from that it is doubtful that possible prognosis for a patient with bronchial asthma and chronic leukemia is comparable to the prognosis for the patient ailing from myocardial infarction and cerebral infarction. In this case comorbidity of patient S, 73 years of age according to this method, is equivalent to mild state (9 out of 40 points).
5. Modified Charlson Index: R. A. Deyo, D. C. Cherkin, and Marcia Ciol added chronic forms of ischemic cardiac disorder and the stages of chronic cardiac insufficiency to this index in 1992.
6. Elixhauser Index: The Elixhauser comorbidity measure include 30 comorbidities, which are not simplified as an index. Elixhauser shows a better predictive performance for mortality risk especially beyond 30 days of hospitalization.
7. Index of Co-Existent Disease (ICED): This Index was first developed in 1993 by S. Greenfield to evaluate comorbidity in patients with malignant neoplasms, later it also became useful for other categories of patients. This method helps in calculating the duration of a patient's stay at a hospital and the risks of repeated admittance of the same at a hospital after going through surgical procedures. For the evaluation of comorbidity the ICED index suggests to evaluate the patient's condition separately as per two different components: Physiological functional characteristics. The first component comprises 19 associated disorders, each of which is assessed on a 4-point scale, where "0" indicates the absence of disease and "3" indicates the disease's severe form. The second component evaluates the effect of associated diseases on the physical condition of the patient. It assesses 11 physical functions using a 3-point scale, where "0" means normal functionality and "2" means the impossibility of functionality.
8. Geriatric Index of Comorbidity (GIC): Developed in 2002
9. Functional Comorbidity Index (FCI): Developed in 2005.
10. Total Illness Burden Index (TIBI): Developed in 2007.

Analyzing the comorbid state of patient S, 73 years of age, using the most used international comorbidity assessment scales, a doctor would come across totally different evaluation. The uncertainty of these results would somewhat complicate the doctors judgment about the factual level of severity of the patient's condition and would complicate the process of prescribing rational medicinal therapy for the identified disorders. Such problems are faced by doctors on everyday basis, despite all their knowledge about medical science. The main hurdle in the way of inducting comorbidity evaluation systems in broad based diagnostic-therapeutic process is their inconsistency and narrow focus. Despite the variety of methods of evaluation of comorbidity, the absence of a singular generally accepted method, devoid of the deficiencies of the available methods of its evaluation, causes disturbance. The absence of a unified instrument, developed on the basis of colossal international experience, as well as the methodology of its use does not allow comorbidity to become doctor "friendly". At the same time due to the inconsistency in approach to the analysis of comorbid state and absence of components of comorbidity in medical university courses, the practitioner is unclear about its prognostic effect, which makes the generally available systems of associated pathology evaluation unreasoned and therefore un-needed as well.

Treatment of comorbid patient

The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patient-specific. The interrelation of the disease, age and drug pathomorphism greatly affect the clinical presentation and progress of the primary nosology, character and severity of the complications, worsens the patient's life quality and limit or make difficult the remedial-diagnostic process. Comorbidity affects life prognosis and increases the chances of fatality. The presence of comorbid disorders increases bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures, and increases the chances of decline in aged people.

The presence of comorbidity must be taken into account when selecting the algorithm of diagnosis and treatment plans for any given disease. It is important to enquire comorbid patients about the level of functional disorders and anatomic status of all the identified nosological forms (diseases). Whenever a new, as well as mildly notable symptom appears, it is necessary to conduct a deep examination to uncover its causes. It is also necessary to be remembered that comorbidity leads to polypragmasy (polypharmacy), i.e. simultaneous prescription of a large number of medicines, which renders impossible the control over the effectiveness of the therapy, increases monetary expenses and therefore reduces compliance. At the same time, polypragmasy, especially in aged patients, renders possible the sudden development of local and systematic, unwanted medicinal side-effects. These side-effects are not always considered by the doctors, because they are considered as the appearance of comorbidity and as a result become the reason for the prescription of even more drugs, sealing-in the vicious circle. Simultaneous treatment of multiple disorders requires strict consideration of compatibility of drugs and detailed adherence of rules of rational drug therapy, based on E. M. Tareev's principles, which state: "Each non-indicated drug is contraindicated" and B. E. Votchal said: "If the drug does not have any side-effects, one must think if there is any effect at all".

A study of inpatient hospital data in the United States in 2011 showed that the presence of a major complication or comorbidity was associated with a great risk of intensive-care unit utilization, ranging from a negligible change for acute myocardial infarction with major complication or comorbidity to nearly nine times more likely for a major joint replacement with major complication or comorbidity.