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Comorbidity definition in mental health

Comorbidity definition in mental health

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What can I do to prevent this in the future?If you are on a personal connection, haelth at home, you can run an anti-virus scan on your device to make sure it is not infected with malware.If you are at an office or shared network, you can ask the network administrator to run a scan across the network looking for misconfigured or infected devices. In medicine, comorbidity is the presence of one or more additional diseases or disorders co-occurring with (that is, concomitant or concurrent with) a primary disease or disorder; in jental countable sense of the term, a comorbidity (plural comorbidities) is each additional disorder or comorbisity.

The additional disorder may be a behavioral or mental disorder.The term can indicate either a condition existing simultaneously but independently with another condition or a related 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." [1] 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. Contents� 1 In medicine� 1.1 Charlson index� 1.2 Comorbidity-Polypharmacy Score (CPS)� 1.3 Elixhauser comorbidity measure� 1.4 Diagnosis-related group� 2 Mental health� 3 Inception of the term� 3.1 Evolution domorbidity the term� 4 Research� 4.1 Psychiatry� 4.2 General medicine� 5 Synonyms� 6 Epidemiology� 6.1 Clinico-pathological comparisons� 6.2 Research� 7 Causes� 8 Types� 9 Structure� 10 Diagnosis� 10.1 Clinical co,orbidity 10.2 Methods of evaluation� 10.3 Models� 11 Treatment of comorbid patient� 12 See also� comorbidity definition in mental health References� 14 External links� 15 Further readingIn medicine [ edit ]In medicine, comorbidity describes the effect of all other diseases an individual patient might have other than the primary disease of interest.Many tests attempt to standardize the "weight" or value of comorbid conditions, healfh 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.The term "comorbid" has three definitions:� to indicate a medical condition existing simultaneously but independently with another condition in a patient (this is the older and more "correct" definition)� to indicate a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient (this is a newer, nonstandard definition and less well-accepted).

[2]� to indicate two or more medical conditions existing simultaneously regardless of their causal relationship. [3]Charlson index [ edit ]The Charlson comorbidity index [4] predicts the one-year mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions).

Each condition is assigned mentla score of 1, 2, xomorbidity, or 6, depending on the risk of dying associated with each ih. 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 Healthh comorbidity indices.Clinical conditions and associated scores are as follows:� 1 each: Myocardial infarct, congestive heart failure, peripheral vascular disease, dementia, cerebrovascular disease, chronic lung disease, connective tissue disease, ulcer, chronic liver disease, diabetes.� 2 each: Hemiplegia, moderate or severe kidney disease, diabetes with end organ damage, tumor, leukemia, lymphoma.� 3 each: Moderate or severe liver disease.� 6 each: Malignant tumor, metastasis, AIDS.For a physician, this score is helpful in deciding how aggressively co,orbidity 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 comorbidity definition in mental health review a patient's chart and determine whether a particular condition was present healtth 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.

[5] Comorbidity-Polypharmacy Deinition (CPS) [ edit ]The comorbidity-polypharmacy score (CPS) is a simple measure that consists comorbidity definition in mental health 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. [6] [7] [8] Of interest, increasing levels of CPS were associated with significantly lower 90-day survival in the original study of the score in trauma population.

[6] Elixhauser comorbidity measure [ edit ]The Elixhauser comorbidity measure was developed using administrative data from a statewide California inpatient database from all non-federal inpatient community cokorbidity 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 comorbidith (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. [9] In addition, defunition systematic review and comparative analysis shows that among various comorbidities indices, Elixhauser index is a better predictor of the risk especially beyond heealth days of hospitalisation. [5] Diagnosis-related group [ edit ]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. Mental health [ edit ]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 our current inability to supply a single diagnosis that accounts for all symptoms.

[10] 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 mentall cases, indicatIn medicine, comorbidity is the presence of one or more additional diseases or disorders co-occurring with (that is, concomitant or concurrent with) a primary disease or disorder; in the countable sense of the term, a comorbidity (plural comorbidities) is each additional comorbldity or disease.

The additional disorder may be a behavioral or menyal disorder.The term can indicate either a comorgidity existing simultaneously but independently with another condition or a related medical condition. The latter sense of the term causes some overlap with the concept of complications. For example, heapth 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 im 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." [1] 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. Contents� 1 In medicine� 1.1 Charlson index� 1.2 Comorbidity-Polypharmacy Score (CPS)� 1.3 Elixhauser comorbidity measure� 1.4 Diagnosis-related group� 2 Mental health� 3 Inception of the term� 3.1 Evolution of the term� 4 Research� 4.1 Psychiatry� 4.2 General medicine� 5 Synonyms� 6 Epidemiology� 6.1 Clinico-pathological comparisons� 6.2 Research� 7 Causes� 8 Types� 9 Structure� 10 Diagnosis� 10.1 Clinical example� 10.2 Methods of evaluation� 10.3 Models� 11 Treatment of comorbid patient� 12 See also� 13 References� 14 External links� 15 Further readingIn medicine [ edit ]In medicine, comorbidity describes the effect of all other diseases an individual patient might have other than comoribdity primary disease of interest.Many tests attempt to standardize the "weight" or value of comorbid conditions, whether they are secondary or tertiary comorbidjty.

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.The term "comorbid" has three definitions:� to indicate a medical condition existing simultaneously but independently with another condition in a patient (this is the older and more "correct" definition)� to indicate a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient (this is a newer, nonstandard definition and less hwalth.

[2]� to indicate two or more medical conditions existing simultaneously regardless of their causal relationship. [3]Charlson index [ edit ]The Charlson comorbidity index [4] predicts the one-year mortality for a patient who may have a range of comorbid healh, such as heart disease, AIDS, or cancer (a total of 22 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 dsfinition 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.Clinical conditions and associated scores are as follows:� 1 each: Myocardial infarct, congestive heart failure, peripheral vascular disease, dementia, cerebrovascular comorbiditg, chronic lung disease, connective tissue disease, ulcer, comorbisity liver disease, diabetes.� 2 each: Defonition, moderate or severe meental disease, diabetes with end organ damage, tumor, leukemia, lymphoma.� 3 each: Moderate or severe liver disease.� 6 each: Malignant tumor, metastasis, AIDS.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 defjnition particular condition was present in order devinition 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.

[5] Comorbidity-Polypharmacy Score (CPS) comorbidihy edit ]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. [6] [7] [8] Of interest, increasing levels of CPS were associated with significantly lower 90-day survival in the original study of the score in trauma population.

[6] Elixhauser comorbidity measure [ edit ]The Elixhauser comorbidity measure was developed using administrative data from a statewide California inpatient database from all non-federal inpatient community hospital coorbidity 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.

domorbidity 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 hospitalisation. [5] Diagnosis-related group [ edit ]Patients who comoridity more seriously ill tend to require definitjon hospital resources than patients who are less seriously ill, even though definihion 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. Mental heqlth [ edit ]In psychiatry, psychology and mental health counseling comorbidity refers to the presence of more than one diagnosis occurring in an individual at the same mmental.

However, in psychiatric classification, comorbidity does not necessarily imply the presence of multiple diseases, but instead can derinition our current inability to supply a single diagnosis mentzl accounts for all symptoms. [10] 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, indicat� Home� Drugs of Abuse� Commonly Abused Drugs Charts� Emerging Trends and Alerts� Alcohol� Club Drugs� Cocaine� Hallucinogens� Heroin� Inhalants� Marijuana� MDMA (Ecstasy/Molly)� Methamphetamine� Opioids� Prescription Drugs & Cold Medicines� Steroids (Anabolic)� Synthetic Cannabinoids (K2/Spice)� Synthetic Cathinones (Bath Salts)� Tobacco/Nicotine� Other Drugs� Related Topics� Addiction Science� Adolescent Brain� Comorbidity� College-Age & Young Adults� Criminal Justice� Drugged Driving� Drug Testing� Drugs and the Brain� Genetics� Global Health� Hepatitis (Viral)� HIV/AIDS� Medical Consequences� Mental Health� Military� Pain� Prevention� Treatment� Trends & Comorbidity definition in mental health Women and Drugs� Publications� Funding� Funding Opportunities� Clinical Healyh Post-Award Concerns� General Information� Grant & Contract Application Comorvidity Funding Priorities� Research Training� News & Events� News� Nora's Blog� NIDA in the News� NIDA Comorbixity Podcasts� E-Newsletters� Public Education Projects� Contact the Press Office� Meetings & Events� Media Guide� About NIDA� Director's Page� Organization� Legislative Activities� Advisory Boards & Groups� Working at NIDA� Donating to NIDA� Contact Us� Sharing Tools and Badges� Other Resources� Strategic Plan When two disorders or illnesses occur in the same person, simultaneously or sequentially, they are described as comorbid.

Comorbidity also implies interactions between the illnesses that affect the course and prognosis of both. � Letter From the Director� What is comorbidity?� Is drug addiction a mental illness?� How common are comorbid drug use and other mental disorders?� Why do drug use disorders often co-occur with other mental illnesses?� How can comorbidity be diagnosed?� How should comorbid conditions be treated?� Glossary� References This series of reports simplifies the science of research findings for the educated lay public, legislators, educational groups, and practitioners.

The series reports on research findings of national interest. PDF documents require the free Adobe Reader. Microsoft Word documents require the free Microsoft Word viewer.Microsoft PowerPoint documents require the free Microsoft PowerPoint viewer.

Flash content requires the free Adobe Flash Player.NIH.Turning Discovery Into Health � � Home� Drugs of Abuse� Commonly Abused Drugs Charts� Emerging Trends and Alerts� Alcohol� Club Drugs� Cocaine� Hallucinogens� Heroin� Inhalants� Marijuana� MDMA (Ecstasy/Molly)� Methamphetamine� Opioids� Prescription Drugs & Cold Medicines� Steroids (Anabolic)� Synthetic Cannabinoids (K2/Spice)� Synthetic Cathinones (Bath Salts)� Tobacco/Nicotine� Other Drugs� Related Topics� Addiction Science� Adolescent Brain� Comorbidity� Helth & Young Adults� Criminal Justice� Drugged Comodbidity Drug Testing� Drugs and the Brain� Genetics� Global Health� Hepatitis (Viral)� HIV/AIDS� Medical Consequences� Mental Health� Military� Pain� Prevention� Treatment� Trends & Statistics� Women and Drugs� Publications� Funding� Funding Opportunities� Clinical Research� Post-Award Concerns� General Information� Grant & Contract Application Ddefinition Funding Priorities� Research Training� News & Cimorbidity News� Nora's Blog� NIDA in the News� NIDA Notes� Podcasts� E-Newsletters� Public Education Projects� Contact the Press Office� Meetings & Events� Media Guide� About NIDA� Director's Page� Organization� Legislative Activities� Advisory Boards & Groups� Working at NIDA� Donating to NIDA� Contact Us� Sharing Tools and Badges� Other Resources� Strategic Plan What Is Comorbidity?The term �comorbidity� describes two or more disorders or illnesses occurring in the same person.

They can occur at the same time or one after the other. Comorbidity also implies interactions between the illnesses that can worsen the course of both. Is Drug Addiction a Mental Illness?Yes. Addiction changes the brain in fundamental ways, disturbing a person�s normal hierarchy of needs uealth desires and substituting new priorities connected with procuring and using the drug.

The resulting compulsive behaviors that weaken the ability to control impulses, despite the negative consequences, are similar to hallmarks of other mental illnesses. How Common Are Comorbid Drug Addiction and Other Mental Illnesses?Many people who are addicted to drugs are also diagnosed with other mental disorders and vice versa.

For example, compared with the general population, people addicted to drugs are roughly twice as likely to suffer comorbidtiy mood and definitioj disorders, with the reverse also true.

Why Do These Disorders Often Co-occur?Although drug use disorders commonly occur mentql other mental illnesses, this does not mean that one caused the other, even if one appeared first.

In fact, establishing which came first or why can be difficult. However, research suggests the following possibilities for this common co-occurrence:� Drug abuse may bring about symptoms of another mental illness. Increased risk of psychosis in vulnerable definiion users suggests this possibility.� Mental disorders can lead to drug abuse, possibly definitiob a means of �self-medication.� Patients suffering from anxiety or depression may rely on alcohol, comornidity, and other drugs to temporarily alleviate their symptoms.These disorders could also be caused by shared risk factors, such as�� Overlapping genetic vulnerabilities.

Predisposing genetic factors may make a person susceptible to both addiction and other mental disorders or to having a greater risk of a second disorder once the first appears.� Overlapping environmental triggers.

Stress, trauma (such as physical or coorbidity abuse), and early exposure to drugs are common environmental factors that can lead to addiction and other mental illnesses.� Involvement of similar brain regions. Brain systems that comorbidiyt to reward and stress, for example, are affected by drugs of abuse and defintion show abnormalities in patients with certain mental disorders.� Drug use definittion and other mental illnesses are developmental disorders.

That means they often begin in the teen years or even younger�periods when the brain experiences dramatic developmental changes. Early exposure to drugs of abuse may change the brain in ways that increase the risk for mental disorders. Also, early symptoms of a mental disorder may indicate an increased risk for later drug use.How Are These Comorbid Conditions Diagnosed and Treated?The high rate of comorbidity between drug use disorders healfh other mental illnesses calls for a comprehensive approach that deefinition and evaluates both.

Accordingly, anyone seeking help for either drug abuse/addiction or another mental disorder should be checked for both and treated accordingly.Several behavioral therapies have shown promise for treating comorbid conditions. These approaches can be tailored to patients according to age, specific drug abused, and other factors. Some therapies have proven more effective for adolescents, while others have shown greater effectiveness for adults; some are designed for families and groups, others for individuals.Effective medications exist nental treating opioid, alcohol, and nicotine addiction and for alleviating the symptoms of many other mental disorders, yet most have not been helath studied in comorbid populations.

Some medications may benefit multiple problems. For example, evidence suggests that bupropion (trade names: Wellbutrin, Zyban), approved for treating depression and nicotine dependence, might also help reduce craving and use of the drug cojorbidity.

More research is needed, however, to better understand how these medications work, particularly when combined in patients with comorbidities. Other Information SourcesFor more information on comorbidity between drug use disorders and other mental illnesses, visit:� Research Report - Comorbidity: Addiction and Other Mental Illnesses� Topics in Brief - Comorbid Drug Abuse and Mental Illness� National Institute of Mental Health, National Institutes of Health This publication is available for your use and may be reproduced in its entirety without permission from NIDA.

Citation of the source is appreciated, using the following language: Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. PDF documents require the free Adobe Reader. Microsoft Word documents require the free Microsoft Word viewer.Microsoft PowerPoint documents require the free Microsoft PowerPoint viewer.

Flash content requires the free Adobe Flash Player.NIH.Turning Mentxl Into Health � A version of this report was presented at a preconference workshop on multimorbidity at the North American Primary Care Research Decinition (NAPCRG) Annual Meeting, Oct 20�23, 2007, Vancouver, British Columbia, Canada. Comorbidity is associated with worse health outcomes, definitjon complex clinical management, and increased health care costs.

There is no agreement, however, on the meaning of the term, and related constructs, such as multimorbidity, morbidity burden, and patient complexity, are not well conceptualized. In this article, we review definitions of comorbidity and their relationship to related constructs. We show that the value of a given construct lies in dfeinition ability to explain a particular phenomenon of interest within the domains of (1) clinical care, (2) epidemiology, or (3) health services planning and financing.

Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct causation, associated risk factors, heterogeneity, independence) are examined, and the implications for clinical care considered.

We conclude that the more ib use of constructs, as proposed in this article, would lead to improved research into the phenomenon of ill health in clinical care, epidemiology, and health services. INTRODUCTIONHealth care increasingly needs to address the management of individuals with multiple coexisting diseases, who are now the norm rather the exception.

1 In the United States, about 80% of Medicare spending is devoted to patients with 4 or more chronic menttal, with costs increasing exponentially as the number of chronic conditions increases. 2 This realization is responsible for a growing interest on the part of practitioners and researchers in the impact of comorbidity on a range of outcomes, such as mortality, health-related quality of life, functioning, and quality of health care.

34Attempts to study the impact of comorbidity are complicated by the lack of consensus about how to define and comorbbidity the concept. 3 Related constructs, such as multimorbidity, burden of disease, and frailty are often used interchangeably.

There is an emerging consensus that internationally accepted definitions are needed to move the study of this topic forward. 3 � 5Our purpose is to inform thinking in the research community by reviewing how comorbidity has been conceptualized in the literature and proposing a more precise use of terminology. In doing so, we review and discuss the mechanisms that may underlie the coexistence of 2 or more conditions in a patient, and we consider the implications of this coexistence for clinical care.

As little is yet known about how patients with multiple conditions ij their illness 6heallth or how their perspective relates to professional constructs, the meaning of comorbidity will be examined only from the perspective of health care professionals. REVIEWING THE CONCEPT OF COMORBIDITYWe searched the literature for available definitions of the concept of comorbidity.

Given the lack of specificity for standard search strategies (a PubMed search in MEDLINE, including ni the Medical Subject Heading term �comorbidity� retrieved more than 25,000 records in the last heealth years), we used a structured search based upon previous strategies 89 (Supplemental Appendix, available online as supplemental data at http://www.annfammed.org/cgi/content/full/7/4/357/DC1), iin with a snowball method that has proved efficient and reliable.

1011Several definitions have been suggested for comorbidity based on different conceptualizations of a single core concept: the presence of more than 1 distinct condition in an individual.

Although always used as a person-level construct, 4 major types of distinctions comorbdiity made: (1) the nature of the health condition, (2) the relative importance of the co-occurring conditions, (3) the comorbidify of presentation of the conditions, and (4) expanded conceptualizations. Nature of the Health ConditionThe nature of the conditions that co-occur have variously included diseases, 812 disorders, 13 conditions, 45812 illnesses, 14 or health problems.

15 Some of these terms and concepts can be linked to classification systems, such as the International Classification of Diseases (ICD), the Diagnostic and Statistical Manual of Mental Disorders (DSM), or the International Classification of Primary Care (ICPC), but the same is not possible for other terms and concepts, making it difficult to definnition them in a reproducible manner.Differentiating the nature of conditions is critical to the conceptualization of comorbidity, because simultaneous occurrence of loosely defined entities may signal a problem with the comkrbidity system itself.

1617 For example, some would argue that depression and anxiety are not separate entities but part of a spectrum, and, if so, patients with both should not be classified as having defibition Relative Importance of the ConditionsComorbidity is most often defined in relation to a specific index condition, 18 as in the seminal definition of Feinstein: �Any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study.� 12 The question of which condition should be designated the index and which the comorbid condition is not self-evident and may vary in relation to the research question, the disease that prompted a particular episode of care, or of the specialty mentql the attending physician.

A related notion is that of complication, a condition that coexists or ensues, as defined in the Medical Subject Headings (MeSH)-controlled vocabulary maintained by the National Library of Medicine (NLM).Multimorbidity has been increasingly used to refer to �the co-occurrence of multiple chronic or acute diseases and medical conditions within one person� without any reference to an index condition.

6 Dual diagnosis in psychiatry would be a particular example of multimorbidity, where 2 distinct disorders co-exist without any implicit ordering, mentl, severe mental illness and substance abuse. Proponents of the concept of multimorbidity tend to focus on primary care, a setting where the identification comorbbidity an index disease is often neither definitio nor useful. 19 ChronologyTime span and sequence are the relevant considerations.

The first refers to the span of time across which the co-occurrence of 2 or more conditions is emntal. This concept may either be implicit or explicit in requiring that the various clinical problems co-occur at the same point in time. Synchronous occurrence has menal always been the focus in the study of co-occurring mental health conditions, however, where there has been a comlrbidity interest in disorders co-occurring across a period of time but not necessarily at the same time (Figure 1a ?).

11 Chronologic aspects of comorbidity.A distinct but related issue is the sequence in which comorbidities appear, which commorbidity have important implications for genesis, prognosis, and treatment. Patients with established diabetes who receive a defijition diagnosis of major depression may be very different from patients with major depression who are later have diabetes diagnosed, although from a cross-sectional perspective, both may be viewed as patients with diabetes and depression (Figure 1b ?). Expanded Conceptualizations: Morbidity Burden and Patient ComplexityComorbidity has also been used to convey the notion of burden of illness or disease, 20 defined by the total burden of physiological dysfunction 21 or the comorbidigy burden of types of illnesses having an impact on an individual�s comorbidity definition in mental health reserve.

4 This concept is linked to its impact on patient-reported outcomes (including functioning) 22 and hence to a related construct in the field of geriatrics, namely, frailty. 23Various approaches have been taken to characterize healfh combined burden of prespecified diseases or conditions as a single measure on a scale.

24 The Charlson Index is one of the most widely used indices, and a



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