How Often Do You See Patients With a Single Illness?

It’s rare in my family practice that patients present with a single problem during a visit. More often than not, I’m asked to diagnose and treat multiple illnesses, or manage several chronic illnesses. Just as ‘birds of a feather flock together,’ some illnesses seem to be comorbid with a frequency that exceeds chance. A ‘bread and butter’ example to the generalist practitioner would be the illnesses that relate to the metabolic syndrome, eg, hypertension, diabetes, obesity, and dyslipidemia. Clusters of chronic illnesses have some general characteristics—for example, monotherapy is the exception rather than the rule. It typically takes more than one pharmacologic agent to corral the symptoms or to meet therapeutic targets. In addition, nonpharmacologic interventions are often crucial to successful treatment.

I’ve noticed a common triad in my practice that fits this pattern—major depressive disorder (MDD), chronic pain, and sleep disorders (see Assessing and Managing Pain and Major Depression With Medical Comorbidities). They’re often comorbid and can be co-contributory.^1–3 In other words, these are not just illnesses that happen to be associated together; they tend to make each other worse.

What are the keys, then, to untying the Gordian knot? Good therapy follows good diagnostics. When I’ve made a diagnosis of any of the three, I look for the other two, because I know that the patient is statistically at increased risk. For instance, I ask direct questions about sleep and pain in my patients with MDD. To supplement my clinical interview, I often use scales to measure the presence and depth of symptomatology. For example, I use the 9-item Patient Health Questionnaire (PHQ-9) to assess depression, analog scales to measure pain, and the SNAP tool to screen for sleep apnea syndromes. Measurements are important not only at diagnosis but also during treatment, to assess efficacy. Because symptom reduction is only half the story, I also focus on functional improvement. To measure the patient’s progress toward wellness, I find the Sheehan Disability Scale (SDS) and the World Health Organization-5 (WHO-5) scale to be helpful.

Knowing that multimodal treatment is the norm, the practitioner should seek to begin treatment with therapies that will have salutary effects on more than one symptom or illness. Take depression and pain, for instance. Pharmacologically, a serotonin-norepinephrine reuptake inhibitor (SNRI) would, in theory, offer both antidepressant and analgesic efficacy.² Therefore, for treatment-naïve depressed patients, I would likely start with an SNRI if they had comorbid pain. When it comes to nonpharmacologic treatments, the choices that positively affect both illnesses are robust, including cognitive-behavioral therapy, exercise, and meditation.^3–5 For some patients, however, access to a therapist, a personal trainer, or a meditation guide can be problematic (especially for patients who are from my rural practice). If patients have difficulty participating in traditional means of therapy, I encourage them to download smartphone apps that can help them accomplish some of the same goals.

Problems of mood, pain, and sleep often appear in the same patients. For the generalist practitioner, it’s certainly challenging to unravel the symptomatology. But few clinical presentations offer the type of dramatic improvements that can occur when these patients are properly assessed and treated.

Supported by an educational grant from Lilly. For further information concerning Lilly grant funding, visit www.lillygrantoffice.com.

Financial disclosure:Dr Jackson is a consultant for Otsuka, Pamlab, and Sunovion and has received honoraria from and is a member of the speakers/advisory board for Pamlab.

References

1. Gupta A, Silman AJ, Ray D, et al. The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study. Rheumatology (Oxford). 2007;46(4):666–671. PubMed

2. Ruoff GE. Depression in the patient with chronic pain. J Fam Pract. 1996;43(suppl 6):S25–S33. PubMed

3. Spiegelhalder K, Regen W, Nanovska S, et al. Comorbid sleep disorders in neuropsychiatric disorders across the life cycle. Curr Psychiatry Rep. 2013;15(6):364. doi:10.1007/s11920-013-0364-5. PubMed

4. Lopresti AL, Hood SD, Drummond PD. A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise. J Affect Disord. 2013;148(1):12–27. PubMed

5. Butler LD, Waelde LC, Hastings TA, et al. Meditation with yoga, group therapy with hypnosis, and psychoeducation for long-term depressed mood: a randomized pilot trial. J Clin Psychol. 2008;64(7):806–820. PubMed