Chronic Physical Diseases Research Articles

Development and Validation of Resilience Scale in Patients with Cardiovascular and Respiratory Diseases

Background: Resilience is defined as skills, abilities, knowledge, and insight that people gain over time to overcome problems and hardships and cope with challenges. Objectives: Due to the lack of a gold standard to measure resilience, the current study aimed at designing and validating a resilience scale in Patients with cardiovascular and respiratory diseases. Methods: The current methodological study was conducted in 2016 in 3 consequential phases. In the first phase, the concept of resilience was defined and analyzed in patients with chronic physical diseases using hybrid concept analysis. In the second phase, based on the findings obtained in the phase 1, the item pool was generated. In the third phase, in order to evaluate the psychometric properties of the tools, 375 patients in public places of Tehran, Iran, were selected using the multistage cluster sampling method to complete the scales. Results: Based on the results of the content analysis, the primary item pool included 142 items, which was reduced to 57 items by excluding the repetitive and combining the overlapping ones. After administering face validity, content validity, and item analysis, a total of 30 items remained. The exploratory factor analysis, by eliminating 1 item, indicated five 5, explaining 65% of the total variance, and the Kaiser - Meyer - Olkin (KMO) index was 0.949, showing a significant difference (P = 0.0001). Discriminant validity showed that patients with higher education were more resilient. Cronbach’s alpha coefficient of the final version of the 29 - item scale was 0.943. Conclusions: The 29 - item resilience scale was a simple, valid, and reliable tool to measure resilience in patients with cardiovascular and respiratory diseases.

Self-perception of children with autism spectrum disorders.

We aimed to evaluate self-perceived competence and self-esteem of primary school children with autism spectrum disorder (ASD) in Japan and compare to those of children with other chronic physical diseases and healthy controls. Data were collected from 227 children: ASD (N.=91), nephrotic syndrome (NS) (N.=52) and asthma (N.=84), using Children's Perceived Competence Scale (CPCS) in 2012-2014. CPCS measures perceived competence in cognitive, social and physical domains, and a general self-worth domain as self-esteem. Scores in the social domain of the ASD group were lower than those of all other groups after adjusting for school age grades and gender. Scores of the ASD group negatively correlated with psychosomatic symptoms in all domains and IQ in the physical domain. These findings are the first data set in Japan on self-perceived competence and self-esteem in primary school children with ASD. Those results were comparable to previous researches in adolescents with ASD. Low social domain scores in the ASD group indicate the CPCS may be one of the useful tools to evaluate difficulty in social competence from the children's point of view. Correlations between CPCS scores and psychosomatic symptoms in the ASD group suggest development of psychosomatic symptoms may be addressed early by attention to low scores, especially in general self-worth.

Alexithymia as a Predictor of Worse Prognosis in Postural Phobic Vertigo

Alexithymia is regarded as a predictor of many chronic physical and neurological diseases, but it has not yet been regarded in connection with different types of dizziness, especially postural phobic vertigo. Patients with alexithymia have difficulties in describing their feelings and sensations; especially, it touches upon the description of neurological symptoms.

Risk correlates for physical-mental multimorbidities in South Africa: a cross-sectional study.

The aim of this study was to identify the risk correlates for coexisting common mental disorders (CMDs) in the chronic care population in South Africa, with the view to identifying particularly vulnerable patient populations. The sample comprised 2549 chronic care patients enrolled in the baseline and endline rounds of a facility detection survey conducted by the Programme for Improving Mental Health Care in three large facilities in the Dr Kenneth Kaunda district in the North West province of South Africa. Participants were screened for depression using the Patient Health Questionnaire (PHQ9) and for alcohol misuse using the Alcohol Use Disorders Identification Test (AUDIT). Data were analysed according to the number of morbidities, disorder type (physical or mental) and demographic variables. Multimorbidity was defined as the presence of two or more disorders (physical and/or mental). Just over one-third of the sample reported two or more physical conditions. Women were more at risk of being depressed than were men, with men more at risk of alcohol misuse. Those who were employed were at lower risk of having coexisting CMDs, while being younger, HIV positive, and food deprived were all found to be associated with higher risk for having coexisting CMDs. In the face of the large treatment gap for CMDs in South Africa, and the role that coexisting CMDs can play in exacerbating the burden of chronic physical diseases, mental health screening and treatment interventions should target HIV-positive, younger patients living in circumstances where there is household food insecurity.

Cognitive behavioral group therapy for patients with physical diseases and comorbid depressive or adjustment disorders on a waiting list for individual therapy: results from a randomized controlled trial

BackgroundDepressive and adjustment disorders are highly prevalent in patients with physical diseases and are associated with poorer quality of life, increased morbidity and mortality, as well as higher healthcare costs. Access to mental health care holds strong importance for these patients, although waiting times for outpatient individual psychotherapy in Germany are often long. Attending an intervention while waiting for individual therapy could improve this problem. For this purpose, we developed an eight-session cognitive behavioral group therapy (STEpS) and tested its efficacy in a randomized controlled trial.MethodsSeventy-six patients with chronic physical diseases and comorbid depressive or adjustment disorders were randomized to either STEpS or a waiting list control group. The primary outcome was self-reported depression measured by the Hospital Anxiety and Depression Scale (HADS-D), while the secondary outcomes included global psychological distress and health-related quality of life. Data was assessed at baseline, post-treatment and 2-month follow-up and was analyzed based on intention-to-treat.ResultsCompared to the control group, the STEpS group showed significantly less depression (d = 0.37; p = .009) and significantly higher quality of life (mental: d = 0.47; p = .030; physical: d = 0.70; p = .001) at post-treatment. The groups did not differ in global psychological distress. At 2-month follow-up, the STEpS group indicated significantly higher subjective physical health (d = 0.43; p = .046), but did not differ from the control group in the remaining outcomes.ConclusionsSTEpS proved effective in improving depression and health-related quality of life in the short term but did not reveal effects on mental outcomes at 2-month follow-up. Nonetheless, the implementation of STEpS as a waiting list intervention prior to individual therapy could help patients to handle long waiting periods in outpatient care.Trial registrationGerman Clinical Trials Register DRKS00005140 (27 August 2013).

Effectiveness of the management of major depressive episodes/disorder in adults with comorbid chronic physical diseases: a protocol for a systematic review and meta-analysis

IntroductionDepression is a global-scale public health problem, and a significant association has been established between depression and chronic physical diseases. This growing comorbidity poses a challenge to healthcare systems. We...

Evidence base for Multiple Family Therapy (MFT) in non‐psychiatric conditions and problems: a review (part 2)

AbstractThis article provides an updated overview of the empirical literature regarding Multiple Family Therapy's (MFT) applications to non‐psychiatric conditions and problems. Although the evidence is not as strong for these disorders as for psychiatric disorders, the benefits of MFT approaches are apparent in the following areas: family management of several severe chronic medical illnesses; prevention of educational failure and exclusion; and treatment of marital distress. MFT research in non‐psychiatric settings has been faced with unique challenges that have mitigated the quality and quantity of outcome and process research produced over the past decade. Future research efforts should focus on: (1) stronger commitment to the evaluation of ongoing MFT programmes; (2) identification and manualization of major MFT programmes; (3) more Randomized Clinical Trials (RCTs) on the effectiveness of MFT programmes in community settings; and (4) higher priority for research on MFT's change processes and patterns of interaction.Practitioner points The treatment of chronic physical diseases is optimized by involving family members, and MFT is a valuable way of doing so: workshops delivered in brief formats are most feasible MFT should be considered for non‐psychiatric problems with the risk of isolation and stigmatization. The presence of other families sharing the same challenges is very useful MFT practitioners should attempt to operationalize their MFT model and include an evaluation component in their therapeutic implementation as routine practice

Dual burden of chronic physical diseases and anxiety/mood disorders among São Paulo Megacity Mental Health Survey Sample, Brazil

BackgroundWe assessed comorbid associations of 12-month DSM-IV mood/any anxiety disorders with chronic physical conditions within the São Paulo (SP) Megacity Mental Health cross-sectional survey of 5037 participants and explored whether strength of comorbid associations were modified when controlling for demographics. MethodsChi-square tests and logistic regressions were used to examine comorbid associations of DSM-IV mood/anxiety disorders as measured by the WHO Composite International Diagnostic Interview (CIDI 3.0), and self-reported chronic physical conditions among adults from the SP Megacity Mental Health Survey. ResultsAmong those with any mood or anxiety disorder, chronic pain disorder was the most common physical condition (48.9% and 44.9%, respectively). Significant unadjusted odds ratios (OR) of comorbidity were found between diagnosis of two or more physical conditions and any mood disorders (3.08, 95% CI: 2.27–4.17), and any anxiety disorders (2.49, 95% CI: 1.95–3.17). Comorbidities remained significant when stratified by gender and controlling for marital status, household income, and education (latter two only included within anxiety models). LimitationsThese results cannot be generalized to other cities or rural populations. Homeless and institutionalized populations were not surveyed. Due to cross-sectional study design, the direction of association between chronic disease/chronic disease risk factors and mood disorders is unclear. ConclusionsDual burden of chronic physical conditions and mood/anxiety disorders is a notable problem among the São Paulo Megacity Survey population, with enhanced comorbidity experienced by community members with multiple physical conditions. Clinicians should consider these findings in understanding healthcare delivery for individuals suffering from both psychiatric disorders and chronic physical conditions.

Mental Health Consequences and Social Issues After the Fukushima Disaster.

The Great East Japan Earthquake and subsequent nuclear power plant accident caused multidimensional and long-term effects on the mental health condition of people living in Fukushima. In this article, focusing on the influence of the nuclear disaster, we present an overview of studies regarding the psychosocial consequences of people in Fukushima. Studies revealed that the experiences of the explosions at the plant as well as the tsunami are deeply embedded in their memory, leading to posttraumatic responses. Chronic physical diseases, worries about livelihood, lost jobs, lost social ties, and concerns about compensation were also associated with posttraumatic responses. Furthermore, the radioactive fallout brought chronic anxiety regarding physical risks of radiation exposure to people, especially young mothers. People often have different opinions about the radiation risk and their own future plans, resulting in a reduction in the resilience that communities and families had before the disaster. In addition, such weakened community resilience may produce a significant increase in disaster-related suicide in Fukushima. Specific social issues, such as "radiation stigma" among the public and self-stigma among evacuees, that are never seen with other natural disasters also increased in Fukushima.

Cognitive Ability in Late Life and Onset of Physical Frailty: The Lothian Birth Cohort 1936.

ObjectivesTo investigate whether poorer cognitive ability is a risk factor for development of physical frailty and whether this risk varies according to cognitive domain.DesignProspective longitudinal study with 6‐year follow‐up.SettingEdinburgh, Scotland.ParticipantsMembers of the Lothian Birth Cohort 1936 (N = 594).MeasurementsFrailty was assessed at ages 70 and 76 using the Fried criteria. Cognitive function was assessed at age 70, 73, and 76. Factor score estimates were derived for baseline level of and change in four cognitive domains: visuospatial ability, memory, processing speed, and crystallized cognitive ability.ResultsHigher baseline levels of processing speed, memory, visuospatial ability and crystallized ability at age 70, and less decline in speed, memory, and crystallized ability were associated with less risk of becoming physically frail by age 76. When all cognitive domains were modelled together, processing speed was the only domain associated with frailty risk, for a standard deviation (SD) increment in initial level of processing speed, the risk of frailty was 47% less (0.53 95% confidence interval (CI) = 0.33–0.85) after adjustment for age, sex, baseline frailty status, social class, depressive symptoms, number of chronic physical diseases, levels of inflammatory biomarkers, and other cognitive factor score estimates; for a SD increment in processing speed change (less decline) risk of frailty was 74% less (RRR = 0.26, 95% CI = 0.16–0.42). When additional analyses were conducted using a single test of processing speed that did not require fast motor responses (inspection time), results were similar.ConclusionsThe speed with which older adults process information and the rate at which this declines over time may be an important indicator of the risk of physical frailty.

Impact of functional somatic symptoms on 5–7-year-olds' healthcare use and costs

ObjectiveKnowledge about childhood functional somatic symptoms (FSS) and healthcare costs is scarce. This study aims to assess whether FSS in children aged 5–7 years are associated with increased future primary...

Screening for Depressive Disorder in Elderly Patients with Chronic Physical Diseases Using the Patient Health Questionnaire-9.

ObjectiveWe aimed to identify depressive symptom profiles that indicated the presence of depressive disorder and present optimal cut-off sub-scores for depressive symptom profiles for detecting depressive disorder in elderly subjects with chronic physical diseases including diabetes, chronic obstructive pulmonary disease/asthma, and coronary artery disease, using the Patient Health Questionnaire-9 (PHQ-9).MethodsTwo hundred and thirty-one elderly patients with chronic physical diseases were recruited consecutively from a university-affiliated general hospital in South Korea.ResultsGreater severities of all 9 depressive symptoms in the PHQ-9 were presented in those with depressive disorder rather than those without depressive disorder. A binary logistic regression modeling presented that little interest [adjusted odds ratio (aOR)=4.648, p<0.001], reduced/increased sleep (aOR=3.269, p<0.001), psychomotor retardation/agitation (aOR=2.243, p=0.004), and concentration problem (aOR=16.116, p<0.001) were independently associated with increased likelihood of having depressive disorder. Receiver operating characteristics (ROC) curve analysis presented that the optimal cut-off value of score on the items for little interest, reduced/increased sleep, psychomotor retardation/agitation and concentration problem (PHQ-9) for detecting depressive disorder was 4 with 61.9% of sensitivity and 91.5% of specificity [area under curve (AUC)=0.937, p<0.001].ConclusionOur findings suggested that the diagnostic weighting of little interest, reduced/increased sleep, psychomotor retardation/agitation, and concentration problem is needed to detect depressive disorder among the elderly patients with chronic physical diseases.

Comorbidity in people with depression seeking help at primary health care centers in Santiago, Chile

International evidence has shown the complex interaction between depression and chronic physical diseases. Depression in scenarios involving multiple comorbidities has not received enough attention in Chile. To characterize the depressed people who consult at Primary Health Care Centers (PHCCs), taking into account the presence of chronic physical or psychiatric comorbidity. A secondary analysis of databases used in a clinical trial. Two hundred fifty six adults seeking professional help were recruited in four PHCCs located in the Metropolitan Region. These people had a major depressive episode, identified with a structured psychiatric interview (MINI), and gave their informed consent to participate. Socio-demographic information was collected, depressive symptomatology was measured with the patient health questionnaire 9 (PHQ-9), psychiatric morbidity was assessed using the Mini International Neuropsychiatric Interview (MINI), and chronic physical diseases were self-reported by the patients. Descriptive analyses of all the variables were conducted. Seventy percent of patients had a history of depression, with a median of two prior depressive episodes. Depressive symptoms were mostly considered as moderate to severe and severe and 31% of the patients had high suicide risk. Seventy eight percent displayed a physical or psychiatric comorbidity. Of these patients, 29% only had a chronic physical comorbidity, while 46% suffered from an additional psychiatric disorder. Depressed individuals who seek help at PHCCs constitute an especially complex population that must be treated taking into account multiple comorbidities.

A Systematic Study of Resilience in Patients with Chronic Physical Diseases

Context Considering the high prevalence of psychological distresses among patients with chronic physical diseases, the question is why do some of these patients not experience any disorders and cope better with their disease? Objectives The current study aims at reviewing the researches on resilience in adult patients with chronic diseases. Data Source In the present systematic review, articles published in English on resilience from March 2000 to July 2015 were searched using the keywords: Resilience OR Resiliency AND Illness OR Disease OR Chronic Disease in databases such as Google Scholar, Science Direct, PubMed, PreQuest, Scopus, and PsycINFO. Study Selection The process of screening and the initial selection of articles were based on systematic reviews and meta-analyses (PRISMA) guidelines. The methodological quality of the articles was studied using a modified version of quality of life index form. Eventually, 17 qualified studies were selected for the review. Data Extraction The form used to extract information included the variables of the first author of the article, the publication year, the place of the study, the type of the study, sample size, the data collecting instruments, and the most important findings. Results The results included resilience outcomes, protective factors and resilience-related risk factors. Psychological distresses were the most common risk factors, and self-efficacy and adaptive coping constituted the most common resilience-related protective factors. The findings showed that the protective factors, by mediating risk factors, resulted in positive outcomes such as proper treatment adhesion, better quality of life, psychological well-being, and self-care behaviors. Conclusions Resilience is a balance between risk factors and protective factors, and it develops or disappears through changes in the protective and risk factors. Patients with high resilience tend to enhance their protective factors and manage their everyday life in spite of disease-related limitations.

A Systematic Study of Resilience in Patients with Chronic Physical Diseases

A Systematic Study of Resilience in Patients with Chronic Physical Diseases

One-year prospective study on the presence of chronic diseases and subsequent cognitive decline in older adults.

The literature is inconsistent regarding the effect of the presence of chronic physical and mental diseases on cognitive decline in older adults. The objectives of this study were to explore the effect of chronic diseases on subsequent cognitive decline assessed via the Mini Mental State Examination (MMSE) in community living older adults. We used data from individuals (n = 2010) participating in the ESA (Étude sur la Santé des Aînés) study. Cognitive status was measured with the MMSE at baseline and after 1 year. Chronic diseases were identified via administrative databases in accordance with International Classification of Diseases 9/10. Multivariate linear regression was used to assess the change in MMSE as a function of chronic physical and mental disorders, while adjusting for socio-demographic and clinical factors. Significant decreases in MMSE scores were found in patients who had a stroke (β value: -2.83) or diabetes (β value: -1.06) and in older adults aged older than 75 years (β value: -0.91). When adjusting for other chronic diseases, stroke, diabetes and advanced age were associated with subsequent cognitive decline in older adults during a one-year follow-up. Longer follow-up is recommended to assess long-term effect.

Exploring the links between mindfulness skills, physical activity, signs of anxiety, and signs of depression among non-clinical participants

Summary Introduction Physical activity has been shown to reduce anxiety and/or depression levels in patients with chronic physical diseases as well as healthy individuals. Similarly, mindfulness- and acceptance-based interventions have also been shown to reduce levels of anxiety and depression. Furthermore, recent research suggests that mindfulness is also associated with the level of physical activity. The aim of this correlational study was to predict signs of anxiety and depression with acceptance, dispositional mindfulness, and levels of physical activity in non-clinical individuals. Methods One hundred randomly chosen participants were interviewed with regard to their general anxiety (BAI), depression (BDI-II), physical activity (IPAQ), acceptance (AAQ-II), and dispositional mindfulness (MAAS). Results On average, participants scored underneath the pathological threshold for anxiety and depression inventories. As expected, dispositional mindfulness and acceptance variables were negatively correlated to the psychopathological variables. Hierarchical model analyses showed that acceptance, dispositional mindfulness, and physical activity level explain 21% of the data for depression level among non-clinical participants. Conclusion This exploratory study may lead other researchers to develop and test the validity of mindfulness- and acceptance-based interventions associated to physical activity programs in order to reduce depression level among healthy individuals.

Alexithymia as a Predictor of Chronic Tension Headaches

Alexithymia as a violation of inter-hemispheric communication which has no visible organic brain changes is now regarded as a predictor of many chronic physical and neurological diseases, but it has not yet been regarded in connection with chronic tension headaches. The authors examined 137 people with tension-type headache (33 men, 84 women) aged 30–50 years (average age 40,75 ± 6,29) in order to clarify a link to alexithymia. The diagnosis of tension headache was conducted according to the International classification of headaches, 3rd edition (beta version). The authors used the original headache diary, Toronto alexithymia scale, Hospital anxiety and depression scale, the measurement of the space under the curve of headache. It was found that the patients with alexithymia have difficulty in describing the place of headaches (the average number of word descriptors at most 1 word), distrust of doctors, abuse of analgesics and tend to use alternative medicine methods. The intensity (p = 0.0001) and the frequency of headaches (p = 0.0028) is significantly higher in patients with alexithymia, and the more common are depression (p = 0.042) and impaired nocturnal sleep (p = 0.001). Patients with chronic tension-type headache associated with sleep disorders, adaptation and symptoms of depression should be considered as alexithymic personalities until the contrary is proved. Physicians should be aware of the fact that alexithymic patients have problems with feelings verbalization, and if patient’s complaints are vague a doctor should use questionnaires, words-descriptors, phrases-descriptors and other auxiliary verbal techniques for accurate diagnosis.

The Effect of Urinary Incontinence on Sexual Quality of Life in Women with Chronic Physical Diseases

This study was conducted in order to determine the effect of the presence of urinary incontinence on sexual quality of life in women diagnosed with chronic physical diseases. The sample of the cross sectional and comparative study consisted of 67.5 % (n = 191) female inpatients with and 32.5 % (n = 92) female inpatients without urinary incontinence complaints being treated for chronic physical diseases in the internal diseases clinic of a public hospital. Data was collected using the patient identification form, the International Incontinence Consultation Questionnaire-Short Form and the Sexual Quality of Life Scale for Women. The average score that women with urinary incontinence took from the sexual quality of life scale (61.50 ± 19.10) was lower than the average score of women without urinary incontinence (77.19 ± 18.75) (p < 0.01). There was a negative meaningful relationship between the frequency, amount, and effect of urinary incontinence and sexual quality of life (p < 0.05). The sexual quality of life of women who were 50 years of age and above, who had respiratory system diseases, had a duration of illness between 6 and 10 years, perceived their general health as bad, parity and gave normal birth, were in their menopausal period, and had hysterectomies was significantly lower (p < 0.05). As a result, in women with chronic physical diseases and urinary incontinence, the sexual quality of life is affected in a worse level compared to those who do not have urinary incontinence.

A Public Health Perspective on Mental and Medical Comorbidity.

Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 CountriesKate M. Scott, MA (Clin Psych), PhD; Carmen Lim, MSc; Ali Al-Hamzawi, MD; Jordi Alonso, MD, DrPH; Ronny Bruffaerts, PhD; Jose Miguel Caldas-de-Almeida, MD, PhD; Silvia Florescu, MD, PhD; Giovannide Girolamo, MD; Chiyi Hu, PhD; Peter de Jonge, PhD; Norito Kawakami, MD, DMSc; Maria Elena Medina-Mora, PhD; Jacek Moskalewicz, PhD; Fernando Navarro-Mateu, MD, PhD; Siobhan O’ Neill, MPsychSc, PhD; Marina Piazza, ScD, MPH; Jose Posada-Villa, MD; Yolanda Torres, MPH, DraHC; Ronald C. Kessler, PhD IMPORTANCE It is clear that mental disorders in treatment settings are associated with a higher incidence of chronic physical conditions, but whether this is true of mental disorders in the community, and how generalized (across a range of physical health outcomes) these associations are, is less clear. This information has important implications for mental health care and the primary prevention of chronic physical disease. OBJECTIVE To investigate associations of 16 temporally prior DSM-IV mental disorders with the subsequent onset or diagnosis of 10 chronic physical conditions. DESIGN, SETTING, AND PARTICIPANTS Eighteen face-to-face, cross-sectional household surveys of community-dwelling adults were conducted in 17 countries (47 609 individuals; 2 032 942 person-years) from January 1, 2001, to December 31, 2011. The Composite International Diagnostic Interview was used to retrospectively assess the lifetime prevalence and age at onset of DSM-IV–identified mental disorders. Data analysis was performed from January 3, 2012, to September 30, 2015. MAIN OUTCOMES AND MEASURES Lifetime history of physical conditions was ascertained via self-report of physician’s diagnosis and year of onset or diagnosis. Survival analyses estimated the associations of temporally prior first onset of mental disorders with subsequent onset or diagnosis of physical conditions. RESULTS Most associations between 16 mental disorders and subsequent onset or diagnosis of 10 physical conditions were statistically significant, with odds ratios (ORs) (95% CIs) ranging from 1.2 (1.0–1.5) to 3.6 (2.0–6.6). The associations were attenuated after adjustment for mental disorder comorbidity, but mood, anxiety, substance use, and impulse control disorders remained significantly associated with onset of between 7 and all 10 of the physical conditions (ORs [95% CIs] from 1.2 [1.1–1.3] to 2.0 [1.4–2.8]). An increasing number of mental disorders experienced over the life course was significantly associated with increasing odds of onset or diagnosis of all 10 types of physical conditions, with ORs (95% CIs) for 1 mental disorder ranging from 1.3 (1.1–1.6) to 1.8 (1.4–2.2) and ORs (95% CIs) for 5 or more mental disorders ranging from 1.9 (1.4–2.7) to 4.0 (2.5–6.5). In population-attributable risk estimates, specific mental disorders were associated with 1.5% to 13.3% of physical condition onsets. CONCLUSIONS AND RELEVANCE These findings suggest that mental disorders of all kinds are associated with an increased risk of onset of a wide range of chronic physical conditions. Current efforts to improve the physical health of individuals with mental disorders may be too narrowly focused on the small group with the most severe mental disorders. Interventions aimed at the primary prevention of chronic physical diseases should optimally be integrated into treatment of all mental disorders in primary and secondary care from early in the disorder course.