Double trouble treble the problem?

How experiencing two or more mental health issues at a time can and does happen.

Last week we introduced comorbidity, and this week we’ll focus when it occurs with two mental health illnesses (or more) at a time. Yes, it is not always physical alongside mental or vice versa. Mental disorders can co-occur with each other as well as with substance use disorders; anxiety disorders often occur with each other, as well as with affective (e.g. depression), and personality disorders.

In many areas of medicine, and certainly in psychiatry, the concept of comorbidity has become widely realised but unfortunately not well-defined or understood. This is probably due to the criteria for one disorder overlapping with the criteria used to define a second disorder so that supposedly separate mental disorders may not be as separate as they seem.

In mental health, one of the more common comorbidities is that of depression and anxiety. When anxiety and depression present together, these illnesses can often be harder to treat. This is because both the anxiety and depression symptoms tend to be more persistent and intense when “working” together.

Establishing causality or directionality of comorbidity is difficult for several reasons. One theory is that the two conditions have similar biological mechanisms in the brain, so they are therefore more likely to “show up” together. Another theory is that they have many overlapping symptoms, so people frequently meet the criteria for both diagnoses (an example of this might be the problems with sleep seen in both generalised anxiety and major depressive disorder). Additionally, these conditions often present simultaneously when a person is triggered by an external stressor or stressors.

While clinicians can typically recognise one mental illness relatively easily, it’s much more difficult to recognise comorbid illness. They must pay careful attention to symptoms that could suggest other disorders such as bipolar disorder and look for other factors such as substance abuse. This requires time with the patient, possibly their families and other significant sources of information, and we know that the health care system today makes this level of assessment difficult, but not impossible.

Individuals with comorbid mental disorders often have a poorer treatment response and a worse course of illness over time (Kessler, 1995) therefore understanding why different disorders co-occur may prevent disorders from occurring where possible, increase treatment responses and to better help individuals and their families who are affected by comorbid mental disorders.

Unfortunately, most research today focuses on patients with one illness, and treatments are then guided by this research. In result, there are many well-researched treatments available for mental illnesses, but not for comorbid mental illnesses. There is a lot that we still need to understand about how we recognise and treat conditions when they present at the same time. If we do not take comorbidity into account when studying individual mental disorders, we may mistake characteristics of the disorder under study for those that are due to an ignored comorbid condition (Kessler, 1995).

More research is needed to fully understand why some patients experience comorbid conditions and others do not. Until then, it is important that those experiencing one, two or multiple mental illnesses engage in treatment early, and find a provider they can work with and understands that more than one illness can arise at one time. While treatment may have more challenges when dealing with comorbidity, success is possible Insha’Allah.

Have you ever given a thought to how someone could experience more than one mental health disorder at the same time?