Indian Journal of Mental Health and Neurosciences IJMHNS Indian Journal of Mental Health and Neurosciences IJMHNS 2581-9445 Indian Psychiatric Society - Tamil Nadu 10.32746/ijmhns.2021.v4.i1.34 Original Article Prevalence of Physicalcomorbiditiesamong Long-Term Psychiatric Inpatients: A Single Centre Study from South India Narmadha V 1 Akshaya A 2 Poornachandrika P 3 Raghavan Vijaya 4 Junior Resident, Institute of Mental Health, Madras Medical College, Chennai, Tamilnadu, India Junior Resident, Institute of Mental Health Madras Medical College Chennai Tamilnadu India Psychology Intern, Schizophrenia Research Foundation, Chennai, Tamilnadu, India Psychology Intern, Schizophrenia Research Foundation Chennai Tamilnadu India Professor of Psychiatry and Director (FAC), Institute of Mental Health, Madras Medical College, Chennai, Tamilnadu, India Professor of Psychiatry and Director (FAC), Institute of Mental Health Madras Medical College Chennai Tamilnadu India Consultant Psychiatrist – Research, Schizophrenia Research Foundation, Chennai, Tamilnadu, India Consultant Psychiatrist – Research, Schizophrenia Research Foundation Chennai Tamilnadu India Address for Correspondence: Dr. P. Poornachandrika, Professor of Psychiatry, Madras Medical College and Director (FAC), Institute of Mental Health, Kilpauk, Chennai 600010, Tamilnadu, India. E-mail: pcmddm@ gmail.com

Running Title: Physical comorbidities among long-term psychiatric inpatients

Narmadha V, Akshaya A, Poornachandrika P, Vijaya Raghavan. Prevalence of physical comorbidities among long-term psychiatric inpatients: A single centre study from South India. Indian Journal of Mental Health and NeuroSciences.2020;4(l): PP 3-9

 04 09 2025 2024 4 1 3 9 01 07 2024 01 07 2024 Copyright © 2024 Indian Psychiatric Society — Tamil Nadu Branch 2024 Indian Psychiatric Society — Tamil Nadu Branch This is an open access article distributed under the terms of the Creative Commons license. ABSTRACT Background:

Physical comorbidities are the most common causes of early mortality among patients with mental disorders. Prevention and early treatment of physical comorbidities would lead to better outcomes. Hence, the aim to the study was to estimate the prevalence of physical health disorders present as comorbidities among long-term stay psychiatric inpatients and to compare the difference in the physical comorbidities among male and female patients.

 Materials and Methods:

The study was conducted at Institute of Mental Health, Madras Medical College, Chennai. It was a descriptive study combining data from clinical files and nursing records related to the physical health of the long-term inpatients. The clinical records of long-term inpatients, defined as the duration of stay in the care facility for more than 5 continuous years between Ist January and 30th June, 2019 were assessed.

 Results:

The estimated prevalence was74.2% (95% CI: 69.5-78.6) for at least one physical disorder comorbidity and 38.8% (95% CI: 33.8-43.9) had more than one physical comorbidities. Female in-patients have 2.7 times higher risk than males to have diabetes mellitus, hypertension and thyroid disorders. They also have 0.92 times higher risk than males to have anaemia.

 Conclusion:

There is a high prevalence of physical comorbidities among long term psychiatric inpatients. Systems for the early detection and better clinical management of these physical comorbidities are essential in any long-term psychiatric facility.

 Keywords: mental illness physical disorders comorbidities inpatients chronic diabetes hypertension INTRODUCTION

It remains a challenge to maintain physical health in the presence of severe mental illness, globally.1, 2 This might be more pronounced among patients with psychiatric illness in long-term care facilities due to the various factors including lack of regular monitoring, reduced physical health promotion activities and inadequate self-report by the patients.3

While physical health issues are prevalent in the general population as well, the impact on people with severe mental illness are significantly greater.4 Moreover, it has established that patients with severe mental disorders have an age-adjusted higher mortality when compared with the general population; the life span of these patients is nearly 15-20 years less than the normal population.5,6,7 The major cause of excess and early mortality among patients with severe mental disorders is due to physical disorders such as cardiovascular diseases, respiratory diseases and infections.4

Various biological, psychological and social risk factors, through their interplay, lead to these poor physical health and physical health disorders among patients with severe mental disorders. For psychiatric in-patients, and in particular for long-term psychiatric in-patients, the challenge of maintaining physical health often relates to various factors, including inadequate monitoring of their physical problems, inadequate self-report by the patients themselves of physical symptoms due to severe psychopathology or cognitive impairment, pre-existing genetic vulnerability and adverse effects of the antipsychotic medications.8,9

Previous studies from the western parts of the world have examined the prevalence of physical comorbidities among long-term stay patients. In a study, the prevalence of physical morbidity in elderly psychiatric patients was observed to be nearly 75%.10 Similarly, Fisher et al., found that 84%oflong-stay psychiatric inpatients had any medical condition with high prevalence of obesity (31%), serious respiratory problems (24%), hypertension (17%), cardiovascular problems (17%) and diabetes mellitus (14%).11 The common comorbid medical conditions are found to be heart failure, vitamin D deficiency, falls, diabetes mellitus, blood pressure, anaemia, clinical nutrition, pressure ulcers, clostridium difficile infection, and insomnia.12 A substantial number of patients suffered from more than one medical condition, highlighting the multi-morbidity status among patients with severe mental illness.

Though physical disorder comorbidities among patients with mental disorders have been studied in India, most of the studies were conducted at the outpatient department with few studies done with inpatients. But, to our knowledge, no study from India has examined the physical health comorbidities among patients with mental disorders as long-term in-patients in a large psychiatric institution. Hence, the aim of the study was to estimate the prevalence of physical health disorders present as comorbidities among patients with mental illness with a long-term stay as in-patients and to compare the difference in the physical comorbidities among male and female patients.

 MATERIALS AND METHODS Study setting

The study was conducted at Institute of Mental Health, Madras Medical College, Chennai. Institute of Mental Health (IMH) is one of the oldest and largest mental health institutions in South India with 1500 beds, rendering specialist psychiatric services to a large geographical catchment area, including Tamilnadu, Andhra Pradesh and Puducherry. Other than general and specialist psychiatric outpatient and acute inpatient services, IMH also provides long-term stay for patients with severe mental illness who are destitute, from other parts of the country who are not able to be reunited with their family members and with severe psychopathology. To note, historically, IMH has long been functioning as an asylum for the care of patients with severe mental illness. Institutional ethical committee approval was obtained before the start of the study.

 Study design

The study was a descriptive study combining data from the clinical file, regular nursing records and other statistics related to the physical health of the long-term inpatients in Institute of Mental Health.

 Study participants

For the purpose of the study, the long-term stay in the institution was defined as for five or more years continuously, though previous studies had a lesser time limit.11 The case records of long-term inpatients in Institute of Mental Health between 1 January and 30 June 2019, were included in the study after checking for the inclusion and exclusion criteria. Inclusion criteria were: 1. Persons with mental illness in the psychiatric inpatient facility; 2. Both gender; 3. Duration of stay of the inpatient care continuously for more than 5 years. Exclusion criteria were: 1. Patients with criminal status; 2. Case records of the patients which were incomplete or needed information not available.

 Data collection and management

Semi-structured proforma was developed to capture the relevant data pertaining to the demographic, clinical, anthropometric and physical health issues variables was prepared, pretested and finalized with suitable modifications. Researcher (VN1), with the help of the nursing staff, identified and sorted the case records based on the inclusion and exclusion criteria. Case records with incomplete data were excluded. The data on all physical health problems were recorded onto study-specific data sheets. Individual patients’ physical-health data – recorded from a number of different sources – was integrated with their demographic and clinical data.

 Statistical analysis

The statistical analysis was done using SPSS 16.0. Discrete variables were represented as frequencies and percentages, while the continuous variables were represented as mean and standard deviation. The prevalence estimates were calculated using OpenEpi.l3Comparison between the groups were done using chi-square test for discrete variables and t-test for continuous variables. Odds ratio was calculated with 95% CI to examine the risk of various disorders between male and female patients. Statistical significance was set at p<0.05.

 RESULTS Socio-demographic and clinical profile of the study participants:

Socio-demographic profile of the study participants is described in Table 1. The mean age of the study participants was 52.2 ± 11.7 years with 171 males and 182 females.53% of the sample had a diagnosis of severe mental disorder and 46% of the sample had mental retardation diagnosis. The average duration of stay in the care facility was 17.3 years.

Demographic and clinical characteristics of the study participants (N = 353)
Variable Mean±SD; n (%)
Age 52.2 ± 11.7
Gender
Male 171 (48.4)
Female 182 (51.6)
Duration of stay 17.3 ± 10.7
Locality
Tamil Nadu 154 (43.6)
Other state 199 (56.4)
Diagnosis
Severe mental disorders 187 (53)
Mental retardation 166 (47)
BMI
Total 20.9 ± 4.9
Male 19.2 ± 3.8
Female 22.4 ± 5.2
Prevalence of physical disorder comorbidities among the study participants and comparison between gender:

Table 2 depicts the prevalence of physical disorder comorbidities among the long-term stay patients and the comparison of the prevalence among males and females. The estimated prevalence was 74.2% (95% CI: 69.5- 78.6) for at least one physical disorder comorbidity and 38.8% (95% CI: 33.8-43.9) had more than one physical comorbidity. The most common physical comorbidities were diabetes mellitus, seizure disorder and anaemia. Less common comorbidities seen in the patients were COPD, varicose vein, hydrocele, CSOM, hernia, uterine prolapse and benign breast lesions.

Prevalence of physical health comorbidities among the study participants and comparison between gender
Variable TotalN (%)(N = 353) MaleN (%)(N = 171) FemaleN(%)(N = 182) p Oddsratio(95% CI)
Physical Comorbidity
No 91 (25.8) 95% CI: 21.4-30.5
At least one 262 (74.2) 95% CI: 69.5-78.6
Two and above 137 (38.8) 95% CI: 33.8-43.9
Diabetes mellitus
Yes 131 (37.1%) 43 (25.1%) 88 (48.4%) 0.00* 2.7(1.7 to 4.3)
No 222 (62.9%) 128 (74.9%) 94(51.6%)
Hypertension
Yes 51 (14.4%) 16 (9.4%) 35(19.2%) 0.01* 2.3(1.2 to 4.3)
No 302 (85.6%) 155 (90.6%) 147 (80.8%)
Seizure disorder
Yes 74 (21%) 40 (23.4%) 34 (18.7%) 0.29 0.75(0.45 to 1.2)
No 279 (79%) 131 (76.6%) 148 (81.3%)
Thyroid disorders
Yes 35 (9.9%) 1 (0.6%) 34 (18.7%) 0.00* 39.05 (5.2 to 288.7)
No 318 (90.1%) 170 (99.4%) 148 (81.3%)
Fracture
Yes 38 (10.8%) 15 (8.8%) 23 (12.6%) 0.15 1.5(0.75 to 2.9)
No 315 (89.2%) 156 (87.4%) 159(87.4%)
Anaemia
Yes 122 (34.6%) 52 (30.4%) 70 (38.5%) 0.17 0.920.65 to 1.1)
No 231 (65.4%) 119 (69.6%) 112 (61.5%)

* p<0.05

Results indicate that female in-patients had 2.7 (95% CI: 1.7-4.3; p<0.001) times higher risk of diabetes mellitus and 2.3 (95% CI: 1.2-4.3; p= 0.01) times higher risk for hypertension when compared with males. Thyroid disorders are significantly higher in females than males (95% CI: 39.05 (5.2 to 288.7); p<0.001).

 DISCUSSION

The aim of the study was to estimate the prevalence of physical disorders as comorbidities among patients with severe mental disorders in long-term stay in a tertiary care institution and the differences among gender.

The results indicate that nearly 75% of the patients with long-stay had at least one physical disorder comorbidity along with severe mental illness. This is similar with the findings from other studies which had wide variations.

While some studies have observed the prevalence to be higher than 70%,9,11,14 others have reported lower estimates.15,16,17 This difference in the estimated prevalence of physical comorbidities among long-term stay patients with psychiatric patients in various studies could be due to the differences in the age composition of the study participants, general population prevalence of physical disorders in the study region and preventative measures put in place by the facilities to reduce physical comorbidities.

Similarly, the high prevalence of nearly 39% of the participants having more than one physical comorbidity is similar with other studies. Various reasons could contribute to this multi-morbidity of physical and mental disorders. From the biological perspective, evidence from the genome-wide association studies (GWAS) has highlighted the fact that many genes implicated in the physical disorders such as metabolic syndrome, diabetes and cardiovascular diseases are also found to play roles in the pathogenesis or course of mental disorders. This shared genetic vulnerability could lead to the emergence of both physical and mental disorders concurrently. For example, leptin gene has been implicated in metabolic diseases like obesity and diabetes mellitus and it’s role has also been studied in mood disorder, neurodegenerative disorder and psychosis.18,19 Also psychosocial factors such as behavioural risk factors among patients with severe mental disorders play a role in the high prevalence of physical disorders in them. Important behavioural risk factors observed in patients with severe mental illness are smoking, sedentary life, poor nutrition and lack periodic physical health assessments.20,21,22,23

The comparison of the physical disorders by gender among patients with severe mental illness had shown that important risk factors of cardiovascular diseases such as body mass index (BMI), diabetes and hypertension were significantly more among the females than males, by nearly 2.5-3.5 times. This increased risk for females could be due to multiple reasons. For instance, studies have shown that antipsychotic drugs administered to females have an impact on their prolactin levels, which is a multifunctional hormone involved in regulating insulin sensitivity and blood glucose stability. It also helps in regulating metabolism and immune regulation. A study shows a shift from risperidone to olanzapine in females lead to significant decrease in prolactin levels.24

Body weight has been shown to change in any direction in patients with severe mental illness. Although patients on long-term antipsychotic treatment have mostly been demonstrated to gain weight, the opposite has also been found, indicating the need for personal follow-up of patients. Obesity among psychiatric inpatients has been ascribed to psychiatric settings that contribute to obesity through increased energy intake and reduced energy expenditure.

The present study indicates a high prevalence of hypertension and diabetes and high multi-morbidity among patients with mental illness who are in a long-term stay with mental health facility. Physical multi-morbidity is commonly seen in patients with severe mental illness,25,26,27 which are all individual risk factors to cardiovascular disorders. Since this population is at high risk, there is an urgent need to optimize care management of physical illness in patients with severe mental illness in long-stay facilities. At present, the main challenge is to achieve coordinated care from different medical specialists so that an integrated mental and physical health care system becomes available. Access to and quality of health care is insufficient as reflected by low rates of screening, monitoring and treatment of cardiometabolic risk factors in this category of patients.28 It opens up areas for further research on association of physical illness and mental illness, its impact on the clinical and functional outcomes and quality of life among patients with severe mental illness in long-term stay facilities.

Major limitations of the study are: 1. Single centre study though such large centres providing care for long-term stay for patients with mental illness are few in India; 2. A relatively smaller sample size to estimate the prevalence of different comorbidities; 3. Collection of physical health data from the clinical files and nurse’s reports; 4. Other physical comorbidities such as infection, falls and aggression among long term psychiatric patient are not included.

 CONCLUSION

High prevalence of physical comorbidity/multimorbidity is observed among long-stay patients with mental illness in psychiatric facilities. As these physical comorbidities are risk factors for cardiovascular disorders leading to high mortality and morbidity, it is imperative that systems to detect and prevent these risk factors early will have a positive impact on the patients with mental illness.

 Acknowledgement

We like to thank the institution for providing us the permission to access the case files of the long-stay patients and the nursing staff for their time and energy in helping us with identification and sorting of the case files.

 Source of funding

This research has not received specific financial grant from any funding agency in the public, commercial or not-for-profit sectors

 Conflict of interest

The authors have declared no conflict of interest with respect to the research, authorship, and/or publication of this article.

 REFERENCES 1 Nakagawa A, Grunebaum MF, Endo Y, et al. Prospective study of falls in long-term inpatients with chronic psychotic disorders. Schizophrenia Research. 2006;l(88):283-285 Nakagawa A Grunebaum MF Endo Y Prospective study of falls in long-term inpatients with chronic psychotic disorders Schizophrenia Research 2006 1 88 283 285 2 Rothbard AB, Blank MB, Staab JP, et al. Previously undetected metabolic syndromes and infectious diseases among psychiatric inpatients. Psychiatric Services. 2009;60(4):534-537 Rothbard AB Blank MB Staab JP Previously undetected metabolic syndromes and infectious diseases among psychiatric inpatients Psychiatric Services 2009 60 4 534 537 3 Ludwick J & Oosthuizen P. Screening for and monitoring of cardio-metabolic risk factors in outpatients with severe mental illness in a primary care setting. African Journal of Psychiatry. 2009;12(4):287-292 Ludwick J Oosthuizen P Screening for and monitoring of cardio-metabolic risk factors in outpatients with severe mental illness in a primary care setting African Journal of Psychiatry 2009 12 4 287 292 4 De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(l):52-77 De Hert M Correll CU Bobes J Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care World Psychiatry 2011 10 1 52 77 5 de Mooij LD, Kikkert M, Theunissen J, et al. Dying Too Soon: Excess Mortality in Severe Mental Illness. Frontiers in Psychiatry. 2019;10.855 de Mooij LD Kikkert M Theunissen J Dying Too Soon: Excess Mortality in Severe Mental Illness Frontiers in Psychiatry. ;10 2019 10 855 6 Saxena S. Excess mortality among people with mental disorders: a public health priority. The Lancet Public Health. 2018;3(6):e264-e265 Saxena S Excess mortality among people with mental disorders: a public health priority The Lancet Public Health 2018 3 6 e264 e265 7 Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. 2015;72(4):334-341 Walker ER McGee RE Druss BG Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis JAMA Psychiatry 2015 72 4 334 341 8 Fleck MPdA, Wagner L, Wagner M, et al. Long-stay patients in a psychiatric hospital in Southern Brazil. Revista de Saude Publica. 2007;41(l):124-130 Fleck MPdA Wagner L Wagner M Long-stay patients in a psychiatric hospital in Southern Brazil Revista de Saude Publica 2007 41 1 124 130 9 Kruger C. Vulnerable long-term psychiatric inpatients need screening for physicalhealth problems: An audit of regular hospital statistics and clinical files. African Journal of Psychiatry. 2012;15(3):176-184 Kruger C Vulnerable long-term psychiatric inpatients need screening for physicalhealth problems: An audit of regular hospital statistics and clinical files African Journal of Psychiatry 2012 15 3 176 184 10 Adamis D, Ball C. Physical morbidity in elderly psychiatric inpatients: prevalence and possible relations between the major mental disorders and physical illness. International Journal of Geriatric Psychiatry. 2000;15(3):248-253 Adamis D Ball C Physical morbidity in elderly psychiatric inpatients: prevalence and possible relations between the major mental disorders and physical illness International Journal of Geriatric Psychiatry 2000 15 3 248 253 11 Fisher WH, Barreira PJ, Geller JL, et al. Long-stay patients in state psychiatric hospitals at the end of the 20th century. Psychiatric Services. 2001;52(8):1051-1056 Fisher WH Barreira PJ Geller JL Long-stay patients in state psychiatric hospitals at the end of the 20th century Psychiatric Services 2001 52 8 1051 1056 12 Messinger-Rapport BJ, Morley JE, Thomas DR, et al. Intensive session: New approaches to medical issues in long-term care. Journal of the American Medical Directors Association. 2007;8(7):421-433 Messinger-Rapport BJ Morley JE Thomas DR Intensive session: New approaches to medical issues in long-term care Journal of the American Medical Directors Association 2007 8 7 421 433 13 Dean A, Sullivan K, Soe M. OpenEpi: open source epidemiologic statistics for public health, version 2.3.1. 2013 Dean A Sullivan K Soe M OpenEpi: open source epidemiologic statistics for public health, version 2.3.1 2013 14 Placentino A, Rillosi L, Papa E, et al. Clinical characteristics in long-term care psychiatric patients: A descriptive study. The World Journal of Biological Psychiatry. 2009;10(l):58-64 Placentino A Rillosi L Papa E Clinical characteristics in long-term care psychiatric patients: A descriptive study The World Journal of Biological Psychiatry 2009 10 1 58 64 15 Koranyi EK. Morbidity and rate of undiagnosed physical illnesses in a psychiatric clinic population. Archives of General Psychiatry. 1979;36(4):414-419 Koranyi EK Morbidity and rate of undiagnosed physical illnesses in a psychiatric clinic population Archives of General Psychiatry 1979 36 4 414 419 16 Marshall HES. Incidence of physical disorders among psychiatric in-patients. British Medical Journal. 1949;2(4625):468-470 Marshall HES Incidence of physical disorders among psychiatric in-patients British Medical Journal 1949 2 4625 468 470 17 Perry DW, Milner E, Krishnan V. Physical morbidity in a group of patients referred to a psychogeriatric unit; A 6-month prospective study. International Journal of Geriatric Psychiatry. 1995;10(2):151-154 Perry DW Milner E Krishnan V Physical morbidity in a group of patients referred to a psychogeriatric unit; A 6-month prospective study International Journal of Geriatric Psychiatry 1995 10 2 151 154 18 Endomba FT, Tankeu AT, Nkeck JR, et al. Leptin and psychiatric illnesses: does leptin play a role in antipsychotic-induced weight gain? Lipids in Health and Disease. 2020;19(l):l-12 Endomba FT Tankeu AT Nkeck JR Leptin and psychiatric illnesses: does leptin play a role in antipsychotic-induced weight gain? Lipids in Health and Disease 2020 >19 l l 12 19 Zou X, Zhong L, Zhu C, et al. Role of leptin in mood disorder and neuro degenerative disease. Frontiers in Neuroscience. 2019;13:378 Zou X Zhong L Zhu C Role of leptin in mood disorder and neuro degenerative disease Frontiers in Neuroscience 2019 13 378 20 Baller JB, McGinty EE, Azrin ST, Juliano-Bult D, Daumit GL. Screening for cardiovascular risk factors in adults with serious mental illness: a review of the evidence. BMC Psychiatry. 2015;15:55 Baller JB McGinty EE Azrin ST Juliano-Bult D Daumit GL Screening for cardiovascular risk factors in adults with serious mental illness: a review of the evidence BMC Psychiatry 2015 15 55 21 Caneo C. Managing cardiovascular disease risk in patients with severe mental illness. The Lancet Psychiatry. 2018;5(2):97-98 Caneo C Managing cardiovascular disease risk in patients with severe mental illness The Lancet Psychiatry 2018 5 2 97 98 22 Dalcin AT, Jerome GJ, Appel LJ, et al. Need for cardiovascular risk reduction in persons with serious mental illness: design of a comprehensive intervention. Frontiers in Psychiatry. 2019;9:786 Dalcin AT Jerome GJ Appel LJ Need for cardiovascular risk reduction in persons with serious mental illness: design of a comprehensive intervention Frontiers in Psychiatry 2019 9 786 23 De Hert M, Detraux J, Vancampfort D. The intriguing relationship between coronary heart disease and mental disorders. Dialogues in Clinical Neuroscience. 2018;20(l):31-40 De Hert M Detraux J Vancampfort D The intriguing relationship between coronary heart disease and mental disorders Dialogues in Clinical Neuroscience 2018 20 1 31 40 24 Kim K-S, Pae C-U, Chae J-H, et al. Effects of olanzapine on prolactin levels of female patients with schizophrenia treated with risperidone. The Journal of Clinical Psychiatry. 2002;63(5):408-413 Kim K-S Pae C-U Chae J-H Effects of olanzapine on prolactin levels of female patients with schizophrenia treated with risperidone The Journal of Clinical Psychiatry 2002 63 5 408 413 25 Ajmera M, Wilkins TL, Findley PA, et al. Multimorbidity, mental illness, and quality of care: preventable hospitalizations among medicare beneficiaries. International Journal of Family Medicine. 2012:2012:823294 Ajmera M Wilkins TL Findley PA Multimorbidity, mental illness, and quality of care: preventable hospitalizations among medicare beneficiaries International Journal of Family Medicine 2012 2012 823294 26 Gray R, Hughes E, Bressington D. Multimorbidity in people with mental illness: translating evidence to practice. Journal of Psychiatric and Mental Health Nursing. 2016;23(5):245-246 Gray R Hughes E Bressington D Multimorbidity in people with mental illness: translating evidence to practice Journal of Psychiatric and Mental Health Nursing 2016 23 5 245 246 27 Woodhead C, Ashworth M, Schofield P, et al. Patterns of physical co-/multi-morbidity among patients with serious mental illness: a London borough-based cross-sectional study. BMC Family Practice. 2014;15:117 Woodhead C Ashworth M Schofield P Patterns of physical co-/multi-morbidity among patients with serious mental illness: a London borough-based cross-sectional study BMC Family Practice 2014 15 117 28 De Hert M, Cohen D, Bobes J, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry. 2011;10(2):138-151 De Hert M Cohen D Bobes J Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level World Psychiatry 2011 10 2 138 151

Copyright © 2024 Author(S). The copyright for articles published in this issue is retained by the author(S) and assign the publisher Indian Psychiatric Society – Tamil Nadu Branch, a non-exclusive licence to publish the article and be cited as its original publisher in case of reuse, and to distribute it in all forms and media. Publisher and source must be acknowledged and a link must be made to the article’s DOI. The Creative Commons Attribution 4.0 International License (CC-BY-4.0) shall apply to all articles published in Indian Journal of Mental Health and Neurosciences.