The Rectangular Curve and Psychiatric Care

By Rodrigo Muņoz, M.D.
APA President

Those who have followed the research by Fries and his associates at Stanford University over the last two decades are aware of the paradox in this column's title.

"The compression-of-morbidity hypothesis says that, in modern populations with relatively low mortality rates, the effect of preventive measures will be greater on age-adjusted disability (morbidity) than on age-adjusted mortality, leading to decreased cumulative lifetime disability (morbidity)," state Fries and his associates in the August 13 issue of the New England Journal of Medicine.

In research published in the April 9 issue of that same journal, the Stanford group found that in low-risk individuals disability was delayed by more than five years, cumulative disability decreased through the age of 75, and disability in the year before death was markedly reduced. High-risk persons are defined as those who exercise less, smoke, are overweight, have high blood pressure, or have other risk factors often associated with heart disease.

These findings, which could help many to realize the ancient desire to live long and die feeling young, have marked implications for social and financial planning associated with preventive medicine. This is the intersection at which geriatric psychiatrists and all other psychiatrists can work together to help ensure that our aging population remains healthy as long as possible. Not only does this benefit an important segment of our population but it also conserves scarce medical and social resources.

As many studies have repeatedly shown, lower socioeconomic status is probably the most powerful single contributor to premature morbidity and mortality. Evidence has shown that smoking, excessive alcohol consumption, high body-mass index, and a sedentary lifestyle may account for only a third of the excess mortality associated with lower socioeconomic status. What are the other factors? Psychiatrists dealing with different populations may combine efforts to clarify them.

• Child psychiatrists may point to the effects of perinatal injuries, brain dysfunction, learning disabilities, and low intellectual performance and their link to decreased earning power, increased morbidity, and early death. Studies of high intellectual output as a protective barrier against early Alzheimer's disease are also of interest.



• Adult psychiatrists may want to focus on violence, hostility, isolation, and depression as likely causes of early decline among older persons. The study by Pennix and her associates at the National Institute on Aging, which appeared in the June 3 issue of the Journal of the American Medical Association, provides evidence that older patients who report depressive symptoms are at higher risk of physical decline earlier than otherwise would have been the case.



• Geriatric psychiatrists not only study the link of early insult to morbidity and mortality but also the effects of declining morbidity in creating a population of older healthy individuals who want to and can remain in the community far longer than their the generation or two just ahead of them. The challenge for all psychiatrists is to understand and integrate in our practices the new psychiatry emerging from having to serve an increasingly older and more vital population.

Dr. Dilip Jeste and his colleagues in geriatric psychiatry have done much to enhance the lives of our patients, our understanding of all mental illness, and our optimism about remaining healthy well into old age. I thank him for leading APA's initiative in geriatric psychiatry.