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INTRODUCTION

Multimorbidity in Health Psychology and Behavioral Medicine

Jerry Suls and Paige A. Green National Cancer Institute, Bethesda, Maryland

This special issue highlights the unique potential that health psychology�behavioral medicine has to dramatically contribute to understanding, prevention, and control of the growing prevalence of multi- morbidity (i.e., concurrent prevalence of more than 1 chronic health disease or condition in an individual). The 9 articles published here include 8 full, peer-reviewed articles and an invited commen- tary. Topics include relevance, measurement, mechanisms, and interventions for multimorbidity. Some articles survey relevant empirical literature, detail the representation of multimorbidity in behavioral intervention trials, or present new empirical data, whereas others present guidelines and system-level proposals to improve health care for patients with multiple health conditions. These articles offer proposals, challenges, and future directions for which health psychology�behavioral medicine is admirably suited to contribute to understanding multimorbidity and improving public health.

Keywords: comorbidity, multimorbidity, health psychology, chronic disease, behavioral medicine

This special issue of Health Psychology is devoted to the prob- lem of multimorbidity (i.e., concurrent prevalence of more than one chronic health condition in an individual). The number of Americans living with multimorbidity is projected to rise to 81 million by the year 2020 (Hoffman, Rice, & Sung, 1996). Aging, prolonged engagement in behaviors that cause multiple chronic diseases, and social determinants contribute to the risk for and increased population-level prevalence of multimorbidity (Barnett et al., 2012; King, Xiang, & Pilkerton, 2018; Marengoni et al., 2011; Suls, Green, & Davidson, 2016).

Biomedical and behavioral researchers often focus on a chronic condition and either exclude patients with multiple chronic condi- tions from study or consider nonindex conditions to be mere nuisance variables (Jadad, To, Emara, & Jones, 2011; Van Spall, Toren, Kiss, & Fowler, 2007). This tendency to overlook multi- morbidity diminishes the ecological validity of much of the re-

search. Conditions such as hypertension, arthritis, diabetes, depres- sion, and cancer tend to cluster in various combinations (Goodman, Posner, Huang, Parekh, & Koh, 2013; Prados-Torres, Calderón-Larrañaga, Hancco-Saavedra, Poblador-Plou, & van den Akker, 2014). Behavioral and psychosocial risk factors for multiple chronic diseases, such as smoking, alcohol abuse, poor diet, physical inactivity, and chronic stress, tend to cluster as well (Noble, Paul, Turon, & Oldmeadow, 2015). It is plausible that concurrent chronic health conditions do not merely produce an additive burden but interact, in some instances resulting in magnified effects. Polyphar- macy resulting from the medical management of multiple chronic conditions often contribute to compromised physical and psycholog- ical well-being (e.g., Uhlig et al., 2014).

In recent years, medicine and clinical epidemiology have begun to recognize the need for more study of multimorbidity (Academy of Medical Sciences, 2018; Parekh, Goodman, Gordon, Koh, & The HHS Interagency Workgroup on Multiple Chronic Condi- tions, 2011; Weiss et al., 2014). Health psychology and behavioral medicine were founded upon the inherent connection between psychological and physical disorders, but co-occurring physical health conditions have, for the most part, not been a primary concern. A better understanding of how the emergence and per- sistence of multiple chronic conditions affect, and are affected by, psychological, behavioral, biobehavioral, social, and environmen- tal factors is needed. Advances in multimorbidity research have the potential to transform research designs and methods, clinical prac- tices and health care delivery systems, public health and well- being, and health care financing policies. This special issue high- lights the potential for health psychology�behavioral medicine, along with epidemiology, clinical medicine, biomedicine, public health, and health policy, to dramatically improve multimorbidity prevention and control. This issue consists of eight peer-reviewed articles and an invited commentary that cover issues related to

Editor’s Note. This is an introduction to the special issue “Multimorbidity in Health Psychology and Behavioral Medicine Research.” Please see the Table of Contents here: http://psycnet.apa.org/journals/hea/38/9/.—KEF

Jerry Suls, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland; Paige A. Green, Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, National Cancer Institute.

The views and opinions expressed in this article are those of the authors and do not necessarily express the view of the National Institutes of Health or any other governmental agency.

Correspondence concerning this article should be addressed to Jerry Suls, Behavioral Research Program, 3E-138, MSC 9761, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD 20850. E-mail: [email protected]

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relevance, measurement, mechanisms, and interventions. Some of the articles review the relevant literature, other articles present new empirical data, and still others present guidelines and proposals to improve health care. The issue also includes a report on the representation of multimorbidity in randomized clinical trials (RCTs) of behavioral interventions and a perspective on how system-level changes in the provision of health services can pro- vide benefits to survivors with multiple conditions.

The first article (Suls, Green, & Boyd, 2019) considers the prevalence and challenges that multimorbidity poses and why the holistic perspective, methods, research, and training of health psychology�behavioral medicine can help meet these challenges. Some unresolved questions and a future research agenda for study of multimorbidity are then presented for three illustrative areas— etiology, prevention and self-management, and clinical care—to which health psychology can significantly contribute.

In the second article, Nicholson, Almirall, and Fortin (2019) review the literature on measurement of multiple concurrent conditions be- cause finding the appropriate measure, among the many available, has been a research impediment (Fortin, Stewart, Poitras, Almirall, & Maddocks, 2012). Nicholson et al. describe the available instruments and highlight their differences. Finally, they present measurement- selection guidelines that take study aims into account.

Friedman and Shorey (2019) describe how inflammation, which is common to many health conditions, might be considered as relatively disease nonspecific and a contributing mechanism for concurrent health conditions. Their discussion situates inflamma- tion in the context of social and psychological processes, which contribute to aging, adaptation to multimorbidity, and disability.

Birk and colleagues (2019) observe that depression frequently co-occurs with multiple chronic health conditions, but the temporal characteristics of these associations remain unclear: Depression may be a consequence of prior health conditions and also a risk factor for subsequent conditions. In Study 1, the researchers used network analysis to assess how prior diagnoses of commonly occurring chronic diseases are associated with current depression in a large, cross-sectional, population-based cohort (The 1995 Nova Scotia Health Survey; MacLean et al., 1996). Study 2 eval- uates the other temporal path—depression as a predictor of onset of prevalent chronic diseases—in a systematic scoping review. The evidence offers support for bidirectional effects. Both studies make a case for developing strategies for managing multimorbid dis- eases that include effective management of depression and more research about the pathways that contribute to depression’s being both a risk factor and a health consequence.

The fifth article (Xu, Mishra, & Jones, 2019) is an empirical report on the role of subclinical depression as a prospective risk factor for multiple health conditions in middle-aged women in the large, community-based Australian Longitudinal Study on Wom- en’s Health (Brown et al., 1999). After an onset of elevated depressive symptoms, women in the cohort had a fourfold inci- dence of multimorbidity even after adjusting for several health behavioral factors (e.g., physical activity, smoking status, alcohol intake). The authors recommend an integrated management ap- proach for the prevention of mental and physical multimorbidity.

Exercise can provide many health benefits for primary, second- ary, and tertiary prevention. However, until recently, exercise guidelines had been developed for healthy people or for patients with a single condition. Dekker, Buurman, and van der Leeden

(2019) describe the need for guidelines for patients with more than one chronic health condition to assure safety and effectiveness. Safety concerns, in particular, often prompt health care profession- als and patients to reduce quantity and quality of exercise to ineffective levels. Dekker et al. present a narrative review of applications of exercise to the patient with concurrent conditions. Their review is followed by a description of four principles for the development of exercise guidelines that assures safety and effec- tiveness for such patients.

Randomized clinical trials targeting particular chronic conditions, like cancer, often exclude patients who also have other health condi- tions, to maximize internal validity, which invariably compromises the trial’s external validity (e.g., Beaver, Ison, & Pazdur, 2017; Kronish et al., 2018). One reason for the exclusion is often that intervention (e.g., surgery, medication, medical device) may confer side effects that exacerbate other conditions the patient is experienc- ing. Stoll et al. (2019) consider whether individuals with multimor- bidity tend to be excluded from health-relevant behavioral trials, because such trials often have low-risk profiles. In a systematic review of primary outcome reports published between 2000 and 2014, Stoll and colleagues analyze the representation of patients with multiple chronic conditions in health-relevant behavioral RCTs. Their analysis reveals a common exclusion of multimorbidity in behavioral trials that limits generalizability and challenges the relevance of trial out- comes. The authors conclude there is an important need to expand eligibility criteria of health-relevant behavioral clinical trials to in- clude individuals who represent phenotypic complexities of those who experience high chronic disease burden.

Spring, Stump, Penedo, Pfammatter, and Robinson (2019) de- scribe how care of patients with co-occurring conditions, such as cancer and cardiometabolic diseases, can be improved by integrat- ing health promotion into existing posttreatment and long-term follow-up care services. Currently, the health care system has gaps in the provision of coping strategies and delivery of services. Patients with multiple conditions are a special challenge because they may be treated by several medical specialists. Spring et al. advocate that health care teams include a health promotionist who uses mobile technologies to track health behaviors, mood, and so forth; integrates behavioral risk factor vital signs from the elec- tronic health record; and is supervised by experts in health behav- ior change. This innovative approach has the potential to create a connected care system for health lifestyle improvement.

The special issue concludes with a commentary by Arlene Bierman (2019), who is the director of the Center for Evidence and Practice Improvement at the Agency for Health Care Research and Quality. She is a general internist, geriatrician, and health services researcher whose work has focused on improving access, quality, and outcomes of health care for older adults with chronic illness in disadvantaged populations.

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Received May 12, 2019 Accepted May 15, 2019 �

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771MULTIMORBIDITY AND HEALTH PSYCHOLOGY