Outlook: Newsletter of the Society of Behavorial Medicine

Fall 2019

Five Important Points about Multimorbidity Behavioral Scientists Should Know

Tammy Stump, Multimorbidities SIG Chair ‚úČ

More than 50% of adults in the United States suffer from multimorbidity - the co-occurrence of two or more chronic conditions.1 In a recent issue of Health Psychology, researchers, including several members of the Multimorbidities SIG, focused on the issue of multimorbidities in health psychology and behavioral medicine. Their articles highlight several points about multimorbidity that warrant broad consideration by behavioral medicine researchers:

1. Depression is a risk factor for multimorbidity. Depression is a common diagnosis among those with multiple chronic physical conditions. New epidemiological data among Australian women showed that developing elevated depressive symptoms led to a four-fold increase in the odds of subsequently developing multimorbidity.2 Similarly, Birk et al. (2019)* found that depression prospectively predicted the development of ischemic heart disease and diabetes.3

2. Health behavior guidelines may need to be tailored for multimorbidity. Behavior change efforts among those with multimorbidity may require a greater degree of individual monitoring and tailoring than is necessary for healthy populations. In the case of exercise, Dekker, Buurman, and van der Leeden (2019)* recommend the following principles for encouraging exercise among those with multimorbidity: 1) Rigorously assess health status prior to exercise initiation, 2) Make adaptations to ensure safety, 3) Use behavior change strategies to encourage adherence, and 4) Employ advanced clinical reasoning skills to make recommendations for the individual patient.4

3. A broad range of measures of multimorbidity are available. Due to the high prevalence of multimorbidity, epidemiological and intervention studies should routinely assess multimorbidity. Nicholson, Almirall, and Fortin (2019) summarized measures of multimorbidity - broadly divided into list measures, which generate a count of number of chronic conditions, and weighted measures, in which the multimorbidity index score is weighted based on both the presence of conditions and their severity. Nicholson et al. encourage researchers to form an operational definition of multimorbidity that is most suitable for their research question in order to guide measurement selection.5

4. Individuals with multimorbidity are often excluded from clinical trials. Through a review of 600 behavioral health interventions, Stoll et al. (2019)* reveal that multimorbidity is not only rarely evaluated as an intervention moderator, it is often used as an exclusion criterion (as was the case in 68.3% of the interventions reviewed). Thus, there is a limited evidence base supporting the use of behavioral interventions, including simultaneously or sequential interventions, to address health behaviors among those with multimorbidity.6

5. Current healthcare systems often fail to promote health behavior change for those with multimorbidities. Considering the specific case of multimorbidities involving cancer and cardiovascular disease, Spring et al. (2019)* discussed the systems level factors that may lead to this population failing to receive behavioral health promotion recommendations or advice. To address the challenge of multiple health providers – each with limited time and limited expertise in health behavior change – Spring et al. propose greater integration of behavioral data in electronic health record as well as the increased use of paraprofessional health promotionists.7

*Denotes article with at least one author from the Multimorbidities SIG



  1. King, D. E., Xiang, J., & Pilkerton, C. S. (2018). Multimorbidity Trends in United States Adults, 1988–2014. The Journal of the American Board of Family Medicine, 31, 503-513.
  2. Xu, X., Mishra, G. D., & Jones, M. (2019). Depressive symptoms and the development and progression of physical multimorbidity in a national cohort of Australian women. Health Psychology, 38, 812-821.
  3. Birk, J. L., Kronish, I. M., Moise, N., Falzon, L., Yoon, S., & Davidson, K. W. (2019). Depression and multimorbidity: Considering temporal characteristics of the associations between depression and multiple chronic diseases. Health Psychology, 38, 802-811.
  4. Dekker, J., Buurman, B.M. and van der Leeden, M., 2019. Exercise in people with comorbidity or multimorbidity. Health Psychology, 38, 822-830.
  5. Nicholson, K., Almirall, J., & Fortin, M. (2019). The measurement of multimorbidity. Health Psychology, 38, 783-790.
  6. Stoll, C. R., Izadi, S., Fowler, S., Philpott-Streiff, S., Green, P., Suls, J., ... & Colditz, G. A. (2019). Multimorbidity in randomized controlled trials of behavioral interventions: A systematic review. Health Psychology, 38, 831-839.
  7. Spring, B., Stump, T. K., Penedo, F., Robinson, J. (2019) Toward a health-promoting system for cancer survivors: Patient and provider multiple behavior change. Health Psychology, 38, 840-850.