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Taking Issue   |    
Referral for Medical Evaluation: An Ethical Obligation?
Glenn D. Grace, Ph.D., M.S.; Richard C. Christensen, M.D., M.A.
Psychiatric Services 2010; doi: 10.1176/appi.ps.61.1.3
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Many behavioral health providers might believe that medical illnesses capable of producing psychological disorders are rare and unlikely to be a significant issue in mental health treatment. However, studies of both inpatient and outpatient clinical samples indicate that an alarming number of patients have unrecognized medical illnesses that directly cause or contribute to their psychiatric symptoms. If these illnesses are unrecognized and untreated, dire health consequences may result.

From a best-practices perspective, it can be argued that a collaborative model of integrated primary and behavioral health care affords patients the greatest opportunity for optimal treatment and recovery. However, most systems that deliver behavioral health care are separated from primary care services by systemic and ideological chasms. Nevertheless, if a somatic illness is suspected to be an underlying cause of a psychiatric disorder, the mental health provider bears the responsibility of referring the patient for a more thorough medical evaluation.

We contend that referring all psychiatric patients with newly diagnosed and treatment-refractory disorders for a medical evaluation is more than good practice: it may be an ethical imperative. Ethical guidelines in all mental health disciplines share language that mandates providers to act in a patient's best interests while practicing within the boundaries of their professional competence. These ethical considerations should have an impact on every facet of a provider's clinical practice, including the decision to refer patients for medical evaluation.

We believe that an obligation to refer is especially true for mental health providers with no medical training, who, understandably, do not have the requisite knowledge of common medical illnesses that masquerade as psychological problems. Consequently, the risk of their missing general medical illnesses during client assessment and ongoing treatment is high. Thus nonmedical behavioral health specialists might view medical referral as an ethical obligation to promote patient welfare and to prevent potential harm. The obligation to refer may be particularly applicable in situations that involve patients who have newly diagnosed or treatment-resistant mental disorders. The obligation is considerably less when a person is being treated solely for work-related or relationship issues.

Psychiatrists and other medically trained providers may have greater latitude in the decision to refer for medical evaluation. However, medically trained mental health care providers should be ever mindful of the limits of their general medical competence and allow patient safety concerns to guide their referral decisions. Indeed, viewing the referral process as a clinical decision shaped by strong ethical concerns will help all clinicians to be more mindful of their abiding obligation to promote and protect the welfare of those who come under their care.

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