To the Editor: We strongly agree with the conclusions and recommendations of Rothbard and colleagues' study (1) in the April issue that there are high rates of undiagnosed general medical illnesses among psychiatric inpatients and that routine testing for such illnesses is needed. However, implications of general medical screening of all psychiatric patients, especially outpatients with newly diagnosed mental disorders, were not explored. The onset of a mental disorder signals an important change in overall health status and may indicate an underlying general medical disorder that is causing or, at the very least, contributing to the patient's symptoms.
Although Rothbard and colleagues examined inpatients, other studies that included outpatients found similar results—that comorbid general medical illnesses are often unrecognized and either directly cause or exacerbate psychological symptoms (2,3). In fact, conservative estimates suggest that up to 10% of all psychological symptoms may be driven by general medical causes (4). Together, these findings suggest that a significant percentage of persons with a recent diagnosis of a new-onset psychiatric disorder may benefit from screening for general medical illnesses.
In our collective experience, mental health providers vary greatly in how often they refer patients for medical evaluation. Although many routinely refer patients for a comprehensive or focused medical evaluation, a large number rarely or never request that patients schedule a medical checkup. Perhaps the most widely accepted recommendation is that each patient be assessed individually for his or her risk of having a medical condition and, only then, be referred for a medical evaluation. However, this approach ignores the reality of our mental health system. Often the individual making the initial diagnosis and treatment plan is a behavioral health specialist with no medical training. Many of these clinicians are unable to recognize signs and symptoms of the most common medical illnesses that produce psychological symptoms (5). Because they lack training, they understandably do not possess the knowledge and skills necessary to assess whether their patients warrant a medical evaluation.
All mental health providers, regardless of their professional background, can easily employ the straightforward recommendation of directing their patients to schedule a medical evaluation with a primary care provider. In some cases, a recent evaluation—within the past six to 12 months—may suffice.
Medically trained mental health providers should consider the costs and benefits of recommending a medical evaluation for each patient with a newly diagnosed mental disorder and refer accordingly. However, to ensure patient safety, clinicians with no medical training would be well advised to refer for medical evaluation their adult patients with newly diagnosed mental disorders.
All clinicians should consider the possibility that their patients may be experiencing the effects of a general medical disorder that is masquerading as a constellation of psychological symptoms. Increasing referrals for medical screenings would not only result in the diagnosis of previously unrecognized comorbid medical conditions but also lead to more effective, integrated, and comprehensive care. Indeed, persons who have comorbid illnesses would then stand a better chance of receiving the safe and effective treatment that they desperately need and so clearly deserve.
Dr. Grace is affiliated with the North Florida/South Georgia Veterans Health System, Gainesville, Florida, and with the Department of Clinical and Health Psychology, University of Florida, Gainesville. Dr. Christensen is with the Division of Public Psychiatry, University of Florida College of Medicine, Gainesville, and with Behavioral Health Services, Sulzbacher Center, Jacksonville, Florida.
1.Rothbard AB, Blank MB, Staab JP, et al: Previously undetected metabolic syndromes and infectious diseases among psychiatric inpatients. Psychiatric Services 60:534–537, 20092.Koran LM, Sox HC Jr, Marton KI, et al: Medical evaluation of psychiatric patients: I. results in a state mental health system. Archives of General Psychiatry 46:733–740, 19893.Hall RC, Popkin MK, Devaul RA, et al: Physical illness presenting as psychiatric disease. Archives of General Psychiatry 35:1315–1320, 19784.Morrison J: When Psychological Problems Mask Medical Disorders: A Guide for Psychotherapists. New York, Guilford, 19975.Grace GD, Christensen RC: Recognizing psychologically masked illnesses: the need for collaborative relationships in mental health care. Primary Care Companion to the Journal of Clinical Psychiatry 9:433–436, 2007