Stigma attached to the field of psychiatry has occasionally led to less diligent efforts by nonpsychiatrists on behalf of psychiatric patients who are referred to general hospital emergency departments (1). Stigmatizing attitudes are held both by health professionals and by the general public (2). Even pharmaceutical advertisements published in psychiatric medical journals tend to perpetuate negative images of mental disorders (3). Over the past 50 years, hundreds of articles have been published that deal with the need for ongoing mental health education and training for primary care physicians (4).
This column reports the results of a study of the interaction between the referring psychiatrist, the psychiatric patient, and the treating physician in the general hospital emergency department. Through an examination of medical documentation, we investigated the diligence of attending physicians in the emergency department in the treatment of patients presenting with an acute physical problem who were referred from a psychiatric hospital.
This study was undertaken prospectively during a one-year period (March 1999 to February 2000). The patients, who were from an open ward in a psychiatric hospital, were sent to emergency departments of general hospitals within the same catchment area for acute medical problems such as high fever, chest pain, and physical trauma. Our hospital's psychiatry residents prepared the patient's referral letters.
Two independent reviewers anonymously analyzed the referral letters of 78 successive patients and matched discharge summaries from the general hospital to which the patients were referred. In all cases the following information was recorded: the presence of a specific psychiatric diagnosis according to DSM-IV (5); the amount and quality of relevant and accurate information included, which was rated on a scale from 1, not sufficient, to 5, very good; and the presence of a specific physical diagnosis. The study received institutional review board approval.
Of 78 referral letters accompanying the psychiatric patients to the general hospital emergency department, 42 (54 percent) included a specific psychiatric diagnosis according to DSM-IV; 18 (23 percent) included a general diagnosis, such as depression or psychosis; three included an incorrect diagnosis (4 percent); and 15 (19 percent) contained no psychiatric diagnosis at all.
In response to the 42 letters that included a specific diagnosis, we received seven discharge summaries (17 percent) that included a specific psychiatric diagnosis according to DSM-IV, six (14 percent) with a general diagnosis, one (2 percent) with an incorrect diagnosis, and 28 (67 percent) with no psychiatric diagnosis whatsoever.
Most of the referral letters that were sent (40 letters, or 51 percent) and almost half of the discharge summaries (35 summaries, or 45 percent) contained a good deal of information (that is, the letter gave a full picture of the medical condition of the patient). An abundance of information (that is, the letter was almost satisfactory but was missing some important information) was found in 26 referral letters (33 percent) and in 19 discharge summaries (24 percent). Overall, there was a strong correlation between the quality of the referral letters and the quality of the discharge summaries (p=.007, Pearson).
Of the 78 referral letters sent, 60 (77 percent) included a specific physical diagnosis, 14 (18 percent) included a general diagnosis, one (1 percent) included an incorrect diagnosis, and three (4 percent) included no physical diagnosis at all. Seventy discharge summaries received included an accurate physical diagnosis (90 percent).
The relationship between general physicians and psychiatric patients is complex, characterized by a combination of interest, ignorance, and discrimination (6). In this study we found no specific psychiatric diagnosis in a majority of discharge summaries for psychiatric patients who were sent back from an emergency department, although most of the referral letters mentioned a diagnosis. Many discharge summaries neglected to include the psychiatric diagnosis, instead including the perplexing diagnosis "psychiatric disorder." About half of the referral letters included a specific diagnosis; others included a general diagnosis or did not include a psychiatric diagnosis at all. However, in terms of physical diagnosis, both types of letters were satisfactory.
The importance of an accurate psychiatric diagnosis in a general hospital must be emphasized. Our finding that more than half of the referral letters prepared by psychiatric residents did not contain a specific psychiatric diagnosis is disturbing.
When a physician has to explain his treatment plan or obtain the patient's cooperation or agreement for any kind of procedure, he or she must know whether the patient is capable of participating in this process. The physician has to evaluate a patient's competence to consent to treatment. In order to do so, the physician should be aware of the differences among the major psychiatric diagnostic categories. He or she should have some idea about reality testing and how to evaluate judgment and should know how to identify those few patients who might not be able to provide informed consent—or at least know when to consult a psychiatrist on this issue. (Of course, it is possible that the physicians in this study were familiar with the diagnostic categories but failed to note diagnoses on the discharge summaries for other reasons, such as time pressure or a view that the information was not really relevant.)
On the other hand, blame cannot be placed solely on the emergency department's physicians. Nineteen percent of the patients were referred with no psychiatric diagnosis at all. It seems that occasionally psychiatrists themselves tend not to categorize the medical charts of their patients into mental and physical subcategories. This lack of quantitative and qualitative information has a strong impact on information sent back in the discharge summaries.
It seems that psychiatrists themselves have some difficulties in terms of their attitudes toward psychiatric patients. Greater exposure to people with mental disorders might not necessarily lead to more positive attitudes toward them. Previous research showed that mental health professionals had more negative attitudes to psychiatric patients than did the general public; these professionals rated long-term outcomes more negatively than did the public (7). These attitudes may come from better knowledge of and experience with the long-term outcomes of chronic mental disorders. On the other hand, it is possible that psychiatrists sometimes try to protect their own patients from the stigma of other health professionals by obscuring their diagnosis, sometimes even without being completely aware of what they are doing.
Psychiatrists might have a role in the stigmatization of persons with mental disorders. Carrying out our clinical duty, which sometimes requires involuntary assessment at a patient's residence, can be a cause of stigma to the patient and his family. Other sources of stigma that we are responsible for are the medications that we prescribe, which cause socially undesirable side effects, such as obesity, tardive dyskinesia, and drooling (8).
The relationship between mental health personnel and general hospital physicians has changed over the past few decades. Interest in psychiatric consultation services in general hospitals is increasing, and liaison psychiatry is a rapidly growing area of expertise (9). In one study, 99 percent of attending physicians in a general hospital agreed that psychiatric consultation services should be available in all large general hospitals (10). In another study, many physicians stated that they wanted routine participation of a psychiatrist in their departments and during case conferences (11).
Nevertheless, psychiatry still confronts many difficulties and discrimination. It has been demonstrated that referring physicians, after frequently consulting with a psychiatrist, did not include the psychiatric diagnosis made previously in their discharge summaries or misrepresented it (9). At the primary care level, physicians tended to underestimate the prevalence of mental disorders (12). In another study, primary care physicians did not diagnose mental illness among approximately half of the patients who had a psychiatric disorder (13). It is also known that physicians tend to abbreviate the evaluation and workup of patients with psychiatric symptoms (9).
These discriminatory attitudes are fraught with real dangers apart from the insult of stigma: they may result in less careful history taking, unfinished medical workups, and a tendency toward shortening the treatment period as a whole. Lack of cooperation from patients who have mental disorders may lead medical staff to abandon treatments that are not considered life saving, even when those treatments are needed to maintain the quality of life of those patients—for example, orthopedic surgery that can prevent severe disabilities. Better communication skills and empathy are needed to achieve these goals.
It would appear from our findings that medicine still faces a psychiatric-physical dichotomy. Physicians in primary care settings receive different degrees of mental health education and training (4,14). Our results emphasize the need to augment these efforts and to continue the mutual and fruitful work by learning more and appreciating each other's competencies.
The authors are affiliated with Abarbanel Mental Health Center and with the Sackler Faculty of Medicine of Tel Aviv University in Israel. Send correspondence to Dr. Mazeh at Psychogeriatric Ward, Y. Abarbanel Mental Health Center, 15 Keren Kayemet Street, Bat-Yam 59100, Israel (e-mail, firstname.lastname@example.org). Douglas H. Hughes, M.D., is editor of this column.