To the Editor: The brief report by Buchanan and colleagues (1) in the August issue underscored the high comorbidity between multiple sclerosis (MS) and depression (more than 40 percent) and found that nearly 90 percent of persons diagnosed as having MS were receiving mental health care. This example of high comorbidity of medical and psychiatric disorders leads us to question what may happen when psychological problems mask medical illness in mental health treatment settings.
For example, consider the following scenario: A woman comes to her initial session complaining of depressive symptoms after a recent divorce. Although she may appear to have a fairly routine mood or adjustment disorder, what if her depression is actually due to an underlying endocrine or autoimmune disease or even the initial symptoms of MS? What percentage of such individuals would be identified and referred for appropriate medical care? Indeed, conservative estimates suggest that at least 10 percent of psychological symptoms are driven by medical or physical conditions; yet many mental health care providers erroneously believe that psychological symptoms are rarely caused by a hidden medical etiology (2,3). Moreover, studies involving both psychiatric inpatients and outpatients have found high rates of medical illnesses that go unrecognized by mental health care providers (4,5).
The scenario we describe is not uncommon, and individuals with these disorders will appear in the caseloads of both medically trained and non-medically trained mental health professionals. However, in behavioral health settings nonmedical professionals routinely conduct initial evaluations and provide treatment for persons presenting with symptoms of mental illness. Moreover, a client's referral for psychiatric or medical evaluation ultimately rests with this same provider. Hence, a central concern is whether nonmedical providers are adequately trained to suspect a hidden medical disorder. Recognizing a hidden physical illness could be particularly challenging for psychologists, social workers, and licensed mental health counselors, whose professional education does not include formal medical training.
Possible solutions involve both collaborative and educational remedies. First, mental health care professionals lacking medical training would be well advised to develop a collaborative relationship with a primary care physician and encourage all new mental health clients to undergo a complete physical evaluation with appropriately indicated laboratory studies. Second, we would recommend that all mental health care professionals—both non-medically trained professionals and psychiatrists—participate in formal educational initiatives that identify the most common illnesses that masquerade as or contribute to psychological problems. Although nonmedical providers should not be expected to make definitive medical diagnoses, being cognizant of potential warning signs could lead to a timely referral.
People come to mental health professionals with the expectation that the cause of their problem will be identified. An underlying medical illness that is unrecognized and treated with only psychological interventions will likely contribute to a downward spiral of the person's health. Being aware of the most common masked medical illnesses that present with psychological or behavioral symptoms should be the responsibility of all who work in the field of mental health care. Indeed, our patients have a right to expect nothing less.
Dr. Grace is staff psychologist at North Florida/South Georgia Veterans Health System in Gainesville, Florida, and courtesy assistant professor in the Department of Clinical and Health Psychology, University of Florida, Gainesville. Dr. Christensen is associate professor and director of the Community Psychiatry Program, University of Florida College of Medicine, Jacksonville.
Buchanan RJ, Schiffer R, Wang S, et al: Satisfaction with mental health care among people with multiple sclerosis in urban and rural areas. Psychiatric Services 57:1206-1209, 2006
Morrison J: When Psychological Problems Mask Medical Disorders: A Guide for Psychotherapists. New York, Guilford, 1997
Taylor RL: Distinguishing Psychological From Organic Disorders: Screening for Psychological Masquerade, 2nd ed. New York, Springer, 2000
Koran LM, Sheline Y, Imai K, et al: Medical disorders among patients admitted to a public-sector psychiatric inpatient unit. Psychiatric Services 53:1623-1625, 2002
Koran LM, Sox HC, Martin KI, et al: Medical evaluation of psychiatric patients: results in a state mental health system. Archives of General Psychiatry 46:733-740, 1989