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Removing roadblocks to medical care for the severely mentally ill

Vol. 2, No. 8 / August 2003

Severely mentally ill patients often do not get the care they need for chronic medical conditions such as diabetes, hypertension, or hepatitis C. They may lack insurance, forget follow-up appointments, or fail to provide adequate or accurate history because of cognitive deficits. Some fear blood work or other tests, and many adhere poorly to treatment.

12 ways to expedite care

The following tips can help remove some of these roadblocks to proper care:

  1. Review the patient’s records—psychiatric and medical—to obtain information the patient might not have provided.
  2. Explain the medical problem in terms the patient understands. Describe why an evaluation or treatment is necessary.
  3. Ask the patient’s case manager or program nurse to follow up with the patient.
  4. Refer the patient to a family doctor or internist who participates in the patient’s insurance plan and with whom he or she is comfortable.
  5. Remind the patient of his or her appointment, preferably that morning. If possible, have the case manager arrange transportation.
  6. Have a family member or staff member accompany the patient on the visit if the patient expresses fear beforehand. Consider offering an anxiolytic to be taken the day of the visit as needed. Above all, be encouraging.
  7. Write a note to the doctor about the reason for the referral. Include some history because the patient may not be able to give it, especially within a 15-minute office visit.
  8. Order specific blood work to be drawn before the visit, if indicated. Have results sent to the doctor’s office.
  9. Consider screening high-risk patients for hepatitis, including those with a history of IV drug use or multiple sexual partners. Do not automatically attribute liver enzyme elevations to divalproex.
  10. Review your patient’s diet and exercise habits. Politely discourage excessive sugar and caffeine intake. I always keep some bottled water and raw vegetables on hand to model recommended habits. Many patients have limited incomes, so recommend affordable, healthy foods.
  11. Monitor for side effects of psychotropics, such as white blood counts for patients on clozapine, liver function and platelet counts with valproate, renal and thyroid function with lithium, etc.
  12. Don’t give up. If your patient has missed multiple doctors’ appointments, keeps insisting he or she is not sick, or repeatedly fails to comply with diet or medication, continue to be encouraging and advocate the need for proper care.

Drug brand names

  • Clozapine • Clozaril
  • Divalproex • Depakote
  • Lithium • Eskalith, Lithobid, others
  • Valproate • Depacon

Dr. Szeeley is associate professor, department of psychiatry, University of Medicine and Dentistry of New Jersey, Camden, and heads the department’s division of community psychiatry.

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