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Med/Psych Update

Keeping patients physically well: A psychiatrist’s ‘CIVIC’ duty

Watch for 5 common medical problems.

Vol. 5, No. 1 / January 2006

Many patients with a severe mental disorder go years without preventive medical treatment, leaving them medically ill or at high risk for a medical illness.(See"Acute MI Risk Protecting you patients heart health" September 2005.)

Blood pressure. Check at each visit for patients with a history of hypertension and every 3 to 4 months for nonhypertensive patients. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)(See"Metabolic syndrome: 5 risk factors guide therapy" April 2005.)

Refer patients with suspected metabolic syndrome to a primary care physician or endocrinologist for management. Refer patients taking anticonvulsants if readings or symptoms suggest hepatitis or dyscrasia. Significant abnormalites include leukocites <2×109, platelets <100,000, new-onset anemia, bruising, bleeding, rash, abdominal pain, jaundice, lethargy, and seizure activity.14

Table 2

At what point do lipid levels indicate cardiovascular risk?




Needs treatment

Treatment options

Total cholesterol




See LDL cholesteroltreatment options

LDL cholesterol




Lifestyle changes


Bile sequestrants

Nicotinic acid


HDL cholesterol




Lifestyle changes

Treat triglycerides

Add nicotinic acid or fibrate





Lifestyle changes


Consider nicotinic acid or fibrate

*Treat according to risk factors. See Adult Treatment Panel III guidelines for specific regimens and cautions.

Three- to 6-month trial of lifestyle changes may be warranted in most cases. Urge patients to reduce saturated fat and cholesterol, eat more soluble fiber, and exercise more.

Removes one risk factor

Source: Adapted from the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (


Vaccinations. Many psychiatric patients are not up to date with vaccinations against hepatitis, influenza, or pneumonia. Ask the patient to recall his or her vaccination history as accurately as possible. If he or she cannot, contact the primary care physician the patient visited most recently.

If you cannot obtain the history, refer the patient to the municipal health department for influenza vaccine and a blood test to verify hepatitis B immunization. Educate patients on the benefits of vaccination, and coordinate with a primary care doctor or case manager to ensure the patient’s immunization.

Table 3

Who needs which vaccines—and how often


Targeted group/frequency


Two-vaccine series for intravenous drug abusers; vaccine series for adults who did not receive primary series; boosters if ≥10 years since vaccination

Hepatitis A

Intravenous drug users, institutionalized persons, homosexual men, and those living or working where hepatitis A is endemic

Hepatitis B

Three-vaccine series for health care workers, sexually active heterosexual men and women, homosexual/bisexual men, hemodialysis patients, intravenous drug abusers, institutionalized persons


Annual vaccination for persons age ≥50; patients with CVD, diabetes, HIV, renal disease, or pulmonary disease; and others who are immunosuppressed, pregnant, or in a nursing home. Check updates from CDC throughout flu season


Persons age ≥65; institutionalized patients age ≥50; those with alcohol dependence, asplenia, HIV, chronic CVD, chronic lung disease, diabetes, chronic liver disease, renal insufficiency, or who live in settings where pneumococcal disease can spread. Repeat dose on or about 65th birthday if immunized ≥5 years earlier

COPD: Chronic obstructive pulmonary disease

STD: Sexually transmitted disease

Source: U.S. Centers for Disease Control and Prevention. Recommended adult immunization schedule, by vaccine and age group (

Guidelines from the U.S. Preventive Services Task Force (USPSTF) spell out who should receive tetanus, hepatitis A or B, influenza, or pneumonia vaccines—and how often they should receive them (Table 3). In many states, municipal health departments offer these immunizations. Alternately, refer patients to a local indigent clinic.

Sexually transmitted disease. Neglected general health or malnourishment can weaken the immune system and increase susceptibility to infections. Patients who live in urban areas or public housing—where infections tend to spread—are especially vulnerable.

In addition, mentally ill persons are more likely than the general population to have a sexually transmitted disease (STD)17,18 because:

  • mental illness can cloud judgment; for example, patients with bipolar mania are at risk for impulsive, hypersexual behavior
  • some mentally ill patients support themselves with prostitution.

While taking a complete history during the initial visit, ask patients how often they have sex and with whom. If the patient acknowledges sexual activity with multiple partners, ask periodically about current sexual activity. Explore the patient’s understanding of the motivations and risks associated with dangerous sexual behavior, then educate him or her about safe sexual practices.

Refer sexually active patients to a hospital or private laboratory for an HIV test and an RPR to test for syphilis. Refer sexually active women age ≤25 for DNA cervical probes for gonorrhea and chlamydia. Evidence is equivocal for screening anymptomatic women age >25 for chlamydia or gonorrhea infection. Sexually inactive women or those in monogamous relationships may not need routine screening. For sexually active men, urine testing to screen for chlamydia or gonorrhea is available.19

Consult a local health clinic or gynecologist for the DNA probe, although some clinical laboratories can check urine for signs of cervical problems. Ask sexually active patients if/when they were immunized against hepatitis B. If needed, refer for vaccination.


Obesity—defined by the National Institutes of Health as BMI ≥30 kg/m2—often precedes preventable chronic diseases and cancer. Persons with chronic severe mental illness tend to be more sedentary than nonmentally ill persons,20 and research suggests that obesity is more common among patients with severe mental illness than among the general population.21 Also, poorer patients have trouble maintaining a balanced diet.

Calculate BMI using the National Heart, Lung and Blood Institute BMI calculator ( Encourage patients with BMI >25 kg/m2 to eat more fruits and vegetables, eliminate empty calories (alcohol, soda pop, juices, candy), and decrease fat consumption (especially fast food). Suggest to patients age ≥50 that they incorporate calcium, 1,200 mg/d, and vitamin D, 400 to 800 IU/d, in their diet to prevent osteoporosis.22

Also encourage patients to exercise moderately for a half-hour daily, 5 days a week, to burn calories. Supplement nutritional counseling with behavioral therapy, focusing on changing eating patterns.23


Many patients with chronic mental illness are not regularly screened for colon, cervical, breast, or other common early-stage cancers. In addition, their cancer rates are significantly higher than those of the general population.24

Ask men at the initial visit when they were last screened for colon or prostate cancer. Ask women when they were last screened for colon, cervical or breast cancer (Table 4). Ask again once yearly.

Colon cancer. Colonoscopy, done by a gastroenterologist, is indicated for patients age >50 every 5 to 10 years, depending on endoscopic findings. In-office fecal occult blood tests (FOBT), performed annually between colonoscopies, can identify patients who may need closer follow-up. You can do in-office FOBT or refer to a primary care physician.25

Cervical cancer is thought to be caused by human papilloma virus (HPV). Refer women with an intact cervix annually to a gynecologist or hospital clinic for a Pap smear, which usually includes testing for high-risk HPV if atypical cells are discovered. Some guidelines suggest decreasing screening frequency after several negative Pap smears for women in a monogamous sexual relationship.

Breast cancer affects 1 in 8 women, and having a first-degree relative with breast cancer increases the risk. Women should receive annual mammograms starting at age 40. The USPSTF notes that mammography’s benefits improve with increasing age between ages 40 and 70.26

Many hospital radiology departments or community health centers provide mammograms on a rotating schedule. Refer patients with abnormal findings to a general surgeon or breast center.

Table 4

Recommended intervals for cancer screening

Type of cancer

Recommended test frequency


Asymptomatic persons age >50 should receive colonoscopy every 5 to 10 years, as directed by the gastroenterologist, and annual fecal occult blood tests


Annual Pap smears for women who have ever been sexually active and still have a cervix


Mammography every 1 to 2 years after age 40


Evidence does not support routine chest x-rays or sputum cytology in asymptomatic patients


Refer men age >50 to primary care physician or hospital laboratory for PSA test; counsel patients about the results and treatment


We schedule a battery of laboratory tests for Mrs. J at the local hospital, including a fasting plasma glucose test and lipid profile to gauge her cardiovascular risk and potential effects from olanzapine, and CBC and LFTs to check for adverse effects from oxcarbazepine.

We ask Mrs. J whether she engages in high-risk sexual activity, which she denies. She cannot recall her vaccination history, so we contact the primary care physician she had seen 5 years ago. Depending on her other comorbidities, housing situation, an early pneumococcal vaccine may be indicated.

We also suggest that Mrs. J quit smoking, but she appears to be at a pre-contemplative stage. We hope to promote a change in her attitude by discussing smoking cessation at each visit

To address Mrs. J’s obesity, we briefly review a dietary plan augmented with increased physical activity. She will bring a 3-day food diary to her next visit and promises to walk 30 minutes four to five times weekly. She says she enjoys mall walking with her children.

We strongly urge Mrs. J to schedule a mammogram, as she is past age 50 and says she has never received one. We try to refer her to a primary care physician to arrange a Pap smear and colonoscopy, but she resists, fearing the results. With continued education, exploration, and encouragement, we will briefly follow up with Mrs. J at each visit to ensure that she gets these needed tests (Box 2).

Box 2

How to effectively coach patients who resist preventive care

Check with patients at each visit to ensure they are following through on their test referrals. If they are not, find out why.

If the patient is procrastinating, try to uncover an underlying cause. If the patient says he or she is pressed for time, ask: “Are you going through stressful life events? Are you afraid the test will hurt or will reveal a serious disease? Did you have this test before? If so, did it make you uncomfortable?

Tell the patent, “I understand your concerns, but this test is important. You need to make it a higher priority.” To work through the patient’s resistance, start by educating him or her about preventable chronic diseases and screening or treatment resources. Then try problem-solving techniques, motivational interviewing, or dissecting cognitive distortions.

Collaboration with a case manager is key when managing an indigent mentally ill patient. Open communication, setting well-defined goals, and a clear understanding of each other’s treatment roles is crucial. Inform the case manager which target tasks, tests, or appointments the patient has agreed to. The case manager can use this information to help the patient navigate the health care system and encourage full participation in care

Finally, build a referral base for indigent and uninsured patients. Look for a nearby internist, gastroenterologist, and OB/GYN who accept uninsured patients.

Related resources

Drug Brand Names

  • Olanzapine • Zyprexa
  • Oxcarbazepine • Trileptal


Dr. Moss recevies research/grant support from the National Institutes of Health and is a speaker for Janssen Pharmaceutica and Pfizer.

Mr. Brammer and Dr. White report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.


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