We read with interest Drs. Carroll and Rado’s article, “Is a medical illness causing your patient’s depression?” (Current Psychiatry, August 2009) and commend the authors for focusing attention upon the role medical illnesses can play in causing or contributing to depressive disorders. However, we believe the authors missed the opportunity to strongly urge behavioral health providers to routinely refer their patients for medical evaluations to better identify illnesses masquerading as psychiatric disorders.
Conservative estimates suggest that at least 10% of presenting psychological disorders are driven by medical or somatic conditions, yet many mental health providers—medically and non-medically trained clinicians alike—mistakenly believe psychological symptoms rarely are caused by a “hidden” medical etiology.1,2 In fact, a recent sampling from a psychiatric inpatient setting found high rates of medical illnesses that were “missed” by mental health clinicians.3 We feel that these studies support a recommendation that persons diagnosed with new-onset or treatment-refractory psychiatric disorders be routinely referred for a medical evaluation.4
Although one might argue that it is more prudent to refer only individuals who are suspected of having a medical illness underlying their presenting symptoms, this approach ignores the reality of our behavioral health system. In most public behavioral health systems (eg, community mental health centers, crisis units, safety net clinics, etc.), the person who makes the initial diagnosis and develops a treatment plan is a behavioral health specialist with no formal medical training. Consequently, many of these frontline clinicians understandably are unable to recognize signs and symptoms of the most common medical illnesses that cause psychological symptoms.5 To ensure patient safety, behavioral health clinicians without medical training should strictly adhere to this recommendation.
After weighing the costs and benefits, medically trained mental health care providers should allow patient safety concerns to guide their decision to refer. We believe that in situations of new-onset or treatment-refractory mental illnesses, referring patients for a medical evaluation will lead to a treatment model that is efficacious, integrated, and comprehensive. Our patients who suffer the effects of comorbid conditions have a right to nothing less from those of us responsible for overseeing their care and healing.
Richard C. Christensen, MD, MA
Professor and chief division of public psychiatry
University of Florida College of Medicine
Glenn D. Grace, PhD, MS
Staff psychologist
North Florida/South Georgia Veterans Health
System
James C. Byrd, MD
Assistant professor of psychiatry
University of Florida College of Medicine
Gainesville, FL
References
1. Morrison J. When psychological problems mask medical disorders: a guide for psychotherapists. New York, NY: Guilford Press; 1997.
2. Koran LM, Sox HC, Marton KI, et al. Medical evaluation of psychiatric patients: I. Results in a state mental health system. Arch Gen Psychiatry. 1989;46:733-740.
3. Rothbard AB, Blank MB, Staab JP, et al. Previously undetected metabolic syndromes and infectious diseases among psychiatric inpatients. Psychiatr Serv. 2009;60:534-537.
4. Grace GD, Christensen RC. Medical evaluations for patients with psychiatric disorders. Psychiatr Serv. 2009;60:849.-
5. Grace GD, Christensen RC. Recognizing psychologically masked illnesses: the need for collaborative relationships in mental health care. Prim Care Companion J Clin Psychiatry. 2007;9:433-436.
Drs. Carroll and Rado respond
We thank Dr. Christensen and colleagues for their comments regarding promoting medical care in patients with mental illness. As physicians trained in internal medicine and psychiatry, we frequently are confronted with the lack of adequate medical care for psychiatrically ill patients. Our primary goal with this article was to educate and assist behavioral health providers in distinguishing depressive symptoms that might have an underlying medical cause.
Although we agree that patients with depression—and mental illness as a whole—are medically underserved, referring all patients with treatment-refractory or new-onset depression might not be fiscally responsible or always necessary. However, we wholeheartedly support encouraging regular follow-up with a primary care provider. Psychiatrists can order laboratory tests that might indicate medical diagnoses—for example, thyroid stimulating hormone or parathyroid hormone—and refer their patients if needed.
The discussion of public behavioral mental health systems is a different topic and outside the scope of our article. Our sentiments are not in disagreement with Dr. Christensen et al, and we are glad to see that our article prompted this discussion.
Virginia K. Carroll, MD
Fifth-year resident
Jeffrey T. Rado, MD
Assistant professor
Departments of psychiatry and internal medicine
Rush University Medical Center, Chicago, IL