Physical health of people with severe mental illness

The post on the lack of screening psychiatric patients for medical
illnesses misses the mark. Who exactly does the author believe is making
these diagnoses? Both of the authors he references are psychiatrists.
His arguments about showing psychiatrists what to do in terms of medical
care do not reflect current or past psychiatric practice in the United
States. The task of screening psychiatric inpatients for comorbid medical
conditions is an asymmetrical task compared with the diagnostic task on
medical and surgical units. In those settings, there is a clear
presenting problem and there is no evidence that further screening or
diagnostic evaluation occurs in those hospital settings relative to what
can be received in inpatient psychiatric units.

For the past fourteen years I have taught medical students and
psychiatric residents how to do medical evaluations of psychiatric
patients. The coursework is more detailed and technical than a dated
manual based on an uncontrolled study using a nonrepresentative sample of
patients (1). Every day psychiatrists like myself diagnose and in many
cases treat medical illnesses that were not previously detected by anyone
else. In addition to that basic skill, we are also involved in the
process of getting treatment for patients who are not able to get
treatment for themselves. That treatment is often acute and life saving.

Psychiatrists are charged with monitoring and prescribing medications
with characteristic patterns of toxicity. Psychiatrists prescribing these
drugs need to know how to monitor various systems with ECGs, hematological
and blood chemistries, EEGs and brain imaging studies (2,3,4).
Psychiatrists are also doing the research on the indications for these
tests. Those detailed findings are incorporated in existing practice
guidelines (5).

On the issue of medical record keeping - most medical centers have
their own system of medical record keeping. The standard medical
evaluation form that I use is more detailed than most. With the recent
concerns about documentation many medical centers have audits to make sure
that diagnostic and billing codes match the actual chart documentation.
Direct feedback is given to all physicians of all specialties on whether
the documentation meets standards or not.

As a former quality reviewer, the standard of medical care provided
to psychiatric inpatients is much higher than the previous post suggests.
In fact, psychiatric units in hospitals and outpatient psychiatric
treatment facilities are frequently the only places where people with
mental illnesses get any medical care at all. Any suggestion that
psychiatrists are not currently screening their patients and making
medical diagnoses is clearly wrong. It is a disservice to psychiatrists
and the patients they treat to make blanket statements about the quality
of medical care they receive based on an inadequate body of literature.

George Dawson, MD
Regions Hospital
St. Paul, MN 55101-2595

1. Koran LM, Sox HC, Marton KI, Moltzen S, Sox CH, Kraemer HC, et al.
Medical evaluation of psychiatric patients. Results in a state mental
health system. Arch Gen Psychiatry 1989; 46: 733-740.

2. Dieperink E, Willenbring M, Ho SB. Neuropsychiatric symptoms
associated with hepatitis C and interferon Alpha: A Review. Am J
Psychiatry 2000; 157: 867-876.

3. Glassman AH, Bigger JT, Jr. Antipsychotic drugs: prolonged QTc
interval, torsade de pointes, and sudden death. Am J Psychiatry 2001;
158:1774-1782.

4. Alvir JM, Lieberman JA, Safferman AZ, Schwimmer JL, Schaaf JA.
Clozapine-induced agranulocytosis. Incidence and risk factors in the
United States. N Engl J Med 1993; 329:162-167.

5. Work Group on Delirium. Practice guideline for the treatment of
patients with delirium. Am J Psychiatry (Supplement) 1999; 156: S1-S17