It is well known that many people with psychiatric symptoms also have physical illnesses. Studies show that, conservatively, about 10 percent of outpatients with mental illness and between 25 percent and 50 percent of patients hospitalized for a psychiatric disorder have a significant physical illness, said Hunter McQuistion, M.D., an assistant clinical professor of psychiatry at Mt. Sinai School of Medicine and medical director of Project Renewal Inc., a nonprofit agency that provides services to homeless mentally ill and substance-abusing individuals.

Ted Mauger, M.D., added that those studies showed that up to 50 percent of patients with psychiatric illness have at least one undiagnosed, nonpsychiatric medical problem. Mauger is a clinical professor of psychiatry at Michigan State University.

There are many hypotheses about this comorbidity, and no one has determined the cause, McQuistion noted, but he hypothesized that a key reason is that patients with severe psychiatric disorders simply receive inadequate general health care. According to psychiatrist Bert Pepper, M.D., for example, a typical scenario that happens with psychiatric patients suffering from a wide variety of physical illnesses including delirium is the following: "Once ER personnel or primary care doctors identify patients as having a mental illness, they often get less attention and not as complete a workup. There is an assumption that their problem is ‘psychiatric’ not ‘medical.’ " Pepper is the executive director of the Information Exchange Inc., a nonprofit agency in New York City that provides information on patients diagnosed with psychiatric illness and substance abuse disorders.

"Doctors are unconsciously driven away from seriously mentally ill patients toward patients who are happier and more appreciative," Pepper said. "And because of this, many primary care doctors opt out of treating these patients, and the patients end up in the public medical clinics, which are more crowded and impersonal."

Roger Kathol, M.D., a clinical professor of psychiatry and internal medicine at the University of Iowa, observed, "Many patients with psychiatric illnesses have personal characteristics that make them difficult to work with. So ER and primary care doctors will do cursory examinations and then clear them without pursuing medical leads." Kathol is a past president of the Academy of Psychosomatic Medicine, Association of Medicine and Psychiatry, and Academy of Clinical Psychiatry. He also is CEO of Cartesian Solutions, LLC, a consulting firm that works to improve the psychiatric care of medical patients and the medical care of patients with psychiatric illnesses.

Mauger, however, was quick to emphasize that "generally the motives of physicians and ER doctors are not evil: They just don’t have the resources and time to make sense out of the patients with psychiatric illnesses—especially when the patients’ communication is impaired."

Despite these experts’ belief that patients with mental illness are receiving poor physical health care, "there is little systematic examination of these patients’ medical treatment and the possible role of that treatment in contributing to. . .poor medical outcomes," said Benjamin Druss, M.D., Ph.D., an assistant professor of psychiatry and public health at Yale. He added that the situation is changing as researchers have recently begun to make this issue a focus of scientific study.

When asked why there were so few studies, Kathol replied, "The focus of research funding for years has neglected issues at the psychiatry-medicine interface. While change has been slow, experts are now realizing the importance of medical care for patients with psychiatric illness."

Despite the paucity of data, experts agreed that three scenarios described by Psychiatric News occur with enough regularity that they represent a significant problem for the treatment of physical illnesses. The scenarios were (1) psychiatric patients prematurely discharged from the ER as "medically clear," (2) ER patients being sent to a psychiatric ward where they receive less medical care than if they were send to a general medical ward, and (3) primary care physicians not doing as extensive a diagnostic workup on patients with mental illness as they would with nonpsychiatric patients.

In fact, all three scenarios are a substantial problem throughout the U.S., noted Pepper, Kathol, and Brian Coopper, director of consumer advocacy for the Mental Health America, and Michael Allen, M.D., immediate past president of the American Association for Emergency.

The problem of obtaining good medical treatment for mentally ill patients can be traced to several critical factors including stigma, lack of physician education and training on working with patients with psychiatric illnesses, financial pressure on physicians to see a high volume of patients in a short time, and lack of integration of mental and other kinds of health care, said McQuistion.

"Another cause of poor medical care, especially in the ER, is that some patients with serious mental illness often have Medicaid or no insurance. And thus the reimbursement—if there is any at all—is minimal for certain procedures," said Coopper.

To address the problem of psychiatric patients getting inadequate medical care, a number of medical associations are collaborating on a promising measure to improve access and reimbursement for medical services in psychiatric settings and psychiatric services in medical settings, explained Kathol. This group, which includes APA, the American College of Physicians, and the American Society of Internal Medicine, is coordinated by the Policy Committee of the Academy of Psychosomatic Medicine. It is working with several members of Congress, business leaders, and national patient-advocacy groups to effect regulatory, credentialing, and legislative changes.

Besides the associations’ efforts, McQuistion noted that both psychiatrists and nonpsychiatric physicians "share the responsibility to [ensure psychiatric patients receive proper medical care]. Whereas nonpsychiatric physicians shouldn’t only think from the neck down, psychiatrists can’t just think from the neck up. Psychiatric treatment guidelines do often include our patients’ medical needs, albeit sometimes only in passing."

Similarly, Thomas Wise, M.D., said that "psychiatrists themselves must respond to these issues." Wise is chair of the department of psychiatry at Inova Fairfax Hospital in Fairfax, Va., and a past president of the Academy of Psychosomatic Medicine.

He suggested that poor communication about medical treatment happens when psychiatrists rely on answering machines instead of beepers, do not call or send a note to referring or attending physicians on behalf of patients, and are not active members of the hospital’s medical staff. Nonetheless, Pepper said, "even if psychiatrists implemented Wise’s suggestions, the problem would not go away. "In large cities patients may go to hospitals where the [psychiatrist] is not an active attending physician," he continued. "Second, there is stigma against people with [serious mental illness]. Third, doctors often do not have a financial incentive to treat these patients."

Despite the barriers Pepper cited, some psychiatrists have made significant headway in solving this problem.

For example, at Project Renewal, which serves more than 1,650 homeless or formerly homeless individuals with severe mental illness each day and is funded through Medicaid and government grants, McQuistion established a primary care clinic system housed in homeless shelters and mobile settings. Before establishing the clinic, a substantial majority of his patients received inadequate care for physical ailments. Now it is a rare occurrence, he noted. The program works, he said, because the primary care services are embedded within a system of comprehensive patient care that includes mental health and substance abuse care, housing assistance, and vocational rehabilitation. It also has a continuing education program for staff that focuses on the interface between psychiatry and primary care, McQuistion said.

But even psychiatrists who are not affiliated with such a clinic can help their patients receive good general medical care. For example, Ann Hackman, M.D., medical director of the University of Maryland’s Program of Assertive Community Treatment (PACT) in Baltimore, implemented a variety of measures that include everything from accompanying patients to and staying with them in the emergency room to educating patients about how to interact with physicians. Since implementing these changes, inadequate medical care for the program’s 200 seriously mentally ill patients, most of whom have been homeless, is a rare occurrence, she said. Funding for the Baltimore program comes through Medicare and Medicaid. Hackman attributed the program’s success in large part to a low staff-to-patient ratio and a policy of calling a patient’s medical doctor before a visit to see if the physician has any concerns the PACT team can answer. "This helps doctors feel that they are not alone as they work with psychiatric patients and decreases their anxiety over working with these patients," she said.