NYAPRS Note: Responses from psychiatrists and other doctors to a New York Times Sunday Review article, “When Doctors Discriminate” written by Juliann Garey.
Medical Care and the Mentally Ill
New York Times August 21, 2013
To the Editor:
Re “When Doctors Discriminate,” by Juliann Garey (Sunday Review, Aug. 11):
For about 100 years, we have known that patients with severe mental illness die 15 to 30 years earlier than the general population, and we are finally beginning to see concerted efforts at improving this statistic.
Some primary care clinics are now located within outpatient psychiatry clinics. Other clinic systems have updated electronic medical records to build better lines of communication between psychiatry and primary care.
There are continuing efforts to better coordinate care, including interdisciplinary meetings between medical and nonmedical specialties to discuss and improve upon patient care.
Important data have shown that the presence of nurse case managers significantly improves the quality and potentially decreases the cost of care provided to patients with severe mental illness. In addition, a few graduate medical training programs around the country offer combined training in internal medicine and psychiatry. I just completed such a program in Atlanta.
Atlanta, Aug. 11, 2013
The writer is a fellow in geriatric psychiatry at Emory University.
To the Editor:
Juliann Garey points out a reality in far too many instances in the nonpsychiatric medical care of people with mental illnesses.
My approach to this problem over the last 35 years, when I refer a patient to a nonpsychiatric physician, whether an orthopedist, ophthalmologist or primary care physician, has been to call first and speak with the doctor on behalf of the patient I am referring. In these cases my patients received excellent care.
Even though this is not a complete solution, it’s a good start to ensure that psychiatric patients receive good medical care and adds to the broader education of nonpsychiatric physicians in the care of those with mental problems.
In the past, most doctors routinely made calls on behalf of their patients, regardless of specialties.
ROBERT T. LONDON
New York, Aug. 12, 2013
The writer is a psychiatrist at NYU Langone Medical Center.
To the Editor:
As an emergency physician, I agree and empathize with Juliann Garey’s plea for doctors to provide the same care to patients with mental illness as other patients. I have frequently seen serious physical illness being wrongly or prematurely attributed to the acute worsening of a chronic psychiatric condition by residents under my supervision.
Assigning breathlessness or chest tightness from cardiac ischemia to anxiety, and severe agitation from psychosis and threats of suicide from worsening depression to illicit drug or alcohol abuse, can result in life-threatening consequences.
I now caution my residents that distressing psychological responses often complicate and confound the diagnosis and treatment of a serious medical condition in any patient, often more so in those with psychiatric co-morbidities. They need to heighten their vigilance for physical illness by conducting a thorough, unbiased assessment.
They should accept a psychiatric explanation only after conclusive evidence of the absence of serious medical illness, a safe diagnosis after exclusion of all physical causes.
Brisbane, Australia, Aug. 11, 2013
The writer is a clinical senior lecturer in the Division of Anesthesiology and Critical Care at the University of Queensland Medical School.
To the Editor:
The article highlights the challenges that people with serious mental illness face when receiving care for medical conditions. Since this population has a much higher prevalence of chronic illnesses like diabetes and heart and lung disease, it’s important to improve access to high-quality care.
Health homes - provider practices that are both the portal and the coordinator of care for mental and physical health needs - are one solution. The Affordable Care Act provides money for states to test systems of care for people with serious mental illness, and a number of states have developed health homes led by behavioral health providers that include physical health providers, care coordinators, information technology and family engagement.
We have been operating homes in Arizona and Iowa for two years. Our early experience and anecdotes are encouraging.
CHARLES M. CUTLER
South Orange, N.J., Aug. 12, 2013
The writer is chief medical officer of Magellan Complete Care.