Assessment of Physical Illness by Mental Health Clinicians During Intake Visits

Abstract

Objectives-This study explored how mental health clinicians assess and respond to physical illness among patients presenting for mental health intake evaluations.Methods-A total of 129 adults were seen for a mental health intake visit. The intake visits were videotaped and involved 47 mental health clinicians from eight clinics who provided outpatient mental health and substance abuse treatment. A total of 120 videos of patient-provider interactions were coded using an information checklist containing 21 physical illness items. Twenty-eight intake visits exemplifying in-depth physical illness assessments were selected and transcribed for qualitative analysis.Results-Physical health was discussed in most intake visits (87%). Clinicians elicited information on physical health in 79 visits (66%), while patients volunteered such information in 80 visits (67%). Frequency of assessment differed by clinician discipline (p<.05) and by patient ethnicity (p=.06). Qualitative analysis revealed characteristics of appropriate assessments, such as formulating whether physical conditions were responsible for psychiatric symptoms in the differential diagnosis, noting physical side effects of medications, adjusting treatment plans, encouraging patient contact with primary care providers, and promoting physical health care.Conclusions-Assessment of physical illness is relatively common for mental health clinicians but was lacking in one-third of the cases in this study, until raised by patients. Because frequency of assessment differed by clinician discipline and patient ethnicity, innovations in patient assessment and clinician education are needed to address disparities in management of physical illness among individuals with mental illness.There are important reasons for mental health clinicians to be interested in the physical health of their patients. Physical illness occurs among more than 45% of psychiatric outpatients and often goes undiscovered (1-6), leading to lower quality of life, decreased functioning, and increased risk of early death (7,8). Individuals with severe mental illness die earlier than the general population because of poor health behaviors, medication side effects, inadequate preventive care, and insufficient medical care (9-12).Primary care interventions that address the physical health of persons with mental illness include care coordinators, specialized primary care clinics, and medical teams within psychiatric settings (11). An expanded medical role for mental health clinicians has been suggested but is less studied (13).The authors report no competing interests. Persons from ethnic minority groups with comorbid physical and mental illness face even greater disparities in medical care, including low rates of treatment for chronic pain, asthma, hepatitis, and diabetes (14,15). However, most health disparities research examines physician behavior in nonpsychiatric settings. In mental health settings that serve as safety-net treatment facilities, social workers, psychologists, and nurses provid...

Prevalence of physical symptoms and their association with race/ethnicity and acculturation in the United States

“…In one study of patient-provider communication in mental health settings, Latinos discussed physical symptoms less than whites did despite endorsing symptoms at similar rates. [39] Alternately, it is plausible that patterns may differ between community samples and clinical samples. For example, some evidence suggests that racial/ethnic minorities are more likely to delay seeking care thus, may present to healthcare providers only once symptoms are severely disabling.…”

How patients and clinicians make meaning of physical suffering in mental health evaluations

“…Qualitative data come from the Patient Provider Encounter Study (PPES), conducted in the greater Boston area of Massachusetts, whose methods have been described in prior publications (Alegrı´a et al, 2008;Carson et al, 2010). Here we report on physical illness discussions from the video recordings of a series of mental health intake sessions and audio-recorded post-diagnostic research interviews.…”

“…With such overlap, mental health clinicians must understand how to address psychological and social suffering in the context of physical illness. In mental health intakes, we have previously noted that physical health issues are volunteered by patients with relatively high frequency (Carson, Katz, Gao, & Alegrı´a, 2010). How patients make meaning of these issues may therefore be a useful area for mental health clinicians to assess in terms of the impact on mental health and functional impairment.…”

“Why Come for Treatment?” Clients’ and Therapists’ Accounts of the Presenting Problems When Seeking Mental Health Care

“…This is despite contrary evidence documenting that physical illness occurs among more than 45% of psychiatric outpatients and that it is often goes undiscovered (Carson, Katz, Gao, & Alegría, 2010; Hert et al, 2011), leading to poorer quality of life, decreased functioning, and increased risk of early death (Baumeister, Hutter, Bengel, & Härter, 2011; Lawrence, Hancock, & Kisely, 2013). Awareness of physical conditions disproportionately affecting psychiatric clients may facilitate prevention through appropriate referrals and support of client self-care (Carson et al, 2010). Special attention should be given to referral paths to mental health care (Alegria, Canino, & Pescosolido, 2009; Nakash, Nagar, Danilovich, et al, 2014) as they determine the point of entry to specialized treatment.…”

“…Similarly, therapists tend to underemphasize the role of medical problems, while primarily focusing on psychiatric symptoms and general emotional distress. This is despite contrary evidence documenting that physical illness occurs among more than 45% of psychiatric outpatients and that it is often goes undiscovered (Carson, Katz, Gao, & Alegría, 2010;Hert et al, 2011), leading to poorer quality of life, decreased functioning, and increased risk of early death (Baumeister, Hutter, Bengel, & Härter, 2011;Lawrence, Hancock, & Kisely, 2013). Awareness of physical conditions disproportionately affecting psychiatric clients may facilitate prevention through appropriate referrals and support of client selfcare (Carson et al, 2010).…”