Cases in Medicine-Psychiatry...Part 1
Dona Denton, M.D.
Graduating Medicine Psychiatry Resident
University of Rochester

     In support of integrated medical and psychiatric care, we have collected cases and comments from practicing physicians. The cases illustrate the problems that arise when medical and psychiatric care are separated. Reimbursement for integrated care is inequitable even when qualified dually trained physicians are available. Below will give a glimpse of some of the problems.

ONE: I saw a patient who had (incorrectly as it turned out) been hospitalized several times on our psychiatric unit for "depression". In fact, he was (and probably had been) delirious. After the medical cause of his delirium had been discovered and treated, his "depression" disappeared (as did his cognitive defects), and he was a happy man. When I proudly told my managed care psychiatrist reviewer of my great discovery, he said, "you are a good doctor, but your patient's problem was medical. He should have been transferred to medicine. I am going to have to deny [payment for] the whole stay!" Of course, we are appealing, which will take at least 6 months, during which the MCO will enjoy the interest from our money.

When labs are ordered by psychiatrists rather than by PCP's, the carveout and the basic plan sometimes toss the bill back and forth and the patient gets left holding the bag. (ie., is a CBC ordered by a psychiatrist a "medical" or a "mental health" expenditure?)

TWO: I was called to the ER one night to see a confused elderly lady. The ER doc assumed she was crazy because he couldn't make sense out of what she was saying and she was disoriented. I discovered in talking with her daughter that she was on digoxin but did not take her medications as prescribed. Not surprising since fewer than 50% do, and even smaller numbers with chronic illnesses. Examination revealed grade 4 pitting edema, she was in heart failure. Her psychiatric disorder cleared up rapidly once she got back on the proper medical treatment. There are many such other examples. Psychiatric physicians assure that the mentally ill get the psychiatric treatment they need and that those with physical illnesses presenting as mental disorders get the medical treatment they need.

THREE: 40 yo w divorced man, with a history of poorly controlled IDDM since 15. Also, a history of Depression and bad, bad BPD, multiple suicide attempts. He had a pattern of neglecting his care to the point of ending up in the hospital with hypoglycemic coma or hyperglycemic delirium. Multiple complications: diabetic retinopathy, peripheral neuropathy and impotence. Also abusing pain killers-prescribed by three speciality clinics unaware of each other. He requests a urology consult for his impotence-from the endocrine team caring for him. Granted. The urologist agrees to perform a penile implant. He fails to let his other doctors be aware of this. The patient doesn't mention his psychiatric issues. He has the surgery, is sent home and develops a post op infection that he neglects. Ends up in the hospital--septic, ICU-ARDS, leaves the hospital 10weeks later on oxygen, with EF 22, CHF, renal failure, etc. He is and was on Medicare.

FOUR: Half of my patients come to me after 6 months of unsuccessful treatment with inappropriate or poorly managed psychotropics prescribed by their FP. One Bipolar man came after his FP had (correctly) diagnosed incipient mania, and had decided to start Tegretol monotherapy, probably based on something he remembered from his residency. The mania was arrested, but the patient cycled into a depression, and eventually found his way to me. He had never had a carbamazepine level or CBC since starting Tegretol, and his last bloodwork of any kind was almost a year ago.

I immediately ordered a carbamazepine level, CBC, and complete chemistries (which, of course, precipitated a fight with the patient's insurance company, since the chemistries were, according to them, "medically unnecessary".) The carbamazepine level was, not surprisingly, subtherapeutic, the CBC was (thankfully) OK -- but the chemistries showed a serum cholesterol of 490!

"Can't be," said the patient, "I'm on Lopid." I called the internist to report my findings. "Can't be," said the internist, "he's been on the same dose of Lopid for years, and his last cholesterol count was 205 eleven months ago." "Of course you're aware," I responded, "that Tegretol, which you prescribed, is a potent inducer of Cytochrome P450 3A4, which is the main metabolizer of Lopid?" The silence was deafening! Finally, the internist said, "Do whatever you think is appropriate to manage his Bipolar Depression, and then send him back to me for management of his serum lipids."

FIVE: I was called to the ER to see an elderly gentleman who was confused, disoriented and weak. The internist said he was incoherent and probably delirious. He could barely speak, but I learned from him that he had been eating very little for many weeks because he had severe constipation and he was afraid to eat lest his bowel explode. He described pencil thin stools that had been dimishing in diameter. I did a rectal examination and found a carcinoma the size of a grapefruit.

My unit is picking up patients who used to be admitted to Neurology or General Medicine. If this role is controversial, I agree with the colleague who posted that our role should be described for credentialing purposes.

I agree that the stigma of mental illness is detrimental to the medical care our patients receive. I routinely tell my patients, especially those with concurrent medical problems, that I will need to communicate with their internists or GP's. All too often a patient will beg me not to contact their PCP, on the grounds that "if he knows I see a psychiatrist, he won't take my medical problems seriously", "I don't want him to think it's all in my head" etc. I have also had the appalling experience of sending patients to the ER because of a medical problem, only to learn that on arrival they were automatically triaged to the Psych ER rather than the Medical because they were known to be psych patients.

The fact is that the mortality rates in seriously physically ill psychiatric patients are higher than in the general population because they do not get the care they need from PCP's. The mental component obscures the presence of a treatable physical illness to the detriment of the patient. The stigma against psychiatry and psychiatric patients within medicine is a potent element in this excess suffering and death. Further the mental component is generally misdiagnosed and mistreated. Consequently it costs more to treat our patients in PCP settings and this higher cost treatment is suboptimal. We need more psychiatrists if not only the mentally ill can, once and for all, get the care they need but the physically ill as well.

Special thanks to all the Physicians who agreed to allow their correspondences to be shared and who shared their cases for both Part 1 and Part 2 of this series (upcoming) (HE, LB, RM, RP, LK, RF, AS, RS, GD, WT, JC, DD).

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