Such advisement was in keeping with an already noted trend of primary care doctors – trained as internists – treating many patients for mental illness, with more than a third of patients relying solely on their PCPs for mental health treatment given limited accessibility of care in many regions as well as concerns about stigma.
Given both the prevalence of mental illness and the high degree to which physicians outside of psychiatry are treating mental illness directly or incidentally to other medical conditions, it is important to evaluate the ways in which non-psychiatrists treat patients with psychiatric histories. Do they treat medical conditions equally for patients with or without histories of mental illness, or are there intentional or inadvertent practices that discriminate in the management of health conditions?
A firsthand account of this was taken up in a 2013 New York Times op-ed, with the author Juliann Garey noting the numerous occasions in which her medical conditions were not treated seriously once the treating physicians noticed her history of bipolar disorder and her medications to treat it. From being given only Tylenol for an ear infection that soon resulted in a ruptured eardrum and permanent hearing loss, to being scolded by her gastroenterologist because of co-existing psychological and stomach problems, she found that the nature of treatment was noticeably poorer once it was revealed to her provider that bipolar disorder was in the mix, a phenomenon referred to as “diagnostic overshadowing.”
The term was coined in 1982 to characterize physicians’ potential propensity to attribute physical symptoms to mental disorders, yielding bias in diagnosis in treatment. Thus, if a patient with a depression history is having digestive symptoms, they might be more quickly attributed to stress as opposed to leading to a GI workup. Mild chest pain might be more quickly attributed to anxiety than a cardiac arrhythmia. While the initial instincts may well be accurate in the end, the disparity in treatment quality may be problematic.
By and large, I have been immensely fortunate in that despite a history of depression and a complex medical history, both have been treated seriously, with my physicians highly invested in my recovery in both domains and treating my health conditions with dignity and professionalism, often going above and beyond the call of duty. I cannot say enough good things about my primary care provider and the specialists I have had over the years. However, a recent and quite severe experience with this at SSM St. Mary’s Hospital in St. Louis, MO necessitates some further discussion on this matter of discrimination on the basis of mental health from those in whom we trust for our care.
Having entered their hospital care by ambulance after severe complications involving psychotropic medications, it was revealed that my previously diagnosed endocrine conditions were acting up at dangerous levels, with electrolyte abnormalities that were worse than in any of my medical workups to date and such electrolyte abnormalities associated with a significant potential for cardiac complications.
Despite my having had prior discharge paperwork from only three weeks earlier to attest to their knowledge of my medication list and dosages to manage chronic parathyroid and stomach conditions, they neglected to provide me with my normal medication regimen, even with the increasingly severe electrolyte abnormalities with which I had presented in their emergency department. Multiple conversations with multiple nurses and the attending physician failed to result in their correcting the numerous deficiencies in this regard: one medication would be approved but another not, another medication prescribed for four times daily (calcium carbonate, hardly carrying any addictive properties) authorized for only once daily. What’s more, the attending psychiatrist ordered the discontinuation of all psychotropic medication without ever once informing me of the decision, let alone explaining the rationale. (It is worth nothing that cold turkey discontinuation of one of these medications, Klonopin, is considered to be medically dangerous).
To fail to so much as inform a patient as to the medications that they are being prescribed, or from which they are now barred, is an act of unprofessionalism. To justify it on the grounds that the patient has a history of severe depression adds a further dimension to this maltreatment, which is discrimination on the grounds of mental illness (covered by the Americans with Disabilities Act of 1990) not only from primary care medicine but also from psychiatry, the very subspecialty of medicine designed to treat these illnesses. It should thus come as little surprise that I left the hospital with declining electrolytes and more noticeable symptoms given their lackadaisical mode of treatment and diagnostic overshadowing that, if in a patient more critical than I, could have resulted in much more significant complications.
While it is perhaps understandable to take with a grain of salt a medical report from a psychiatric patient, particularly one whose condition contains psychotic features or delusional thinking (neither of which typically applies to unipolar depression), prior medical records and prescription records from pharmacies, and the ability to consult with one’s primary care physician should assuage concerns in this regard and should not result in the failure to adequately treat the medical needs of those who have co-occurring medical and psychiatric disorders and move beyond these discriminatory treatment practices.
In a perfect world, such a change would be in the interest of all parties – certainly patients, but also for physicians seeking to do their best jobs in treating their patients, depressed or not (though such an approach may admittedly result in more insurance claims). More realistically, practices will be adjusted strategically on the basis of risk aversion with respect to medical malpractice litigation. With any luck, with more primary care physicians involving themselves to some degree in the mental health care of their patients through routine screenings and such, so too will there be increased understanding of mental health among PCPs whose work had not previously focused on such conditions, and with that greater knowledge in treatment, also greater compassion and thoroughness in treating other conditions in those same patients.