Telemedicine encompasses different types of programs and services provided for the patient. Videoconferencing: Real-time transmission of digital video images between multiple locations. Jay H. Shore, M. I Accept. All Topics What is Telepsychiatry? It can benefit patients in a number of ways, such as: Improve access to mental health specialty care that might not otherwise be available e.
Evidence for Effectiveness There is substantial evidence of the effectiveness of telepsychiatry and research has found satisfaction to be high among patients, psychiatrists and other professionals. Used in a Variety of Settings Telepsychiatry is used in a variety of different settings, including private practice, outpatient clinics, hospitals, correctional facilities, schools, nursing homes, and military treatment facilities.
Cost and Insurance Click to view larger image Thirty-two states have legislated that private insurance cover telemedicine, according to the American Telemedicine Association as of July , see map. Definition of Terms APA Position Statement on Telemedicine in Psychiatry Telemedicine in psychiatry, using video conferencing, is a validated and effective practice of medicine that increases access to care. Telepsychiatry in the 21st Century: Transforming Healthcare with Technology. Perspective in Health Information Management. Summer Hilty DM, et al.
Telemedicineand e-Health. June , Vol 19, No. Beck M.
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What is Telepsychiatry? Your Guide to DSM Also, access to more varied client populations can decrease burnout and thereby increase workforce retention. In addition, telepsychiatry enables psychiatrists to advise primary care providers PCPs , who are often on the front lines of treatment. Another collaborative model, developed at UW, embeds psychiatrists in primary care practices, where they oversee cases, provide consultation, and see only the most challenging patients.
A Cochrane Review of 79 studies on the approach, called Collaborative Care, noted its effectiveness in treating anxiety and depression. The potential impact on patients is what draws many to psychiatry, notes Kirch. And at the same time we are beginning—through brain imaging, genetics, and other techniques—to understand the biological basis of mental disorders, which creates the opportunity to develop more effective treatments.
Sign In Profile. New section. New section Patient Care Workforce Addressing the escalating psychiatrist shortage. Stacy Weiner , Senior Staff Writer. Learn what academic medicine is doing to help deliver care now and train more psychiatrists for the future. New section Fearing she may be depressed, a young woman calls a psychiatrist. The growing mental health shortage In the United States, nearly one in five people has some sort of mental health condition. Similarly, no study has shown the ability of a specific rating scale or assessment instrument to predict suicide in an individual Assessment and Management of Risk for Suicide Working Group ; Haney et al.
Furthermore, the utility of any assessment depends on availability of an effective treatment for the identified disorder or risk factor. Despite these limitations of the available research evidence, there is consensus by experts that the benefits of assessing the factors described in statements 1, 2, and 3 in an initial psychiatric evaluation clearly outweigh the potential harms, including unclear costs.
Suicide and suicide attempts occur at an increased rate in individuals with psychiatric disorders Assessment and Management of Risk for Suicide Working Group ; Baxter and Appleby ; Borges et al. Suicide is rare, even within populations with a specific, high-risk mental disorder, such as major depressive disorder. Nevertheless, when suicide occurs, it is a devastating outcome for patients, their families, their communities, and clinicians. Substantial morbidity also occurs because of suicide attempts and other suicide-related behaviors.
When a patient is judged to be at risk, the clinician may use information obtained during the evaluation to determine an appropriate treatment setting and formulate an individualized treatment plan that addresses specific modifiable risk factors and may include heightened observation. Inquiring about suicidal thoughts and related risk factors during the initial psychiatric evaluation may improve identification of patients who are at increased risk of suicide.
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There is no evidence that risk of suicide is increased by asking a patient about prior experiences, symptoms such as hopelessness, or current suicidal ideas or suicide plans. This could result in unneeded treatment, hospitalization, or other consequences for patients. Just as it is not possible to predict which individuals will die by suicide, there is no way to predict which individuals would be incorrectly identified as being at significant acute risk and no way to estimate the potential magnitude of this harm.
The cost of a suicide assessment is difficult to separate from the overall cost of an initial psychiatric evaluation, but both are low relative to the cost of suicide and suicide-related morbidity. Depending on the clinical characteristics of the patient and constraints such as time and setting, clinicians may prioritize suicide risk assessment over other parts of the evaluation and be unable to address other issues in as much detail.
Potential consequences include reducing time available to inquire about and document other, potentially more important findings of an evaluation. Typically, an evaluation involves a direct interview between the patient and the clinician. In some circumstances such as an evaluation of a patient with severe psychosis or dementia , obtaining information on history, symptoms, and current mental status may not be possible through direct questioning.
With all patients, other sources of information, such as prior medical records, and other treating clinicians can be important in corroborating information obtained in the interview or in raising previously unknown information. They may also have observed behavior or been privy to communications from the patient that suggest suicidal ideation, suicide plans, or suicide intentions. In implementing these recommendations, the clinician should note that some terms and concepts do not have precise definitions. When the clinician is questioning a patient about suicidal behaviors, the primary goal is to identify any suicidal behaviors in which an attempt is begun, recognizing that it may not be conceptualized by the patient as a suicide attempt if it was stopped or interrupted.
Many suicide risk factors, such as hopelessness, are difficult to assess in a standardized way. It would be impossible to list all of the possible elements that may contribute to a reason for living, a psychosocial stressor, a way to access suicide means, or a motivation or plan for suicide. Consequently, the clinician will need to frame specific questions related to these topics based on other information that has already been gathered in the interview.
Flexibility is also needed in the way that specific information is elicited. However, it is also important to frame the question in a way that gives the patient hope or suggests ways of coping if symptoms were to worsen e. It may be useful to include family or friends in building support and strengthening approaches to coping. In some individuals, suicidal ideas may be motivated by feelings such as loneliness, self-hatred, or a sense of being a burden, not belonging, feeling trapped, or having no purpose Jobes ; Van Orden et al.
Such psychologically painful thoughts may be difficult to share, particularly at an initial interview. Throughout the assessment, clinical judgment is needed in synthesizing information and observations. Affirmative answers to some questions will often suggest other important lines of inquiry. For example, if a patient reports impulsivity, the clinician may be led to inquire about traumatic brain injury or thoughts about harming others; if a patient reports a suicide attempt, the clinician may be led to ask about precipitants, preparatory behaviors, method, physical damage, degree of lethality, and subsequent treatment.
Determining the quality and strength of the therapeutic alliance is also a multifaceted clinical judgment. At an initial evaluation, information may be limited to behavioral observations such as whether the patient appears to be cooperative with the assessment and forthcoming in answers to questions in contrast to being sullen, guarded, irritable, or agitated.
When the clinician is communicating with the patient, it is important to remember that simply asking about suicidal ideas or other elements of the assessment will not ensure that accurate or complete information is received. In older individuals, difficulty understanding questions may signal unrecognized impairments in cognition or in hearing. Flexibility may be needed to frame questions in a clearer manner. In other circumstances, the patient may minimize the severity or even the existence of his or her difficulties, particularly if help seeking is not voluntary.
If other aspects of the clinical presentation seem inconsistent with an initial denial of suicidal thoughts, additional questioning of the patient or others may be indicated. Factors such as time pressures, interviewing style, and clinician attitudes can also influence the ability to conduct an accurate assessment.
Thus, the psychiatrist will want to be aware of his or her own emotions and reactions that may interfere with the interview process.
These recommendations should not be viewed as representing a comprehensive set of questions relating to suicide risk assessment, nor should they be seen as an endorsement of a checklist approach to evaluation. They also should not be viewed as suggesting the use of a standardized scale to identify individuals at high suicide risk. Many such scales have been designed and studied. Scales may be useful clinically—for example, to assist the clinician in developing a thorough line of questioning or to open communication with patients about particular feelings or experiences.
However, no scale has been shown to provide a numerical score with clinically useful predictive value Assessment and Management of Risk for Suicide Working Group ; Haney et al. Furthermore, no study has shown an ability to use population-based risk factors or combinations of those risk factors to accurately predict patients who die by suicide Assessment and Management of Risk for Suicide Working Group ; Brown et al. In the context of suicidal behaviors, risk factors and protective factors interact in complex ways Kraemer et al.
When the clinician is estimating suicide risk and developing a plan to address it, it is helpful to distinguish between nonmodifiable risk factors and modifiable risk factors. Although proximal and distal risk factors may each be modifiable, they may require different types of interventions to address risk. Examples of nonmodifiable risk factors include demographic variables such as age and sex and factors related to clinical history such as past hospitalizations, past suicidal behaviors, childhood abuse, history of trauma, loss of a child, or family history of suicide or psychiatric illness.
Although these factors are immutable, their relative impact on suicide risk may vary. For example, the relative risk of suicide can change as a person ages, with particularly high risk seen in white males over the age of The risk associated with a prior hospitalization or prior suicide attempt is highest in the weeks to months after the event, but such events still confer some increased risk months or years later. Individuals with multiple suicide attempts or hospitalizations have additional increases in static risk. When there is a history of suicidal ideas, risk may vary depending on the worst-ever suicidal ideas.
Learning about the ways in which the patient kept from acting on suicidal ideas can provide clues about available coping strategies as a protective factor. Factors such as an early age at onset of depression or impulsive-aggressive traits, in combination with family history, can also be a marker of underlying vulnerability and risk Mann et al. Psychiatric diagnoses and serious medical conditions, particularly those that are chronic, debilitating, disfiguring, or painful, can also contribute to an increase in the long-term relative risk of suicide Assessment and Management of Risk for Suicide Working Group ; Baxter and Appleby ; Harris and Barraclough ; Haney et al.
Again, the extent of risk can vary depending on factors such as illness severity, recency of diagnosis, and the number of comorbid conditions that are present. Among psychiatric disorders, mood disorders, psychotic disorders, anxiety disorders, posttraumatic stress disorder, substance use disorders, and disorders associated with impulsivity are most often associated with increased risk. Most patients will also have one or more modifiable factors, superimposed on the nonmodifiable risk factors described above, that influence their suicide risk. Some of these factors are indications of an underlying or newly identified psychiatric disorder and can be reduced by treating the disorder itself or through targeted treatment of the specific sign or symptom.
Examples of such signs and symptoms that can influence risk include psychosis, mood changes, hopelessness, insomnia, irritability, agitation, aggressive behaviors, and increases in substance use. In terms of suicidal ideas, the clinician will generally assign a higher level of risk to patients who have high degrees of suicide intent or describe more detailed and specific suicide plans, particularly those involving accessible means and violent irreversible methods.
Psychosocial stressors may serve as precipitants to suicidal behaviors. Examples include lack of social support; stress relating to immigration; bereavement; problematic relationships e. Other stressors may be relevant to certain groups of patients e. These stressors may be modifiable to some degree, but they also may be ongoing contributors to risk.
Individuals also have a unique balance between their personal motivations for suicide on the one hand and their reasons for living on the other hand. Motivations for suicide can include factors such as revenge, shame, humiliation, delusional guilt, command hallucinations, gaining attention or reaction from others, escaping physical or psychological pain, loneliness, self-hatred, or a sense of being a burden, not belonging, feeling trapped, or having no purpose. In contrast, reasons for living can include factors such as religious beliefs, sense of responsibility to children or others, plans for the future, or a sense of purpose in life.
A strong social support network can also serve as a protective factor. Given the large number of factors that can affect the risk of suicide, the clinician can neither review nor document all possible factors that could conceivably influence suicide risk. Rather, the clinician provides an estimated level of suicide risk, including factors that influence risk. It may also be helpful to conceptualize the overall risk in terms of underlying nonmodifiable risk factors as well as more immediate precipitants that may contribute to acute risk but are more likely to be modifiable.
In addition to supporting clinical decision making and communication, such documentation can also serve as a foundation for planning of treatment. Depending on the setting and clinical characteristics of the patient, the clinician may judge some parts of the evaluation as being of greater value in addressing safety concerns and planning initial treatment. Prior aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide.
Past aggressive behaviors e. Legal or disciplinary consequences of past aggressive behaviors. Exposure to violence or aggressive behavior, including combat exposure or childhood abuse. Past or current neurological or neurocognitive disorders or symptoms. When it is determined during an initial psychiatric evaluation that the patient has aggressive ideas, APA recommends 1C assessment of the following:. Impulsivity, including anger management issues. Specific individuals or groups toward whom homicidal or aggressive ideas or behaviors have been directed in the past or at present.
History of violent behaviors in biological relatives. APA suggests 2C that the clinician who conducts the initial psychiatric evaluation should document an estimation of risk of aggressive behavior including homicide , including factors influencing risk. The goal of this guideline is to improve, during an initial psychiatric evaluation, the identification of patients at risk for aggressive behaviors. The strength of research evidence supporting this guideline is low. A substantial body of epidemiological, cohort, and case-control studies has shown associations between the risk factors described in this guideline and medium- to long-term relative risk of aggression in populations Coid et al.
However, there is no evidence that assessment of any of these factors can predict aggression in an individual Buchanan et al. Similarly, no study has supported the ability of a specific rating scale to predict aggression in an individual. Despite these limitations of the available research evidence, there is consensus by experts that the benefits of assessing the factors described in statements 1 and 2 in an initial psychiatric evaluation clearly outweigh the potential harms, including unclear costs.
Inquiring about aggressive and homicidal thoughts and related risk factors during the initial psychiatric evaluation may improve identification of patients who are at increased risk of aggressive behaviors. For example, assessment may help the clinician to determine an appropriate treatment setting and formulate an individualized treatment plan that may include heightened observation or may target specific modifiable risk factors.
There is no evidence that risk of aggression is increased by asking a patient about prior experiences, symptoms such as impulsivity, or current aggressive and homicidal ideas or plans; however, assessment could identify individuals as being at risk when they are not. This could result in unneeded treatment or hospitalization or other consequences for patients. Just as it is not possible to predict which individuals will exhibit aggressive behaviors, there is no way to predict which individuals would be incorrectly identified as being at risk and no way to estimate the potential magnitude of this harm.
The cost of assessing aggression is difficult to separate from the overall cost of an initial psychiatric evaluation, but both are low relative to the costs and harms of aggressive or homicidal behaviors.
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Depending on the clinical characteristics of the patient and constraints such as time and setting, clinicians may prioritize assessment of aggression risk over other parts of the evaluation and be unable to address other issues in as much detail. As noted above, potential harms could include reducing time available to document other, potentially more important findings of an evaluation. In some circumstances e. With all patients, other sources of information can be important in corroborating information obtained in the interview or in raising previously unknown information.
When available, prior medical records, input from other treating clinicians, and information from family members or friends can provide added details on issues such as recent symptoms, stressors, past history, and family history. Exposure to violence by nonbiological family members can also be important to consider. When the clinician is communicating with the patient, it is important to remember that simply asking about aggressive ideas or other elements of the assessment will not ensure that accurate or complete information is received.
Such individuals may also become more agitated when feeling overwhelmed or overloaded with cognitive demands. Flexibility may be needed to frame questions in a clearer and simpler manner. If other aspects of the clinical presentation seem inconsistent with an initial denial of aggressive thoughts or prior aggressive behaviors, additional questioning of the patient or others may be indicated.
Emergency rooms slow to treat, transfer psychiatric patients
Factors such as time pressures, interviewing style, and clinician attitudes, including concern for personal safety, can also influence the ability to conduct an accurate assessment. Thus, the psychiatrist will want to be aware of his or her own emotions and reactions that may interfere with the interview process and also attend to his or her own safety as well as that of the patient.
Some terms and concepts used in this guideline are impossible to define precisely. Many aggression risk factors, such as impulsivity, would be difficult or even impossible to assess in a standardized way. When you do become angry, do you lose your temper easily? How often do angry urges happen and how long do they last? Do you ever get so angry that you feel like you want to hurt someone? Do you ever daydream about hurting others? Are there specific individuals who you have thought of hurting?
What helps you calm down when you are feeling angry? What ways do you use to keep yourself from acting on your angry impulses? Understanding the reasons that the patient is presenting for evaluation is also important in determining the interpersonal and psychosocial context in which aggressive thoughts might arise. For example, firearms may be readily available in some geographic regions or with some occupations.
Relevant psychosocial stressors may commonly include housing problems or homelessness, financial stresses, job loss, relationship loss, or lack of social support but may also include other stressors that are particularly salient for a given individual e. In addition, the clinician will need to frame specific questions based on other information that has already been gathered in the interview. Inquiring about legal or disciplinary consequences of aggressive behaviors, such as school expulsions, warrants, arrests, jail or prison sentences, probation, parole or orders of protection, would depend on the answers to prior questions.
When aggressive behaviors have occurred, it is often helpful to learn about the context of those events e. In terms of neurological disorders, common concerns would include traumatic brain injury Fazel et al. Clinical judgment may also be needed in synthesizing information and observations from the interview. Diagnostic considerations can also be relevant, because research studies have identified diagnostic subgroups, such as individuals with substance use disorders or antisocial personality disorder, who show an increased relative risk of aggression on a long-term basis in community settings for more information, see Coid et al.
Individuals in other settings, including psychiatric inpatient or forensic units, or with specific diagnoses may show somewhat different patterns of risk factors Cornaggia et al. Such behaviors are also a common precipitant for hospital admission when a neurocognitive disorder is present Toot et al. For an individual patient, other factors may be relevant to clinical decision making about aggression risk. For example, for a patient whose psychiatric disorder is currently symptomatic, the severity of symptoms may be relevant as well as whether the patient is unusually angry or irritable during the evaluation, feels persecuted by an identified individual, or is experiencing command hallucinations to harm others.
Whenever an individual has aggressive or homicidal ideas or behaviors, it is important to identify any intended targets of aggression. If a specific target is identified, the clinician will need to use his or her clinical judgment in deciding whether the patient requires a more supervised setting of care to provide protection for the identified target and more intensive treatment for the patient or whether the identified target should be warned of the potential for harm, or both.
There is also considerable variability by state on the case law and statutes that address the Tarasoff duty to protect Soulier et al. Assessment of aggressive ideas will commonly be integrated with assessment for suicidal ideation, and if suicidal thoughts are identified, it is important to look for factors that might suggest a possible risk of murder-suicide.
These recommendations should not be viewed as representing a comprehensive set of questions relating to aggression risk assessment, nor should they be seen as an endorsement of a checklist approach to evaluation. Although structured assessments of aggression risk have been developed and studied, none has sufficient predictive validity to identify individuals at high aggression risk in clinical settings Buchanan et al. This clinical decision-making process and a discussion of the factors that are judged to influence the risk of aggressive behavior for the individual patient can be included as part of the clinical documentation, typically in a brief paragraph.
Distinctions between modifiable risk factors e.
Table 1. The Key Principles and Characteristics of an Effective Hospital Medicine Group (HMG)1
Depending on the setting and clinical characteristics of the patient, the clinician may prioritize some parts of the evaluation and documentation process that are judged to have greater value in addressing safety concerns and planning initial treatment. The goal of this guideline is to improve, during an initial psychiatric evaluation, identification of cultural factors that could influence the therapeutic alliance, promote diagnostic accuracy, and enable appropriate treatment planning.
Despite this, there is consensus by experts that the benefits of including the assessments described in statements 1 and 2 in an initial psychiatric evaluation clearly outweigh the potential harms. Individuals present for psychiatric assessment with a wide range of backgrounds, cultures, and beliefs. Data from the American Community Survey U. Census Bureau show that the U. Approximately one-fifth of the U.
Of these individuals, slightly more than one-half also speak English very well. Nevertheless, increasing numbers of individuals in the United States have limited proficiency in English, which can affect their receipt of appropriate health care. Furthermore, in nonpsychiatric settings, the use of professionally trained interpreters during the evaluation of patients with limited English proficiency has been found to reduce communication errors and enhance comprehension of medical information, health care utilization, clinical outcomes, and satisfaction with care Karliner et al.
This is true even when the patient speaks the same language as the clinician. Some patients will speak more than one language and have differing levels of fluency in each. Verbal and written language fluency may be discordant, and comprehension may differ from spoken language fluency. Some of these factors, including sex, race, ethnicity, and sexual orientation, have been found to be associated with disparities in medical care and health outcomes Gone and Trimble ; Hall-Lipsy and Chisholm-Burns ; Lagomasino et al. Individuals from different backgrounds may also differ in their explanations of illness, views of mental illness, and preferences for psychiatric treatment, particularly given the cross-cultural differences in the stigma of psychiatric disorders Abdullah and Brown ; Angermeyer and Dietrich ; Jimenez et al.
The relevance of cultural factors to both diagnosis and treatment suggests potential benefits of identifying personal and cultural factors and integrating that understanding into the provision of care, including psychoeducation and other interventions to address culturally related stigma and shame. Such an approach has been recommended by experts Mezzich et al. Department of Health and Human Services Clinicians can improve their ability to assess cultural factors that are relevant to diagnosis and treatment by using an assessment instrument such as the DSM-5 Cultural Formulation Interview and by learning about cultures that are represented among their patients Lim et al.
In an initial psychiatric evaluation, the clinician typically gathers information about a patient through a face-to-face interview. Use of an interpreter could improve the accuracy of diagnosis by allowing the patient to communicate nuances of his or her mental state and symptoms.
It could also ensure the formulation and implementation of an appropriate treatment plan and assist the clinician in providing education about symptoms, potential treatments, and their possible side effects. There are no plausible harms of assessing the need for an interpreter, and the cost of the assessment seems negligible. For example, for cultural reasons, a patient may consider some treatments to be particularly valuable and others unacceptable.
Furthermore, interventions may be available that are designed for patients with a specific cultural background or that are designed to address disparities in the care of specific populations such as ethnic minorities Grote et al. Potential harms of a cultural assessment e. The cost of doing a cultural assessment is difficult to separate from the overall cost of an initial psychiatric evaluation, which varies depending on the patient, the setting, and the model of payment. When time is used to focus on cultural issues, the time available to address other issues of importance to the patient may be reduced.
For many patients, language needs can be easily determined. For others, assessment may need to establish both the need for an interpreter and the appropriateness of different interpreter options. This may be apparent at the time an appointment is being scheduled, but it may also be identified as a need at the time of the initial visit. Although language-concordant physicians or trained in-person interpreters have typically been used Locatis et al. However, remote interpreting services can be more challenging to use if patients speak softly or are unable to cooperate fully with the interview.
Some individuals who are deaf or hard-of-hearing may prefer to communicate through an in-person or video-based sign language interpreter, whereas others prefer to communicate through other approaches e. In addition to considering concordance of language per se, clinicians and interpreters will want to consider the effects that different dialects and uses of idiom can have in the communication process.
These questions may flow naturally from the reasons that the patient presents for evaluation or may require more specific attention during the interview. An individualized approach is important because there is substantial heterogeneity of individual beliefs, including those related to cultural factors Lim et al. Individuals within a specific cultural group will have a wide range of beliefs relating to that culture. Some patients will use culturally specific treatments, including medications, supplements, health practices, and consultation with culturally specific healers.
Other treatments may be prohibited or misunderstood because of cultural beliefs. When present, cultural networks e. In many cultures, families play an important source of support during times of illness, and in some cultures treatment decisions are made by family members rather than by the individual.
Examples may include spiritual beliefs that are not part of an organized religion or cultural or religious rituals, including food preferences. A number of barriers exist to conducting such an assessment, including underlying cultural biases of clinicians and the time needed to conduct a thorough exploration of culturally related beliefs, influences, and networks.
Some clinicians are unsure of the value of assessing cultural factors or feel unskilled in conducting a complex assessment of this type. For clinicians who lack experience in assessing cultural factors, the DSM-5 Cultural Formulation Interview American Psychiatric Association a offers a semi-structured framework for initiating questioning relating to key elements of the cultural identity of the individual, cultural conceptualizations of distress, psychosocial stressors and cultural features of vulnerability and resilience, and cultural features of the relationship between the individual and the clinician.
APA recommends 1C that the initial psychiatric evaluation of a patient include assessment of whether or not the patient has an ongoing relationship with a primary care health professional. General appearance and nutritional status. Involuntary movements or abnormalities of motor tone. Speech, including fluency and articulation. Physical trauma, including head injuries. Past or current medical illnesses and related hospitalizations. Relevant past or current treatments, including surgeries, other procedures, or complementary and alternative medical treatments.
Past or current sleep abnormalities, including sleep apnea. APA recommends 1C that the initial psychiatric evaluation of a patient include assessment of all medications the patient is currently or recently taking i. APA suggests 2C that the initial psychiatric evaluation of a patient also include assessment of the following:. Height, weight, and body mass index BMI. Skin, including any stigmata of trauma, self-injury, or drug use.
Past or current endocrinological disease. Past or current infectious disease, including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infectious diseases such as Lyme disease. Past or current symptoms or conditions associated with significant pain and discomfort.
Statement 5. In addition to a psychiatric review of systems, APA suggests 2C that the initial psychiatric evaluation of a patient include a review of the following systems:. Constitutional symptoms e. The goal of this guideline is to improve, during an initial psychiatric evaluation, identification of nonpsychiatric medical conditions that could affect the accuracy of a psychiatric diagnosis and the safety of a psychiatric treatment plan. The strength of research evidence supporting statements 1, 2, and 3 is low.
The studies also did not address whether treatment safety is affected by physical assessment, medical history, review of medications, or review of systems, or whether diagnostic accuracy is affected by review of medications or review of systems. The lack of generalizability of these studies is an additional factor that weakens their strength.
Despite this, there is consensus by experts that including the assessments described in statements 1, 2, and 3 in an initial psychiatric evaluation has benefits for diagnostic accuracy and treatment safety that clearly outweigh the potential harms. Individuals with psychiatric disorders can have medical conditions that influence their functioning, quality of life, and life span. Estimates suggest that the life span of an individual with a mental illness is approximately 8 years shorter than the life span of individuals in the general population Druss et al.
For individuals with serious mental illness, the reduction is even more dramatic: up to 25 years Parks et al. Individuals with mental illness have increased cardiovascular mortality Miller et al. Dental health is also poorer in those with severe mental illness Kisely et al. Physical functioning is often reduced as well Chafetz et al. When individuals with a serious mental illness are diagnosed with medical conditions, they may be less aware of their concomitant disorders than individuals without a mental illness Kilbourne et al.
In addition, the quality and type of treatment they receive is frequently disparate from care received by the general population Druss et al. Furthermore, some individuals with mental illness may be unable to understand and adhere to treatment for their illness. These disparities in care for those with psychiatric illness worsen the morbidity and mortality due to medical conditions as compared with individuals in the general population.
Psychiatric and medical issues are interrelated in a number of other ways. Medical conditions can contribute to the genesis of psychiatric symptoms and syndromes American Psychiatric Association b ; David et al. For example, an individual with hyperthyroidism may develop symptoms of anxiety.