Clinicians Should Be More Assertive in Soliciting Physical Symptoms

Physical health conditions are often discussed in an outpatient mental health intake visit—but sometimes not until the patient volunteers information about a condition.

In two-thirds of 120 videotaped outpatient mental health intake visits, a physical health condition experienced by the patient was not discussed until the patient volunteered the information.

Further, discussion of health problems—either as elicited by clinicians or volunteered by patients—appeared to be particularly infrequent among Latino patients.

Those were some of the findings of a naturalistic study of clinician-patient interaction published in the January Psychiatric Services.

The study assessed whether mental health clinicians—including 35 psychiatrists, 25 psychologists, 53 social workers, and seven nurses—specifically asked or “elicited” information about health problems or whether the information was volunteered by the patient.

Researchers assessed whether the clinicians discussed any of 15 health conditions during the mental health intake visits, which were videotaped for the study. Those conditions included “problems with physical health” (referring to nonspecific physical complaints), injury, “physical illness” (referring to any mention of illness without specific diagnoses), chronic physical pain, HIV, epilepsy or seizures, diabetes, high blood pressure, hepatitis C, allergies or hay fever, heart disease, asthma, severe headaches, arthritis, and cancer.

Clinicians most often elicited information about problems with physical health, injury, physical illness, chronic physical pain, and HIV/AIDS. Patients most frequently volunteered information about severe headaches, physical illness, and chronic physical pain.

The study found that physical health was discussed in 87 percent of the 120 visits, but in 66 percent of the visits, a specific health problem was not discussed until the patient had volunteered the information. (Clinicians might “elicit” information about one specific health problem during a visit, but the patient may volunteer information about another condition during the same visit.)

Moreover, while most psychiatrists included in the study discussed physical health problems in the visits, they lagged behind nurses and social workers in actively eliciting information. At least one item was elicited by 100 percent of nurses, 74 percent of social workers, 63 percent of psychiatrists, and 44 percent of psychologists.

Latino patients were less likely than whites or blacks to be asked about a physical health problem by a clinician and less likely to volunteer the information. At least one item was elicited from 78 percent of white patients, 71 percent of black patients, and 56 percent of Latino patients.

“Physical comorbidity is very common among patients presenting for mental health intakes, and just because patients do not raise the issue does not mean there may not be significant physical problems affecting mental health,” lead author Nicholas Carson, M.D., told Psychiatric News. “This seems particularly relevant for Latino patients.”

In the Psychiatric Services study, Carson and colleagues suggested that Latino patients may feel uncomfortable raising physical problems during mental health intake visits.

“All mental health [professionals] are capable of screening for physical health problems, confirming relationships with primary care providers, and promoting their patients' physical health care.

“Social workers did elicit physical symptoms more often than psychiatrists, but overall these symptoms were discussed at similar rates among both disciplines,” Carson said. “This finding among social workers is very encouraging. Psychiatrists may be waiting for patients to volunteer symptoms on their own. Many did so, but the risk here is that some individuals may be uncomfortable raising physical symptoms until the provider validates these concerns by directly inquiring about them.”

Carson is an instructor in psychiatry at Harvard Medical School and a clinical research associate at the Center for Multicultural Mental Health Research.

Carson and colleagues also suggested that psychologists and psychiatrists who receive more psychodynamic training may more readily employ open-ended approaches to eliciting information about physical illness and may therefore have waited for patient-initiated discussion of physical illnesses.

Twenty-eight of the videotapes were transcribed for a qualitative analysis. Carson and colleagues noted that the qualitative analysis revealed that medically trained clinicians “integrated physical problems into differential diagnoses, formulations, and treatment recommendations.”

They added that although it is not recommended that psychologists and social workers diagnose or treat physical illnesses, “these clinicians can review physical problems, encourage follow-up with primary care, and support patient efforts to maintain physical health.”

The study was a reanalysis of the Patient-Provider Encounter Study, originally published in the November 2008 Journal of Public Health Management and Practice under the title “How Missing Information Can Lead to Disparities in the Clinical Encounter.”

Patients with psychosis were included in the study, so there may have been less need to address metabolic problems associated with antipsychotic medication. But Carson noted that in the qualitative analysis, “providers rarely made reference to treatment guidelines about monitoring for metabolic consequences of psychiatric medications.”

An abstract of “How Missing Information Can Lead to Disparities in the Clinical Encounter” is posted at <www.ncbi.nlm.nih.gov/pubmed/18843234>. “Assessment of Physical Illness By Mental Health Clinicians During Intake Visits” can be accessed at <ps.psychiatryonline.org> under the February issue.