A Disconnect in Today’s Health Care
There are 2 primary reasons why patients with comorbid general medical and psychiatric illness find it difficult to obtain coordinated physical and psychiatric services. The first and most obvious is that the health system pays for mental health and chemical dependency care from segregated budgets.6 This is based on the erroneous assumption that mental health and substance use disorders are somehow sufficiently different from other health problems that they require completely separate clinical delivery areas and payment mechanisms. In fact, psychiatry is the only area of allopathic medicine in which this occurs.
As jointly trained physicians in internal medicine and psychiatry, we argue from our experience in day-to-day clinical care that patients with psychiatric disorders are as similar to patients with physical illness as patients with surgical conditions are to those with chronic medical illnesses treated with medication only. Each area of medicine has unique features but none to the extent that mandate independent service locations and independent reimbursement. The artificial separation of psychiatric care from physical health care is a disservice to the physical health of patients in whom emotional and behavioral factors contribute to poor illness outcomes. It is also a disservice to patients with psychiatric disorders in whom coexisting general medical illness causes or exacerbates psychiatric symptoms and/or leads to premature death.
The second reason for “disintegrated” physical and psychiatric services is tradition. Nonpsychiatric physicians and psychiatrists have lived in separate worlds for so long that they can no longer visualize a medical environment in which coordinated care could occur. Few physical health physicians have much more than passing knowledge of advances that have been made in psychiatric diagnosis and treatment during the past 30 years, thus few use evidence-based approaches to care or see a need to request assistance from psychiatric specialists. Moreover, primary and specialty medical physicians find it convenient that “psych” patients are cared for in different locations. That way they can inconspicuously avoid involvement in those patients’ medical care since clinical service locations make it inconvenient to do so.
Psychiatrists harbor their own biases. Many continue to argue that psychiatric disorders require special privacy laws—as if erectile dysfunction and treatment for spousal abuse are not equally in need of privacy. Privacy is necessary for all personal health information, whether general medical or psychiatric, but information should not be withheld between clinicians. Psychiatrists have also made themselves largely unavailable to nonpsychiatric physicians. While this originated with payment disparities, it has grown to a “we” versus “they” mentality, with hostile overtones in some settings. Wait times of 3 weeks to 3 months for adult psychiatric appointments and 3 to 6 months for child psychiatry are the rule rather than the exception.
Many psychiatrists feel uncomfortable treating patients in whom comorbid medical illness must be factored, just as their medical counterparts feel out of their element when emotions or aberrant behaviors interfere with medical/surgical interventions. Separate assessment and treatment of physical and mental illnesses has allowed practitioners to focus on treatment in their primary discipline while their comfort with cross-disciplinary disorders deteriorates. However, patients with comorbid physical and mental illness are the norm, and practitioners have yet to adequately address this disease complexity.