Mental illness accounts for a third of all years lived with disability and is associated with twice the relative risk of all-cause mortality. It also contributes to other leading causes of death such as heart disease, cancer, and cerebrovascular disease. An estimated 8 million deaths are attributable to mental disorders every year, with two-thirds due to comorbid medical illness.
Medical and psychiatric conditions are often interdependent with complex relationships between them. Medical conditions can cause mental illness by way of psychological and/or physiological effects; mental illness may make it difficult to engage in medical care due to barriers to access, poor motivation, functional impairment, and the like; and many medical and psychiatric conditions share common psychosocial determinants (eg, adverse childhood experiences).
CASE VIGNETTE 1
A 56-year-old man with schizophrenia, hyperlipidemia, and hypertension who smokes a pack of cigarettes a day presents to the emergency department (ED) with chest pain. The diagnosis is acute coronary syndrome; he is admitted and scheduled for cardiac catheterization with possible angioplasty. On admission, blood pressure and cholesterol medications are continued. However, the primary team is unaware of his recent increase in risperidone dose from 2 mg qhs to 2 mg bid and starts him on 2 mg qhs. Nicotine replacement is not discussed.
The patient becomes distressed and increasingly paranoid about blood work and cardiac monitoring; he refuses cardiac catheterization for two days, saying, “I’ll think about it and let you know tomorrow.” On hospital day 3, he accuses his nurse of trying to poison him and refuses all medications. Agitated, he demands an against-medical-advice discharge and pushes the nurse, prompting security involvement, physical restraint, and sedation.
The medical team orders a constant companion (ie, sitter) and consults psychiatry. The patient is psychotic when evaluated by the consultation-liaison (C-L) psychiatrist the following day and found to lack capacity to refuse medical care. The patient’s cardiac enzymes normalize with medical treatment instead of cardiac catheterization while the hospital pursues temporary conservatorship. The patient waits another three days until a psychiatric hospital bed becomes available. He is in the psychiatric wing of the hospital for several days when he once again has chest pain at rest, and he is promptly transferred back to a medical wing.
CASE VIGNETTE 2
A 46-year-old woman with chronic PTSD and a general mistrust of authority figures is admitted to the hospital with hematochezia, hypotension, and concern about a lower gastrointestinal bleed. On admission, the patient is identified on chart review by a proactive C-L service because she has a major psychiatric diagnosis and a documented history of psychiatric hospitalization.
During a brief evaluation by a psychiatric social worker the morning of hospital day 2, the patient is hypervigilant and ruminates about an anticipated colonoscopy; the social worker recommends that the primary team order a psychiatric consultation. A C-L psychiatrist sees the patient that day, begins to develop rapport with the patient, and helps to establish basic principles of trauma-informed care. Feeling more comfortable with her treatment team and the outlined plan of care, the patient undergoes colonoscopy without delay or incident; she is referred for mental health aftercare for treatment of PTSD.
Dr Oldham is Assistant Professor of Psychiatry, Dr Chahal is Fellow, Consultation-Liaison Psychiatry, and Dr Lee is Professor and Chair of Psychiatry, University of Rochester Medical Center. The authors report no conflicts of interest concerning the subject matter of this article.
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