In February 2024, while on consultation-liaison (CL) psychiatry service, I was caring for a patient with a resident from the primary service. The patient was a 59-year-old man with severe mental illness (SMI) taking numerous psychiatric medicines. His chief complaint was worsening shortness of breath for the past year, with acute worsening over the past week. He was no longer able to walk even short distances, whereas historically he’d been very independent and moderately active. Psychiatry was consulted to reconcile his psychiatric medicines and assess if they could be contributing to the current presentation. Of note, none of the psychiatric medicines had been changed in the past three years, and he had been psychiatrically stable since 2008. After seeing the patient, I was very concerned that there was an underlying medical problem, so I discussed my worries with the primary team. Because their consult question was answered, they were reluctant to have further discussion regarding the cause of the patient’s presenting symptoms.
I returned to my office discouraged and dismayed about these symptoms being overlooked. This was not the first time I had felt that my patients’ medical symptoms were being ignored due to their comorbid psychiatric illness. I began to wonder if there was information in the literature about biases and perceptions toward patients with SMI, and the consequences of this on medical care and outcomes. It has been well established that people in the U.S. with SMI die earlier than the general population — 10 to 20 years earlier on average. The leading cause of death for those with SMI is cardiovascular disease. Numerous lifestyle factors are likely to play a significant role in this, including but not limited to obesity, smoking, poor diet, and lack of exercise. A 2011 paper found that the excess mortality of these patients is more than 90% attributable to medical causes. It is important to acknowledge that much research describes the lifestyle risk factors for medical conditions affecting patients with SMI, and these certainly contribute to their mortality. However, our CL team regularly encounters situations in which medical care is denied or deferred for our patients with SMI — and we wonder if this is due to clinician-held biases and misperceptions contributing to disparities in care.
The factor obvious to any consult psychiatrist is the manner in which non-psychiatric clinicians often blame psychiatric medicines for medical symptoms. In the aforementioned patient’s case, he died five days later, likely due to medical illness. Indeed, when I asked other CL psychiatrists why there was little formally published literature on the topic of bias toward patients with SMI and ensuing negative medical outcomes, one colleague responded to my amusement, “It’s just a truism all accept as fact!” (Later, I discovered a recent piece from the American Medical Association Journal of Ethics that found that patients with SMI endure iatrogenic harms up to three times as often as other hospitalized patients.)
Additionally, it is not uncommon for consult psychiatrists to receive dismissive or cavalier comments from non-psychiatric physicians when a medical workup is recommended by our team for a patient with SMI. Other recent examples of the medical disparities we have witnessed include the cardiology consult team initially declining pacemaker placement in a patient with an arrhythmia (heart rate of 30 bpm) due to the patient being “psychiatrically unstable” despite reassurances from our team that the patient was appropriately stable from our standpoint. Most recently, we had a patient admitted for a medical condition who endorsed SMI and was requested to be admitted by psychiatry. Our team assessed him and determined he was delirious, and shared our concern for another medical reason for his altered mental state. The following day, the patient was found in a comatose state, with a bilirubin greater than 20.
Why would non-psychiatric physicians have these biases? I suspect that part of the explanation is that non-psychiatrists may be uncomfortable caring for patients with SMI, because these diagnoses seem far outside the realm of medical illness, and patients with SMI are unpredictable. (Indeed, even some mental health clinicians may hold these biases — a study from the VA found that both mental health clinicians and PCPs were less likely to refer a patient with schizophrenia, versus without, to a weight-reduction program.)
Generally speaking, however, psychiatrists seem to view their patients with SMI similarly to how other physicians view patients with any medical diagnosis. Like anything else in medicine, patients often have more than one medical illness simultaneously — and psychiatrists, particularly CL psychiatrists, always have this in mind. SMI itself is a medical diagnosis, and though it is psychiatric in nature, it is a diagnosis that coexists with others. Most research documenting decreased lifespan for people with SMI focuses on factors that patients themselves control, such as lifestyle habits. In an ideal world, the medical establishment would examine beliefs and attitudes physicians have regarding patients with SMI and the ways that this could be influencing access to and receipt of appropriate medical care — as it could be a significant contributing factor to the medical disparities faced by this patient population.
Note: this op-med was written by acting intern Olivia M. Dhaliwal based on the experiences of Dr. Schuermeyer. The views and opinions expressed in this op-med are purely those of the authors, and do not reflect their institutions and/or employers.
Have you ever treated a patient with SMI? How did you approach it? Share your experience in the comments.
Dr. Dhaliwal feels so blessed to be entering full-spectrum rural family medicine training in the beautiful High Country of North Carolina with the MAHEC Boone Family Medicine Residency. She is immensely grateful for the wisdom her CL psychiatry mentors at the Cleveland VA have shared, as she knows mental health care is a massive need in rural America. Olivia looks forward to guiding whole people, for their whole lives, to thrive and live well; you can keep up with her story through poetry and prose on her blog, http://dear-future-healer.ghost.io.
Isabel Schuermeyer, MD is a consult psychiatrist with nearly 20 years of experience; she practices in Cleveland at the Louis Stokes VAMC. When not caring for patients at the interface of medicine and psychiatry, she is an avid world traveler and watercolor painter, and enjoys attempting to embarrass her kids by misusing teenage slang.
Image by GoodStudio / Shutterstock
