When Physical Symptoms Have a Psychological Component: The Case for Integrating Mental Health Into Hospital Care
By Dr. Prerna Keshari
Patients who have constant headaches, chest pain, and stomach issues, along with a continued feeling of body aches, and skin problems, can move across several departments in the hospitals while trying to find solutions for their ailments. They could undergo multiple diagnostic tests and consult different specialists, with little improvement in their condition until it is discovered that they are suffering from psychological ailments.
In healthcare, this is an issue that goes beyond just the diagnosis. If the presence of psychological stress in a patient is ignored, it can increase the duration of healthcare use and its costs while also putting the patient and their family under stress.
Dr. Prerna Keshari, KIMS Hospitals, Mahadevapura, Bengaluru
Physical Symptoms Often Cross Departmental Boundaries
Multiple studies have shown that there is a strong relationship between psychological stress and physical condition. Stress can affect the autonomic nervous system functioning, quality of sleep, degree of muscle tension, pain perception and digestive tract functioning.
Moreover, anxiety and depression may emerge together with chronic physical conditions rendering the treatment more complicated.
The World Mental Health Report 2022 issued by the World Health Organization pointed out the existence of a worldwide burden of mental diseases and the necessity of integrating mental health services into general healthcare services. The studies have proven that mental and physical health have many common features.
In the general medical outpatient department of the hospital patients complain about the same symptoms including prolonged headaches, weakness, fatigue, aches all over the body, burning sensations and trouble with sleeping. Doctors in the gastroenterology department receive the same complaints: heartburn, reflux, vomiting, constipation and diarrhea, including the problems stemming from gut-brain disorders.
Cardiology also presents a case of overlap. In the emergency departments patients may complain about pain in their chest, problems with breathing, heartbeat disturbances and pain in the arm.
Dermatology, neurology, pulmonary medicine, and endocrinology may also receive patients that have physical and mental symptomatology intertwined.. Stress could make an existing skin condition worse. On the other hand, in the case of hair pulling and constant skin-picking, doctors may require
psychological help. Other symptoms such as trembling, dizziness, and pain can have different causes, both psychological and neurologic. Eating disorders and eating in excess may also be due to stress.
The issue faced by doctors in this regard is that physicians should not judge immediately that the symptoms are completely psychological but rather evaluate in depth with mental health as one of the vectors.
The Cost of Missing the Psychological Component
The effects of being slow in recognizing certain issues are twofold: there are financial implications and consequences for human health. Patients can have numerous examinations done and go through quite a few hospital visits, but without getting better or being able to relieve symptoms . The expenditures related to such trips can be rather high for patients arriving from small towns or even other states.
Persistent symptoms can hinder one's ability to work, focus and function normally.
Aside from the issues faced by patients, from a management perspective, repeated consultations and procedures take much time and resources to complete.
The accurate expense of treatment depends on particular groups of patients, illnesses, and facilities. Thus, it is vital that hospitals examine their specific tendency toward repeat visits and testing instead of uniformly expecting a certain expense of certain departments.
People may lose something even more valuable than money – their trust. Patients who recover after they receive needed psychological treatment may wonder why this option was not available before. The individuals providing treatment may run into trouble in keeping up the treatment process if their patients visit different departments without a common therapy plan.
Building Integration Through Everyday Clinical Practice
At KIMS Hospitals located in Mahadevapura, Bengaluru, referrals made from different departments give an illustration of the collaboration between physical and mental health care in practice. Dr. Prerna Keshari has noted referrals from the cardiology department once some cardiac conditions were ruled out. Physicians also have an understanding of the mental aspects of care in instances where smoking cessation is considered before a cardiac surgery is carried out and behavioural support can play an important role in surgical outcome.
This method depends on clinically relevant knowledge and communication skills so that mental health is incorporated into a patient's treatment path in a way that prevents him/her from disliking their intervention. Rather than employing a single protocol of screening being used across departments, physicians determine the issues based on their assessments and refer patients when needed.
Hospitals that are considering implementing this approach can draw from the consultation-liaison psychiatry framework. The psychiatrist works together with the doctors and surgeons to evaluate patients where there is a coexistence of mental issues with the physical disease. This could range from bedside consultations to outpatient assessments and clinics based on the availability of resources.
Screening is an additional method to the process. There are validated screens for anxiety and depression, which could assist in identifying patients that require further evaluation. Screening does not in any way replace the diagnostic process, nor should it be taken at face value as the cause of the physical ailment.
What Hospitals Need to Put in Place
Integration will be unsuccessful unless something more than just employing a psychiatrist is done. This includes three main points in its implementation:
The first step is to train all teams involved in frontline service provision. Specialists must undergo training to determine potential mental aspects of physical symptoms, identify manifestations of the problem and communicate their findings without causing any stigma towards the patient. In the course of provided training, one should keep in mind that both mental and physical disorders can coexist.
The second step is to set particular pathways for referring the patients. Referring must be defined by a hospital in terms of what are the reasons for referral, who conducts it and whether it is urgent or not. A particular person can be appointed for this role to simplify the process and avoid delays.
The third step is to implement certain types of screening to identify sick patients. This screening may be brief and done when the patient’s case is selected based on the persistent character of his/her symptoms or number of consultations. The screening must be combined with a clear idea of further plan concerning clinical examination, referrals made and follow-up.
A Practical Starting Point for Hospital Leaders
The implementation of integration programs by hospitals does not require undertaking a holistic integration programme in every hospital department at the same time. A better approach is to follow a phased introduction strategy.
To begin, leaders can identify departments in which there are many patients being referred to them as well as departments that see recurrent patterns of unexplained symptoms and subsequently carry out a pilot program that will involve psychiatry and two to three clinical departments that participated voluntarily.
Baseline data should be gathered on the volumes of referrals, return visits, investigation patterns, waiting times, and patient outcomes.
Next comes the phase of training the staff, introducing standard referral criteria, and having multidisciplinary meetings on a regular basis. Finally, the hospital will be ready to analyze the impact of the programme on the mental health care accessibility, patient experience, and continuity of treatment.
The manner of the conversation is also significant. By stating that what a patient is experiencing is simply “stress”, we run the risk of invalidating their feelings and damaging trust. By explaining that stress can have an effect on the body while still addressing medical problems, we make it easier to understand and accept the provision of psychological care.
Integrating psychological care into hospital services is not meant to divert patients from getting their medical treatment. It means bringing more comprehensiveness into the process of care. When physical symptoms, emotional state, and medical diagnoses are analyzed together, hospitals can be in a better position to minimize disconnectedness in care, help clinicians and assist patients in their recovery process.
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