A Medical Algorithm for Detectmg Physical Disease in Psychiatric Patients

Harold C. Sox, Jr .. M.D. Lorrin M. Koran, M.D. Carol H. Sox, M.S. Keith I. Marton, M.D. Fred Dugger, P.A. Teruko Smith, R.N.

An algorithm for: screenrng psychiatric patient: for physical disease uas empirically derived from a comprehensive assessment of 509 patients in California's mental health system. T'be fint 343 patients were used to deveiop the algori tbm, and the remaining 166 u'ere used asa test group. Calculations were made for several uer-

Dr. Sox. is Joseph M. Huber Professor a.nd chairman of the department of medicine at (he Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire 03755. Dr. Koran is a professor in the department of psychiatry at Stanford (Calif.) University School of Medicine. Ms. Sox is a research assistant in the department of industrial engineering at Stanford University, Dr, Marton is chairman of the department of medicine at Pacific Presbyterian Medical Center in San Francisco. Mr. Dugger is a physician's assistant in Palo Alto. Ms. Smith is a physician's assistant ,It the Palo Alto Medical Clinic. ,\ n 'earlier version of this paper 'Vas presented May 4, 1985. at the annual meeting of the American Federation for Clinical Research in Washington. D.C.. and March 31, 1987. at a National I nntitute for Mental Health conferr-nce in Boston on analytical methods in mental health care.

1270

s io ns of the algorithm. and the data u/ere compared with the diagnoses listed in the patients' admission mental health record. The algorithmic procedure U'aJ more accurate and more cost-effect ice than the medical e ualnat ion procedures used by the state m ent al health system. When applied to the test group, the algorithm detected up to 90 percent a/patients Ida had an active, important physical disease at a cost of S 156 per patient, The mental health system had detected 58 percent of test-group pat i ents with a disease at a cost 0/ S230 per patient,

Many mental health pr ogr arns.are nor staffed with physicians practiced in medical diagnosis and thus are unprepared to detect a large propo rrion of physical diseases in their patie nts. A s described eJsew here, California's state mental health programs fail to dere cr man y diseases that could be causing or exace [bating psychiatric disorders (I). Mental health programs need effective methods for screening their patients for physical disease.

Ideally, the methods should be suitable for use by personnel with litde medical training. A number of articles have discussed the detection of physical illness in patients WIth mental disorders (2-9). Most have described the frequency of physical diseases in the pane nrs, and some have suggested strategies for screening. A medical algorithm, which is a set of instructions for solving a clinical probIem (10,1 l ), is one screening strategy especially welJ suited to personnel with little medical training.

In this paper, we describe the development and testing of an algorithm that uses the patient's history

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VoL 40 No. 12

and blood pressure and selected diagnostic tests to detect physical disease in persons with mental disorJers. The algorithm, which is based on a cornorehe nsive clinical evaluation of patients drawn from public secror menral health programs in Califorrua, detected more diseases than the mental health programs at a lower COSt per diagnosed/case. A preliminary report of our findings has appeared in aosrracr form ( 12).

Other screening studies

Several other studies have addressed [he best way to screen for physical disease in mentally il! persons. Hall and associates (2.3) evaluated acutely ill psychiatric inpatients with a comprehensive barrerv of procedures that was more thorough and ccsrly than Ours (5400 in 1979 dollars). They found [hat patients with morerhan four symptoms had a particularly high incidence of serious disease. Three ocher studies. each in narrowly defined patient populations. suggested that a small amount of data will detect most physical dis~ ease. In a sample of chronically ill outpatienrs, Barnes and associates (4) found that a fasri ng serum glucose, urinalysis, blood pressure, and careful review of systems disclosed 75 percent of diagnoses chat were new or required treatment. Eastwood and Tennent (5) found that measuring blood pressure and performing blood hemoglobin and urinalysis tests would have detected 75 perc em of disease in psychiatric patients seen 10 an emergency room. Dolan and Mushlin (6) found that 4 percent of psychiatric inpatients had important medical diseases that could be reliably diagnosed by a battery of ten laborarorv tests ..

In COntrast to the earlier studies. we studied patients from across the

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spectrum of public mental hea lt h programs. We also present several alternative versions of the screening algorir hrn and assess the traJe()ffs between detection rates and C05tS.

Methods.

Our study subjects were 509 parie nrs in 2'5 of California's countyoperated mental health programs and in one state hospital. We performed a standard i zed e val uation that i neluded a complete history obtained through a quesrionnairc. a physical examination, and laboratory screening tests. Study iriter nisr s reviewed the data and referred f:'"" tienrs whose results suggested previously undiagnosed disease to community inrernists or neurologists. The study internists then reviewed all data, including any reports from community physicians. and made a final diagnosis. It was assumed that the inrerrusrs detected all cases of active physical illness, and thus their diagnosis became the "gold sr andard" for the presence of disease in parie n rs who had been referred to them.

Some patients had an active, important physical disease, as defined by one of five criteria: the disease was acutely life threatening, could cause or exacerbate a psychiatric cisorder, was treated with agents that can interact with psychotropic rnedications or cause side effects that mimic psychiatric signs and symptoms, was communicable, had r-orenrially significant long-term health consequences, or was chronic arid could markedly impair self-esteem by causing disfiguremen r, social stigma. Of loss of role functioning. U ~ing recursive partitioning, we identified the best pred ictors of these diseases and combined them into clinical algorithms for disease detection. The process of enrolling patients, obtaining data, and establishing the diagnosis of active, important disease nas been described elsewhere ( I).

Formrdat ing the screening algorit bm. Our goal was to develop a screening procedure rhar could be used by mental health program personnel with limited physical assessment skills. Therefore, we used only the history questionnaire findings, the laboratory test panel results, and

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the vital signs (blood pressure, pulse. and temperature) as clinical pr edicro rs of disease. After all final JWgnoses had been assigned. rhe alg~ri thm was developed on the first 343 study patien ts (the training set).

We used recursive partitioning to idcnrify the best combination of findings for detecting active physical disease (13). As applied to medical diagnosis, recursive partitioning is a cyclic procedure for subdividing a population into groups that have d i fFerenc prevalences of active physical disease. The process requi res a computer file that contains a standard set of data, including a final diagnosis, on each of many patients.

The first step of each cycle identifies the clinical finding that best d iscriminates between pauenrs with the disease and patients without the disease. The second step of eac h cycle divides the population inro ctwo groups: patients with the highly d iscr irninaror y finding and patients withour it. In the group in which all patients have the discriminatory finding, the prevalence of disease is relati veiy high. I n the group in which none of the members have the finding, the prevalence of disease is relatively low. In the second cycle, the process is repeated for both of the subgroups created in the first cycle. Thus at the end of the second cycle there are four subgroups. The process may be repeated for many cycles, until no additional discrirninarorv findings are identified.

For classifying a patient, each clinical finding can be regarded as a fork or node in an algorithm, with one branch to be followed when the finding is present and another when it is not present. To use a recursive partitioning algorithm, a health worker obtains the clinical finding specified by the first fork, follows

. the appropriate branch to the next fork, and obtains the clinical finding specified there. The process is repeated until there are no more branches. The prevalence of disease in the subgroup at the terminal fork is used as an estimate of the probability of disease in the patient.

We modified the recursive parririo ning process slightly. In each cycle, we partitioned only the group

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VoL 40 No. 12

Wl[h the lower likelihood of disease. The criterion for deciding whether a fi nel i ng inc r e as ed the Ii kelihond of active disease was its likelihood rario-i-irs frequency in patients with an acr ive disease divided by its frequency in patients with no active disease I n the first cycle of our recursive par ricioning process, clinical findings WIth a likelihood ratio of at least I () were identified (see node A of Figure 1). A II patients with one or more of these findings were removed frelm (he training set. The second cycle was performed on the patients remaining In the training set. We icie nti f ed fi ndings with a I ikelihood ratio of at leasr 5.5 (node B of Figure I) and again removed pauenrs wi rh one or more of these findi ngs from the training set. This process was repeated six times, with progressively lower likelihood ranos. at which paine running additional cycles did not identify more patients with a physical disease.

E ca! nat ion of the screening algorithm. We used the screening algorithm CO c lassify the remalrllng IGG parre nrs (the test set) and cornpared the accuracy of classification for test-set patients with chat for the tr aining-set patients. We used tWO measures to evaluate the accuracy of each node. One was the number of patients with an active disease who were c lassi fied as having active disease by the node and all preceding nodes. We expressed this measure as the cumulative proportion of diseased patients that the algorithm had identified as likely to be diseased (the true-positive rate, or sensitivity). The other measure was the cumulative proportion of nondiseased patients that the algorithm had Identified as likely to be diseased (the false-positive rate). We compared the algorithm's accuracy for the training set with that for the test set by plotting the cumulative truepos i t ive and false-positive fate values as tWO receiver-operating characteristic (ROC) curves, one for the rraini ng set and one for the test set (14, IS) (Figure 2). _

Costs of eualuat ing patients/or physical disease, The legislation authorizing this study required that we estimate the cost-effectiveness of

1271

physical disease screening as currently performed by scare- and counry-operared mental health programs in California. To establish rhe COSt of screening, we reviewed each parie nr's meneal health file and itemized all medical evaluation procedures and tests Iisred in the admission workup of study patients (performed in the first 72 hours of hospitalization or the first rwo visits to an outpatient setting).

This method may underestimate the true cost because physicians' return visits in inpatient settings were not recorded. and we could nor include the $ 3 3 Medicaid payment for return visits. We used Medicaid payment races, obtained from the state Medicaid data system, as a proxy for the COStS of screening by the county mental health programs. We did not include health costs billed to Medicare or third-party insurance, COStS paid directly by the patient, and noncollectible COStS because they were not of interest to the

Explanation of Figure I

The algorithm depicted in Figure 1 places a 'patient in one and (.nl), ;,:1e subgroup. To obtain the odds that a patient has active physical disease, multiply the odds of physical disease in the patient's mental health program (see Table 3 for the odds of disease in the differenr me-ntal health programs in this study) by the likelihood ratio (L.R.) enclosed in the box corresponding co the patient's subgroup.

Example; Suppose char a day treatment parient has none of the findin_gs in branch node A bur has a hisrory of seizu res (branch node B). The prevalence of discase for patients in day treatment is .2R (the corresponding odds are .. '19 to I). The odds of disease for rh is patient are the product of the prior odds (.39 to I) and the likelihood ratio for a positive finding at branch node B (5.7). The odds of disease are therefore 2.22 ro 1, which corresponds to a .69 probabilirv of active disease. If the same patienr has none of the findings at any of rhe branch nodes A through F, rhe odds of disease would be the product of the prior odds (,39 to I) and the likelihood ratio if no fif'dings are present (.21), or .OR ro l. The (orrespcnding probability of active disease is .07, as given by the formula probabiliry :: odds/t 1 v + odds).

L272

Fig ure I

Algorithm for detecting active physical disease in psychiatric patients

HOOE A
L serum T4 0( -4.S rnCQ:/dl or "'n n < 1 nOldL
2. "em.loeIH < 19 ... (m! ee .;:3~% ,n
J. hematocrit > 56% 1m) Of > ,2% II) YES "0 .ny~ J 01..... I
'. whH. blood count c: '100 leu mm
5. .mlnollan.'.r.'1. ,SOOT) 111I:ely
t.rum .:lIp.tllt. I LA. =' 6."
,. rso lUlL
6. Ufum Ilb.:tmln '0(' 2,0 OrrvdL
T. Ulum oC:'lleh,Jm ,. 12.0 I'nQ/dL,.
B. glycoturla Iby dlp.llek)
I NO (10 ,III
l 01 ..... ' •• 1 " •• 'y I
L.R. = 0.B2
~.
NODE B YES (to iiln.,.)
I. HIIIO/V of epllep.y .I 01..... J
2. History r:1f !IIm~h"''I"m. Illuly
:J. HltlOry of blood or put In Ih. utln. l L.R. ;: :5.7
<. Hem.lurl. (by dlptllck) 10 m.l.
I gKi o .... r '0 '1" r,
I NO 11O ,U)
I 01 ..... I ... "k.,y I
L.R. = O.~B
~
NODE C YES
I. hls1or.,. oj dl.b.IOJl <.0 any) J 01..... I
2. serum T4 . 12.5 mCQ/dl or tt •• U )0 -1.4 nQ/dl 11".1'1'
J. proteinuria Iby dlpsllck) I L.R.: 2.T~
4. ,.rum .spI,III •• mlno tr.nloleru. (SGOT) > IX) lUlL
or IItum .I.n(n ... mlnotr.n.ltt ... (So.OTl :. 7$ lUll
I NO (10 .II}
I DI ..... , ... "~.Iy I
L.R. = 0.59
+
NODE 0
YES (10 .ny) J Dr..... I
1. hi$tory ot "Itlm,
2. ~islory 01 hjoQ" blood pressure Ilicel y
3. diastolic: blood pre."ur. ,. 94 mm HO I L.A. = 2.2
<. serum ... it'mln 9'2 < 200 pQ/l
j NO 110 .11)
I 01..... I... 1I •• ,y I
L.A. = 0.39
+
NOOe E YES 110 ony)
I. pain In tl1e chest whlls II rUI J 01..... I
II .... ely
2. headaches nsocliled wllh yornltlnQ lUI. = 1.9
a, "1,lory or thyroid dlseu.
4. serun-. .(buml" < s.s om/L
I NO (1o IH)
I 01 ..... I ... IIkoly
L.A. = O.l'
!
NODe F
1. los til et conlrol of urine O( $1001 YES (10 .ny~
2. while blOod <:oun~ )0 , 1,000 leu mm J Of.e.s. 1.7 J
l. IIIIrtJm cholullIHol )0 no mCldL 0' I ~.~~'~
nrum trIQlye:::arld. )0 400 I'TlO/dL
.. ,.rum pot:u,lum ~ ~ . .:s. moqlL
5. forum e odturn « 1:1. tn.qiL
! NO (10 .iI)
I D!..... I... IIk.ly I
L.A. = 0.21 December 1989

Vol. 40 No. 12

Hospital and Community Psychiatry

Figure 2

Receiver-operating characteristic curves for the training set (shadeJ circles: and

, !

the test set (open circles)

. 8
~
e
>
0
c.
. .4
2
.2
II. . 2

Each point corresponds to a form Dr the sc r een i ng algor ir hm shown in Figure I. For e xarnpje , Aigmithm A ((raining set) is denoted oy uppercase II. and All'nrirhm A (test set) is denoted bv lo ... 'ercase «. The vertical and horizontal bars represent one standard deviation (or each al,~(Jritl!m's rruc-posirive and [als e-po sir ivc rates, respectively. When there are no oars, the standard deviation is less than .O~.

study's sponsor, the state of California through the state's department of mental health.

We measured the cost of the screening protocol performed on all study patients and estimated the COSt

of using the algorith m. \Y/ e assumed that the examination would be performed in a state or county program whose COStS would be paid directly by public funds. Therefore, we estimated the total cost of the examination from the salaries of the physician's assistants, the cost of renting and supplying a mobile van in which

to perfurm [he examinations, [he portion of the study internists' salaries that reflected the time spent on this part of the project, and the Medicaid payment rates for laboratory tests. An additional variable LOSt was the Medicaid payment for rhe ' , services provided by [he community physician to whom we referred patients for a definitive evaluation.

The cos rs per patient of the tests used for the screening protocol were urinalysis (by dipstick), S2.24; chemistry panel, S 14.7;'; complete blood count, S;'.;':~; total serum thy roxine and 3,;',3' -rriiodothy-

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ronine (TI) uptake, S II. [7; blnoJ drawing, 55.S5; and serum B 12, S 16. ') 7. The COSt of the entire panel of diagnostic tests, including rests that were not used (or the algorithm in Figure I, was 383.31, which included handling cosrs and the salaries of the study internists who reviewed the data to decide whether the patient should be referred for fu rther evaluation. The cost (Of obrai ni ng a complete medical history was estimated at S 13.84; the S.07 per history question was rounded up to S.10 for calculating the cost of using the screening algorithm. The total for the physical examination was SI8.60, including 51.95 for taking blood pressure. The COSt to Medicaid of referring patients to an internist or neurologist was 532.95; the average charge by the community physicians was S82.77.

We defined the cost-effectiveness of the screening methods as (he cost per case of active, important disease detected, which was calculated by dividing the roral COSt of screening all patients by the number of patients with newly detected disease. The marginal cost-effectiveness of an additional step in the screening algorithm was the incremental cost of obraining the additional dara J ivided by the number of diseased patients identified by the additional step. The unit cost of screening-cost per patient screened-was the total cost divided by the number of patients screened. I n calculating cost-effectiveness, we assumed chat every patient referred for definitive evaluation would keep the appointment with the physician. In fact, missed appoihernents are common, and recontacting the patient incurs additional program COSts.

1.0

Results

Detection o/physical disease by the mental health system. A detailed report of the characteristics of the stud y population and the detection of physical disease by the California mental health system has been published elsewhere (1). The principal finding of the study reponed in rhar paper was the prevalence of undiscovered physical disease. Of the 509 patients, 200 09 percent) had at least one active physical disease. The

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VoL 40 No. 12

specific disease categories are listed in Table 1. The screening program discovered a previously undiagnosed active. im portant disease in 63 patients (12 percent), The county mental health program was aware of only 47 percent of the 291 active, important diseases .

Detecting physical disease. The purpose of the screening algorithm is to identify which patients should be referred from the mental health program to a physician. As shown in Figure I, when any of the findings at a branch node were present, the patient was placed in a subgroup that was at relatively high risk of having a physical disease .

There are several versions of the algorithm. One may choose to obtain the data for the first branch node (Algorithm A), for all six branch pornrs (Algorithm F), or for an intermediate number of branch nodes (Algorithms B through E). Depending on which version of the algorirhrn is used, up to 93 percent of training-set patients and 90 percent of test-set patients with active, important disease were correctly placed in one of the high-risk categories (Table 2). The screening algorithm identified a much greater proportion of the patients with active, important physical disease than did the state and COUnty mental heal t h programs. The med ical record used by the mental health

Table 1

Active, important physical diseases identified by study assessment in 509 mental health program patients!

Disease N2

Cardiovascular 48

Eye 2

Gastrointestinal 39

Gynecological 2

Hematological 23

Metabolic and endocrine 37

Musculoskeletal 3

Neurologic 81

Respiratory 28

Skin 20

Toxic 2

Urological and renal 5

Miscellaneous 2

I Source: Koran and associ-res (I)

2 Patients in both [raining and test sets

1273

Mobile Medical Screening T earns for Public Programs

Lorrin M. Koran, M.D. Harold C. Sox, Jr., M.D. Keith I. Manon, M.D.

Physical disease is common in memallydisorderedindividuals.In ;ome settings 5 to 15 percent of patiems have a physical disease causing their mental symptoms. An additional 20 to 50 percent suffer from physical disease that coexists with or exacerbates their mental disorder (1,2). Responding to these findings, the California legislature has funded a study of (he prevalence of previously unde[wed physical disease in clients of (he public mental health system. The study is testing the feasibility of using a medical screening team (hat travels to screening sites in a motor home converted into a medical screening facilitv rJ). We hope [hat our early results will stimulate medical screening in other states.

Rationale for the study

A, mobile medical evaluation team staffed by physician's assistants or nurse practitioners can mitigate problems that discourage screening. They include space limita[ions, physicians' lack of interest in medical screening, and tOO few new-patient visits to justify hiring

The authors are associated with the Stanford University Medical Center, Dr. Koran as associate professor of psychiatry (clinical), Dr. Sox as associate profeslor of medicine (clinical), and Dr. Marton as assistant professor of medicine. Sally Moltzen was data manager of the project. Correspondence should be addressed to Dr. Koran at the Department of Psychiatry, Room TD-1l4, Stanford University Medical Center, Stanford, California 94305.

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screening personnel for each program.

Most, bur nor all, new patients should receive medical screening. Even patients referred by their family physicians may have undetected physical disease (2). The risk of physical disease is highest in patients who manifest a first episode of psychiatric illness, are age 50 or older, have an abrupt onset of illness or episodic course, show an absence of psychosocial stress, have cognitive impairment or visual hallucinations, currently use psychorropic drugs, have a his corv of alcohol or drug abuse or impaired organic functioning, have a family' history of inheritable brain Or metabolic disease, or show an unexpectedly poor response co psychiatric treatment (4).

New screening programs should be considered for all mental health settings. Careful screening in psychiatric inpatient units, outpatient clinics, and skilled nursing facilities will uncover substantial amounts of physical disease (l,2,4,5). Approximately 15 percent of the first 300 patients whom we screened had previously undetected, clinically important physical disease. The prevalence of newly detected disease ranged from 10 percent of patients in day treatment and jail mental health programs to 33 percent of patients in' board-and-care homes and crisis living situations.

Guidelines for developing a screening program

Staff training. We recommend that nurse practitioners or physician's assistants screen mentally ill patients, with an internist providing supervisory consultation (6). The nurse practitioners and physician's assistants should become skilled in recognizing psychiatric signs and symptoms and should

November 1984 Vol. 35 No. II

understand the major diagnostic categories of the Diagnostic and Statistical Manual of Mental DiJo1'den, third edition WSM-Ill). They should be able to elicit and recognize mental status findings that suggest impaired brain function. Neurological examination skills should be emphasized (4). During training, interviews and examinations conducted by the nurse practitioner or physician's assistant should be observed to assure correct techniques and accurate findings (7).

Medical history forms. We have found that most patients can complete a medical history form. The form saves examiner time and facilitates rhe internist's case review. The form should include a review of systems; information on current medications; past history of illness" es, operations, injuries, and allergies, and family history of genetically transmitted diseases (for example, Huntington'S chorea).

Laboratory tests. little is known about the sensitivity and specificity of diagnostic tests in the medical screening of mentally ill patients. Still, by combining certain general principles and the disease prevalences reponed in psychiatric patients, one can devise a reasonable battery (8). Cardiovascular, endocrine, metabolic, nutritional, central nervous system, and toxic or drug-related conditions appear to be the most prevalent (1,2). For example, in the first 300 patients we screened, previously undiagnosed conditions included essential hypertension (three cases), hypothyroidism (three cases), pernicious anemia (one case), seizure disorder (two cases), and side effects of psychotropic drugs (ten cases).

Our screening battery included a chemistry panel 26, complete blood COUnt, sedimentation rate, T3, RAI, T4, serum folate and vitamin B;2, fluorescent treponemal antibody absorption, and urinalysis (without microscopic examination). The 1983 charge for this test battery was about S72. We did not routinely include CAT (computerized axial tomography)" scanning for even the most psychotic inpa-

1151

tients, In the absence of focal neurological findings or an abnormal electroencephalogram, the diagnostic yield is extremely low (9),

Using an internal medicine consultant. It is necessary to have a consulting internist to help the nurse practitioner or the physician's assistant decide which patients to refer for additional studies or care. Telephone consultation suffices, but occasional on-site review helps to maintain the examination skills of the screening staff. A nurse practitioner or physician's assistant can examine and record data from one cooperative patient per hour, including set-up and ten minutes of consultation time; less cooperative patients may require two hours. The internist must be interested in psychiatric patients, in working with nurse practitioners and physician's assistants, and in the relation of physical disease [Q psychiatric symptoms (l O).

Diagnostic algorithms. Diagnostic algorithms have been used to assist the screening staff in making treatment and referral decisions in general medicine (6). We are testing algorithms that can be used in written form or implemented on an IBM Personal Computer. The algorithms trigger referrals for diagnosis or care based on single findings strongly suggesting serious disease, the presence of multiple abnormal findings, or findings typical of common medical conditions.

Financing the screening program. Certain costs can be anticipated. They include an appropriately modified recreation vehicle ($60,000 purchase, 51,500 monthly lease); salary and benefits for a well-qualified nurse practitioner or physician's assistant (52 J 00 to $2,600 per month); fees for a consulting internist (535 to $65 per hour, or 5560 ro $1,040 per month); salary and benefits for a one-tenth-time mid-level administrator ($200 co $250 per month) who is responsible for staff recruitment and program planning and evaluation; and funds for office supplies, copier, and postage to mail reports to referral physicians.

1152

For medical screening to be implemented successfully, the state legislature must be asked to appropriate funds specifically for that purpose. Mental health staff will oppose the diversion of treatment funds to medical screenir:g.

Relationships with screening site staff The ·screening program administrator must negotiate written logistic arrangements with the administrators of each screening site to prevent inrerstaff conflict. Staff of mental health facilities may resist the introduction of medical screening because it creates additional work or represents a professional threat (the detection of diagnostic errors).

To minimize resistance, several steps should be taken. Facility staff should be educated about the prevalence of physical disease, involved in planning screening ar-' rangernenrs, assured that discovery of unsuspected physical disease will not result in negative staff evaluations, rewarded for recognizing physical disease, informed of administrative support for screening, and informed of successful treatment outcomes.

Arranging follow-up care.

Treating newly detected illness is essential to realizing the benefi rs of a screening program. Mentally disordered panenrs, however, often fail to seek recommended medical care. Written permission to inform a relative and the mental health staff of the need for care should be obtained. Repeated urging by the facility staff may be necessary ro effect a referral.

Conclusion

The high prevalence of previously undetected, important physical disease in mentally disordered patients argues strongly for medical screening of this population. A mo bile screening program can bring this service to mental health programs where screening space and physicians' services are unavailable or too expensive. Further research is needed to determine the most cost-effective screening approach for each kind

November 1984 Vol. 35 No. 11

of mental health program and for particular patient groups.

References

1. La'Bruzza At: Physical illness presenting as psychiatric disorder: guidelines for differential diagnosis" Journal of Operational Psychiatry 12 :24-31, 1981

2 Koranyi EK: Undiagnosed physical ill· ness in psychiatric patients. Annual Review of Medicine 33:309-316, 1982

3. Collen MF (ed): Multiphasic Health Testing Services. New York, Wiler.

1978 .

4. Hoffman RS, Koran LM: Medical screening of mental healih parienrs. Psychosomatics (in press)

5. Hoffman RS: Diagnostic errors in the evaluation of behavioral disorders" .lAMA 248:964-967, 1982

6. Sox He Quality of patient care by nurse practitioners and physician's assistants: a ten-year perspecnve. Annals of Internal Medicine 91459-468. 1979

Koran LM The reliability of clinical methods, data, and judgments: l.ll. New England Journal of Medicine 293:642-646,695-701. 1975

8. Martin AR: Common and correctable errors in diagnostic test ordering. Western Journal of MeciiCloe 136:456-461, 1982

9 Rosenberg CE, Anderson DC

Mahowald MW: Computed rornography and EEG in parienrs without focal neurologic findings. Archives of Neurology 39:291-292, 1982

10. Jefferson JW, Marshall j R: Neuropsychiatric Features of Medical Disorders New York, Plenum, 1981

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Alzheimer's Disease

To the Editor: It was with great interest and pleasure that we read the article entitled "Helping families Cope With Alzheimer's Dis-

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