Unrecognised psychiatric illness in medical patients.

Of the several papers published on unrecognised psychiatric illness in medical patients, most have appeared in psychiatric journals and may not have come to the attention of general or specialist physicians. Nevertheless, in the Lancet review in 1979 the incidence of psychiatric illness reported ranged from 25% to 83%.' Clearly this figure depended on how psychiatric illness was defined and the type of hospital surveyed. Many of the papers reviewed had been by psychiatrists, who pointed to the failure of their general medical colleagues to recognise psychiatric problems in their patients. This judgment, however, was largely based on a scrutiny of the case notes, summaries, and doctors' letters to decide whether the psychiatric aspect had been recognised, and it may have underestimated the ability of the non-psychiatrist to spot a psychiatric component in a patient's illness. To make a balanced assessment three problems need to be considered. Firstly, how common is psychiatric illness in medical patients? Secondly, how important is it that it should be recognised and documented? Thirdly, if it is important what can be done to ensure more frequent recognition? In a study in the particularly busy medical wards of the Radcliffe Infirmary in Oxford, 170 patients were given the general health questionnaire, and the 77 who had a score suggesting psychiatric problems were interviewed by a psychiatrist. (It is worth noting that of the 93 patients thought to be psychiatrically normal, six were later found to have problems.) As a result of the interview 20 patients were judged to have moderate or severe psychiatric problems and 25 mild disturbances. Of these 45 patients, 22 had been recognised by the medical staff as having psychiatric problems. Twenty five were depressed, 10 had anxiety, and one phobias. Physicians were most likely to recognise psychiatric disturbances if the patient was uncooperative or noisy, weepy or agitated, or if a psychiatric history was mentioned in the general practitioner's referral letter. Quiet and uncomplaining patients tended not to be recognised or referred. In a recent study of 100 patients in the nourological wards of a Manchester teaching hospital (p 656) the incidence of psychiatric disorder was assessed, by a psychiatrist, as about 40%, with only just over a quarter of the cases being recognised by the neurologists. In this series also depression and anxiety were the commonest diagnoses. Clearly, an appreciable amount of anxiety and depression