this article to a friend
The following Field Manual
was compiled by order of the California legislature. It reveals
that 39% of psychiatric patients studied were found to have active
medical diseases, many of which caused or worsened their mental
condition. The Manual explains the importance of screening
patients for disease and lays out a step-by-step process for doing so.
Prepared for the
California Department of Mental Health and Local
Mental Health Programs Pursuant to Chapter 376, Statutes of 1988Assembly
MEDICAL EVALUATION FIELD MANUAL
By Lorrin M. Koran, M.D., Department of Psychiatry and
Stanford University Medical Center
Stanford, California 1991
Sign up here for our free monthly online newsletter, The Alternative Mental Health News, and other valuable information.
Get past issues
Alternative Mental Health News Here
The author wishes to express his deep appreciation for critical
readings of drafts of this Field Manual and for thoughtful suggestions
Harold C. Sox, Jr., M.D. and Keith I. Marton, co-investigators for
The SB 929 Study. Dr. Sax and Dr. Marton contributed many of the ideas
embodied in this Field Manual and helped to elucidate these ideas
through their comments on drafts of the Manual.
Ken Meinhardt, M.D. and Yvette Sheline, M.D., of the Santa Clara
County Bureau of Mental Health,
Eric M. Jacobson, M.D., John Blossom, M.D., Michael W. Brady, M.D.,
John A. Sponsler, M.D., Captane P. Thomson, M.D., and Ms. Kris Calvin of
the Committee on Mental Health of the California Medical Association,
Michael E. Meek, M.D. and Ms. Sue North, of the Government Affairs
Committee of the California Psychiatric Association,
Stephen N. Wilson, M.D., Alan Albright, M.F.C.C., Alex Anagnos, R.N.,
M.S., Cynthia Bloomfield, L.C.S.W., R.W. Burgoyne, M.D., Bill Goggin,
L.C.S.W., M.F.C.C., Jim Gordon, L.C.S.W., Fred Hawley, R.N., Terrell
Hedstrom, R.N., Arnaldo Moreno, M.D., Josie Romero, L.C.S.W., Stan
Taubman, L.C.S.W., John Wells, M.D., and all of the Clinical Services
Committee of the California Conference of Local Mental Health Directors.
Ultimate responsibility for the content of this Field Manual rests
with the author, who hopes that it will contribute to better patient
INTRODUCTION AND RATIONALE This Field Manual shows
California mental health program administrators and staff how to
screen their patients for active, important physical diseases.
The Manual explains how, where, and when to screen, how to
initiate and staff a screening program, and how to maximize its
cost-effectiveness. The Manual also includes a list of clinical
findings that characterize patients whose mental symptoms are
quite likely to be caused by an unrecognized physical disease.
For several reasons, mental health professionals working within a
mental health system have a professional and a legal obligation to
recognize the presence of physical disease in their patients. First,
physical diseases may cause a patient's mental disorder. Second,
physical disease may worsen a mental disorder, either by affecting brain
function or by giving rise to a psychopathologic reaction. Third,
mentally ill patients are often unable or unwilling to seek medical care
and may harbor a great deal of undiscovered physical disease. Finally, a
patient's visit to a mental health program creates an opportunity to
screen for physical disease in a symptomatic population. The yield of
disease from such screening is usually higher than the yield in an
This Manual was developed from the methods and results of the
California Medical Evaluation Study carried out in 1983 and 1984. The
study was authorized by Senate Bill 929, (Chapter 208, Statutes of
1982). The methods and results of the SB 929 study have been reported in
detail to the California Legislature30,31 and in several
scientific publications29,32,48 that are included in Appendix
B of this Field Manual.
The SB 929 Study team performed complete medical evaluations of 476
patients drawn from 24 county mental health programs spread across four
Northern California counties and of 53 patients at Napa State Hospital.
The most important findings of that study are: 31,32 para
Nearly two out of five patients (39%) had an active, important physical
2. The mental health system had failed to detect these diseases
in nearly half (47.5%) of the affected patients.
3. Of all the patients examined, one in six had a physical
disease that was related to his or her mental disorder, either
causing or exacerbating that disorder.
4. The mental health system had failed to detect one in six physical
diseases that were causing a patientís mental disorder. (Five of 33
cases of physical disease causing a mental disorder had not been
5. The mental health system had failed to detect more than
half of the physical diseases that were exacerbating a patientís
mental disorder. (Twenty-seven of 49 cases of physical disease
exacerbating a mental disorder had not been detected.)
Screening the SB 929 patients cared for in county mental health
programs caused neither a net increase nor a net decrease in the state's
combined medical and mental health costs for these patients in the year
after screening compared to the year before screening.
These results are consistent with those of studies in other mental
health settings (Appendix B, Table 1). These studies have reported that
from 15% to 93% of mentally ill patients had a concomitant, active,
important physical disease. From 4% to 80% of patients had a physical
disease that was detected initially through screening carried out by the
mental health program. From 4% to 32% of patients had a physical disease
that was either causing or exacerbating their mental disorder.
These findings underscore the need to improve screening for physical
disease among patients in California's public mental health system. The
screening methods now in use, ranging from very limited to moderately
complete medical histories and physical examinations, often do not
detect important physical disease and are not very cost-effective.
To facilitate improved screening, the SB 929 study team developed a
screening algorithm that uses a limited set of items from a patient's
medical history, a blood pressure measurement, and selected laboratory
tests to detect physical disease. (An algorithm is a set of step-by-step
instructions for solving a problem.) The algorithm detected more
physical diseases than the mental health programs had detected among the
SB 929 patient sample, did so at a lower cost per diagnosed case, and
can be performed by mental health personnel after very limited training.
A detailed description of the development and results of the
algorithm, including measures of its cost-effectiveness, is
included in Appendix B.48 The body of this Field
Manual describes the content of the algorithm, how to set up a
screening program, and the procedures for deciding which of the
algorithmís six steps to implement.
For mental health programs that wish to screen for physical disease
by means of complete medical evaluations, the Appendix to this manual
includes a recommended Standard Medical History Form to be completed by
patients and a recommended Standard Physical Examination Record Form for
recording the results of physical examinations performed by clinical
staff. Other medical history and physical examination forms are included
as additional sources for mental health program staff who wish to design
their own forms.
Where to Screen: Recommended Settings for Screening|
Inpatient Settings and Hospital
As a matter of law, regulation or policy, screening for physical
disease within California's public mental health system already takes
place in local hospitals, psychiatric health facilities, state
hospitals, skilled nursing facilities and some crisis programs (e.g., in
hospital emergency rooms). Unfortunately, the medical evaluations may
not be careful or thorough, as indicated by the large number of patients
with previously unrecognized physical disease that the SB 929 Study
discovered in these settings.
To improve the quality of evaluation in these settings:
1. Require that the clinical staff use the SB 929 Standard Medical
History Form, (Appendix A) and a standardized, detailed Physical
Examination Record (Appendix A). If the program's physicians do not wish
to use standardized forms, evaluate the content and the consistency of
their screening procedures through peer review and quality assurance
2. Teach the clinical staff to obtain a complete medical history from
mentally disordered patients and to perform a complete and accurate
3. Audit periodically the Standard Medical History Forms and Physical
Examination Records to evaluate the percentage of patients with
completed forms and the percentage of questions answered on completed
forms. Audit the frequency with which
staff follow up the medical problems identified by screening.
The facilityís administrative and clinical program chiefs
should review the audit reports.
Outpatient Mental Health Programs
Outpatients in mental health settings are seldom evaluated medically.
The aim of screening outpatients is to detect physical diseases that
- quickly become life threatening
- masquerade as mental disorders
- exacerbate mental disorders
- interact adversely with psychotropic medications
- pose significant long term health consequences, especially if the disease is spread by person-to-person contact (e.g., viral
- expose the mental health program to liability for negligence and malfeasance due to failure to diagnose.
Routine screening for physical disease in these programs should be
initiated using the SB 929 medical screening algorithm, described
subsequently. Using the SB 929 screening algorithm is much less costly
than complete medical evaluations, and can detect up to 90% of the
physical disease detected by complete evaluations.48
Outpatient programs should consider the pros and cons of performing
routine screening for physical disease at the first versus the second or
third outpatient visit. At many sites, up to half of outpatients do not
return for a second visit and do not, therefore, establish an ongoing
therapeutic relationship. Successfully referring such patients for
follow-up of suspected physical illness would entail insuperable
logistic difficulties. Since detecting physical disease in outpatients
is seldom an emergency, and since disease is easy to detect when it is
serious enough to constitute an emergency, routine screening of
outpatients might well be delayed until the second or third visit. The
choice between screening at the second or the third visit should be
guided by the proportion of second visit patients who make third visits.
If the proportion is high, screening can be carried out at the second
visit. If it is low, screening should be delayed to the third visit so
that referrals for complete medical evaluation, when indicated, can be
Day Treatment and Community Care Settings
Patients entering day treatment and community care programs may have
had a recent medical evaluation in an inpatient setting. Day treatment
and community care programs should make arrangements with inpatient
programs to receive a copy of this medical evaluation when the patient
is transferred for continuing care. Patients who have not had a recent
medical evaluation, (i.e., within the past two months), should be
screened by means of the SB 929 screening algorithm or a complete
medical history and physical examination.
Re-screening Readmitted Patients
Existing regulations and policies govern the medical evaluation of
patients readmitted after a brief interval to local hospitals,
psychiatric health facilities, state hospitals, skilled nursing
facilities and some crisis programs (e.g., hospital emergency rooms).
Again, reevaluations should be careful and thorough, since exposure to
infectious, toxic, traumatic or other disease-producing agents or
processes can have taken place.
In outpatient, day treatment, and community care
settings, the extent of screening should depend on the
interval since a previous screening evaluation. Obtain the
SB 929 screening algorithmís medical history items and
blood pressure determination if more than two months have
elapsed since the patientís last visit. If less than two
months have elapsed, the patientís therapist should
inquire about the patientís physical health status and
source of medical care, as indicated on the Essential
Medical Information Form. If six months have elapsed, obtain
the SB 929 screening algorithmís laboratory panel as well.
How to Screen: When A Complete Examination is Used
Screening for important
physical diseases may take the form of a complete medical evaluation or of
the SB 929 screening algorithm. The choice between these options may
depend on the kind of mental health program, e.g., inpatient versus
outpatient, and on factors unique to individual facilities.
When the Screening Procedure is a Complete Medical Evaluation
The patient should complete the Standard Medical History Form
(Appendix A). Provide the patient with assistance if his or her
condition interferes with understanding or attention span. Perform a
complete physical examination, including a detailed neurological
examination and genital and rectal examinations unless contraindicated
by the patient's psychiatric condition. Record the results of the
physical examination on a Standard Physical Examination Record (Appendix
A) . Obtain a battery of laboratory tests. Programs that employ medical
or nursing staff or a physician's assistant can arrange blood drawing on
site. Other programs should contract with a local hospital or laboratory
for phlebotomy services. The physician carrying out the screening or the
consulting internist, when a nurse practitioner or a physician's
assistant does the screening examination, should decide which laboratory
tests to include.
Mental health programs that employ a nurse practitioner or
physician's assistant to perform physical examinations should
measure the reliability and validity of their examinations by
the programís internal medicine consultant or another
physician to observe approximately ten patient examinations
and corroborate the findings. The SB 929 Study utilized an
extensive battery of laboratory tests in order to minimize the
possibility of missing instances of important physical
The tests included:
- a complete blood count,
- a 23-item chemistry panel, (including determinations for glucose,
albumin, serum urea nitrogen, creatinine, calcium, phosphate,
alkaline phosphatase, aspartate aminotransferase, alanine
aminotransferase, gamma-glutamyl transferase, bilirubin, iron, and
- a serum fluorescent treponemal antibody test,
- thyroid tests (a triiodothyronine resin uptake, total serum
thyroxine, and a free-thyroxine index),
- serum folate and vitamin B12 levels,
- a dipstick urinalysis.
The mental health program could select a somewhat less extensive, but
still reasonable, screening battery with the advice of a specialist in
internal medicine. For example, the thyroid screening test could be
limited to the sensitive thyroid stimulating hormone assay or to a
measurement of serum free thyroxin. If the laboratory test panel
includes a complete blood count, chemistry panel, thyroid panel, and
urinalysis (without microscopic exam), it will lead to new, previously
unsuspected diagnoses or to changes in psychiatric treatment in from 1%
of patients to as many as 6.4%, 8%, 12%, or 28% of patients.
The benefits of laboratory testing in the context of a screening
- Increasing physician confidence when mental illness impairs the
patient's cooperation in providing a reliable history and physical
- Detecting physical diseases that were not suspected on the basis
of the history and physical examination.
- Assisting in differential diagnosis.
- Providing reassurance to patients.
A skilled physician should evaluate abnormal test results in the
context of other information about the patient. False positive screening
tests are common in people with few or no symptoms of physical disease,
and the decision to carry out or not carry out further evaluation often
requires sophisticated clinical judgment.
How to Screen When The SB 929 Algorithm is Used
The SB 929 screening algorithm has several appealing characteristics:
- It is limited to those findings that best predicted the presence
of physical disease in a sample of patients cared for within the
California public mental health system.
- It saves the effort and expense of gathering data that may not
help in detecting physical disease.
- The data used in the algorithm can be obtained by
mental health staff and do not require a physician,
nurse or physicianís assistant.
When the Screening Procedure is the SB 929 Screening Algorithm
The SB 929 medical algorithm requires 10 items of medical history,
measurement of blood pressure, and 16 laboratory tests (13 blood tests
and 3 urine tests). These data were the only strong predictors of
physical disease in the SB 929 patients.48
The county mental health department must decide whether to gather all
of this information or just part of it and whether to add questions that
have not been investigated as screening items. (The California SB 929
Study did not ask about the use of alcohol, illicit drugs and
prescription drugs) . This decision will be influenced by the trade-offs
between maximizing the probability that a patient referred for further
evaluation will have an important physical disease, maximizing the
proportion of only sick patients that the screening program detects, and
the program's budget. These trade-offs, in turn, are influenced by the
perceived costs of failing to detect important physical disease, the
perceived costs of sending well patients for evaluations, and the
perceived value of detecting important physical disease. Fortunately,
The SB 929 Study results (Appendix 5) provide much of the data needed to
make these judgments.
To maximize the probability that referred patients will be found to
have an important physical disease, one would gather only enough
information for algorithm steps A and B in Figure 1. The odds are high
that a physical disease is present if any item in step A or step B is
abnormal, 6.4 to 1 for step A and 5.7 to 1 for step B in the SB 929
patient sample. That is, if an SB 929 patient had any of the abnormal
findings in step A, that individual was 6.4 times as likely to have a
physical disease as were individuals who did not have any of the above
abnormal findings within step A. This information is conveyed by the
likelihood ratio of 6.4, which is shown to the right of NODE A in Figure
1. (An example of how to use the likelihood ratios to estimate the odds
of disease being present in patients in different treatment settings is
presented in Appendix B.48,p.1272
The costs of screening using only steps A and B are low since only
inexpensive laboratory tests are required (a serum T4, hematocrit, white
blood count, serum aspartate aminotransferase, serum albumin, serum
calcium, and urine dipstick tests for glycosuria and hematuria).
However, step A detects only 20% of patients with important physical
disease, and step A and B together detect only 47% of such patients. To
maximize the proportion of truly sick patients detected by the screening
program, one would gather all of the information required through step
F. Ninety percent of truly sick patients will have at least one of the
findings in steps A through F, and will, therefore, be referred for
evaluation by a physician.
Methods for estimating the cost and the cost-effectiveness
of the six branch nodes, or steps, embedded in the SB 929
screening algorithm are detailed elsewhere18
(Appendix B). With these data, a mental health program
director can calculate the costs of continuing through each
step of the algorithm and decide which steps are within the
To obtain all the data needed for the SB 929 screening
algorithm, the screening program nurse, nurse practitioner or
physicianís assistant should:
- ask the patient to complete the 10-item Medical History
Checklist, assisting the patient as necessary.
- Obtain a sitting blood pressure measurement.
- Request the patient to provide a urine sample, and
- Draw the blood specimens for the laboratory battery.
The laboratory panel of tests should consist of:
1. a hematocrit
2. white blood cell count
3. serum aspartate aminotransferase
4. serum alanine aminotransferase
5. serum albumin
6. serum calcium
7. serum sodium and potassium
8. serum cholesterol and triglycerides
9. serum T4 and free T4, and
10. serum Vitamin B12
Mental health programs that do not employ medical or nursing staff
may prefer to send the patient to a local laboratory for blood drawing.
The patient's urine should be examined by dipstick for glucose, blood
The items of information obtained from this screening procedure
should be grouped according to the six-step algorithm shown in Figure 1.
The reason for grouping the information as shown is to help interpret
abnormal findings. Abnormal findings listed in the earlier steps of the
algorithm more strongly predict the presence of physical disease than
those occurring in later steps and hence more urgently require a
physician's attention. A patient who has any positive findings from any
step in the algorithm should be referred for further evaluation to a
physician who specializes in internal medicine or family medicine.
Because further medical evaluation takes place as a result
of a physicianís judgment (the physician who authorized the
screening program or who serves as its consultant), the cost
of the further evaluation is billable to third party payers.
The clinical staff of the mental health program can arrange
the referral, which, for insurance purposes, does not require
further review by a physician. The mental health program
should provide the evaluating physician with a copy of all
medical information available regarding the patient and with
information regarding the patientís psychiatric diagnosis,
mental status, and psychotropic medications.
The SB 929 screening algorithm was validated by applying it
to the clinical findings of the last 166 patients to be
enrolled in the SB 929 study. However, it has not been studied
in an entirely separate population. Moreover, the SB 929
patients were not completely representative of Californiaís
statewide population of public mental health patients. For
example, the legislation authorizing the SB 929 study required
that the study exclude patients with a primary diagnosis of
alcoholism. For these reasons, county mental health policy
makers should regard the SB 929 screening algorithm as
tentative until it has been validated in their setting. Adding
items to screen for alcohol or substance abuse, for example,
may be helpful.
A county mental health department that decides to employ the
algorithm may wish to evaluate its validity by comparing referral
decisions generated by the algorithm with the results of careful,
complete medical evaluations of the same patients. This comparison will
allow an estimate of the algorithm's false negative rate (missed
diagnosis rate). The mental health policy maker should seek a
statistician's advice regarding sample size and study design. Several
articles are available to guide a validation study.40,42,47,50
and help us reach others with this information!
this article to a friend
The information of this Website is for educational purposes only and is
not intended to replace the advice of physicians or health health care
practitioners. It is also not intended to diagnose or prescribe
treatment for any illness or disorder. Anyone already undergoing
physician-prescribed therapy should seek the advice of his or her doctor
before reducing the dosage or stopping such treatment.
questions or comments
about this site please E-mail us