In patients with chronic disabling physical symptoms, clinicians often overlook an associated mental illness. Why? Patients typically do not offer the psychological symptoms needed to make a diagnosis. Instead, they emphasize physical symptoms and their disability. To make a diagnosis, I’ll review that clinicians need to view severe physical symptoms as a “red flag” for a comorbid mental health problem.
An earlier KevinMD post highlighted that primary care providers lack training in mental disorders. Making a diagnosis more difficult in medical settings, the limited training we did receive taught us that a mental disorder announces itself with psychological symptoms such as sadness, worry, or hearing voices.
This flouts the well-recognized observation that most mental disorders in primary care and other medical settings present only with physical symptoms that, to some degree, interfere with the patient’s life. The greater the severity of the disability, the more likely a comorbid mental illness. (Patients with physical disorders who have no disability have no more than baseline prevalences of a mental illness.) And a co-occurring mental disorder is common: 17 percent of all patients with chronic physical disorders have a comorbid mental disorder, some 30 million Americans.
To diagnose mental disorders in patients with chronic physical symptoms that compromise their lives in some way, ask directly. For example, you might introduce the topic by “How’s the neuropathy pain (shortness of breath, weight loss) affecting your life (family, business)” or “Some people with so many problems become depressed (anxious, drink too much), how about you?” or “In someone with as much pain as you have, keeping you from going to work, I wonder if you feel somewhat down. How’s your mood, your sleep, your enjoyment of life?” You then need to elicit the criteria found in standard textbooks for depression, anxiety, and/or substance use disorders, the three most common problems to look for in medical settings.
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The mental disorder can precede or follow the physical symptoms, and the disabling physical symptoms fall into one or both of the following categories.
- Symptoms of an organic disease with a known pathophysiological basis, for example, refractory heart failure or emphysema, cancer not responding to treatment, or difficult-to-control diabetes with painful neuropathy.
- Symptoms may have no disease explanation, for example, chronic pain, fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome.
It’s not well understood why these patients don’t express the psychological symptoms of their mental health problem, but here are some possibilities.
- Self-stigmatization for having emotional or psychological problems
- Not accustomed to discussing personal issues, especially in medical settings
- Belief physicians will be uninterested or critical
- Unaware of their psychological symptoms
While the cause of the physical symptoms makes no difference in treatment, recognizing comorbidity does have tremendous therapeutic implications. First, the mental illness needs to be treated for the relief this affords the patient. Second, effectively treating the mental disorder improves the patients’ response to treatment of their physical disorder. Sadly, when the mental issue is not treated, the disease itself often fails to improve. Common examples are the repeated re-hospitalizations of patients with, say, heart failure and diabetes. They are easily “tuned up” in the hospital only to return out of control in a few weeks. Failure to recognize and treat the mental illness, often depression, causes the problem but is seldom recognized. Indeed, only 12 percent of patients with comorbid disorders receive any treatment. A careful actuarial analysis demonstrated that effective treatment would save from $26 to $48 billion per year. Effective treatment also makes the clinician’s care easier as a formerly “brittle” patient stabilizes and improves.
The take-home message: View debilitating, chronic physical symptoms as a “red flag” for an underlying mental disorder. In anyone with any disability from a physical health problem, ask directly about mental health problems. Although they seldom volunteer the information, the patients almost always are open about it when asked directly, and pleased that someone recognized their plight.
Robert C. Smith is a University Distinguished Professor of Medicine and Psychiatry Emeritus at Michigan State University. His group defined the first evidence-based patient-centered interview, published as Smith’s Patient-Centered Interviewing: An Evidence-Based Method (McGraw Hill, 4th edition, 2018). They also identified the first evidence-based primary care mental health model, published as Essentials of Psychiatry in Primary Care: Behavioral Health in the Medical Setting (McGraw Hill, 2019). Educators use both books to teach medical, nursing, and other health care learners in the U.S. and abroad.
Fed up with medicine’s resistance to improving training in mental health care, Smith decided to take the problem to the public and wrote Has Medicine Lost Its Mind? (Prometheus Books, 2025). It describes the poor state of mental health care in the U.S., why medicine ignores it, what needs to be done, and how the public can accomplish this politically.
His scholarship spans patient-centered interviewing, medically unexplained symptoms, the biopsychosocial model, and mental health training in primary care, with work appearing in Annals of Internal Medicine, the Journal of General Internal Medicine, Patient Education and Counseling, and Social Science & Medicine. It includes the invited opinion piece “The mental health crisis: Only top down regulation will cure medicine’s folly” in PLOS Mental Health. He writes at robertcsmithmd.com and shares updates on Facebook, LinkedIn, and X.
