When physical symptoms point to a mental health problem

Tabitha* was seeing me for a sixth opinion; she was sure she had persistent offensive vaginal discharge. She had seen all the other gynaecologists to no avail. She noted the test results were always reported to be normal. 

I took my time to examine Tabitha and arrived at the same conclusion as my predecessors. We sat down for the real chat. I wanted to know why Tabitha thought she had a smelly discharge. I was distressed to learn that she had lived with this belief for the almost two years. She had missed out on so many life-changing events because of the fear of embarrassment; weddings, funerals, family events and even a whole opportunity for a masters degree. 

It took an hour to convince Tabitha that she would need to see a psychiatrist as she was suffering from body dysmorphic disorder. The transformation in Tabitha two years later was astounding. She was a thriving professional working on her post-graduate thesis. 

Sandra* was brought by her mum to see me. Sandra was distressed about her hormonal imbalance. She was struggling with irregular menses and terrible acne. She was so fixated on her acne and it had affected her self-esteem. The dermatologist had already started treatment but thought she would benefit from hormonal modulation. 

Teenagers are fairly sensitive with regard to their looks, but the degree of distress to the point of faking illness to avoid going to school was definitely inappropriate. Sandra needed urgent care. She had already demonstrated suicidal ideation though she was only speaking about it for the first time ever. She was willing to seek care but her mother was being the barrier. It took several visits to finally get Sandra’s mother to acknowledge her daughter’s struggles. 

Marsha* had period pains from hell. She suffered deep pelvic pain and was convinced she had endometriosis - tests done for diagnosis and possible planning of surgery. Her imaging studies revealed normal pelvic findings, even as she would lie on the cold floor writhing in pain for two days every month. She knew this was not how she wanted to live her life. She did not get any relief even from strong painkillers. She eventually stopped bothering. 

Marsha was scheduled for a diagnostic laparoscopy; a minimally invasive surgery that allows the surgeon to put a camera in the abdomen in order to look for possible pathologies. The surgeon was as disappointed as the radiologist. Everything looked spiffy in there. There was no obvious reason for her severe menstrual pain. 

Marsha was tired of the distress. She came to me because she wanted her uterus removed. She would rather never bear children than live with the torture. It was a very thin line between helping Marsha and challenging her autonomy. I requested her to see a psychiatrist before we went to surgery. She obliged me out of respect but nothing else. Marsha’s surgery is still on hold as she partners with her psychiatrist and psychologist to unbundle her post-traumatic stress disorder. Her period pains are no longer a concern. 

In medical school, we are taught to not only treat the patient for her immediate problem, but also find out what other underlying medical conditions that they may have, knowingly or unknowingly. Upon picking out these other chronic illnesses, we will treat the emergency condition and refer the patient for continued care with the specialist that she requires. 

For this reason, the lady with fibroids and high blood pressure will be sent to the cardiologist; the asthmatic will find herself at the pulmonologist’s clinic as the diabetic will be off to the endocrinologist. For these patients, diagnosis is a vital sign check or a lab test away, and the diagnosis is quickly established and the patient passed along the care chain to the right specialist. 

This cannot be said for mentally ill patients. Unless the patient is overtly psychotic and disruptive, many health care workers will not be able to diagnose mental illness even if it struck them between the eyes. They are likely to attribute subtle symptoms to the patient’s personality issues or to a frank physical illness. 

This has resulted in gross under-diagnosis of mental illness, especially in outpatient care. In a study by Hans-Ulrich Wittchen et al., (2003), it was noted that despite UK estimates indicating that at least 50 per cent of the population do experience at least one mental disorder in their lifetime, with 25 per cent having suffered in the past year, only about half of those, being seen by a general practitioner, were able to get diagnosed; and worse still, less than half of those diagnosed managed to get care. 

This situation is most likely far much worse in Kenya and probably in the region; where challenges include stigma, negative cultural beliefs with regard to mental illness, poor access to quality healthcare and even more discouraging, limited access to comprehensive mental healthcare. 

In the last few years, there has been a steady increase in the number of psychiatrists, psychologists and mental health nurses in Kenya. This progress is greatly welcome. However, it is not enough. These specialised professionals do not have easy access to general patients in order to diagnose them. They heavily rely on general practice doctors, our clinical officers and nurses to be able to suspect mental illness and initiate the cascade of care to the psychiatrists and psychologists. 

Our training curriculums are teaching mental health and psychiatry, but the practice is not entrenching triggers in practice that continuously remind primary care physicians and other specialists to maintain a high index of suspicion , a move that can increase chances of diagnosis. We need quick, easy-to-use tools to use at every patient contact, that allow us to screen for mental health conditions, just like we do routine blood pressure checks at every contact a patient has with the health care system. 

It is not enough to raise awareness with the public about safeguarding our mental health, yet when they come into contact with us, we fail to pick the red flags. That is equivalent to teaching the public about how to reduce the risk of HIV transmission, but being unable to diagnose the patient when they sit in front of us in the clinic. Our work is cut out for us, we need to truly rise to the occasion!

 Dr Bosire is a gynaecologist/ obstetrician