Sociopsychological Correlates of Teen-Age Pregnancy in the United States Virgin Islands

Consultation-liaison (C-L) and emergency psychiatry are two aspects of public psychiatry that experienced considerable development during the last decade in France. Major disparities still persist as regards endowment in professional resources and organization of C-L activity from one general hospital to another. Several emergent practices are described that underlie the role attributed to the C-L psychiatrist or psychologist as an expert in some systematic screening or assessment requests, as well as address the issue of combining, for some clinical situations, psychiatric and medical consultations. Substantial efforts have also been made for implementing C-L psychiatry outside the general hospital wards, notably in prisons. Psychiatric emergencies are, henceforth, integrated within emergency facilities of general hospitals. Several sociological changes or health policy decisions in France, such as the deinstitutionalization movement of the mentally ill, led to an increased numbers of patients at psychiatric emergency departments. Progress in crisis management, as well as opening of crisis units outside the hospital wards and some experimental mobile emergency units to operate at patients' homes, limit the number of psychiatric hospitalizations, whether they are with or without patient's consent, which is following a visit to the emergency department of a general hospital. Management of suicide attempts and prevention of recurrences remain a priority goal of emergency psychiatry, as are a better exploration of mixed medical and psychiatric situations and the implementation of facilities specially devoted to child and adolescent emergencies.     

European Consultation-Liaison Psychiatric Services: the ECLW Collaborative Study

OBJECTIVE: To describe the patterns of organization of consultation-liaison (C-L) services in 11 European countries in relation to hospital characteristics and national approaches to C-L psychiatry. METHOD: Cross-sectional survey. RESULTS: Services can best be described in terms of their size and seniority of their staff and whether or not they are multidisciplinary. Single-discipline services are based upon the standard medical consultant model, whereas those with multidisciplinary teams work in a way that is comparable with community mental health teams. German psychosomatic C-L services belonged to either model. National differences were found. CONCLUSION: This first international study provides empirical evidence for the wide variation in the organization of C-L services. In view of the increasing numbers of patients with psychiatric disorder who are being treated in general hospitals and the changing patterns of medical care there are important implications for clarification and improvement of the role of C-L services.     

European guidelines for training in consultation-liaison psychiatry and psychosomatics: report of the EACLPP Workgroup on Training in Consultation-Liaison Psychiatry and Psychosomatics

Objective

The European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) has organized a workgroup to establish consensus on the contents and organization of training in consultation-liaison (C-L) for psychiatric and psychosomatic residents.

Methods

Initially, a survey among experts has been conducted to assess the status quo of training in C-L in different European countries. In several consensus meetings, the workgroup discussed aims, core contents, and organizational issues of standards of training in C-L. Twenty C-L specialists in 14 European countries participated in a Delphi procedure answering a detailed consensus checklist, which included different topics under discussion.

Results

Consensus on the following issues has been obtained: (1) all residents in psychiatry or psychosomatics should be exposed to C-L work as part of their clinical experience; (2) a minimum of 6 months of full-time (or equivalent part-time) rotation to a C-L department should take place on the second part of residency; (3) advanced training should last for at least 12 months; (4) supervision of trainees should be clearly defined and organized; and (5) trainees should acquire knowledge and skills on the following: (a) assessment and management of psychiatric and psychosomatic disorders or situations (e.g., suicide/self-harm, somatization, chronic pain and psychiatric disorders, and abnormal illness behavior in somatically ill patients); (b) crisis intervention and psychotherapy methods appropriate for medically ill patients; (c) psychopharmacology in physically ill patients; (d) communication with severely ill patients and dying patients, as well as with medical staff; (e) promotion of coordination of care for complex patients across several disciplines; and (f) organization of C-L service in relation to general hospital and/or primary care.In addition, the workgroup elaborated recommendations on the form of training and on assessment of competency.

Conclusion

This document is a first step towards establishing recognized training in C-L psychiatry and psychosomatics across the European Union.     

综合医院老年精神科联络会诊：附131例分析

目的了解和探讨综合医院老年精神科联络会诊的特点。方法对申请精神科会诊的131例综合医院老年患者,通过精神检查依照ICD—10进行诊断,并电话随访疗效。结果患者年龄65～109岁,平均（77．62±9．09）岁;会诊请求中最困扰的精神问题为行为障碍（69．5％）,会诊诊断谵妄状态（42．0％）最为常见;会诊后疗效很好和有效的比例分别为36．6％、57．1％。结论综合医院老年精神科会诊有其特点,会诊有助于精神状态的判别和治疗。     

Referral pattern of neurological patients to psychiatric Consultation-Liaison Services in 33 European hospitals.

The referral pattern of neurological patients to 33 European psychiatric consultation-liaison (C-L) services in the general hospital was examined. Analyses were conducted on the ECLW CS data set, which consists of 14,717 psychiatric C-L referrals made in 56 European hospitals during 1991. Psychiatric referrals of patients admitted to neurological wards were compared to referrals from other wards. Information was obtained from 33 neurological wards, consisting of 34,506 neurological admissions. Of these admissions, 839 were referred to C-L psychiatry. The median consult rate among the hospitals was 1.8%. Compared to other hospital wards, patients referred from neurology were more frequently diagnosed as suffering from somatoform (P<.01) and dissociative disorders (P<.01), and less from substance abuse (P<.01) and delirium (P<.01). Referral to C-L psychiatry from neurological wards is characterized by an underestimation of psychiatric co-morbidity and a late detection, comparable to other medical specialties. An appeal is made for a standardized referral procedure including admission screening method, detecting patients at risk for nonstandard care during their hospital admission.     

Current status of general hospital psychiatry in Japan.

The current status of general hospital psychiatry was overviewed to clarify the progress and the stagnation. To facilitate well-organized community psychiatric care, general hospital psychiatry should play a central role in psychiatry. The policy makers of the Japanese mental health system should place a special emphasis on general hospital psychiatric beds to further process of shifting from a hospital based to a community based psychiatry system. It is also necessary that general hospital psychiatry should become more aggressively involved in community psychiatry, e.g. emergency psychiatry. Consultation-liaison (C-L) psychiatry has been quickly developed and become one of the main psychiatric fields. For further development, a multidisciplinary team approach with co-medical staffs is necessary to supply efficient and effective care to medically ill patients. A proactive model of C-L care rather than a doctors' needs model should also be considered. Well designed research evaluating the efficiency and effectiveness of C-L activities in medical settings needs to be done to increase funding to general hospital psychiatry. This research evidence would also lead to a more fully integrated general hospital psychiatry into the practice of medicine and catch up with the ongoing medical reform in Japan.     

Psychiatrie de liaison : quelle psychiatrie pour quelles liaisons ?

The term of “liaison psychiatry” is used for a wide range of medical practices. The liaison psychiatry is the exercise of psychiatry in general hospitals, with patients hospitalised in somatic care departments: full time hospitalisation, day-limited stays, emergency units, and outpatient's consultations. It also aims to help caregivers and medical institutions. Liaison psychiatry works in collaboration with psychologists. Liaison psychiatry is supposed to answer two requests: one from the patient and the other from the caregivers or their institution. The psychiatrist is supposed to have polyvalent abilities concerning the entire psychiatric spectrum, as well as an in depth knowledge of links between somatic and psychological symptoms. He is also required to have an expertise in some specific medical fields essentially in specialised medical or surgical department recruitments in the hospital he works in. The liaison psychiatrist is confronted to numerous difficulties, essentially due to his external position concerning the medical departments. Generally psychiatry is conceived as part of the institution's services. A good example of these difficulties has been provided by the psychiatric care given to suicidal patients who have ingested caustic products. Psychiatry liaison will expand in the future. Today the limited number of doctors allowed to practise in French hospitals essentially limits it.     

Development of consultation-liaison psychiatry in The Netherlands. Its social psychiatric heritage

Dutch consultation-liaison psychiatry (C-L psychiatry) has followed a developmental line separate from the American system. First, C-L psychiatry in the Netherlands has been less influenced by psychosomatic medicine than by social psychiatry. Second, the presence of psychiatric units in general hospitals that appear to be correlated with the growth of C-L psychiatry in the United States occurred later in the Netherlands. Third, little government support for clinical care, research, and especially for training has been available to Dutch psychiatry. Consequently, there has been little recent financial pressure on C-L psychiatry from reduced government support, as occurred in the United States. Finally, the relationship between primary and secondary health care in the Netherlands allows C-L psychiatry to have a direct impact on several inpatient and ambulatory levels in the health care chain. A nationally accepted database form for the computerized registration of the Psychiatric Consultations at the eight university hospitals and ten other general hospitals is currently in use. To facilitate standardization and recording the psychiatric consultation process, the Netherlands Consortium for C-L psychiatry (NCCP) was formed.     

Consultation-liaison psychiatry in Korea.

The Korean Psychosomatic Society, our national organization for consultation-liaison (C-L) psychiatry was formed within the Korean Neuropsychiatric Association (KNPA) in 1992. Since then, there has been increasing interest in C-L activities in general hospitals. All psychiatry departments in university teaching hospitals offer C-L experiences as part of the rotation for residents. Recently, there have been increasing research activities in C-L psychiatry. However, there are some current obstacles to further development of C-L psychiatry. No reimbursement for C-L activities is one of the most pressing problems facing C-L psychiatrists. Insufficient staffing at C-L services and stigmatization of mental illness are also problems to be dealt with. In order to resolve those issues, a more organized approach to demonstrate the usefulness of psychiatric C-L activities will be needed.     

Consultation-liaison psychiatry training and supervision results in fewer recommendations for constant observation

In this study, we tested two hypotheses. First, that consultation-liaison (C-L)-trained psychiatry residents would order constant observation (CO) less frequently than psychiatry residents untrained in C-L. Second, we predicted that CO would be ordered less frequently under circumstances when experienced C-L psychiatry attending and fellows would be available to supervise psychiatry residents training in C-L. We reviewed a total of 138 consultations during a 6-month period. Constant observation was recommended in 31 cases (22.5%). Consultations were done by residents who had received training in C-L psychiatry (n=34) and by residents who were not trained in C-L (n=34). Residents not trained in C-L had a significantly higher percentage of CO orders (44.1%) compared to those trained in C-L (15.4%) (chi(2)=12.1, df=1, P<0.001). Because C-L-trained residents provided regular-hour and after-hour consults while residents without C-L training provided only after-hour consults, we also separately analyzed data from the 102 after-hour cases. We again found that residents with C-L training had a significantly lower rate of ordering CO (22.1%) than those who had not yet received C-L psychiatry training (44.1%) (chi(2)=5.31, df=1, P<0.05). We also found that C-L-trained residents ordered CO less frequently during regular hour consults (2.8%) when experienced staff are available in supervision compared to after hours (22.1%) (chi(2)=6.72, df=1, P<0.01). Our findings suggest that training in C-L psychiatry has a significant impact on the use of constant observation for patients in the general hospital thereby reducing the cost of care.     

Investigation of recent problems in an acute care psychiatric ward considering the number psychiatrists working in the ward]

In July 2001, psychiatric wards for acute treatments (PWAT) were investigated in Japan using a questionnaire to clarify current and recent problems in 79 PWAT. The questionnaires were sent to wards, patients and psychiatrists and were returned by 72.2% overall. The number of admissions per ward was calculated as 21 patients per one month, and comprised half of all admissions to the hospital. 50% were schizophrenia, 17% were affective disordes and 16% involved drug abuse. Seventeen patients were discharged from PWAT per one month, and comprised 43% of all patients discharged from the hospital. These results indicate that both 21 patients admitted and 17 patients discharged per month and needs to maintain the essential standard for PWAT and the standard should be come more flexible as admission from the other unit of ward than PWAT. As rate of re-admission within 3 months after discharge was around 10% of the total number of patients in the ward, 3 months was considered suitable length of acute treatment in the field of psychiatry in Japan. There was one psychiatrist working in PWAT, and specialized psychiatrists had 17.4 patients, the most number of patients among types of psychiatrist. Simulations of one psychiatrist to 16 and to 32 patients in PWAT were performed to determine how many psychiatrists were needed for a ward. When the ratio was 32 patients to 1 psychiatrist, it was necessary to increase the number of psychiatrists to a ward by 1, and in the case of 16 patients, 1-3 psychiatrists were needed. These indicate the standard number of psychiatrists for PWAT should be at most one psychiatrist for the ward or all of the psychiatrists working in PWAT should be allowed to work simultaneously in other wards. Preparing wards to treat acute phase psychiatric patients is a very important role of each psychiatric hospital, the standard for PWAT should include not only a high level of medical staff, but also preparing easy criteria for each hospital.     

Liaison psychiatry: A model for medical care on a general hospital psychiatric unit

Liaison psychiatry is traditionally practiced on the medical and surgical floors of the general hospital. The need for liaison psychiatry on the inpatient psychiatric unit as opposed to its usual setting was realized when the medical care requirements of hospitalized psychiatric patients was assessed. In many general hospitals this medical care is provided by a psychiatrist in consultation with medical and surgical colleagues. Over a three-year period at the Medical Center Hospital of Vermont 563 medical/surgical consultations were provided to the inpatient psychiatric unit. To utilize these consultations most effectively, the role best suited for the psychiatrist was that of liaison-consultee. Case examples are used to demonstrate the effectiveness of employing liaison skills in the treatment of somatic problems on the inpatient psychiatric unit. The educational implications of learning the liaison model in this context are discussed.     

综合医院会诊-联络精神病学10年间变化

目的：了解综合医院会诊-联络精神病学10年变化的情况。方法：对本院1991年和2001年临床各科住院病人邀请精神科会诊的数量、科室分布、精神科诊断与处理情况进行对比分析。结果：年会诊率1991年与2001年分别为0．45％与0．71％，呈上升趋势；会诊的科室以内、外科为主，会诊的疾病种类1991年与2001年前三种疾病仍分别是躯体疾病所致精神障碍、脑器质性疾病所致精神障碍及神经症。结论：综合医院住院病人精神医学问题呈上升趋势，应加强会诊-联络精神病学的研究与推广。     

Alcoholism consultation and general hospital psychiatry

The author explores the relationship between consultation-liaison psychiatry and alcoholism as it presents in the general hospital. He discusses cases that illustrate specific problems, reviews the studies of alcoholism prevalence in the medical and surgical services of general hospitals, and emphasizes the liaison and consultation roles of the general hospital psychiatrist around alcoholism diagnosis, management, and treatment referral.     

Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disorders

Consultation-liaison (C-L) psychiatry has an important role in the management of somatoform disorders (SD). Characteristics of SD patients in C-L psychiatry are largely unknown and are presented in this paper. We analyzed 13,314 Dutch psychiatric consultations from 1984 to 1991 and compared patients diagnosed with SD to patients with other mental disorders and to those without a mental disorder. The comparison included socio-demographic variables, consult characteristics, medical history, current somatic morbidity, information about additional diagnostic tests, hospital admission time and aftercare management. Of the 544 SD patients 39.5% (n = 215) were diagnosed with a conversion disorder that illustrates the highly selected nature of SD patients in C-L psychiatry. Employment among SD patients decreased significantly from 58% in the group aged 20-29 years to 6% in the group aged 50-59 years. This decrease was significantly larger as compared to other mental disorders and no mental disorders and was virtually unaffected by correction for potential confounding by gender. Contrary to our expectation no difference between the three groups was observed in claims for disability benefits. Of the SD patients 74.5% were referred for aftercare management, significantly more than the other two groups which is considered a promising development in C-L psychiatry.     

Further evolution of a literature database: the international use of a common software structure and methodology for the establishment of national consultation/liaison databases

Every day there are 6000-7000 papers published in science. Since the C-L psychiatrist may be asked to consult on a patient with any medical illness, and who may be on any medical drug, methods need to be developed to review the recent literature and have an awareness of current findings. At the same time, teachers need to develop a current listing of seminal papers for trainees and practitioners of this subspecialty of psychiatry. Experts chosen because of their writings and acknowledged contributions to their subspecialty interests have sifted through thousands of articles to select the ones they regard as the most important for trainees in C-L psychiatry. In addition, certain countries--Spain, Portugal, Germany, Mexico, Australia and Brazil are developing national databases of C-L literature not only for their own use, but also to bring them to the attention of other parts of the world. This fifth iteration of the C-L literature database has especially targeted the period of 1996-1999--the millennium issue--in order to have easier access to contemporary essential studies on common problems. Part II of this issue describes the seminal cardiac drug-psychotropic drug interactions that the C-L psychiatrist may encounter in the most common medical disease in the United States--coronary heart disease--with advise to the practitioner as to their management. The use of the Internet and institutional Intranets is described.     

Patterns of referral from consultation-liaison to social work services

Despite their importance, the nature and context of referral patterns among mental health disciplines in the general hospital has not been sufficiently explored. This study focuses on consultation-liaison (C-L) psychiatry patterns of referral to social work services (SWS). From a structured data base of 1170 consults, it was observed that C-L referred 24% of the cases seen by psychiatry. Psychiatry was more likely to refer those who are: female (p = less than 0.05), living with others (p = less than 0.05), described as less urgent (p = less than 0.05), diagnosed with personality disorders (p = less than 0.01), under greater psychosocial stress (Axis IV) (p = less than 0.001), and evaluated as having better functional status (Axis V) (p = less than 0.001). Regression analysis revealed that four variables had the greatest impact on differentiating those C-L referred to SWS from the "others": 1) constant observation recommended (log -586, p = 0.0001); 2) type of psychiatric management (log -573, p = 0.0001); 3) Medicaid insurance (log -564, p = 0.0001); and 4) original referral for the consultation was the refusal of tests or medical treatment (log -559, p = 0.002).     

上海市综合医院精神卫生服务现状调查

目的 了解上海市综合医院精神卫生服务资源等现状。方法 对上海市区15所三级和14所二级综合医院的精神卫生服务现状进行问卷调查。内容包括:医院规模及医疗服务资源;精神卫生服务机构设置及人员配置状况;会诊联络精神病学开展情况以及医院对临床医师进行精神卫生知识培训情况等。结果 (1)在29所综合医院中,17所甲等医院设置精神卫生科室,占59％,显示近年来综合性医院开始重视精神卫生服务工作。(2)已设立精神卫生科室的医院中精神科年会诊率为0.63％;而未设立的医院中精神科会诊率为0.10％,两者间差异具非常显著性(P>0.01)。(3)在被调查医院中仍有55％的医院未开展或仅是偶尔开展会诊联络精神病学工作。(4)精神科医师以不同形式和程度参加各科医疗工作;(5)已设立精神卫生科室的医院其临床医师在接受精神卫生培训方面显著优于未开设精神卫生科室的医院。结论 需要大大提高综合医院精神卫生服务能力,且设立精神卫生机构势在必行。     

A multicenter investigation of consultation-liaison psychiatry in Italy. Italian C-L Group.

In order to evaluate the extent and quality of consultation-liaison (C-L) activity in Italy, a multicenter investigation was conducted in 17 general hospitals. All of the hospitalized patients referred to C-L psychiatry during a 1-year period were assessed by means of a specific instrument (Patient Registration Form, PRF-SF). Of 518,212 patients, 4182 were referred to C-L services (referral rate = 0.72%). Typical consultations were for female patients (60.1%), admitted to medical wards (71.5%), aged 55-75 years. Most interventions were carried out within 2 days; a minority (22%) were urgent requests. Gastrointestinal and cardiovascular disorders, and unexplained medical symptoms were the most frequent ICD-9 somatic diagnoses at admission. One-third of the patients were not informed of having been referred to C-L and half of them had a lifetime history of psychiatric disturbances. Most frequent ICD-10 psychiatric diagnoses were neurotic, stress-related, and somatoform syndromes (33.1%), affective syndromes (19.4%), and organic mental syndromes (10.7%). Two-thirds of the patients were given only one consultation whereas the reminder received two to four follow-up visits. The rate of transfer to psychiatric wards was low (2.1%). Psychopharmacological treatment was suggested in 65% of cases, and 75.5% of the patients were referred to community psychiatric care at discharge. The implications of the findings are discussed.