Outpatient consultation-liaison psychiatry: A valuable addition to the training of advanced psychiatry residents

With current health care reimbursement conditions and recent research denoting the important relationship between mental health status and poor functioning, especially in medically ill patients, one would think that consultation-liaison (C-L) psychiatry would have an increasingly viable role in the outpatient health care sector. However, only a small number of outpatient C-L clinics are reported and recently several of these have folded. These outpatient C-L clinics can follow different clinical models and have the potential, especially at the residency and fellowship training levels, for interesting and useful educational opportunities. This paper describes a recently founded outpatient C-L clinic—the Medical Illness Clinic—in a university medical center's department of Psychiatry. We highlight the structure of the clinic, the kinds of patients seen, and focus on the unique educational residency training opportunities this setting presents. The results of clinic rotation evaluations by residents are also presented. We conclude with recommendations for more exploration of this clinical model and evaluation of its utility in psychiatric residency education.     

A Canadian community mental health program: A clerkship experience

The authors describe a consultation-liaison relationship between a community psychiatry outpatient service and private community family practitioners, including some problems and solutions that have arisen as a result of this relationship. A medical student clerkship in this consultation-liaison setting is particularly useful in orienting students to community aspects of psychiatric care in primary care practice. Since 50% of medical students from McMaster University enter some form of primary care activity, this exposure and sensitization to community mental health activities is especially relevant.     

A comparative study of psychiatric outpatient treatment in two geographically defined populations

Asignificant change in the pattern of psychiatric care has taken place over the last decade, including the reorganization of the traditional mental hospitals, the establishment of psychiatric wards in general hospitals, the trend toward outpatient as opposed to inpatient care, and the increasing recognition of the importance of community psychiatry.^1–4 But few attempts have been made to discern whether categories of patients get the same treatment at different types of outpatient clinics. It would be interesting to know if, for example, a psychotic patient will get similar treatment and have a similar chance for admission in a community-oriented clinic and an outpatient clinic affiliated with a hospital.The present investigation was carried out in order to describe the demographic and diagnostic characteristics of psychiatric patients treated at two types of outpatient clinics and to compare the psychiatric service of a clinic affiliated with a psychiatric ward at a general hospital to a clinic forming part of a community psychiatric project. Recent data concerning general information about both these services have been published by Kastrup et al.⁵ and Nielsen.⁶     

General hospital psychiatry in Italy: On the hospitalization of psychiatric patients and consultation-liaison psychiatry after Law 180, 1978

The type of psychiatric assistance carried out in Italy before Basaglia's views gained ground—that is, before 1968, when his book L'Istituzione Negata was published—is first described. The “Democratic Psychiatry” movement he launched was the mainspring of Law 180 (1978), known to have led to the closing of asylums. This law has brought about moves to create new mental health community services covering wide areas, the setting up of special diagnosis and care sections in general hospitals responsible for compulsory adminssions—and overcrowding in private clinics and University clinics within general hospitals. The role of the psychiatric ward (opposed by the supporters of “Democratic Psychiatry”) and of consultation-liaison psychiatry within the ambit of the general hospital is then discussed in the light of our experience.     

A psychosomatic outpatient clinic

Current emphasis in clinical psychosomatic medicine is on psychiatric interventions in acute medical and surgical situations (consultation-liaison psychiatry and medical-psychiatric units). Little interest has been taken in psychosomatic interventions in chronic situations and outpatient settings. The functioning of a psychosomatic outpatient clinic (POC) is described. One-hundred consecutive referrals were analyzed. The most frequent diagnostic finding--according to DSM III criteria--was subsumed under the rubric of "psychological factors affecting physical condition," followed by affective illness, anxiety disturbances, and somatoform disorders. The results indicate that a POC may serve a specific and definable segment of patients, whose characteristics depart from the clinical populations in consultation-liaison psychiatry and medical-psychiatric units.     

The benefits of a psychiatric consultation--liaison service in a general hospital

In this period of increased governmental regulation and decreased reimbursement for psychiatric services by third-party carriers, a fully staffed and financially stable psychiatric consultation-liaison service in the general hospital may still generate significant benefits for patients, hospital administrators, and psychiatrists: an increased rate of diagnosis of psychiatric and medical disorders, a reduction in the length of stay of medical or surgical patients, a decreased utilization of medical services and the development of innovative consultation-liaison activities. This article summarizes these benefits and outlines training obstacles that must be overcome to increase cooperation between psychiatry and medicine so that these benefits may be realized.     

Recording psychiatric consultations: a preliminary report.

Two new forms, specifically designed for computer processing of data from a contemporary consultation-liaison service, are described. The need for such data and their immediate applicability to problems currently facing this psychiatric subspecialty are discussed. Clinical, administrative, and evaluation uses are reviewed. It is hoped that this work will provide a stimulus to consultation-liason practitioners to use this system or to develop similar systems that will permit documentation, exploration, and enhancement of the consultation-liaison effort.     

Some methodological issues in consultation-liaison psychiatry research

This is a research methodologic design model that may be useful to consultation-liaison psychiatrists. It is intended to facilitate such researchers in setting up and executing carefully controlled studies of the effectiveness (in psychiatric, medical, surgical, functional, cost, or other areas) of consultation-liaison interventions. The specific variables discussed are areas of particular interest to the authors, but many other variables may be readily substituted into this basic model. The design may be expanded or contracted relatively easily as would be appropriate for particular projects. The overall purpose of this paper is, hopefully, to serve as a catalyst for consultation-liaison psychiatrists to consider such research in their academic settings and to foster increased discussion and critical thinking regarding such research. The authors consider such research efforts important for the future regarding the scientific basis, proven effectiveness, and funding of consultation-liaison and general hospital psychiatry.     

A historical review of outpatient consultation-liaison psychiatry

Outpatient consultation-liaison psychiatry evolved from the application of clinical principles learned in inpatient work. The author reviews reports of outpatient C-L psychiatry and categorizes them into four groups: 1) Comprehensive Medicine Clinics; 2) Consultation to Other Outpatient Settings; 3) Psychiatric Consultation Clinics; and 4) Behavioral Medicine Clinics. Advantages and disadvantages of each are postulated, and evolution of these clinics to the present time as well as suggested future research directions are discussed.     

Panic disorder on a child psychiatric consultation service

In a review of all cases seen from 1984 to 1988 by the psychiatric consultation-liaison service of a tertiary referral pediatric hospital, four cases of definite panic disorder meeting DSM-III-R criteria were identified. Three of these children were referred to the consultation service after intensive investigation of physical complaints had failed to yield a diagnosis. These cases of panic disorder differed from those previously reported in child psychiatric populations by their relative absence of psychiatric comorbidity. This suggests that uncomplicated panic disorder may present with primarily somatic symptoms in pediatric subspecialty clinics, while panic disorder, complicated by behavioral or emotional disturbance, is more likely to present directly to child psychiatric services. Children presenting with somatic symptoms are at risk for receiving nonproductive investigations while having delayed diagnosis and treatment of the panic disorder.     

Psychiatric consultation to a general hospital medical evaluation service

Psychiatric consultation to a general hospital medical evaluation service was reviewed and compared with consultation patterns for general hospital inpatients and psychiatric emergency service patients. Results of a questionnaire survey indicated nearly 1 in 5 patients admitted to this acute medical service (24-hour maximum stay) required psychiatric consultation. A study of those patients seen by psychiatric consultants is reported. The prevalence of depressive illness as well as the psychiatric hospitalization referral rate was substantially greater than in general hospital inpatient or psychiatric emergency service evaluations. The implications of this relatively new area of consultation-liaison for hospital staffing and medical education are discussed.     

Hypnosis as an “entree” for consultation-liaison psychiatry

In addition to its indicated uses, hypnosis can play another important, more indirect role in consultation-liaison psychiatry. It can serve the consulting psychiatrist as an entree to physicians or patients who have not identified a problem as psychiatric or who have rejected traditional psychiatric help. Four case studies which illustrate this point are presented and discussed.     

Family burden and care participation: A test-retest reliability study of an interview instrument concerning families with a severely mentally ill family member

Objective: Many youngsters with mental health problems are not referred to mental health clinics. Parents play an important role in the referral process of youngster to mental health clinics. The main aim of this study was to explore the role of the parent–child relation for referral of adolescents to outpatient psychiatric clinics. Method: Employing a cross-sectional design, we compared a referred sample of 39 adolescents in outpatient psychiatric treatment with a non-referred matched control sample of 39 adolescents. The Parental Bonding Instrument and Youth Self-Report were employed to assess the characteristics of these two population groups. Results: Adolescents referred to Norwegian mental health clinics for mental health problems report more perceived care from mothers and a trend of more care from fathers compared with non-referred controls matched on level of mental health problems, age and gender. Implications of the finding for the role of parents on referral of adolescents to mental health clinics and for treatment compliance are discussed.     

Commentary: psychiatry and primary care

The role of the psychiatrist in educating primary care physicians has evolved from one of leadership to that of weakened collaboration. Concurrently, other mental health professionals compete with the psychiatric physician for actual clinical referrals. The primary care physician's fear of loss of control, stigmatization from psychiatric labels, and issues of time and money are reasons cited for limiting psychiatric intervention. Although the consultation-liaison service has proved to be a useful vehicle for integrating psychiatric services in hospital settings, how best to integrate psychiatric education and service in the ambulatory-based practice is still a challenge. Issues of clinical uncertainty and medical responsibility that the primary care provider regularly experiences may offer solutions for reestablishing the psychiatric physician as the leader in such educational and clinical initiatives.     

Post-discharge Contact with Mental Health Clinics and Psychiatric Readmission: A 6-month Follow-up Study

Background: Continuity of mental health care is a major topic in the post deinstitutionalization era, especially concerning its possible importance as a contributing factor in preventing rehospitalization. Objectives: To examine a) the association between continuing care and time to rehospitalization; and b) the predictors of time to first outpatient contact after discharge from psychiatric hospital. Methods: Hospitalization records of all patients discharged from the Tirat Carmel psychiatric hospital in Israel, between January 1, 2006, and December 31, 2006, the National Register of Psychiatric Hospitalizations database and administrative databases of all psychiatric outpatient clinics in this catchment area were used to monitor continuing care and rehospitalization within 180 days from discharge. Predictors of time to rehospitalization and outpatient visits were examined using a Cox proportional hazards regression model. Results: Out of the 908 discharged inpatients, 29% were rehospitalized and 59% visited an outpatient clinic during the study period. Of those who visited a clinic, 22% were rehospitalized compared with 40% of those who did not visit. Not making aftercare contact with a mental health clinic during the study period and/ or having a history of more than four hospitalizations were significant predictors of earlier psychiatric readmission. Males and patients diagnosed with schizophrenia or affective disorders made contact with outpatient clinics significantly earlier. Patients who were discharged from the hospital after a daycare period contacted outpatient clinics significantly later than those who were not in daycare. Conclusions: The findings suggest that psychiatric rehospitalization is associated with discontinuity of contact with psychiatric services but not with diagnosis. Patients with schizophrenia or affective disorders were found to adhere to a greater degree to clinical aftercare, which may explain why they are not rehospitalized earlier than less severe patients.     

Medical and surgical consultations to a general hospital psychiatric unit

This study reviews 563 medical and surgical consultations to a general hospital psychiatric unit over three years. In addition to an analysis of the consultations by service and month, consulted patients are compared with nonconsulted patients by age, sex, and diagnosis. Parallels are drawn to psychiatric consultations as reported in the consultation-liaison literature to medical and surgical patients. Two important findings from the present study are that depressed patients received significantly (P < 0.01) fewer consultations than expected, and that 49% of one year's consultations were for active medical problems not related to the reason for psychiatric admission.     

Teaching psychosocial issues to medical house staff: A liaison program on an oncology service

In a one-year controlled study, the authors assessed the impact of an active consultation-liaison teaching program on the attitudes of medical house officers toward psychosocial issues related to the care of oncology patients, consultation-liaison psychiatry, and its importance for them and their patients. Fifty medical interns, residents, and fellows, divided into a test group (N = 25) and a control group (N = 25), were followed during a one year period. A 52-item questionnaire was administered to test group subjects before and after a one- to two-month clinical rotation on the hematology/oncology service, and to the control group members at similar intervals. After their experience with consultation-liaison psychiatry, the test group members showed a significant positive change in the importance they placed upon psychiatric consultations, case presentations and the role of psychiatrists in the development of their attitudes toward the psychological case of cancer patients. The house officers also recorded significant positive changes in their attitudes toward the effectiveness and role of the consultation-liaison service in educating and assisting them in learning more about psychosocial issues. The control group demonstrated no significant change.     

Psychiatric consultations in a Dutch university hospital: A report on 1814 referrals, compared with a literature review

A report is presented of four years of psychiatric consultations with inpatients in the University Hospital Leyden, The Netherlands. The characteristics of these 1814 consultations are compared with a comprehensive review of 42 publications (mostly from the United States) on psychiatric referral patterns in gereral hospitals. Compared to the literature, the present study covers a long period of investigation and a high number of consultations in quite a large hospital. Yet, the figures in this report are surprisingly similar to the median numbers that can be compiled from the literature. There is, however, a striking lack of conformity in the classifications used by authors in reporting reasons for referral, psychiatric diagnoses, and the actions of psychiatric consultants. A plea is made, therefore, for better definition and classification of patients seen by consultation-liaison services.     

Alexithymia in somatizing patients

Aexithymia is a clinical concept referring to the difficulty some people have in verbalizing their feeling states. It is prevalent in patients suffering from a variety of psychosomatic illnesses. The authors conduced a controlled study to investigate the presence of this trait among patients attending a psychosomatic clinic and those attending a traditional outpatient psychiatric clinic in a county general hospital. The results indicate that, in this lower socioeconomic population, alexithymia is equally present in both clinics. The discrepancy between these results and those previously reported are discussed, as are the ramifications of the findings.     

Neurologic referrals to a psychiatric consultation-liaison service. A study of 199 patients

The findings in a 199 neurology patients referred to a psychiatric consultation-liaison service are analyzed. Neurology referrals differ from general hospital referrals in reasons for referral and in patterns of diagnosis. The most common conversion symptoms seen are pain and pseudoseizures. The psychiatric diagnosis made in those patients with functional pain varies with the site of the pain. These two conversion symptoms, pain and pseudoseizures, have differing ages of onset and prognoses. A number of patients were given no psychiatric diagnosis and the reasons for this are discussed. The incidence of various neurologic diagnoses made in those patients referred to the consultation-liaison service is compared with the incidence of those diagnoses made in consecutive admissions to the neurology ward.