The current status of placebo in hospital practice

Despite a voluminous literature on the topic of placebo, there has been little documentation of either actual clinical practice of prescribing placebo or the attitudes that surround it. Through a questionnaire survey of all head nurses of clinical units in one health services area of Connecticut, data were obtained on current practices regarding placebo use in the natural hospital setting. Multiple reasons for placebo use in the natural hospital setting. Multiple reasons for placebo use were given, and it was noted that patients receiving placebo tended to be viewed in certain ways. The effectiveness of placebo in symptom relief was reported as nearly double that reported in the experimental literature. Methodologic issues of the study and of placebo investigation, in general, are discussed. Because common clinical problems appear to generate most instances of placebo use, several issues pertinent to medical education are raised. Some future directions for placebo research are proposed.     

Defining discipline roles in consultation psychiatry: the multidisciplinary team approach to psychosocial oncology

Multiple mental health professions are often involved in the management of cancer patients. Psychiatry, psychology, social work, and nursing have all developed entrees to the medical setting that lead to clinical involvement of one or more of these professions at any given time. Much confusion remains about the specific contribution of these different mental health professions, and lack of role definition makes it difficult for programs to logically plan for mental health services or for services already in place to organize themselves in a collaborative manner. While these disciplines have interacted formally and informally in a number of settings for many years, there have been few published attempts to delineate the unique contributions of each and to suggest a model for their collaborative interaction. This paper attempts to define the unique contributions of each of these disciplines in relation to an oncology consultation program in a general hospital setting. The definitions are proposed as a model that can be generalized to other consultation programs.     

Integrated psychiatric treatment of a dying patient

The following case presents a 22-year-old woman with relapsing polychondritis and depression treated in liaison, consultation, and outpatient settings by one psychiatrist using a variety of techniques. The discussion focuses on the implications of the case for integrated medical model and psychotherapeutic care, and for technical aspects of the treatment of the dying patient.     

A psychiatric unit becomes a psychiatric-medical unit: administrative and clinical implications

Increasing awareness of the frequent concurrence of medical and psychiatric illness has led to a resurgence of interest in psychiatric-medical units. This paper describes the conversion of a 19-bed general hospital psychiatric unit to a psychiatric-medical model. The conversion involved hiring a full-time chief and changing priorities for elective admission, but did not involve major changes in staffing; community-based psychiatrists continued to admit the majority of patients. Arrangements were made for medical house staff coverage of emergent medical problems, while daily medical care remained in the hands of the psychiatrists and their private medical consultants. In the year following the transition numerous patients with combined acute medical and psychiatric illness not treatable in the previous model were accepted and successfully treated. Quantitative study of annual statistics from the pre- and posttransition years revealed the following: The average age of patients increased from 46 to 54 years. The proportion of patients over 65 increased from 19% to 34.9%. The proportion of patients with identified concurrent medical diagnoses increased from 54.7% to 69.1%. Dispositions to nursing homes and chronic care facilities decreased from 10.5% to 8.9%. Length of stay increased from 19.3 to 23.1 days. The average daily hospital bill for psychiatric inpatients rose by 24.6%, compared with a hospital-wide average increase of 16.3%. Although the change in model appeared to offer effective treatment to previously underserved patients, it implied a significant shifting of patients and of costs. Administrative implications are discussed, and a list of preconditions for a successful conversion are suggested.     

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.     

Social characteristics of a hemophilia clinic population: A survey and literature review

The incidence and variety of social dysfunction in one hemophilia clinic patient population were identified through questionnaires completed by professionals; comparison with other hemophilia populations, as cited in the literature, revealed only slight differences. All population studies show a high incidence of social dysfunction, with little change through the years. Several apparent reasons for these findings in our patient populations are: (a) the full effects of home treatment have not yet been felt or tabulated because questionnaires were completed during transition years when the rate of home treatment went from 13% to 48%, (b) the complications of treatment are high, and (c) supportive educational and psychiatric services are scarce. A reassessment of social functioning of our patient population would be appropriate in six months to a year from now, to assess the impact of increased home treatment. Inhibitor patients in our clinic worked as frequently as other hemophiliacs and showed a slightly lower incidence of disability pay. Figures on social problems of inhibitor patients have not been found elsewhere in the literature.     

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.     

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.     

The consultee-attended interview: an approach to liaison psychiatry.

The consultee-attended (C-A) interview, a format in which the liaison psychiatrist interviews the patient in the consultees' presence, is described. The background, strategy, concepts and methods, obstacles and resistances, and countertransference difficulties of C-A interview are discussed. The C-A interview is an experiential teaching instrument with which to facilitate consultees' "participant-observation," a clinical posture that complements other approaches to the care of sick people.     

Psychopharmacologic management of the psychiatric emergency patient

The general hospital emergency room has become the locus of care for many psychiatric patients. It has become essential for emergency department personnel to be able to manage the behavioral emergency. Critical to this management is the rational use of psychotropic drugs. The author offers guidelines for the use of antipsychotic drugs and minor tranquilizers. The importance of differential diagnosis and the correlation of drug use with patient variables are stressed. The section on anti-depressants addresses the issues of when, and under what conditions the treatment of a depressive disorder can be initiated in an emergency setting. An approach to the toxic-behavioral-confusional state is offered. The final section reviews the approach to the patient who is a diagnostic dilemma and/or mute.     

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.     

A comprehensive psychiatric service

A comprehensive psychiatric service was established in 1969 in the Faroe Islands. This service was created as a department of a general hospital. The spheres covered by this department, operating in the midst of the community were: acute and chronic patients, a liaison-psychiatric service, and an outpatient service. The number of chronic patients has not decreased, due to an influx of unruly senile patients. The close proximity of the service to the community has increased the pressure with regard to the care of such patients. Other services, such as outpatient treatment of alcoholics and neurotics, have suffered, due to the increased workload caused by these senile patients.     

Consultation-liaison psychiatry: Past failures and new opportunities

Although the concept of liaison psychiatry is not new, progress in its development has been slow. Obstacles to its development are examined and new prospects discussed in light of combined economic, political, and social forces which provide the opportunity for an expanded scope of clinical, teaching, and research activities.     

The effects of a psychiatric liaison program on the utilization of psychiatric consultations: an evaluation by chart audit.

The effects of a psychiatric liaison program were studied by a chart audit examination of psychiatric consultations on a medical service. A comparison of the full liaison ward with the other wards revealed significant differences in the use of emergency consultation and psychiatric follow-up treatment. The results indicated improved psychologic management of medical patients on wards with intense liaison involvement but no measurable change in attitude toward the psychiatrist. Evaluation methodology and implications of the results are discussed.     

Detection of cognitive deficits by a brief mental status examination : The Cognitive Capacity Screening Examination, a reappraisal and a review

Results of a brief mental status questionnaire, the Cognitive Capacity Screening Examination (CCSE), were compared with the clinical evaluations of 59 patients on a neurology service. In 71% of the cases, the CCSE scores correctly indicated a cognitive deficit (true-positive) or the absence of one (true-negative); false-negative results were observed in 15% and questionable negative results were found in 10%. Abnormal neurologic physical signs were present in 90% of all patients with cognitive deficits. In this population, although positive CCSE scores were reliable, negative scores were often misleading. Mild diffuse intellectual dysfunction (dementia) and some discrete intellectual deficits (aphasia and anosognosia) went undetected. Cognitive deficits associated with major cerebral disease were unappreciated in nine patients. Caution is recommended in interpreting negative CCSE scores. Abbreviated screening devices are only a preliminary approach to mental status evaluation; this test requires further refinement.     

Medical and surgical inpatients who referred themselves for psychiatric consultation

Medical and surgical inpatients who referred themselves for psychiatric consultation are characterized. The 25 "self-referred" compared to 787 "others" referred to the Consultation-Liaison Psychiatry Division were more likely to state depression (52%/25%) and anxiety (36%/11%) as reasons for referral. "Self-referrals" were less likely to be referred by physicians for behavior management (8%/23%), general diagnosis (4%/22%) or suicide evaluation (4%/25%). The "self-referral" represents a challenge to the current medical model referral mechanism in which the physician controls access to consultants. The data indicate that there should be a mechanism for the patient's contribution to the referral process and that increased sensitivity to psychologic difficulties in coping with medical illness would improve the use of psychiatric consultation in the medical setting.     

Preventive psychosocial intervention with newly diagnosed cancer patients

To study the effectiveness of preventive intervention in lowering emotional distress and improving coping, 381 newly diagnosed cancer patients were assessed shortly after the time of initial diagnosis. Subjects predicted by a screening instrument to be at risk for high levels of emotional distress and poor coping during the second through sixth months of their illness were randomly allocated to one of two short-term intervention programs (N=59). Specific techniques to lower distress and improve coping were given during the four weeks following diagnosis. A control group (N=58) received no intervention. All were followed at two-month to 6-month intervals by interview and testing. There was a significant lowering of emotional distress in the intervention group as compared to the control group (p < 0.05). There was also a significant increase in the level of problem resolution in the intervention group (p < 0.01), although the numbers of problems experienced by both groups were no different.     

An oral examination of the psychiatric knowledge of medical housestaff: Assessment of needs and evaluation baseline

To assess the psychiatric knowledge of medical housestaff, the authors devised an oral examination based on two simulated clinical encounters and administered it to 26 medical residents. The case material embodied those psychiatric problems known to be common in medical populations, namely depression, delirium, dementia, and “psychogenic” pain. The stan-dardized simulations were punctuated by standardized “open” questions with followup probes. A panel of experienced clinicians developed rating criteria for each question such that responses could be categorized as “good,” “adequate,” “inadequate,” or “poor,” in terms of “what an internist needs to know,” Blind raters of the exam achieved an interrater reliability of 0.88. The results indicated major deficits in the knowledge needed for assessment and treatment of these common problems. Only 16% of answers were “good,” whereas 42% were “inadequate” or “poor.” For example, 88% of the doctors could not name three factors that help distinguish organic from “functional” psychosis, and 88% could not list three side-effects of tricyclic antidepressants. The doctors' level of experience was not correlated with test scores, either overall or question by question. These results, together with measures of attitude and skill, have been used to develop a needs-based liaison psychiatry curriculum and to evaluate the effectiveness of that curriculum.     

Patient transfers from medical and surgical settings to psychiatric inpatient wards

The transfer of patients from medical/surgical inpatient units to inpatient psychiatric wards is the subject of this paper. Clinical vignettes and available statistics from program evaluation studies provide the basis to examine aspects of transfer such as patient care, systems implications, teaching in the medical setting, and further research.