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.     

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.     

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.     

Determinants of psychiatric hospitalization after attempted suicide

OBJECTIVE: This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD: All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS: We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION: Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.     

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.     

General hospital psychiatry from the perspective of medical economics

The purpose of this study was to investigate the efficacy of consultation-liaison (C-L) psychiatry from the perspective of medical economics, by comparing a part-time and full-time psychiatric department. One full-time (5 days per week) psychiatrist began work at a general hospital (GH-A), and one part-time (once per week) psychiatrist had been working at another general hospital (GH-B). Both general hospitals are teaching hospitals of the same size. The number of patients and the medical reimbursements were investigated each month and compared. This study demonstrated that the establishment of C-L psychiatry was economically profitable in contrast with what was the common belief among general hospital administrators. Also, the differences in the total number of patients (GH-A: GH-B = 500:35-50 patients/month) and the total reimbursement (GH-A: GH-B = 3 million: 2-300000 yen/month) was not explained by the number of working days (GH-A: GH-B = 5:1 day/week). The full-time model of C-L psychiatry has also indirect effects (i.e. educational and relieving effects) on the hospital staff. Promoting the establishment of C-L psychiatry requires many evidence-based studies that demonstrate the necessity for C-L psychiatry and can directly persuade hospital directors.     

The role of an old age psychiatry consultation liaison nurse

Objective. To assess and describe service changes when a psychiatric consultation liaison nursing service is introduced. Design. Prospective collection of basic service data before and after implementation of the service change. Setting. A newly established comprehensive old age psychiatry service. Patients. People on medical and surgical wards aged over 65 years referred for psychiatric assessment. Outcome measures. Numbers of referrals made and patients seen, details of psychiatric diagnoses made and follow-up offered before and after the change in the service. Results. Within 6 months there was an increase in liaison referrals to the service. The proportion of people offered follow-up showed little change and delay before assessment decreased substantially with the PCLN service. Conclusions. A psychiatric consultation liaison nursing (PCLN) service was successfully initiated. Numerous difficulties were encountered but this is a useful model for old age psychiatry services to consider researching and developing further. © 1998 John Wiley & Sons, Ltd.     

The changing pattern of referrals for psychogeriatric consultation in the general hospital: An eight-year study

An eight-year retrospective evaluation of referrals to a psychogeriatric consultation service demonstrated a highly significant linear increase of total referrals with a selective change of case mix that included more depressions and fewer cases of acute confusion or referrals with no psychiatric disorder. This did not occur with referrals from general practice, where case mix remained stable though total referrals also increased. It is suggested that this selective change relates to an educational influence of the specialist consultation service operating within the hospital and represents a desirable change of referral behaviour. The degree of psychiatric morbidity on general hospital wards far exceeds the capacity of a consultationservice whose primary objective must be education to enable non-psychiatrists to detect and manage the majority of these disorders without recourse to specialist referral. Research that will further define the elements of the educational process that have greatest impactis needed and offers a new research direction for liaison psychiatry of old age.     

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.     

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).     

Collaboration of the general practitioner and the psychiatrist with the psychiatric hospital. A literature review

Co-operation of physicians in private practice with psychiatric hospitals was investigated in Germany scarcely until now, although evaluation of consumer satisfaction is of great importance to quality assurance in psychiatry. In this paper, findings from previous studies are presented together with data from interviews with general practitioners and psychiatrists, evaluating their expectations regarding psychiatric hospitals. Substantial problem area in collaboration is referral to the psychiatric hospital. Apart from sociodemographic and disease-related variables, referral practice depends on referring physician's attitudes and competence in psychiatry, and provider influences like delay of admission, communication with referring physician, and competence of the hospital. As conclusion, constructive collaboration must be developed at the interface of outpatient and inpatient care. On account of increasing diversification of psychiatric services, functional network should be an ongoing goal to improve treatment continuity of patients with mental disorders.     

What is the relationship between general practitioners' community referrals,and hospital referrals to an old age psychiatric service?

There is a large variation in the referral rates of general practitioners (GPs) to specialist services. There is also evidence that GPs under-refer patients with dementia and depression to old age psychiatric services. However, little is known about individual GP referral rates to these services. Patients may be referred to psychiatric services by GPs in the community (community referrals), or by physicians or surgeons, while the patients are receiving medical or surgical care in hospital (hospital referrals). One way of controlling for GP variables, such as practice size and the age profile of patients, may be to examine the relationship between hospital and community referrals for each GP. Our hypothesis was that there would be a positive correlation between these types of referral. Six hundred and seventy-four new referrals from 62 local GPs were examined over a 6-year period. The GPs made an average of 7.1 community referrals and 3.8 of their patients were hospital referrals. There was a large variation in the number of referrals (range 1-45). However, there was a significant positive relationship between the number of hospital and community referrals for each GP ( p =0.001). These findings support the hypothesis, and suggest that it may be useful to use the ratio, hospital to community referrals, to identify GPs with abnormal referral patterns.     

A UK survey of psychiatric services for older people in general hospitals

BACKGROUND: Psychiatric illness is common in older people in general hospitals, but little is known of the service models operating in the UK, or of the views of old age psychiatrists regarding service provision in this area. We set out to determine the range of UK old age psychiatry service models for older people in general hospital wards, and the opinions of clinicians on future service priorities and development. METHOD: A postal questionnaire survey of old age psychiatrists providing psychiatric services to older people in general hospital wards. RESULTS: 73% of services were provided through a generic, sector-based, consultation psychiatry model. The remaining 27% employed a range of general hospital-based liaison psychiatry services for older people, involved in proactively seeking referrals and educating general hospital staff. Those providing a generic sector-based model were significantly slower at responding to referrals. 89% of respondents were unhappy with their service to older people in general hospital wards, with only 11% preferring the generic sector-based model. Organisational barriers to change identified included the management of mental health care and physical care by different organisations. Training, both of psychiatric staff in this specialist area, and of general hospital staff in the detection and basic management of common psychiatric conditions in the general hospital setting, was felt to be necessary. CONCLUSIONS: The management of co-morbid psychiatric and physical illness in older people is an important issue for health services. Old age psychiatrists are unhappy with the prevalent, reactive, consultation-based model, preferring a range of liaison psychiatry models based in the general hospital. The most important barriers to service development in this area were the separate managerial arrangements for psychiatric and physical care services, and a lack of evidence for effective old age psychiatry services in this setting.     

Psychiatric referrals from a renal unit: a study of clinical practice in a British hospital

Renal patients referred for a psychiatric opinion were compared with patients from the same unit who had never seen a psychiatrist. Overall the referrals had more psychiatric symptoms, but syndrome profiles of the two groups were very similar. In diagnostic terms, the referrals differed in having a range of adjustment disorders characterised by changes other than simple mood disturbance. There were relatively few major mental illnesses. Three other factors were associated with referral: youth, absence of a confiding relationship; and currently receiving haemodialysis. Most referrals were managed with short term non-intensive therapies, and there was little need for psychiatric in patient care. Psychiatric disorder did not influence survival. The significance of these findings for renal unit psychiatry is discussed.     

Pediatric referrals to psychiatry: II. Factors relating to delays in referral.

Delays in requesting psychiatric consultation were examined, in relation to 220 referrals from a medical ward in a pediatric hospital, to determine why children referred for psychiatric evaluation remained in hospital longer than the non-referred. Request delays did not correlate with age, sex, or length of hospitalization, but were likely to be shorter for acutely ill patients and those whose admission diagnosis evidenced the pediatrician's awareness of the possibility of significant emotional factors. The onus may be on the psychiatrist to increase the medical staff's awareness of the possibility that emotional factors often contribute to their patient's ills. This increased awareness may result in prompt referrals to psychiatry, and shorter, less costly hospitalization.     

Patterns of two psychogeriatric hospitalization services in israel: A one-year survey

We compare two different approaches to inpatient psychiatric hospitalizations in the elderly (age 65+) in Israel. In one, 79 patients were hospitalized during the year 1993 in specialized psychogeriatric wards, at Sha'ar Menashe (ShM) psychiatric hospital. In the other, 133 patients were hospitalized during the same period in general psychiatric wards, at Abarbanel (Ab) psychiatric hospital. This study retrospectively evaluates: demographic data, sources of referral, characteristics of emergency admissions, psychiatric history, psychiatric diagnoses, use of medical services, and outcome measures (length of hospitalization, death rates, nursing status at discharge, placement at discharge). Rate of admission (per 100 000 population) is 2.2-fold higher at ShM than at Ab. The two centres differ significantly in sources of referral (closer links with geriatric services at ShM) and the use of medical services (prevailing use of medical ambulatory services and the hospital's internal medicine wards at ShM, while at Ab more patients were referred for general hospital evaluations). All other variables studied (demographics, characteristics of emergency admissions, psychiatric history, psychiatric diagnoses, outcome measures) were similar between the two centres. The discussion emphasizes the 'audit' orientation of the study. It also stresses the surprising lack of differences between centres in some major variables, and frames research questions for future use.     

Referrals to a psychogeriatic consultation–liaison service

This study reviews referrals of elderly medically ill patients to a psychogeriatric team in a district general hospital. Sociodemographic variables, medical diagnosis, source and reasons for referral, and primary DSM III diagnosis were determined. The impact on referral patterns of the introduction of a pscychogeriatric liaison attachment to complement the existing consultation service was also assessed. In three years, 217 patients were referred, the majority from the general medical specialities. The median age of the sample was 79.5 years, more than half were female and over 60% demonstrated multiple physical pathology, particularly cerebrovascular and cardiovascular disorders. The most prevalent psychiatric diagnoses were dementia, delirium and depression. The pattern of referrals changed significantly with the introduction of the consultation–liaison service. The number of referrals increased by over 100% and there was a significant increase in the recognition and referral of functional psychiatric disorders, especially depression. The role of the geriatricians and the liaison psychiatry attachment in promoting these changes and the clinical, teaching and research advantages of this type of collaboration are discussed.     

Psychiatric units in Brazilian general hospitals: a growing philanthropic field

BACKGROUND: Some countries, mainly in North America and Europe, have adopted psychiatric wards in the general hospital as an alternative to the classic psychiatric hospital. In Brazil there are 6,169 general hospitals, 1.3% of which with a psychiatric unit. This service strategy is scarcely developed in the country and comprises only 4% of all psychiatric admissions. There was no information on the facilities and functioning of the psychiatric units in general hospitals. OBJECTIVE: To determine the main characteristics of psychiatric units in Brazilian general hospitals and to assess the current trends in the services provided. METHOD: A mailing survey assessed all 94 Brazilian general hospitals which made psychiatric admissions. A two-page questionnaire was designed to determine the main characteristics of each institution and of the psychiatric unit. RESULTS: Seventy-nine (84%) questionnaires were returned. In contrast to the 1970s and 1980s, in the last decade the installation of psychiatric units has spread to smaller philanthropic institutions that are not linked to medical schools. A fifth of hospitals admit psychiatric patients to medical wards because there is no specialist psychiatric ward. They try to meet all the local emergency demands, usually alcohol-dependent patients who need short term admission. This could signal the beginning of a program through which mental health professionals may become an integral part of general health services. CONCLUSION: The inauguration of psychiatric wards in philanthropic hospitals, as well as the admission of psychiatric patients in their medical wards, is a phenomenon peculiar to this decade. The installation of psychiatric services in these and other general hospitals would overcome two of major difficulties encountered: prejudice and a lack of financial resources.