Consultation-Liaison outpatient clinics

This paper describes the history of the provision of psychiatric services to outpatients in general (medical) hospitals in the United States. It also reviews the rationale for the development of consultation-liaison psychiatric clinics that have been created to meet the psychiatric needs of these patients. Results of a random survey of current consultation-liaison psychiatry outpatient clinics are presented and recommendations are made for a model outpatient clinic.     

Introduction: research at the interface of medicine and psychiatry

Linkages between psychiatry and other medical specialties have become increasingly evident over the past decade. Reinstatement of the medical internship for psychiatric trainees, expansion of psychiatric liaison services, growth of general hospital psychiatric units, determination of the extensive role served by nonpsychiatric physicians in providing mental health care, and research evidence of the economic benefits of incorporating mental health services in general health settings all have served to break down artificial boundaries between mental health and general health concerns. The psychiatric consultation-liaison service initiated in 1981 by the NIMH at the NIH Clinical Center in Bethesda has afforded opportunity for numerous collaborative research projects with clinical investigators of various categorical disease programs. In addition to offering new etiological insights into psychiatric and general medical illnesses, the work described in this symposium promises to move clinical practice closer toward the Engel model of biopsychosocial medicine.     

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.     

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.     

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.     

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.     

The use of the medical team model on a consultation-liaison teaching service

This paper describes a consultation-liaison (C/L) teaching service that uses a medical team rounding model; four teams cover distinct geographic areas of the hospital, each team consisting of an attending psychiatrist, a resident, two medical students, and a psychology graduate student. Daily attending rounds on the medical/surgical wards provide prompt and direct patient care supervision for the team members, allowing for coordination of their activities and communication with the attending physician, who serves as a role model. Psychological testing can be readily integrated into the clinical setting; neurology and family practice residents can also get their psychiatric training in this setting. The medical team model of rounding is different from other models used on C/L services; its pros and cons are discussed.     

Implementing a consultation-liaison service in a psychiatrically underserved area.

Most multidisciplinary consultation-liaison services are developed in settings where there are both psychiatric residents and an adequate psychiatric liaison faculty. In this paper, the authors report some of the obstacles and attempts at overcoming them in the implementation of such services in an underserved area in which there is a scarcity of both residents in training and psychiatric liaison faculty. The process of collaboration between a primary-care-oriented medical school and a community general hospital is described, and roles of program participants are defined. Special attention is paid to funding problems.     

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.     

Psychiatric consultation-liaison service: Patients,requests, and functions

Prospective data were gathered from 388 psychiatric consultations performed in a general hospital setting. Data included demographic, medical, psychiatric, and illness behavior characteristics of the patients seen, as well as consultant functions and recommendations. Results indicate that consulted patients suffer from a wide variety of medical problems, are frequently taking psychoactive medications before the consultation, and experience a spectrum of psychosocial problems in coping with their disease. Primary physicians infrequently provided any psychiatric data or reasons for referral other than for depression. Consultants determined what they felt were the motivating reasons for referral and besides patient psychopathology found a significant amount of maladaptive illness behavior and staff/patient conflict. Comparison with other studies supports the high incidence of primary (21%) and secondary (18%) depression in this population and the active involvement in its treatment by consultation-liaison psychiatrists. Research, training, and clinical issues generated by the finding are discussed.     

Hospice consultation team: A new multidisciplinary model

The term “hospice” refers not only to certain facilities, but also to a philosophy of comprehensive, humanistic treatment for the patient and his family. Because death will always be a part of the general hospital setting, hospice concepts provide a useful method for improved patient care. This paper describes the development of a multidisciplinary team that provides consultation-liaison services for terminally ill patients and their families, either while in hospital or while being followed in a home-care treatment service. Cases are presented that illustrate the benefits of such an approach to the care of the dying patient and his family.     

Psychiatric consultations in a general hospital. A report on 1,000 referrals.

1,000 medical and surgical inpatients referred for psychiatric conSULTATION SHOWED CONCURRENT PHYSICAL AND PSYCHIATRIC DISORDER IN 68.2% of cases. This is in accordance with epidemiological findings that these two types of morbidity have a positive association and coexist in 20-50% of patients. Depression was the commonest psychiatric disorder in all classes of organic disease and accounted for 53% of all psychiatric diagnoses. Organic brain syndromes, acute and chronic constituted 18% of referrals. Almost twice as many women as men were referred despite their nearly equal distribution in hospital population. One-third of the females had no positive medical diagnosis compared to one-fifth of the men. Alcoholism was a major problem in 8.9% of referrals. 7.8% of patients were referred following suicidal attempt. Of the 50 patients with cancer. 66% had depression. Too few medical patients with psychiatric complications are referred and adequately treated. Greater emphasis on teaching psychiatric syndromes is called for. Psychiatric consultation-liaison services offer the most direct form of collaboration between psychiatry and medicine in the interests of comprehensive patient care.     

Medication noncompliance: Systematic approaches to evaluation and intervention

Medication noncompliance is a significant problem in medical practice, but many intervention strategies developed for noncompliant patients (such as tangible rewards, contingency contracting) are not practical for the large numbers of patients seen by private practitioners on an ongoing basis. Based upon a review of the literature concerning the key determinants affecting compliance, the authors have developed a practical, rational, and systematic approach to assessing medication compliance that may serve as a guide for psychiatrists in formulating consultation recommendations, in liaison teaching activities, and in clinical psychiatric practice. Special emphasis is placed upon the identification of psychiatric syndromes that may negatively affect compliance. Implications for compliance-related research in consultation-liaison psychiatry are also discussed.     

Bereavement and its complications in medical patients: a guide for consultation-liaison psychiatrists

Bereaved individuals consult their physicians, including psychiatrists, at an increased frequency for the many symptoms of normal or pathological grief as well as related medical and psychiatric disorders. As many as 25 percent of patients seen by a consultation-liaison service may be suffering from recent unresolved grief. The consultation-liaison psychiatrist needs to be sensitive to the manifestations and course of bereavement in both its uncomplicated and pathological forms. This report provides an overview of these issues as a guide for the accurate assessment and treatment of this often unconsidered condition.     

Liaison psychiatry in an Irish hospital: a survey of a year's experience

A brief summary of the pattern of mental illness in Ireland is given and the work of a psychiatric consultation-liaison service in a general hospital in the southern part of the country is discussed in this context. The referral rates to the service mirror the referral rates in the United Kingdom more than those in the United States. The high rates of alcoholism and functional psychosis found in referred patients probably reflect the increased prevalence of these conditions in the general community. In Ireland, as elsewhere, the rate of referral of general hospital inpatients to a psychiatric consultation-liaison service is below the rate of psychiatric illness found in hospital inpatients.     

The use of DSM-III in a general hospital consultation-liaison service

Eighteen months' use of DSM-III by a consultation-liaison service in a university hospital is reported. DSM-III's multiaxial system seems to be feasible and revealing, but presents some problems. Adjustment Disorder and Organic Mental Disorders were the most frequent Axis I diagnoses. Approximately one-fourth of the patients received an Axis II diagnosis and 85% received an Axis III diagnosis. In 70% of the patients there was both a psychiatric diagnosis (on Axis I or II) and a physical disorder (on Axis III). On Axis IV and V, this population appeared to be under moderate to severe psychosocial stress and had, as a group, a fair or better level of previous adaptive functioning. The possible significance of these findings and potential areas for further refinements and investigations are discussed.     

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.     

Funding consultation-liaison psychiatry via Medicare screening.

Despite offering many benefits to patients, the hospital, and the hospital staff, an academic psychiatric consultation service is difficult to fund. By screening Medicare patients for psychiatric complications and comorbid conditions, the consultation-liaison (C-L) service can generate incremental revenue for the hospital by moving patients from lower-paying to higher-paying Diagnostic Related Groups (DRGs). The C-L service chief can negotiate with the hospital to obtain a portion of these incremental funds to support the C-L service. Concurrent psychiatric disorders that move patients to more complex DRGs include substance abuse, substance dependence, drug-induced delirium, drug-induced organic affective syndrome, and psychotic depression. This paper presents a method of calculating the incremental hospital revenue generated by such screening along with the results of applying the method to selected DRGs at a west coast teaching hospital. Implementing this program at that hospital in fiscal year 1989 would have resulted in screening 142 Medicare patients (2.2% of Medicare admissions), discovering an estimated 25 patients with comorbid psychiatric conditions, and generating $51,800 in incremental hospital revenue. In creating a screening program, a C-L service chief must be prepared to negotiate issues with the medical records department, referring physicians, and the hospital administration.     

Psychiatric consultations in a military general hospital. A report on 1065 cases

The authors describe the demographic and diagnostic characteristics of 1065 medical and surgical inpatients referred for psychiatric consultation over a 1-year period at a military medical center. The referral rate was 5.8% of all hospital admissions with the percentage of referrals from surgical and neurology services being higher than recent civilian studies. Although the variety and frequency of psychiatric and physical disorders are quite similar to civilian consultation-liaison (C/L) psychiatric services, the authors reported lower rates of personality disorder diagnoses and higher percentages of V code and no-psychiatric-disorder diagnoses.     

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.