Consultation-liaison: a patient-based overview.

As the consulting psychiatrist and his or her fellow physicians come to know each other better, their interaction when offering comprehensive patient care becomes increasingly effective. This report is an overview of consecutive psychiatric consultations in a busy general hospital. In addition, the authors speculate about the components of an effective consultation liaison service.     

A psychiatric consultation service for hospitalized children

The authors describe the organization of the child psychiatric consultation service of the Massachusetts General Hospital. They review the conceptual framework of consultation to pediatric inpatients and analyze a nine-month study of 72 consultations by categorizing them according to the type of request for consultation. The largest number of requests (38%) reflected the children's concerns about their illnesses and hospitalization. Liaison activities, designed to provide information and to help the staff tolerate stress, are exemplified in five brief case reports     

Organic mood disorder: a valid psychiatry consultation diagnosis?

To determine the validity of the DSM-IIIR category organic mood disorder, we compared 50 psychiatric consultations with this diagnosis to 50 psychiatric consultations diagnosed with major depression in the medically ill. Organic mood disorder patients were more likely to be in the index affective disorder episode and have a negative family history of depression. Despite similar pharmacologic treatment between groups, the organic mood disorder group was less likely to be completely recovered at 4 years follow-up. This study suggests organic mood disorder is a valid diagnosis in the psychiatry consultation service.     

A database review in C-L psychiatry: characteristics of hospitalized suicide attempters

A computerized database was used to study the characteristics of psychiatric consultations in patients admitted to nonpsychiatric services. The authors reviewed a consultation practice with suicide attempters over a four-year period and compared the patients with a patient sample matched for gender and age also seen by the service. For suicide attempters, the time elapsed between admission to the service and the consultation, as well as the lengths of stay, were significantly shorter. Suicide attempters were significantly more likely to have mood disorders and Axis II disorders. The authors review the role of consultation psychiatrists with these patients and suggest that a triage model fits the services provided and the needs of nonpsychiatric physicians.     

Factors affecting the relationship between the timing of psychiatric consultation and general hospital length of stay

The purpose of this study was to examine the factors affecting the timing of psychiatric consultations and length of stay in the current managed care era. It also assessed the relationships between the timing of consultations and demographic/clinical characteristics. Medical records of 541 consecutive psychiatric consultation patients at a university teaching hospital in 2001 were reviewed for demographic characteristics, lengths of stay, number of days from admission to consultation, specialty services requesting consultations, reasons for the referral given by the referring physicians, and all five axes of DSM-IV. Earlier consultations independently predicted shorter lengths of stay. Delayed consultations were seen more often in women; surgical patients; those seen with a request to assess depression; and those seen with a diagnosis of adjustment disorder, delirium, or no psychiatric disorder. Delay in psychiatric consultations continues to be associated with longer lengths of stay in the current managed care environment. It is now possible that early detection strategies for high-risk patients with behavioral health problems in the medical setting, such as use of the INTERMED, may lead to reduction in delayed psychiatric consultations and thus shorter lengths of stay.     

Mental health and medical consultation in primary care settings

This paper examines the effect of psychiatric morbidity, as measured by the GHQ-60, on the probability of being in contact with a primary care physician, and the socio-demographic factors which influenced this effect. We found that the presence of psychiatric morbidity emerged as a major determinant of primary care utilization in both sexes, and about one-sixth of consultations in men and one-fifth of consultations in women could be attributed to it. Logistic modelling was used to investigate the joint effect on general practitioner consultation of psychiatric morbidity and seven socio-demographic variables. Sex, age, and psychiatric morbidity exerted independent, but not interactive, effects on consultation.     

Clinical experience with the management of schizophrenia in the general hospital

On the basis of experience with 74 psychiatric consultations involving patients with schizophrenia admitted to a general hospital medical or surgical ward over a 17-month period (3% of the psychiatric consultations during that period), the authors identified 10 types of problems leading to requests for consultation. The authors used these categories to organize recommendations for management of patients with schizophrenia in the general medical hospital. In addition to conducting conventional consultations, the consultation psychiatrist in such cases often has a role in educating hospital staff about schizophrenia and in serving as a physician for the mentally ill.     

Utilization of a psychiatric consultation service

In an effort to clarify the role of the psychiatrist as a consultant in a general hospital, a survey was made of how frequently physicians on various services requested consultations, what problems led to the consultation requests, and which psychiatric services the requesting physicians considered most valuable. Results showed wide variations between and within the medical services, pointing up the need for the psychiatric consultant to be trained in a multiplicity of consulting roles.     

Factors associated with the use of psychiatric consultations in short-term general hospitals

A significant number of patients in general hospitals suffer from psychiatric distress or illness, but not all receive psychiatric consultation. This study examined several potential predictors of such consultation. These included patient characteristics (age, sex, race, insurance, disease stage, and number of medical diagnoses), characteristics of hospital stay (number of procedures, other consultations, length of stay, discharge destination), hospital characteristics (size, percent occupancy, teaching status, presence of a psychiatric unit, type of control), and community characteristics (region, urban/rural setting). Data were derived from a national sample of 327 hospitals. Parallel analyses using stepwise logistic regression were carried out across four samples: patients determined at discharge to have been hospitalized for diabetes, hip fracture, chronic obstructive pulmonary disease, and coronary artery bypass surgery. Results show a wide variation in the use of psychiatric consultations across different subgroups. Longer lengths of stay, urban setting. Northeast region, younger patient age, and other consultations were the most consistent predictors of the probability of psychiatric consultation. These variations may reflect differences in the need for consultation, differential recognition of these needs by providers, or differential availability of psychiatric consultation services. Moreover, they may have implications for equity and/or quality of hospital care.     

Consultation-liaison fellowships: effect on internists' attitudes toward psychiatric consultation

The results of a questionnaire sent to 495 internists indicated that they would be more likely to request psychiatric consultations for their patients if they had access to psychiatrists who had completed consultation-liaison (C-L) fellowships. The attitudes of those internists initially highly reluctant to obtain psychiatric consultation were significantly more enhanced on learning about the specially trained C-L psychiatrists than were the attitudes of less reluctant internists. Examination of various sources of reluctance suggests that many internists have low confidence in the value of psychiatric consultations. Only 31% of the internists polled were aware of C-L fellowships.     

The mortality of delirium: An underappreciated problem?

The author reviewed 116 charts of medical-surgical inpatients evaluated by a university hospital psychiatric consultation service. Five of 15 consultation patients with delirium died within three months after the consultation, whereas only one of 43 depressed patients died. Neither consultees nor psychiatric consultants usually considered patient prognosis, according to chart notations. Mortality associated with delirium may be underappreciated in the assessment of delirious patients.     

Medical provision for the homeless in Manchester

The events leading up to the establishment of a separate primary care service for the homeless and rootless population in Manchester are described.

The organization, funding and commitment of the project are outlined and an insight into the life-style of this population is provided.

During the first quarter of 1981, 2,049 consultations were given. The most common causes for consultation were psychiatric, alcoholic and respiratory conditions.

     

A follow-up study of psychiatric consultations in the general hospital: What happens to patients after discharge?

BACKGROUND: An appropriate follow-up is considered essential in the consultation-liaison psychiatry setting, but it is often neglected. This study evaluated the effectiveness of the psychiatric consultation process in the general hospital, by investigating what occurred to patients 3-5 months after discharge. METHODS: We used a three-part questionnaire: (1) the results of the consultation process; (2) a telephone interview with patients, and (3) a telephone interview with the patients' primary care physician, to whom the patients were referred after discharge from hospital. We contacted all consecutive, unselected patients referred to psychiatric consultation from January to July 1999. Complete data were available for 119 patients from an initial group of 318. RESULTS: The consultation process was well accepted by patients and useful to general hospital physicians to complete the final diagnosis of the patient when discharged from hospital. In most cases (78.9%), the psychiatric letter was attached to the discharge letter. The second part of the questionnaire indicated that most patients were satisfied with the consultation process. They thought it helped focus their problems and 60% asserted that they felt better after following their psychiatrists' instructions or therapy. The primary care physicians agreed with the diagnostic results of the psychiatric consultation, mainly followed the psychiatrists' advice, and generally expressed positive comments about the consultation-liaison service. CONCLUSIONS: Compliance of hospital physicians, patients, and primary care physicians was good. Follow-up studies on outcome of psychiatric consultations are few and further analysis is strongly recommended.     

Conversion symptoms in a general hospital

Analysis of 1,000 consecutive psychiatric consultations shows that the prevalence of conversion disorder (5%) in a general hospital remains significant. Conversion patients referred for psychiatric consultation were predominantly married young women of lower socioeconomic class and rural background. We observed rapid remissions of presenting symptoms in most cases upon treatment and found a significant proportion of somatization disorder (34%) or history of conversion disorder (38%). Other phenomenologic findings are discussed in regard to previous reports or hypotheses about conversion symptoms.     

Why physicians fail to tell patients a psychiatrist is coming

A survey of 103 psychiatric referrals in a medical center showed that 68% of the patients had not been informed by their physicians that psychiatric consultations had been requested for them. To understand this phenomenon, the authors inter viewed the patients, their referring physicians, and a random sample of 30 other physicians. The most prevalent reason for the physicians’ failure to inform their patients about psychiatric re ferrals was the physicians’ misperception that laymen have negative attitudes toward psychiatry. In fact, approximately two thirds of the patients had positive or uncommitted attitudes about the psychiatric interviews before they occurred. Imparting psychological skills to referring physicians would improve their preparation of patients for psychiatric consultation.     

Implementation of a psychiatric consultation service: a single-site observational study over a 1-year-period.

This study describes changes in consultation process variables and referral patterns after implementation of a psychiatric consultation service at a university hospital in Germany. Two hundred eighty consecutive medical-surgical inpatient referrals for psychiatric consultation during a 1-year period were documented prospectively with a structured database. Changes took place in referral patterns and in psychiatric interventions and recommendations but not in psychiatric diagnoses. In addition, information is given on psychiatric and psychosomatic consultation service delivery in Germany.     

Consultation/liaison psychiatry utilization patterns in different cultural groups.

This study examined the effect of cross-cultural factors on psychiatric consultations in a general hospital. Using a retrospective case review, 476 patients receiving a psychiatric consultation were contrasted with 14,620 who did not receive a psychiatric consultation. The rate of psychiatric referral was lower for Hispanics compared with Anglos, blacks, and Asians (p less than 0.001). The reason for requesting psychiatric consultation was also different across the ethnic groups. There were more requests for evaluation of depression and suicide in Hispanics and fewer such requests in blacks. More requests for evaluation of grossly abnormal mental status were found in blacks. The different cultural groups also had differences in psychiatric diagnosis. Hispanics were more frequently diagnosed with an adjustment disorder; blacks were more frequently diagnosed with a primary thought disorder and delirium; and Anglos were more frequently diagnosed with dementia.     

How does the content of consultations affect the recognition by general practitioners of major depression in women?

BACKGROUND. Major depression is a common and disabling condition. However, for many reasons, the condition is not recognized in about half of the patients with major depression. AIM. The aim of the study was to establish whether the content of general practice consultations affected general practitioners' recognition of major depressive illness in women patients. METHOD. The 30-item general health questionnaire was used as a first stage screening instrument for psychiatric morbidity. Patients newly recognized as depressed by their general practitioner and those not recognized as depressed who scored 11 or more on the questionnaire were interviewed, usually within three days of consulting their general practitioner, using the combined psychiatric interview. Videorecordings of the consultations for these two groups of women were analysed; analyses were based on mentions of physical, psychiatric and social symptoms and on whether the first mention of a psychiatric symptom was within the first four mentions of any symptoms (early in the consultation) or after four mentions of any symptoms (late) or if psychiatric symptoms were not mentioned. RESULTS. A paired sample of 72 women with major depression was obtained from patients consulting 36 general practitioners, each general practitioner providing one patient whom he or she had correctly recognized as being depressed and one patient whose depression had not been recognized. Women with major depression were about five times more likely to have their depression recognized if they mentioned their psychiatric symptoms early in the consultation compared with those who either left it later to mention such symptoms or never mentioned them. Major depression was more likely to be recognized if no physical illness was present. After adjusting for physical illness, depression was 10 times less likely to be recognized if the first psychiatric symptom was mentioned late in the consultation, or not mentioned at all, than if it was mentioned early in the consultation. CONCLUSION. General practitioners need to remember that patients who present with symptoms of physical illness may also have depression. They also need to remember to give equal importance diagnostically to mentions of symptoms at whatever point they occur in the consultation, regardless of the presence or absence of physical illness.     

Mood and behavioral disturbances in hospitalized AIDS patients

A retrospective chart review of 127 patients with acquired immune deficiency syndrome (AIDS) was undertaken to determine the rate of requests for psychiatric consultation. Thirty-six patients (28.3%) had received psychiatric consultations. This is similar to the rate of consultations seen in other studies. Patients who were not intravenous (iv) drug abusers were more likely to be seen for mood disturbances; iv drug users were more likely to be seen for behavior disturbances. The implications of these findings for future demands on consultation-liaison services for AIDS patients are discussed.     

Clarity of request for consultation: its relationship to psychiatric diagnosis

Psychiatric consultants’ ratings of the clarity of requests for 203 psychiatric consultations by medical and surgical services were studied prospectively during a three-month period. The subsequent psychiatric diagnoses were grouped depending on whether or not a major mental illness (MMI), mainly in the form of dementia, delirium, affective disorders, and schizophrenic disorders, was present according to DSM-III criteria. An MMI was diagnosed in 61% of cases in which the reason for the consultation request was considered unclear, but in only 32% of cases in which the reason was considered clear. These findings support earlier speculations that patients with serious psychiatric disturbances tend to affect the clarity of communications among members of the treatment team.