Timing of psychiatric consultations: the impact of social vulnerability and level of psychiatric dysfunction

The authors examined the timing of patient referrals to a psychiatric consultation-liaison service in relation to the patient's social vulnerability and level of psychiatric dysfunction. One hundred consecutive patients were assessed with the INTERMED, a method to document biopsychosocial and health care-related aspects of disease. Although 30% of patients were referred within the first day of admission, 19% of requests for referrals were made after 2 weeks. Late referral was associated with high social vulnerability and early referral with severe psychiatric dysfunction. The authors illustrate the disadvantages of a psychiatric liaison model focusing on psychopathology alone and demonstrate the need for an integrated patient assessment in the general hospital, focusing on detecting frail elderly patients.     

Cumulated need for psychiatric service as shown in a community psychiatric project

District psychiatric services often supplement intramural mental health programmes. They usually result in an increase in the number of referrals to the mental health facilities, which reflects a cumulative need for psychiatric examination and treatment in the population. A significant decrease in the annual first referral rates per 1000 inhabitants aged 15 years and above is apparent in an analysis of the trends in the Danish Sams? community psychiatric service from its inception in 1957 until 1982. The average annual rates were 19.4 in the first 5-year period, 10.0 in the second 5-year period, and 8.4 in the 'steady state period' from 1967 to 1982. The conclusion is, therefore, that the work load connected with the cumulative need for psychiatric examination and treatment should be terminated in approximately 10 years. A comparison of the two 5-year periods, 1957-61 and 1978-82, demonstrated a decrease in first referral rates in almost all diagnostic groups: this is significant among manic-depressive psychoses, neurotic states and unspecified mental disorders. The rates of no mental disorders and senile and arteriosclerotic psychoses were almost unchanged. In the 10-year age groups there was a decrease in first referral rates for all groups, except for the groups aged 75 years and above whose rates were unchanged. The concept of cumulative need for psychiatric examination and treatment is discussed in relation to the reports of various district psychiatric service programmes in different European countries.     

Non-attendance at psychiatric outpatient clinics: communication and implications for primary care.

BACKGROUND: What should happen when an outpatient fails to attend a psychiatric clinic? Guidelines from the General Medical Services Committee suggest that general practitioners (GPs) have no further responsibility of care for a patient once a referral to a psychiatrist has been made. This raises questions about the formulation of effective management plans for those patients with whom psychiatric services find it difficult to engage due to non-compliance with assessment and follow-up. AIMS: To investigate communication between GPs, patients, and psychiatrists at referral and following attendance or non-attendance at outpatient appointments. METHOD: A prospective study of a random sample of attenders and non-attenders at psychiatric outpatient clinics. Patients and GPs were interviewed to obtain data about the referral process. GPs' views on communication from psychiatrists and the appropriate course of action following clinic non-attendance were investigated. The quality of referral and clinic letters for attenders and non-attenders was compared. RESULTS: There was no difference in the quality of referral letter for attenders and non-attenders. Psychiatrists were less likely to write to GPs about follow-up patients' appointments than new patients' appointments; communication was least likely when a follow-up patient missed their appointment. GPs considered follow-up non-attenders were more likely to need a further appointment than new patient non-attenders, but did not identify a role for themselves in engaging with follow-up non-attenders. CONCLUSION: Communication between GPs and psychiatrists about new patients seems adequate. However, there are important deficits in communication from psychiatrists to GPs about follow-up patients, especially non-attenders who are often more severely ill and difficult to engage. An effective response for this group is likely to need cooperative health and social service action rather than rigid guidelines concerning clinical responsibility.     

General practitioner referral to specialist psychiatric services: a comparison of practices in north- and south-Verona

Specialist psychiatric services run by the Italian National Health Service are mainly hospital-based in North-Verona and community-based in South-Verona. Ninety-two GPs from both areas participated in a one-day survey of their provision of psychiatric care, and this paper focuses on socio-demographic and clinical variables associated with specialist psychiatric referral. The one-day prevalence figure for GP referral to specialist psychiatric services was 7.3% (17.6/10,000): the figures did not differ between the sexes or between the two areas. Whereas in North-Verona 49% of the patients referred were sent to the two local hospital-based public services and 51% to other agencies (mainly to private psychiatrists), in South-Verona 71% of referrals were to the community-based public service. Log-linear analysis showed that past psychiatric history, psychological presenting complaint, social problems and GPs' psychiatric diagnosis exerted positive joint main effects on GP referral to specialist psychiatric services, and that diagnosed organic illness had a negative effect in this regard. In the presence of a psychological complaint, a psychiatric diagnosis proved to be quite unimportant, so that those without a psychiatric diagnosis were just as likely to be referred as those with one. However, in the absence of a psychological complaint a GP diagnosis of depression greatly increased the risk of referral. Though the type of psychiatric service proved not to be an important determinant of GP referral to specialist psychiatric services it influenced the GPs' choice of referral agency.     

某三级甲等综合医院住院患者精神科会诊3年资料分析

目的:了解某三级甲等综合医院精神/心理服务需求的特点。方法:汇总某三甲综合医院2006年7月1日-2009年6月30日期间所有经心理医学科会诊的患者共2082例次,分析会诊率、会诊科室、会诊原因、精神科诊断及随诊情况。结果:3年来会诊率由1.01%升至1.48%,随诊率为15.77%。重症监护病房会诊率最高(4.77%),特需科室随诊比例最高(27.04%)。占1%以上的邀请会诊原因有10类,其中"目前情绪症状"最多,占28.4%。精神科诊断以"神经症性、应激性障碍及焦虑状态"为主,占44.2%,诊断为躯体形式障碍及医学不能解释的症状(Medical Unexplained symptoms,MUS)的患者随诊比例最高,达26.6%。结论:综合医院对精神/心理服务的需求全面,精神专科应提供全面深入、特点突出的会诊联络服务。     

Community psychiatric nursing: a survey of patients and problems

The work of a community psychiatric nursing service for acute psychiatric conditions was reviewed for the period 1980-82. Five community psychiatric nurses operated in 10 health centres. General practitioners were the most frequent users of the service and a wide range of psychiatric problems were encountered. The age structure of all referrals was found to be significantly related to sex, with the proportion of females in all age groups at least twice that for males. The most frequent reason for referral was mood/affect disturbance; female patients referred for the first time were predominant. Over half of all problems resolved within three months of referral and a limited number of patients were sent for further psychiatric investigation.     

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.     

Antihypertensive drugs and depression: a reappraisal.

Eighty-nine new referral hypertensive out-patients and 46 new referral non-hypertensive chronically physically ill out-patients completed a mood rating scale at regular intervals for one year. The results showed a high prevalence of depression in both groups of patients, with no preponderance in the hypertensive group. Hypertensive patients with psychiatric histories had a higher prevalence of depression than the comparison patients. This was accounted for by a significant number of depressions occurring in methyl dopa treated patients with psychiatric histories.     

Characteristics of obstetrical inpatients referred to a consultation-liaison psychiatry service in a tertiary-level university hospital

A review of psychiatric consult notes of 96 obstetric inpatients referred to a Consultation-Liaison (C-L) psychiatry service in a tertiary-level university general hospital was carried out in order to compare the characteristics of such a service in a North American setting with similar services in other parts of the world. Data extracted from consult notes included: reason for referral, current diagnosis (DSM-IV-R), psychiatric history, obstetrical history, recommended treatment approaches, current psychotropic medications, current gestational age or number of days postpartum, patient age, and partnership status. In addition, obstetrical referrals were calculated as a percentage of hospital-wide referrals to C-L psychiatry. The most prominent findings include: (1) a high C-L psychiatry referral rate from obstetrics as a percentage of total C-L referrals within the study hospital; (2) past psychiatric history alone as a prevalent reason for referral; (3) adverse reproductive event (past and/or current) as a common reason for referral. These findings differ markedly in certain ways from comparable studies and may reflect both the hospital’s large high-risk pregnancy service that represents an at-risk group for mental health issues, and the focus on educational collaboration with obstetrical staff regarding risk factors for, and consequences of, perinatal mental illness. Inpatient perinatal C-L psychiatric services require creative approaches to the accurate identification and treatment of women at risk for antenatal and postpartum mental illness due to psychiatric history and/or reproductive crises.     

Psychiatric cases: an ethnography of the referral process

Investigation into the referral histories of a consecutive series of new patients attending two psychiatric out-patient clinics questioned the assumption that only the more severe and problematic cases are selected by general practitioners for specialist referral. In 40% of cases, clinical indications only became decisive in relation to emergent difficulties in managing the case, while 38% of patients or their relatives requested referral. The implications of these observations are considered in relation to alternative models of psychiatric intervention in the management of psychosocial disorders in primary care.     

Deliberate self harm patients with depressive disorders: treatment and outcome

BACKGROUND: Depression is the most common psychiatric disorder in deliberate self-harm (DSH) patients and in those who commit suicide. The aim of this study was to examine the treatment received by DSH patients with depression and their progress following DSH. METHODS: A representative sample of 106 patients with an ICD-10 depressive episode who presented to a general hospital following an episode of DSH were investigated in terms of their treatment before and after the episode and their outcome at follow-up. RESULTS: Prior to the index episode of DSH, 39 patients (36.8%) were receiving treatment from the psychiatric services and a further 35 (33.0%) were receiving treatment for mental health problems from their general practitioner. Fifty-two patients (49.1%) were receiving antidepressants (in therapeutic dosages in 93.6%). After the episode of DSH 94 patients (88.7%) were offered treatment with the psychiatric services, either as a new referral or continuation of treatment they were receiving prior to DSH. Of the patients who were followed-up, 36.3% remained in contact with the psychiatric services, 52.3% showed poor compliance with recommended treatment and 60.2% no longer fulfilled the diagnostic criteria for depression. Almost one-third reported a further episode of DSH during the follow-up period. LIMITATIONS: The nature and quality of non-physical treatments provided by the psychiatric services was not investigated. Reports of the treatment provided by general practitioners, the timing of improvement in symptoms and compliance with treatment largely relied on patients' self report. CONCLUSIONS: All patients presenting following DSH need to be carefully screened for depressive illness. Randomised controlled studies need to be conducted on DSH patients with depression to determine which treatments are effective.     

Survey of the demographic characteristics of patients requiring restraints in a psychiatric emergency service

This paper examines the previously studied topic of the prevalence of uncontrollable behavior in psychiatric emergencies, using the need for restraints as an indicator, and seeks to discover demographic characteristics that were associated with patients needing restraints. The variables considered are sex, referral source, marital and financial status, race, education, diagnosis, age, and disposition. The findings of this survey were compared with those of another survey, which was conducted with a different population in a different community context, using tendency toward assault as an indicator of uncontrollable behavior. Although the two surveys were not strictly comparable, some interesting points were raised regarding differences and similarities.     

Psychiatric referral rates and the influence of on-site mental health workers in general practice.

Psychiatric referral rates vary widely between different general practices. To increase our understanding of this variation, we conducted a one-year prospective observational study of outpatient psychiatric referrals made by all general practices (622 referrals from 29 practices) within the catchment area of one inner-city psychiatric service. Contrary to our hypothesis, practices with higher allocations of on-site mental health workers did not have lower psychiatric referral rates. On the other hand, the highest referring practices had lower mental health worker allocations suggesting a possible influence upon referrals in this subgroup. A wide range of quantitative variables explained very little of the referral rate variation, implying that more subjective factors, such as general practitioner attitudes, may be influential in the decision to refer a patient to the psychiatrist.     

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.     

Variations in referral pattern to the psychiatric services by general practitioners.

Referral rates to psychiatric services in North-East Scotland by 147 individual urban and rural general practitioners were calculated. Among city doctors, the greater the number of years since qualification the more patients were referred. Single-handed city doctors also had very high referral rates. Subsequent interviews were conducted with 76 general practitioners. Topics covered included reasons for referral to psychiatric services. Psychotics, severely depressed patients, alcoholics and violent patients were the most frequently referred groups.     

Psychiatric complications of pediatric asthma.

Asthma is the most common chronic illness of childhood. An increased prevalence of psychopathology has been shown repeatedly to occur in severely asthmatic children, but little evidence exists to suggest that this is true for children with mild asthma. A major problem in interpreting the psychological literature addressing asthma has been the absence of studies of children with specified subtypes of the disease and the analysis of heterogeneous samples including children with a wide range of ages and poorly defined disease characteristics. Depression and anxiety disorders occur at a greater prevalence in severely asthmatic children and may be exacerbated by antiasthmatic medications. Vocal cord dysfunction may be misdiagnosed as asthma and is suggested to be associated with an increased risk of psychiatric disturbance. The presence of depressive illness in very severe asthmatic patients is associated with greater asthma mortality and requires intervention. Treatment considerations include the need for a high level of suspicion for noncompliance in patients who are nonresponsive to antiasthmatic medications, judicious use of antidepressant medication, referral of children with co-occurring psychiatric symptoms for psychiatric assessment and management, and consideration of early intervention strategies to minimize the initial expression of asthmatic symptoms.     

Psychiatric morbidity in renal transplantation

51 patients on chronic dialysis, awaiting transplantation, were assessed using a standardised psychiatric interview, together with measures of anxiety, depression, locus of control and social adjustment. 33% of the patients warranted a psychiatric diagnosis. During the study period, 30 patients received a transplanted kidney and 18 could be followed up 12 months after transplantation, when only 3 had a psychiatric disorder (17%). Previous psychiatric history was the main predictor of psychiatric symptomatology and of psychiatric referral during follow-up. However, symptomatology at follow-up also correlated with affective symptoms and selected aspects of social adjustment at initial interview.     

A 3.5-year naturalistic follow-up study of depressed out-patients

Outcome studies of patients suffering from depression indicate high relapse rates and a tendency towards chronicity. The present study describes the long-term outcome of 95 depressed outpatients in a third-level referral centre. and examines the relationship between baseline-variables (age, sex, level of psychopathology, age at onset of first psychiatric disorder, duration of illness at baseline, diagnosis) and outcome variables. After 3.5 years, 34 patients (36%) had a chronic course, 24 patients (25%) had at least one recurrence and 37 patients (39%) had a non-recurrent course. Chronicity was significantly correlated with an early age of onset of the first psychiatric disorder, a high level of psychopathology and a high level of depressive symptoms at baseline. The duration of depression at index did not differentiate chronic course from recurrent or non-recurrent course. After 1 year of follow-up, patients with recurrence were significantly more likely to stop antidepressant treatment. The results confirm the great chance for chronicity and recurrence in depression and the need to develop long-term treatment programs to prevent relapse.     

General practitioner referral rates to district psychiatry and psychology services.

The number of referrals made to a district psychiatry service by each of the local general practitioners over a five year period was counted and a large variation in general practitioner referral rate was found. Ten referral letters from each of the general practitioners were independently assessed for the amount of detail included and a mean score for each general practitioner obtained. A significant negative correlation was found between referral rate and amount of detail in referral letters, that is low referrers wrote very detailed letters. The procedure was repeated over an 18 month period including referrals to the district psychology service. Referral rate to the psychologists was positively correlated with detailed referral letters, that is those who referred many patients to the psychologists wrote detailed letters. This study has indicated a wide variation in the use of the psychiatry and psychology services by general practitioners which cannot be explained solely on the basis of a general referral tendency. It is likely that constructive liaison between psychiatrists and general practitioners, especially those who refer a large number of patients, could enhance the care of patients with psychiatric disorder in general practice.     

A population survey of ischaemic heart disease and minor psychiatric disorder in men.

Associations between ischaemic heart disease and psychiatric morbidity in hospital recruited samples may be confounded by differential referral of patients with co-morbidity. Associations of angina, past history of myocardial infarction, blood pressure, and electrocardiographic evidence of ischaemia with psychiatric disorder can best be examined in community samples as reported here in 2204 middle-aged men from the Caerphilly Collaborative Study. There was a strong association between past history of myocardial infarction, non-specific chest pain, Angina Grade II and psychiatric disorder measured by the 30-item General Health Questionnaire. Electrocardiographic evidence of ischaemia alone was not significantly associated with psychiatric disorder. It is suggested that non-specific chest pain is a symptom of psychiatric disorder; conversely in severe angina psychiatric disorder is secondary to the pain, restricted activity and threat to life which angina implies.