A psychiatrist's experience in a primary health care setting.

Psychiatrists have, for years, offered consultation to their nonpsychiatrist colleagues in many settings and have worked with them in a variety of ways. The development of new programs in primary medical care offers new challenges and opportunities to the liaison psychiatrist. This paper describes the experience of a full-time psychiatrist in a hospital-based primary health care setting. Special problems are encountered in developing working relationships with patients, physicians, nurses, social workers, administrators, and other members of the health care team. Effective resolution of these problems makes it possible to offer comprehensive mental health services as an integral part of primary health care. This psychiatrist's role differs from other consultation-liaison functions by virtue of full-time economic, patient care, academic, geographic and administrative assimilation into the primary health care setting itself. It is suggested that this role is an effective way to bring supportive and educational psychiatric services to patients and providers of all levels of sophistication and need.     

Concordance with recommendations in a consultation-liaison psychiatry service

We studied the concordance of physicians with the recommendations of psychiatric consultants in a sample of 270 consultations in a 400-bed general hospital. Of the patients about whom a consultation was sought, 37% had a past psychiatric history, and 67% were on psychotropic drugs. Twelve percent had Organic Mental Disorder, 35% Affective Disorder, and for 24% no DSM-III diagnosis could be made. The psychiatrist made psychotropic drug recommendations in 62%, and the physicians' concordance with this recommendation was 86%. The physician's discharge summary included a diagnosis which concorded with the psychiatrist's diagnosis in 53% of files. The psychiatrist recommended further investigations in only 5.2% of files.     

Attitudes of general hospital emergency room personnel towards attempted suicide patients

The aim of this study was to compare the attitudes of emergency room staff towards patients who have attempted suicide between two general hospitals, one with psychiatric consultation available and the other without. The Understanding Suicidal Patients (USP) Questionnaire was given to all staff in the emergency rooms of Jorvi Hospital (in the city of Espoo, with routine psychiatric consultation) and Malmi Hospital (in the city of Helsinki, without routine psychiatric consultation) (n=115). There were clear differences in staff attitudes between the hospitals. Female gender, older age and working in Malmi Hospital without routine psychiatric consultation were associated with more positive attitudes towards attempted suicide patients. Surprisingly, only working in Jorvi Hospital was associated with more negative attitudes. Differences in attitudes towards suicide attempters between personnel working in the different hospitals were found. Further investigation is needed to find the ideal psychiatric consultation arrangement for suicide attempters in good cooperation with emergency room staff.     

Pain in the neck, face, and head. Role of the consultation-liaison psychiatrist

The special nature of pain in the face, head, and neck is not emphasized in the psychiatric literature on chronic pain. Although chronic pain of all types and locations share many features the psychological and symbolic significance of the head in the development of self-esteem, body image, and interpersonal relationships often confers special characteristics of pain on this area. As psychiatric consultation is not likely to be requested for patients with head, face, and neck pain in the absence of blatant "psychiatric" problems, it behooves the psychiatrist to exercise his liaison functions to enhance patient care in the inpatient setting and to help physicians recognize the utility of early psychiatric assessment on an outpatient basis with patients not yet requiring hospitalization. A collegial relationship with internists, dentists, neurologists, and surgeons facilitates the psychiatrist's role as a "team participant," often more effective in providing brief diagnostic, therapeutic, and management recommendations for patients who are usually not psychologically-minded and reluctant to pursue ongoing psychiatric treatment. However, the consultation-liaison psychiatrist can play an important role in expanding his colleagues' awareness of the multiple meanings of pain and the accompanying illness behavior, provide pedagogic help in the interviewing or history-taking process, offer suggestions about psychopharmacologic and other drug treatment, and serve as a resource for appropriate referral to sources of a variety of chronic pain treatments, including biofeedback, acupuncture, and family consultation. To fulfill both his consultative and liaison functions, it is incumbent upon the psychiatrist to be knowledgeable as well about nonpsychiatric aspects of pain of the head, face, and neck. We must acknowledge also how much we yet do not know: for example, why the psyche "chooses" a locus of pain in the body; how an external (or internal) stimulus is converted via cognitive, neuroendocrine, enzymatic, and other pathways to a somatic representation; the biochemistry of pain reduction by naturally occurring and synthetic drugs; and what characteristics distinguish the continuously creative individual who sustains persistent pain with barely an utterance from another who may "cave in" to seemingly trivial distress that results in total invalidism.     

Psychiatric disorders and the need for mental health services among a sample of orthopedic inpatients.

This report concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed.It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.^1–6 Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19%–86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.^3,7,8 Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified.In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.^2,4,9–12 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients.     

Pediatric referrals to psychiatry: III. Is the psychiatrist's opinion heard?

At least one psychiatric diagnosis was made for 205 of 220 children whose psychiatric evaluation had been requested by the medical service. Only 78 of 242 psychiatric diagnoses given the 205 patients were reflected correctly in the medical discharge diagnoses. In addition, seven of fifteen patients considered to be "normal" by the consulting psychiatrist had a psychiatric or mixed medical-psychiatric diagnoses included in the discharge diagnoses. Psychophysiological disorders, psychoses and special symptom diagnoses were likely to be correctly reflected in the discharge diagnoses, while depression and adjustment reaction were not. Possible reasons why the psychiatrist's diagnostic opinion is not correctly reflected in the discharge diagnosis in over one-half of the referrals are discussed. Pediatricians may be reluctant to label their patients "neurotic" for life, or may consider the problem transient-that is, only a "passing phase". But these theories are discounted by the fact that seven patients considered to be emotionally normal when assessed by the psychiatrist were discharged with a psychiatric or mixed medical-psychiatric diagnosis.     

A Descriptive Study of Psychiatric Consultations in a Community Primary Care Center

BACKGROUND: This retrospective chart review study describes on-site psychiatric consultations at a large, urban community primary care center. The referral population, diagnostic reliability of primary care providers (PCPs) and social workers, appropriateness of PCP-initiated treatment, impact of treatment recommendations, and outcomes are examined. METHOD: Charts of all patients who received psychiatric consultations (N = 78) during an 8-month period (August 1996 to April 1997) were reviewed. RESULTS: Prereferral diagnoses by PCPs matched the psychiatrist's diagnosis based on DSM-IV diagnostic criteria approximately half the time. PCPs initiated psychopharmacology in half the referrals (39/78) and used generally appropriate medications (30/39) based on diagnosis by a psychiatrist, but at subtherapeutic doses (21/39). PCPs tended to continue medications recommended by the psychiatrist. At 1 year, PCPs clearly documented improvement in nearly a third of the consults (24/78). CONCLUSION: Diagnostic disagreement of caregivers, inadequate PCP psychopharmacology practices, and patient nonadherence are 3 main problems that impede optimal care within the model of psychiatric consultation described in this study.     

Psychiatric liaison with private facilities caring for discharged patients.

Motivated by concern about the fate of psychiatric hospital patients after discharge to the community, a community mental health center decided to send a psychiatrist into the community to establish liaison with private-care facilities and to determine the needs of such discharged patients. As a result of the psychiatrist's efforts, owners of the area's private-care facilities acquired a better understanding of the needs of their residents and learned where they could turn for help in caring for discharge psychiatric patients. A study of one board-and-care facility revealed a marked decrease in the use of the center's emergency service and in the number of hospital admissions after one year of this extended service.     

Psychiatric aspects of organ transplantation

Technical advances in surgery and the new antirejection agents cyclosporine and muromonab-CD3 have led to improved outcome for organ transplantation. Allograft rejection and complications of immunosuppressant therapy are often associated with considerable stress, so availability of psychiatric consultation is a necessity. As a transplant team consultant, the psychiatrist treats perioperative anxiety, depression, and organic brain dysfunction and addresses medical and ethical aspects of patient selection. Studies indicate that many patients with psychopathological conditions have good postoperative results and that most living kidney donors participate spontaneously and consider donation a positive experience.     

Cutaneous manifestations of psychiatric disease that commonly present to the dermatologist--diagnosis and treatment.

Patients whose psychopathology is expressed in cutaneous lesions often consult a dermatologist rather than a psychiatrist. Dermatologists may not be interested in working with these difficult patients. The need for liaison dermatology is becoming more widely recognized. This article discusses the place of psychiatric consultation in the dermatology setting, and describes the common dermatologic presentations of psychopathology: cutaneous delusions, obsessive-compulsive symptoms, expressions of depression, and dermatitis-artefacta. Diagnostic criteria for these conditions are outlined and a treatment approach, within the competence of the interested dermatologist, is offered.     

Length of hospital stay of medical and surgical inpatients referred for psychiatric consultation: a retrospective study

Retrospective analysis of 406 consecutive psychiatric consultations with general hospital inpatients revealed that their mean length of stay (LOS) was 26.1 days, while the mean LOS of the other hospital patients was only 11.1 days. In 36.5 percent of the consultation patients the LOS in hospital was longer than that exceeded by 10 percent of the hospital patients. The factor most strongly related to a very long LOS of psychiatric consultation patients appeared to be the referring ward. Particularly on cancer wards very long LOS patients were referred to the psychiatrist. The psychiatric consultant often supported the ward staff by making recommendations for the management of such patients. Patients with a long LOS might be a suitable group for carrying out a controlled cost-effectiveness study of psychiatric consultations in a natural setting.     

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.     

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.     

The traumatized child at the emergency department

The emergency department child and adolescent psychiatrist is in the unique position of informing and helping emergency department providers address the traumatic impact of the cause of a child's emergency presentation and the potential iatrogenic exacerbation of the acute traumatic response. The child and adolescent psychiatrist must become a clinical traumatologist who provides the necessary consultation and education that lead to practice change in emergency department awareness and procedures and performs the optimal evaluation and interventions for children who present in psychiatric crisis.     

Interdisziplinäre Station für psychisch Kranke mit erheblichen somatischen Komorbiditäten

In this article we describe in detail a specialised facility geared toward caring for patients presenting with major psychiatric and somatic comorbidity. Located in a psychiatric hospital, an important feature of the treatment offered in this unit is that psychiatric/psychotherapeutic and somatic care are provided by the same team members. Working in this unit places high demands on the medical team, which must be competent in both fields, especially during emergency situations. Due to the severity of the patients' symptomatology, the unit requires more staff than regular psychiatric wards. Frequent psychiatric diagnoses necessitating the transfer of patients to this ward include delirium associated with internal/neurologic disorders or occurring postoperatively, and affective syndromes and dementia due to general medical conditions. Somatic disorders frequently requiring treatment in this ward include acute cardiovascular syndromes, liver or renal failure, infections, and conditions arising postoperatively or following trauma.     

A self-assessment program for multidisciplinary mental health teams

OBJECTIVE: The authors describe a self-assessment training program for multidisciplinary mental health teams that was developed in a public multihospital system, the process of implementing the training at a state psychiatric hospital, and a measurement instrument, the Scale for Leadership Assessment and Team Evaluation (SLATE), which they have used for self-assessment of multidisciplinary teams and which is currently being studied. They assessed whether changes in team self-assessments could be seen after the training program. METHODS: A total of 102 mental health professionals from 12 inpatient units representing the disciplines of psychiatry, psychology, nursing, social work, and occupational and activity therapy completed the SLATE before and after participation in a training program that consisted primarily of team self-assessment in the context of treatment planning sessions. The training program included structured feedback, didactics, consultation, and videotaping of sessions. Aggregate data were used to compare mean item scores for the SLATE overall and for its four subscales (team, psychiatrist, participation, and treatment plan) at baseline and after the training. RESULTS: Scores increased significantly for the overall SLATE and for all four subscales, indicating improved team functioning in the areas addressed. The increase in mean score was greatest for the subscale that assessed the leadership of the psychiatrist. CONCLUSIONS: Treatment planning sessions can be used successfully by multidisciplinary mental health teams to examine team functioning in various areas in a self-assessment model. Participation in a training program that included videotaping of sessions, consultation, and structured attention to team functioning was associated with improved ratings of team functioning.     

The role of the psychiatrist in organ transplantation

The psychiatrist has multiple roles on the transplant team, beginning with the transplantation psychiatry consultation (TPC). It addresses such issues as risks of exacerbation or recurrence of a psychiatric illness, pharmacokinetic and pharmacodynamic considerations due to organ failure, potential drug interactions involving psychotropic and immunosuppressant medications, adequacy of support system, history of medical compliance, emotional and cognitive preparedness for transplantation, mental status findings supplemented by standardized cognitive testing and psychosocial rating instruments, and decision-making capacity. The consultation concludes with an overall assessment of the patient's psychosocial strengths and limitations, and recommended interventions to optimize his or her candidacy for transplantation. The consultation findings aid the psychiatrist and the transplant team in striving for fairness and the ideal of "neutrality" in an effort to serve the needs of the patient, other transplant candidates, and society with regard to optimal organ stewardship.     

Relationships between patient, family, and significant other disposition preferences in psychiatric emergency services and the clinical symptom ratings and disposition decisions of psychiatrists

A previous paper examined the relationship between 10 clinical ratings made by psychiatrists and 465 psychiatric emergency service (PES) dispositions. A logistic regression model explained 52% of the variance in the psychiatrist's decisions to admit to inpatient services or release. The 5 clinical ratings in the model, rated on 8-point scales, were severity of danger to self, psychosis, inability to care for self, impulse control, and depression. The current paper examines the relationships between patient and family/significant other dispositional preferences expressed in the PES, and the psychiatrist's disposition decision and the 10 clinical ratings. It found that the dispositional preferences of the patient, family, and other individuals (community clinician, police, or ambulance driver) were very consistent with the actual decision made by the PES psychiatrist. Further, it found that these preferences explained an additional 35% of the variability in the psychiatrist's decision to admit or release. Finally, the ten clinical ratings made by the PES psychiatrist explained only a small amount of the variance in the dispositional preferences, and some of the significant coefficients were in the opposite direction expected. Patient, family and other significant individuals' expressed preferences and expectations in the PES are important and should be routinely recorded in the charts. The small relationships between clinical ratings and preferences suggests that the reasons the family/significant other and the patient seeks hospital admission or release may differ with psychiatrists' reasons for disposition.     

Isolating the impact of psychiatric consultations in the general hospital: psychiatric comorbidities and nursing intensity

The amount of nursing services represents a substantial portion of the total cost of hospital treatment of medical/surgical patients. Patients receiving psychiatric consultations were compared to matched patients (DRG and LOS) who did not receive psychiatric services on the intensity of their nursing service needs. These two groups were then compared on the measure of nursing intensity before and after the timing of the consultation. Those who received a consultation had significantly lower intensity scores prior to seeing the psychiatrist. Although patients receiving psychiatric consultations did not show a significantly greater reduction in nursing acuity relative to their baseline levels than did the matched control patients, the amount of time the psychiatrist spent with consultation patients was positively related with the change in nursing intensity post-consultation.