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.     

The psychological and physical status of chronic psychiatric inpatients

Our concern for the chronic patients residing in state psychiatric hospitals tals has led to the development of a variety of treatment modalities for these patients in the community and in the hospital.^1–3 Yet there is debate about effectiveness of these treatments, as well as the social, economic, and political impact of community treatment versus hospitalization.^4–6 Despite the fact that treatment strategies should be based on the actual needs of patients, there have been few large surveys of the psychological and medical needs of patients in and out of psychiatric hospitals. Most surverys in this area have assessed mortality and physical illnesses and have found that death rates among psychiatric patients are higher than those among the general population.^7,8This paper will address the needs of the living by presenting the results of a survey of a large number of patients residing in state hospitals. It will describe the frequency of mental and physical disorders, particularly those which may be life-threatening or require staff attention. In addition, it will present estimates of the amount of staff care required for the monitoring and treatment of these disorders.     

General hospital psychiatry in Italy: On the hospitalization of psychiatric patients and consultation-liaison psychiatry after Law 180, 1978

The type of psychiatric assistance carried out in Italy before Basaglia's views gained ground—that is, before 1968, when his book L'Istituzione Negata was published—is first described. The “Democratic Psychiatry” movement he launched was the mainspring of Law 180 (1978), known to have led to the closing of asylums. This law has brought about moves to create new mental health community services covering wide areas, the setting up of special diagnosis and care sections in general hospitals responsible for compulsory adminssions—and overcrowding in private clinics and University clinics within general hospitals. The role of the psychiatric ward (opposed by the supporters of “Democratic Psychiatry”) and of consultation-liaison psychiatry within the ambit of the general hospital is then discussed in the light of our experience.     

Cost comparison of psychiatric outpatient clinics based in hospitals and in primary care (general practice health center)

The first study to compare the costs of hospital-based and primary care (general practice health center)-based psychiatric outpatient clinics is reported. The operating costs of both clinic settings were estimated to be similar. There are many advantages of primary care-based clinics compared with hospital-based clinics. However, as there are no evaluative studies of the comparative efficacy of either clinic setting, before policy decisions to encourage primary care clinics are made such evaluative studies should take place.     

A study of the inpatient service of a Nigerian psychiatric hospital

Psychiatric hospitals and psychiatric units of teaching hospitals are gradually replacing the “civil asylums” in prisons, for the care of mentally ill patients in Nigeria.According to Boroffka,¹ 15 of such asylums still exist in addition to eight psychiatric hospitals and four psychiatric units situated in teaching hospitals. The phasing out of these asylums is due partly to the availability of more effective treatment for mental disorders and increasing numbers of psychiatrists in the country.Apart from Anumonye² and Jegede and Adaranijo,³ who have described the pattern of psychiatric practice in a psychiatric unit of a teaching hospital with four beds, no comprehensive information exists on the types of psychiatric patients requiring admission, either for a long- or a short-term stay and the management pattern and the relationship of such management to the underlying psychiatric illness. The present study is a preliminary report of a long-term longitudinal study, which aims at investigating both of the above problems, using the inpatients of a large psychiatric hospital.     

What should general hospital psychiatry do in a community?]

Some experiences in Nagano Red Cross hospital and Nagano Prefecture are presented, and the role of general hospital psychiatry (GHP) in a community is discussed. Psychiatric services in Nagano prefecture with population 2.21 million consist of four blocks. Our unit is in north block, providing treatment for acute phase and, in 2000, 1504 cases were new outpatients, daily outpatients were 198 cases and new inpatients were 604 cases including 146 emergency inpatients. In fiscal 2001, 25.6% of notifications of involuntary hospitalization from all psychiatric hospitals were submitted from GHP occupying 12.9% psychiatric beds, and 129 notifications from our unit were largest in Nagano prefecture. Total 7 GHPs with beds are presented by some data, suggesting two types as GHP. One type has relatively many new inpatients by small beds with short-term hospitalization like our GHP, and another type has relatively small new inpatients by large beds with long-term hospitalization like conventional mental hospital. It is necessary for GHP to pursue the former type, and to functionally differentiate from psychiatric hospital. Results of psychiatric emergency system in Nagano prefecture are presented. Designated hospitals are our GHP with 60 beds in north block, Prefectural Hospital with 310 beds in south block, National Sanatorium with 280 beds in east block and rotating 5 psychiatric hospitals with total 968 beds in west block. GHP with 60 beds hospitalized more emergency new cases than other psychiatric hospitals with large beds and discharged 84% of emergency inpatients to their home. Recently, short-term hospitalization of general hospital beds has rapidly progressed, and shared goal settings are needed, and treatment plans with teamwork by various types of experts have started from community-based home care. This teamwork will be expected throughout community psychiatric services. Although until today GHP's ward unit is financially disadvantageous, patients anticipate medical care of GHP on same level as a part of general hospital of course. For community psychiatric care and short-term hospitalization it is necessary for GHP to cooperate with various types of social resources. As for users of rehabilitation facilities in Nagano prefecture, GHP outpatients occupy 27.2%, and as for day care users, these occupy 19.6%, thus GHPs are able to cooperate with facilities. Above-mentioned facts indicate there is high necessity as a GHP, not a psychiatric hospital or a clinic. Cooperation between GHP and other social resources including welfare services will enrich community psychiatric services. GHP is a wide entrance for psychiatric care from a viewpoints of whole psychiatric care. When GHP accepted all patients on demands from acute cases to chronic, manpower will be diffused, and safety of medical care will be undermined. Therefore, psychiatric triage mainly functioning to treat early stage in severe cases with combined medical and psychiatric illness above all is necessary for GHP in order to offer proper treatment to a community. Accessibility in early stage of disease, priority of seriously ill patients and rehabilitation programs at a community as daily life space are essential for community mental health. We believe the first role of GHP in a community is to seek for psychiatric treatment on same level as general medicine. The second role is the psychiatric triage in order to function as GHP in a community. The third role is to cooperate with other social resources in a community. In order to promote the above it is necessary to self-evaluate GHP concerning the difference with specialized psychiatric hospitals or clinics. From these viewpoints GHP will become a core of community psychiatry. Currently, however, preparation concerned with GHP is poor compared with other advanced countries, so an aggressive improvement in medical policy is expected.     

Post-discharge Contact with Mental Health Clinics and Psychiatric Readmission: A 6-month Follow-up Study

Background: Continuity of mental health care is a major topic in the post deinstitutionalization era, especially concerning its possible importance as a contributing factor in preventing rehospitalization. Objectives: To examine a) the association between continuing care and time to rehospitalization; and b) the predictors of time to first outpatient contact after discharge from psychiatric hospital. Methods: Hospitalization records of all patients discharged from the Tirat Carmel psychiatric hospital in Israel, between January 1, 2006, and December 31, 2006, the National Register of Psychiatric Hospitalizations database and administrative databases of all psychiatric outpatient clinics in this catchment area were used to monitor continuing care and rehospitalization within 180 days from discharge. Predictors of time to rehospitalization and outpatient visits were examined using a Cox proportional hazards regression model. Results: Out of the 908 discharged inpatients, 29% were rehospitalized and 59% visited an outpatient clinic during the study period. Of those who visited a clinic, 22% were rehospitalized compared with 40% of those who did not visit. Not making aftercare contact with a mental health clinic during the study period and/ or having a history of more than four hospitalizations were significant predictors of earlier psychiatric readmission. Males and patients diagnosed with schizophrenia or affective disorders made contact with outpatient clinics significantly earlier. Patients who were discharged from the hospital after a daycare period contacted outpatient clinics significantly later than those who were not in daycare. Conclusions: The findings suggest that psychiatric rehospitalization is associated with discontinuity of contact with psychiatric services but not with diagnosis. Patients with schizophrenia or affective disorders were found to adhere to a greater degree to clinical aftercare, which may explain why they are not rehospitalized earlier than less severe patients.     

Psychiatric treatment in a delimited population-with particular reference to outpatients. A demographic study.

The present investigation analyses the psychiatric service available to and utilized by a population in a geogrphically delimited area, namely the Randers area with a population of 108.928. During the period 1970-74, the average yearly rate of patients admitted to the three psychiatric institutions covering this area was per 1,000: 7.9 males and 9.1 females. During 1970-71, 1.2 males and 1.8 females per 1,000 were treated as outpatients in a psychiatric clinic affiliated to a psychiatric hospital, and a psychiatric outpatient clinic in a general hospital discharged 4.1 males and 7.7 females per 1,000. It seems probable that despite outpatient treatment the number of admissions increases slightly rather than decreases, and consequently, outpatient treatment cannot replace psychiatric admission.     

Treatment prevalence in a community mental health service with special regard to depressive disorders

In the community psychiatric service in Samsø, 1.24% of the male population and 3.1% of the female population were in treatment on April 1. 1976. Approximately two-thirds of the patients had 1 or 2 referrals, the rest had 3 or more. Of the 1222 consultations, 74% were home visits. Thirty-one percent had a treatment period of less than 1 year. Only 35% of the patients in treatment had previously been hospitalized in psychiatric hospitals and 21% were in a psychiatric hospital on prevalence day.Patients with manic-depressive psychoses comprised 38% of those in treatment, giving a treatment prevalence for manic-depressive disorders of 7.7 per 1000 population.A number of the patients with manic-depressive disorders had previously been treated under the diagnoses of depressive or anxiety neuroses. It is our experience that many patients with signs of depressive neuroses are, in fact, manic-depressive and respond very well to tricyclic antidepressive drugs.When comparing the incidence for manic-depressive disorders in the Samsø clinic, the Århus county register, and Danish psychiatric hospitals we found a significantly higher incidence in Samsø with 2.38 per 1000 compared with 0.62 per 1000 for the Århus county register and 0.28 for Danish psychiatric hospitals.The purpose of the present study has been to analyze a number of conditions concerning the patients in treatment on April 1. 1976, in a community psychiatric service in a Danish geographically delimited rural population. In Denmark such one-day prevalence studies have previously been made for psychiatric hospitals.^1–4 but not in a community psychiatric service.     

Medical clinic characteristics and access to behavioral health services for persons with HIV

OBJECTIVE: Many persons with HIV do not receive needed behavioral health services. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. METHODS: This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. RESULTS: After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2-3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3-4.4, for off-site affiliated care; OR=2.1, CI=1.2-3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5-12.2, for off-site affiliated care; OR=3.2, CI=1.3-8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1-2.5). CONCLUSIONS: The organizational structure of medical clinics can have an important effect on use of mental health and substance abuse specialist care.     

Alexithymia in somatizing patients

Aexithymia is a clinical concept referring to the difficulty some people have in verbalizing their feeling states. It is prevalent in patients suffering from a variety of psychosomatic illnesses. The authors conduced a controlled study to investigate the presence of this trait among patients attending a psychosomatic clinic and those attending a traditional outpatient psychiatric clinic in a county general hospital. The results indicate that, in this lower socioeconomic population, alexithymia is equally present in both clinics. The discrepancy between these results and those previously reported are discussed, as are the ramifications of the findings.     

An epidemiologic study of deaths of psychiatric inpatients.

There have previously been several studies of deaths of psychiatric inpatients, mainly in northern European countries and the U.S.^1–10 Alström,⁶ Odegard,⁷ and Malzberg⁸ reported that the patients admitted for the first time to mental hospitals have a relative risk of death four to ten times higher than that of the general population and concluded that this was attributable to conditions specifically associated with the hospital facilities and with the hospitalized patient group.The physical conditions of mental hospitals have undergone major changes over time and so have the psychologic and social characteristics of hospitalized patient groups. As a result, factors associated with patients' deaths have also been subject to changes with this passage of time. From the epidemiologic point of view, studies of psychiatric patients who have died in mental hospitals may therefore raise interesting questions.Using two sources of information, i.e., death certificates and mental hospital discharge records, the author has investigated all psychiatric patients who have died in the mental hospitals of Kanagawa Prefecture for 3 years. These deaths have then been related to total deaths in the general population of the Prefecture in the same period.     

The liaison clinic: A model for liaison psychiatry funding,training, and research

While liaison or similar clinics have existed since at least 1931, they remain uncommon. The Mount Sinai Medical Center Liaison Clinic is presented as a model for psychiatric evaluation and care of medical patients as well as training, research, and funding. In addition, it is a model for linking general and mental health systems in the tertiary care setting. The first year of operation of the clinic is described, including the sources of referral, demographic data, psychiatric, and medical diagnoses, and type of clinic contact. A total of 96 patients were seen in 390 visits, equaling three quarters of a liaison fellow's salary.     

General hospital psychiatry: Are its roles and functions adjunctive or pivotal?

General hospital psychiatric divisions are an important part of the mental health care delivery system; however, in Canada and the United States, their role and function have not been well defined. In most places, the general hospital is peripheral to the mental hospital, and is thus an adjunctive element in the resulting two-tier mental health care delivery system. The adjunctive type of general hospital psychiatric division provides brief treatment to highly selective types of patients, and is relatively inaccessible to a wide variety of patients. In contrast, the general hospital can be central to the mental health care delivery system--in a pivotal position to patients, other mental health facilities, and community agencies. Important features of the pivotal type are: defined catchment areas, broad admitting criteria and effective discharge planning, linkages with extramural and community programs, staff reorientation, appropriate architectural features, and the ability to hear and respond to the needs of the community. The pivotal type of general hospital psychiatric division can provide appropriate levels of inpatient care, as well as the linkages and backup to extramural and community programs for the long-term mentally ill. The mental hospital would no longer be used as a backup for general clinical disorders, involuntary patients, or patients usually rejected by adjunctive hospitals. There would be collaboration with other agencies in developing programs for special clinical groups (low prevalence disorders), as well as for alcoholism, psychogeriatrics, and adolescent disorders. This article reviews the current polemic on the role and function of the general hospital psychiatric division, as part of the mental health care delivery system.     

The revolving door patient

The introduction of effective psychopharmacological treatments for psychiatric disorders in the 1950s has revolutionized psychiatry and psychiatric care.¹ Not only have they fostered the move of psychiatry back to medicine,^2–4 but they have also been instrumental in the move towards deinstitutionalization.⁵ This trend towards early discharge of patients from hospitals has developed under the banner of “community care,” and has given rise to the problem of the so-called revolving door patient. This problem has been accentuated by the failure to adequately recognize the chronic and/or relapsing nature of many psychiatric disorders, and by the failure of the community to provide adequate alternative care.^6–8 Thus, many chronic psychiatric patients now find themselves living a lonely existence in an uncaring community^9.10 or are a tremendous burden on their families.¹¹Revolving door patients make up over half of all admissions to psychiatric hospitals. A review of studies up to 1974 on the problem of recidivism found that only one variable, namely, number of previous admissions, predicted rehospitalization, and it was argued that focusing on psychopathology or diagnosis was too narrow a focus.¹² A further study in which 36 of 107 patients were readmitted found that these patients were more likely to be unemployed and tended to be single, separated, or divorced.¹³ A subsequent study found that 9%–14% of all admissions were readmissions within 1 month of discharge, and that compared with the total population admitted, these patients who were of no particular diagnosis contained a high proportion of young and divorced or separated patients.¹⁴ Another study found an inverse relationship between length of hospital stay and rate of rehospitalization across diagnosis.¹⁵The present article looks at the preceding variables in relation to readmission by comparing data on those with and without previous hospital admissions over a 10-week period, and by noting who over the following 6 months were readmitted to this hospital.     

Characteristics of patients completing referrals from an emergency department to a psychiatric outpatient clinic

Many patients referred from emergency departments for psychiatric outpatient treatment fail to make contact with the facilities to which they have been referred.^1–4 Completion rates in the range of 7.1%–63% have been typically reported.^2,3,5 While diverse explanations such as the method of referral³ and characteristics of facilities¹ have been suggested as determinants of the low completion rate, research has focused largely on demographic characteristics of the patients referred.^3,5,6 For example, patient's sex,^2,5 socioeconomic status,¹ race,⁵ and age^2,3 have been found to relate to the completion of referrals made in the emergency department.While the clinical characteristics of psychiatric emergency department patients have received some attention, studies have focused more on describing these patients^6–9 than on investigating the relationship between their characteristics and successful completion of referrals. Furthermore, studies which have attempted to relate clinical characteristics to completion rates,^2,4,10 along with those focusing on demographic characteristics, have tended to overlook the question of whether patients who failed to complete their referrals to a particular facility actually made contact with some other psychiatric facility.The purposes of the present study are (1) to investigate both the demographic and clinical characteristics of patients who successfully complete referrals from a psychiatric emergency department to a psychiatric outpatient clinic and (2) to determine by means of a thorough follow-up the characteristics of patients who failed to complete the referral but sought treatment elsewhere in the community.     

British community psychiatry and its implications for American planning

British programs in community psychiatry are mainly extended activities of mental hospitals. Their establishment has depended upon the hospital superintendent's securing the cooperation of the local health authority and the general practitioners in the area served by the hospital. Being hospital directed, these services are chiefly concerned with treatment, rehabilitation, and follow-up care of psychotic patients, and provide a striking contrast to community programs in the United States, where the focus until recently has been on the outpatient clinic offering dynamic psychotherapy to neurotic patients. Consequently British programs have much to offer the American who participates in the planning of comprehensive community mental health services.     

Attitudes, knowledge and preferences of the Israeli public regarding mental health services

We examined the public's preferences regarding the site of provision of mental health care and the basis for those preferences. A representative sample of the adult Israeli population (N = 1,583) was interviewed by telephone about their knowledge and attitudes. Self-referral to mental health professionals and primary medical doctors for milder disorders was low. Psychiatric clinics were preferred by 46% of the public; 35% preferred the general clinics, and the remaining 19% were indifferent. Quality of care was noted by 78% of respondents for their preference for psychiatric clinics. General hospitals were preferred for psychiatric inpatient care by 51% of the respondents compared to 23% who opted for psychiatric hospitals. Despite reasonable familiarity with mental health care, one-third of the respondents did not know whether there was a clinic in their neighborhood. Implications for action are discussed in light of the transfer of responsibility for psychiatric care from the Ministry of Health to the health maintenance organizations     

Development of Community Care for People with Schizophrenia in Chile

Chile has greatly reformed its approach to psychiatric care in the last two decades, having transitioned from a model centered around a psychiatric hospital to one in which mental health care is based in the community. During this period, patients were moved from large psychiatric hospitals into ambulatory clinics, and the number of people who were in hospitals for extended periods decreased. At the same time, mental health service networks—consisting of ambulatory clinics, day hospitals, rehabilitation centers, and community group homes—were created, each responsible for a specific population. The reform process, however, has occurred in different, unequal degrees throughout the country. The purpose of this investigation is to compare the characteristics, resources, and results of the mental health service networks that have successfully transitioned to and developed in the community with respect to those that are still centered in a hospital. The structural aspects were evaluated with the EvaRedCom-TMS (Evaluación de Redes de Servicios Comunitarios para Trastornos Mentales Severos), and the level of functioning was measured with World Health Organization's International Classification of Mental Health Care. Area networks with higher levels of community-based services show better indicators of geographic and financial accessibility, use less human resources (particularly psychiatrists and nursing assistants), have an equal level of specialization, and yet show better treatment adherence among the patients (84.2 percent versus 41.8 percent), despite the fact that the patients have worse socioeconomic and clinical indicators than area networks with lower levels of community-based services. In conclusion, the community-based psychiatric care model is more effective than the hospital-centered model.     

Death in aftercare

Modern studies on the mortality risk of persons with psychiatric illness have viewed the problem from a variety of different perspectives. Shinozaki¹ found the death rate among inpatients in a group of Japanese mental hospitals to be seven times the death rate of the general population. Other studies have identified persons at the time of hospital admission or discharge and presented mortality data on follow-up. Affleck et al.² after 12 years, found an average annual mortality more than three times greater than the general population for schizophrenic women. Zitrin et al.³ noted a death rate double the expected rate among 867 persons discharged from the psychiatric unit of New York's Bellevue Hospital and followed-up at 2 years. Tsuang and Woolson⁴ report increased mortality risk after four decades of follow-up in Iowa. The mortality risk varied with decade of follow-up, sex, and diagnosis but was highest for schizophrenics in the first decade of follow-up.Mortality rates among mixed groups of inpatients and outpatients are also reported. Babigian and Odoroff⁵ found the relative risk of death for persons seeking psychiatric care in Monroe County, New York to be 2.5 to 3 times greater than that of the general population. Innes and Miller⁶ found an overall death rate twice the expected rate for a group of inpatients and outpatients at 5-year follow-up in Scotland. Rorsman⁷ noted a death rate approximately 1.6 times the expected rate for a group of mainly nonpsychotic inpatients and outpatients in Sweden.Two studies, Sims⁸ and Keehn et al.⁹ report excess mortality among patients with exclusively nonpsychotic diagnoses. A single known study, Claghorn and Kinross-Wright¹⁰ found no increased mortality among a group of psychiatric patients followed-up for years.