Liaison And Consultation Psychiatry Research Paper

1. Psychiatric Comorbidity In Physically Ill Patients

The need for c-l psychiatric services stems from the high comorbidity of psychiatric illnesses in patients suffering from physical diseases.

1.1 Psychiatric Comorbidity In The General Hospital

It is estimated that between 30 and 50 percent of physically ill patients in general hospitals show comorbid psychiatric disorders, especially organic psychoses (ICD-10 F0), psychological and behavioral disturbances due to psychotropic substances (ICD-10 F1), and acute stress reactions (ICD-10 F4), with percentages of these diagnoses ranging as high as 16 percent, 8 percent and 10 percent in medical, and 17 percent, 8 percent and 13 percent in surgical patients, respectively (Arolt 1997). Special patient populations—such as those in organ transplantation programs, intensive care units, or oncological patients- —show an even higher psychiatric comorbidity. The presence of psychiatric comorbidity does not always call for psychological treatment at the same time as the underlying or concomitant physical disease is being treated by physicians or surgeons. Neverthless, conservative estimates point to a figure of some 10 percent of general hospital inpatients who should receive psychiatric care alongside somatic care.

While the evaluation of patients committed to Accident and Emergency Departments after attempting to harm themselves is an important task for psychiatrists, and will often be performed by c-l services, their care is only one part of a larger picture of care for patients suffering from medical and psychiatric comorbidity, with the latter impacting negatively on course and outcome of the former. A prerequisite for psychiatric services to achieve an impact on this group of patients is the integration of psychiatry into general hospitals. Thus, in the USA, where the foundation of psychiatric departments as integrated parts of general hospitals started as early as the 1920s, c-l psychiatry has a long tradition, whereas in the Federal Republic of Germany, for instance, where state mental hospitals have given way to general hospital psychiatric departments only since the end of the 1970s, c-l psychiatry started to gain shape only toward the end of the twentieth century. Overall, international interest in c-l psychiatry increased outside the USA during the 1980s and 1990s with special emphasis in the UK, the Netherlands, Australia and New Zealand, where c-l psychiatric sections exist within national psychiatric organizations. The history of c-l psychiatry shows that the acceptance of psychiatric care for patients with medical–psychiatric comorbidity is dependent largely on the regular availability of psychiatrists in general hospitals, which provides the opportunity to demonstrate the added value of psychiatric diagnosis and treatment to other medical disciplines in the care of comorbid patients.

1.2 Psychiatric Comorbidity In The Primary Care Sector

While c-l psychiatry developed primarily in the general hospital setting, there was growing emphasis worldwide on diagnosis and treatment of psychiatric comorbidity of patients in the primary care sector toward the end of the twentieth century. Results from the National Institute of Mental Health Epidemiological Catchment Area Program show that about 16 percent of the community-dwelling adult population fulfil criteria for at least one psychiatric disorder. This figure increases to at least 21–26 percent of primary care patients. Studies show that most cases of adjustment disorders and about three-quarters of depressive disorders are treated in primary care. In most cases, these patients present with physical symptoms that are not caused by physical disease. The proportion of undetected and untreated psychiatric (co-)morbidity in this patient group is high (APM 1997).

1.3 Psychiatric Morbidity In Nursing Homes

The percentage of the population older than 65 years of age is increasing. It is estimated that 20–50 percent of these people will eventually live in nursing homes. In the USA, it is estimated that the total number of nursing home residents will exceed 4 million by the year 2040. The very high prevalence of psychiatric-related illness among those in nursing homes is documented in a number of studies, showing that up to 70 percent of nursing home residents may meet diagnostic criteria for dementia, and 90 percent may have at least one form of behavioral disturbance, such as agitation, delusions, or depression. Depression is largely undetected and undertreated in this population, despite the fact that the majority of cases treated, e.g., with antidepressants, will recover from a depressive episode. Only recently, there has been growing awareness that people with mental retardation (or learning disability) show a significantly higher percentage of psychiatric comorbidity than the average population. While attempts are made to achieve a close to normal living situation for a large part of this clientele, people with severe mental retardation—which is often complicated not only by psychiatric comorbidity but also by other physical diseases such as epilepsy—will receive adequate care only in nursing home settings (Reichman and Katz 1996).

In sum, there has been increasing awareness of hidden mental comorbidity in the general hospital, primary care and nursing home sectors, and of the need for specialist psychiatric treatment in a significant percentage of patients.

1.4 Effects Of Psychiatric Comorbidity In Physically Ill Patients

Studies show a significant association between psychiatric comorbidity and more complicated illness courses, both for patients in the primary care sector, and for general hospital inpatients. Patients with somatization disorder use nine times the healthcare services of the general population, panic disorder patients have 10 times the number of visits to hospital emergency rooms than nonanxious patients, and 70 percent will see more than 10 physicians before an accurate diagnosis is made. Medically ill patients with depression have a poorer prognosis than nondepressed patients with equal somatic comorbidity. For example, postmyocardial infarction patients with depression are at significantly greater risk of death over a period of 6 months following the infarction, and depressed stroke patients show poorer results in rehabilitation programs with more persistent disability than nondepressed stroke patients. It has been shown that a small percentage of patients are responsible for the use of a major portion of healthcare, with, for example, 10 percent of patients of a large health maintenance organization in the USA consuming approximately one-third of all primary care visits, 52 percent of all speciality visits, and 40 percent of inhospital days. Fifty percent of those high utilizers of healthcare showed some form of psychiatric comorbidity, e.g., 20.2 percent somatization disorder, 33.6 percent generalized anxiety disorder or panic disorder, and 40 percent major depression or dysthymia (APM 1997).

In general hospital inpatients it has been shown that medically ill patients with psychiatric comorbidity show longer lengths of stay in hospitals, more frequent re-admissions, and an overall increase in costs for treatment as compared to patients without psychiatric comorbidity. Adjustment for other factors associated with longer length of stay and rehospitalizations, such as severity of underlying medical disease, did not reduce the significance of the negative impact exerted by psychiatric comorbidity (APM 1997). The elderly are exposed to special risks, with about 10 percent of elderly patients admitted to a general hospital suffering from delirium. About 30 percent of elderly medical inpatients have dementia, which makes more complex management necessary, with problems arising from, for example, diminished compliance with medication, and in following through with rehabilitation programs.

2. The Practice Of Consultation And Liaison Psychiatry

The scope of c-l psychiatric services spans primary and hospital care settings, the care of elderly residents in nursing homes, and of clients with learning disability and accompanying psychiatric disorders.

2.1 C-L Psychiatric Services In The General Hospital

Despite the high percentage of psychiatric comorbidity in the general hospital, referrals to psychiatric c-l services amount at most to only a small number of physically ill inpatients, approaching an average number of 1 percent of general hospital inpatients worldwide. Usually, the majority of patients are referred by internal medicine departments, with a large percentage being older than 65 years of age. Despite all differences in service delivery that are due to local necessities in the provision of care for given populations, c-l psychiatrists most often diagnose delirious states and other disorders of cognition, followed by depressive syndromes and adjustment disorders, fitting well to the above mentioned prevalence figures of psychiatric comorbidity in general hospital patients. In contrast, despite their obvious frequency, patients with alcoholuse disorders are referred much less by their treating physicians. The low rate of referrals to psychiatric c-l services has led to the assumption that nonpsychiatric physicians do not recognize psychiatric disorders sufficiently, or, if they do, do not think of psychiatric interventions as being helpful to their patients. Liaison psychiatry proper takes its vantage point from this discrepancy: other than the usual psychiatric consultation with its mainly emergency psychiatric character that by default is only able to care for the tip of the iceberg of psychiatric comorbidity, i.e., patients having passed the filter of recognition of a nonpsychiatric physician. Liaison psychiatric approaches aim at the denominator (Strain 1999) of psychiatric comorbidity, triggering specialist psychiatric care, e.g., by screening patients on hospital admission, or identifying problem behavior in joint rounds with nonpsychiatric physicians, or by educating the latter in how to better identify patients that might profit from referral to specialist psychiatric care. Thus, liaison psychiatric approaches try to go well beyond the ‘firefighter function’ of typical psychiatric consultation, aiming at changing referral patterns of nonpsychiatric departments, e.g., enabling physicians to deal with and/or prevent the development of delirious states, or increase referral rates of depressed patients or patients with alcohol-use disorders by demonstrating the efficacy of even time-limited psychiatric interventions (Guthrie and Creed 1996).

Both in consultation, and to a somewhat lesser extent in liaison psychiatric approaches, psychiatrists have to be aware of the stages a psychiatric consultation will typically go through. In the initial phase, and due to uncertainty about how to deal with a patient the consultant’s referral diagnosis might be rather imprecise. In such cases it must be the task of the c-l psychiatrist to help in working out what is in fact the problem. The ensuing intervention must then be, other than in a typical psychiatric office situation, directed not only toward the patients, but also take into consideration the whole system, including the ward doctor, nurses, and relatives. Otherwise, c-l psychiatric interventions, when performed in isolation and/or out of context, might be unsuccessful (Diefenbacher 2000).

2.2 C-L Psychiatric Services In Primary Care And In Nursing Homes

Along with the growing interest in psychiatric (co)morbidity in primary care patients and nursing home residents, international c-l psychiatry shows a remarkable shift from the general hospital setting to collaborative care practices in the primary care setting, and, though still in its beginnings, to liaison psychiatric services with nursing home populations. For primary care settings, studies show that inclusion of a psychiatrist in primary care treatment teams, e.g., on the basis of regularly performed visits of a psychiatrist, leads to a marked improvement in the symptoms of patients with somatization disorder or depression than provision of services by primary care physicians alone (APM 1997). For nursing home populations, the need to consider psychopharmacological as well as nonbiological interventions such as talking therapies, recreational therapies, and so on, in combined treatment plans tailored to specific residents and specific nursing home settings, stress the need for psychiatrists to oversee the implementation of such integrated approaches. Hence, liaison models with more intense involvement of psychiatrists working with other nonpsychiatric physicians, as well as administrative and nursing staff in addition to care for residents and their relatives will be developed in the near future. The latter holds especially true for people with mental retardation (or learning disability) living in nursing homes, as diagnostic and treatment approaches in this clientele will require special expertise not necessarily familiar to primary care physicians, or even psychiatrists themselves. Especially in patients that are not able to communicate verbally, ‘cooperative’ and ‘uncooperative’ behavior may reflect an underlying psychiatric disorder, which in turn may be treatable, as in the case of hostile behavior in demented patients with dysphoric depression that may well respond to pharmacological treatment with, for example, selective serotonin reuptake inhibitors. C-l psychiatrists working in such settings are ideally placed to teach nursing staff and primary care physicians that expert assessment of behavioral and psychological symptoms in nonverbal patients may lead to more specific management and better patient care. Thus a patient with dementia whose delusional experiences lead to bizarre behavior should be treated differently from a demented patient who suffers from pain, or a depressed nonverbal patient who refuses aggressively to accept food (Reichman and Katz 1996).

Despite the increasing interest in models of collaborative care in the outpatient, as well as nursing home sectors, it has to be borne in mind, that, at least at this point in time, many patients with somatopsychic comorbidity are seen for the first time by a psychiatric specialist after having been admitted to a general hospital. Thus, psychiatrists as well as planners of health services will have to bear in mind the importance of the general hospital as a pathway to specialist psychiatric care.

2.3 Evaluation Of C-L Psychiatric Interventions

Psychiatric care leads to improved management of medically ill patients with psychiatric comorbidity. This is the rationale of the practice of c-l psychiatry, whose benefits can be demonstrated within a value matrix, taking into account treatment outcomes in medically ill patients with psychiatric comorbidity, as well as economic savings by adding specialist psychiatric treatment to standard medical treatment. Cost–benefit issues of consultation psychiatry service delivery have been demonstrated initially in general hospital inpatients, with primarily US studies showing a trend to reduced length of hospital stay with corresponding reductions in cost of treatment in medical patients after a psychiatric liaison service was inaugurated, compared with control groups without such an intervention program (APM 1997). However, as other studies failed to show such an effect, the overall conclusion was that this research approach had to be judged as inconclusive in the face of a sharp decrease in lengths of hospital stays worldwide due to secular trends in shifting the provision of healthcare into the outpatient sector in order to reduce the escalation of overall healthcare costs. Consequently, research on the efficacy of psychiatric intervention strategies in patients with psychiatric (co-)morbidity in the primary care sector has increased. Studies showed that integrated c-l psychiatric approaches, but not those that only offered screening strategies to identify patients with psychiatric disorders, has led to improved outcomes in patient care (Katon and Gonzales 1994). In the inpatient setting, models of integrated medical and psychiatric care also are being proposed.

3. Future Developments In C-L Psychiatry

Future developments will see an increased emphasis on the education of psychiatrists in collaborating with primary care practitioners in the treatment of medically and psychiatrically ill patients, the development of models of integrated care, and the need to develop and implement guidelines and standards of care in quality assurance programs.

3.1 Education

The education of physicians working at the interface of medical–surgical and psychiatric medicine has to be twofold. Psychiatrists have to learn how to treat medically ill patients with psychiatric comorbidity. Psychiatric training cannot remain restricted to gaining experience predominantly with patients with schizophrenia or manic-depressive illness, but has to take into account the needs of patients suffering from medical illnesses and comorbid psychiatric illness, for example, depressive patients suffering from cardiac disease or stroke, who require somatic as well as psychological treatment. To achieve this goal, c-l psychiatric curricula are being developed within specialist psychiatric training, e.g., in Europe and the USA. Psychiatrists will have to become proficient in mastering diagnostic and treatment problems arising from somatopsychic comorbidity, e.g., address problems of diagnosing depressive disorders in the medically ill, and adjusting psychological as well as psychopharmacological treatment issues for patients suffering form both medical and psychiatric disorders.

On the other hand, c-l psychiatrists will have to expand the education of primary care physicians, in order to broaden nonpsychiatric doctors’ knowledge of and experience in diagnosis, referral, and treatment of patients with psychiatric (co-)morbidity, in order to improve the care of patients with somatopsychic disorders in primary and hospital care settings. Psychiatrists, as well as nonpsychiatric physicians, will have to adopt behavioral medicine treatment strategies for patients with for example, somatization disorders and chronic pain syndromes, and will have to learn treatment strategies other than psychotropic drug prescribing, strategies such as cognitive behavioral treatment for patients with adjustment disorders, anxiety disorders, and the milder depressive disorders (so-called subthreshold disorders), as these disorders make up the bulk of psychiatric comorbidity treated in the primary care sector.

3.2 Guidelines And Quality Assurance

As the awareness for an improved psychological care of medical and surgical patients increased toward the end of the twentieth century, one step has been the development of guidelines in order to define standards of care. In the UK, conjoint working parties of physicians, surgeons and psychiatrists (Royal Colleges of Physicians, and Psychiatrists 1995, Royal Colleges of Surgeons and Physicians 1997) published documents with practical suggestions regarding methods of identifying potentially harmful psychological components of patients’ illnesses, and recommendations for the provision of care as well as for referral for psychiatric help when appropriate. As only a minority of patients will need psychiatric care in addition to medical- –surgical treatment, these guidelines underline that normally physicians and surgeons should be able to make some assessment of psychological factors. The guidelines propose simple screening mechanisms in order to improve detection of psychological disorders in the general hospital, for example, the CAGE Questionnaire for screening for alcohol misuse. Overall, the implementation of guidelines is thought to help in a number of areas, such as in reducing the number of investigations performed for physical symptoms that result from underlying stress, as, for example, in patients with somatization; help in relieving symptoms of stress and improving the quality of life of patients with serious physical illness; and, from an economic perspective, reducing the length of stay in hospital caused by psychiatric comorbidity.

It is assumed that the implementation of guidelines within quality assurance programs will lead eventually to improved patient care. However, measures against which to gauge c-l psychiatric interventions have yet to be established. Given the low referral rate for psychiatric consultation as compared with the high prevalence of medical–psychiatric comorbidity, and the need for specific psychiatric treatment in general hospital inpatients, as a first step to improving care, the C-l Psychiatric Section of the Royal Australian and New Zealand College of Psychiatrists proposes to define the benchmark for psychiatric referrals to be 5 percent of all admissions to medical–surgical wards of a general hospital. If this percentage is not reached, an audit should be performed to establish whether there are identifiable reasons for not providing psychiatric support in an adequate number of patients in medical–surgical departments of a given general hospital.

3.3 Research In C-L Psychiatry

Basic requirement for research in c-l psychiatry is the identification of high-risk patient groups, such as those suffering from a significant amount of psychiatric comorbidity. Failure to identify such high-risk groups, along with the overstated assumption that just one psychiatric consultation might lead to improved patient outcomes may have been the basis of the ambiguous results of general hospital inpatient intervention studies performed in the USA in the 1980s. C-l research in the primary care setting, on the other hand, has demonstrated that restriction to a high-risk group with identifiable psychiatric comorbidity, e.g., high utilizers in primary care suffering from a psychiatric disorder, such as somatoform disorder, may that demonstrate a psychiatric intervention can lead to improved patient outcomes, if the intervention is intense enough, i.e., consisting of an eight-session block of group therapy (Katon and Gonzales 1994).

Problems that need to be solved in order to improve care of patients with medical–psychiatric comorbidity are:

(a) To develop a more precise description of the phenomenology of psychiatric illnesses comorbid with particular physical illnesses, e.g., as in the case of the diagnosis of depression in cancer or stroke patients (Guthrie and Creed 1996).

(b) To study the natural course of psychiatric comorbidity in relation to an underlying or concomitant physical disease, e.g., in which patients suffer from a depression not expected to be resolved spontaneously once the physical disease has been treated successfully.

(c) To further study efficacy and effectiveness of psychotherapeutic and psychopharmacological treatment strategies in patients with medical comorbidity. Meta-analyses point out that antidepressants are as effective in depressive patients with medical comorbidity as in those without (Gill and Hatcher 1999).

The effectiveness of different models of care for patients with medical–psychiatric comorbidity with regard to different outcome measures such as clinical improvement, quality of life, or cost effectiveness, will require further investigation, especially in inpatient settings for different patient populations, e.g., acute vs. chronic care patients, with regard to differential effects of more traditional consultation or liaison approaches vs. models of integrated medical–psychiatric care.

3.4 Integrated Medical And Psychiatric Services

A model for integrated medical and psychiatric treatment programs within the general hospital are so-called medical–psychiatric units. Such units received increasing interest in the USA during the 1990s. Medical–psychiatric units are run jointly by physicians, mainly internists, and psychiatrists. They care for high-risk patients, for example, delirious patients who cannot be managed on a medical ward, or suicidal patients in need of acute medical treatment that cannot be provided on a psychiatric ward. It seems possible that such conjoint models of care in the inpatient setting lead to improved patient outcome while saving costs, as compared with traditional models of sequential care with referrals from psychiatric to medical departments and vice versa (Rundell and Wise 1996). They may be the new wave of the future in a changing health care environment that will be looking for more effective ways of treatment beyond the boundaries of traditional departmental structures of general hospitals.

4. Epilogue

Readers interested in widening their knowledge of the topics dealt with in this research paper are referred to the Consultation-Liaison Psychiatry Database, compiled and in part commented upon, by international experts in c-l psychiatry, which contains approximately 2,500 citations of articles, book chapters, and books delineating the state of the art in the field (Strain 1999).

Bibliography:

1. APM (Academy of Psychosomatic Medicine) 1997 Mental Disorders in General Medical Practice: Adding Value to Healthcare through Consultation-Liaison Psychiatry. Kendall Hunt, Dubuque, IA
2. Arolt V 1997 Psychische Storungen bei Krankenhauspatienten (Psychiatric Disorders in General Hospital Inpatients). Springer, Berlin
3. Diefenbacher A 2000 Consultation and liaison psychiatry. In: Helmchen H, Henn F, Lauter H, Sartorius N (eds.) Contemporary Psychiatry. Vol 1, Part 2: General Psychiatry. Springer, Berlin, pp. 253–67
4. Gill D, Hatcher S 1999 Antidepressant drugs in depressed patients who also have a physical illness (Cochrane Review). The Cochrane Library, Issue 2. Update Software: Oxford, UK (www.cochrane./org/cochrane/revabst/ab001312.htm)
5. Guthrie E, Creed F (eds.) 1996 Seminars in Liaison Psychiatry. Gaskell, London
6. Katon W J, Gonzales J 1994 A review of randomized trials of psychiatric consultation-liaison studies in primary care. Psychosomatics 35: 268–78
7. Reichmann W E, Katz P R (eds.) Psychiatric Care in the Nursing Homes. Oxford University Press, New York
8. Royal Colleges of Physicians and Psychiatrists 1995 Joint Working Party Report: The Psychological Care of Medical Patients. London
9. Royal Colleges of Surgeons and Physicians 1997 Report of the Working Party on the Psychological Care of Surgical Patients. London
10. Rundell J R, Wise M G (eds.) 1996 The American Psychiatric Press Textbook of Consultation-Liaison Psychiatry. American Psychiatric Press, Washington, DC
11. Strain J J 1999 Consultation-liaison psychiatry database (2000 update). General Hospital Psychiatry 21(6): 402–502