|Year : 2019 | Volume
| Issue : 2 | Page : 144-147
Consultation-liaison psychiatry in newly established general hospital psychiatry unit: Scope and suggestions
Himanshu Gupta1, Deeksha Elwadhi2, Zara Ahmed2, Ram Chander Jiloha2
1 Department of Psychiatry, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
2 Department of Psychiatry, Hamdard Institute of Medical Sciences and Research, New Delhi, India
|Date of Web Publication||22-Jul-2020|
Room Number 102, DHR, First Floor, IRCS Building, 1, Red Cross Road, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Consultation-liaison (C-L) psychiatry is the subspecialty of psychiatry dealing with mental health disorders in nonpsychiatric settings. The ubiquity of mental health problems has increased the need for such a service to exist in general hospital psychiatric units, as many psychiatric patients report to a different specialty of medicine for the first time. This study aims to evaluate the utilization of psychiatry C-L services by nonpsychiatric inpatient units in a general hospital psychiatry unit taking into consideration the paucity of data for understanding the trends and improving service provision in the future. Materials and Methods: A retrospective chart review of all inpatient referrals received by the psychiatry department from July 2015 to February 2017 was conducted. The sociodemographic profile, source of referral, reason for referral, and psychiatric diagnosis using the International Statistical Classification of Diseases-10 were analyzed using descriptive statistical methods. Results: A total of 605 patients were referred, which comprised 0.86% of total indoor admissions. Maximum number of consultations was sought from internal medicine. “Unexplained physical symptoms” was the most common reason for referral (35%). Consequently, neurotic, stress-related, and somatoform disorder (25.5%) was the most common psychiatric diagnosis followed by mood disorder (19.8%). Conclusion: Poor and variable referral rate from various departments highlights the increasing need to sensitize all clinicians regarding psychiatric comorbidity. There is a need to explore factors that would result in increasing referral rates and making psychiatric consultation services effective and efficient.
Keywords: Consultation-liaison psychiatry, general hospital psychiatry unit, referral rate
|How to cite this article:|
Gupta H, Elwadhi D, Ahmed Z, Jiloha RC. Consultation-liaison psychiatry in newly established general hospital psychiatry unit: Scope and suggestions. J Mental Health Hum Behav 2019;24:144-7
|How to cite this URL:|
Gupta H, Elwadhi D, Ahmed Z, Jiloha RC. Consultation-liaison psychiatry in newly established general hospital psychiatry unit: Scope and suggestions. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Aug 9];24:144-7. Available from: http://www.jmhhb.org/text.asp?2019/24/2/144/290518
| Introduction|| |
Consultation-liaison (C-L) psychiatry as a subspecialty has been defined as the area of clinical psychiatry that encompasses clinical, teaching, and research activities of psychiatrists and allied mental health professionals in the nonpsychiatric divisions of a general hospital. C-L psychiatry indicates the bipolarity of its practice according to whether the intervention is addressed to the patient (consultation) or the staff (liaison). At present, consultation model is mostly used in India. C-L psychiatry has brought forward the concept of psychiatric sequelae of medical disorders and contribution of psychiatric manifestations to the etiology, course, and outcome of various medical illnesses. Influence of psychosocial features on etiopathogenesis and prognosis of many chronic diseases such as ischemic heart disease, diabetes, and cancer is already known. Furthermore, medical conditions have a major impact on one's quality of life and self-awareness as an ill-person can often lead to a psychiatric disorder. It is worth noting that psychiatric disorders, when in comorbidity with other medical disorder, worsen outcome, lengthen hospital stay and are associated with increased mortality and health service utilization, thus increasing the health-care burden., The incidence of mental disorders in hospitalized physically ill patients has been found to range from 5.0% to 50.0%.
With the paradigm shift in psychiatry from mental hospitals to general hospital psychiatry, C-L service has become all the more pertinent. In a number of cases, many psychiatric conditions might present to another specialty, in addition to the increasing evidence regarding comorbidity of mental health disorders with chronic conditions and/or as sequelae to them. There is a dearth of data about such services, especially from the developing countries.
This chart review was conducted in a newly established medical college with tertiary care facility to observe referral rate, reasons for referral, and psychiatric diagnosis, to generate data for furthering our understanding of the current working of such a service, and to guide future implications regarding organization and utilization of C-L psychiatry.
| Materials And Methods|| |
A retrospective chart review was conducted in a tertiary care 600-bedded teaching hospital in South Delhi. The study population consisted of in-patients who were referred for psychiatric consultation from other departments over a period of 20 months, from July 2015 to February 2017. There were no stringent selection criteria applied, so as to get an overall picture of C-L psychiatry service. All the referred patients were evaluated by a qualified psychiatrist, and the diagnosis was made as per the International Statistical Classification of Diseases-10 (ICD-10) – Classification of Mental and Behavioral Disorders. Other details such as sociodemographic profile, source of referral, and reason for referral were also recorded.
Ethical approval was taken from the hospital review board. Information was collected from the register that is maintained as a routine clinical process after due permission from the department head. During analysis, the data were de-identified.
The data which were obtained were analyzed using descriptive statistical methods.
| Results|| |
A total of 605 patients were referred to the psychiatry department from various other specialties during the study. The proportion of females (63%) in the referred population was much higher than males (37%). Referral rate was calculated by dividing the total number of referrals received during the study by the number of inpatient admissions in the nonpsychiatric specialties and was found to be 0.86%. The mean age of the study population was 37.25 years (standard deviation ± 16.65).
[Table 1] shows the distribution of referrals based on the referring departments. As can be clearly seen, most patients (64.5%) were referred from the medicine department, followed by 16.5% of the referrals from intensive care unit and 7.8% from the surgery department. There was only one referral from the dermatology department throughout the study period.
[Table 2] shows the common reasons for referral, out of which most common was unexplained physical symptoms (34.9%). About one-fifth of the cases were referred for a suicidal attempt.
25.5% of the referrals were diagnosed under various categories of the neurotic, stress-related, and somatoform disorder, which was the most common ICD-10 diagnosis [Table 3].
| Discussion|| |
The referral rate in the study was comparable to previous studies, which have shown them to vary between 0.06% and 3.6%. Our study showed a female preponderance in the referred patients. There have been varying numbers in the previous studies with some showing a male dominance, and other female.,, In our study, greater prevalence of female patients can be explained by the fact that most of the patients referred for suicidal attempt were female. Furthermore, there is a culturally ingrained belief of females being more prone to stress and therefore mental disorders which could have led to increase in number of female referrals.
Studies reporting the incidence of mental disorders in hospitalized physically ill patients have found it to vary from 5.0% to 50.0%. However, the referral rate in comparison is quite less. According to McKegney, there is a factor associated with both consultants and patients, which leads to underutilization of C-L services such as lack of awareness, internal bias, stigma, and physical explanations of mental symptoms among others. A systematic review exploring barriers to utilization of CL psychiatry (CLP) services found various systemic, referrer, and patient factors. In our study, one of the main factors of decreased referral rate could be patient factors such as decreased awareness, stigma, and patient's preference of not to be referred. In addition, the lack of training in screening patients by nonpsychiatric physicians and nursing staff could also be a major barrier in utilization of consultation services.
Majority of patients were referred from the medicine department. This was in agreement with findings of previous studies which have shown that 54.3%–64.78% of patients were referred from the department of medicine., Most patients with somatic complaints, substance abuse, and deliberate self-harm usually present to the medicine department and are then referred to the psychiatry department. In many cases, these patients are lost in the system and do not receive correct treatment. One of the solutions could be booster training of internal medicine physicians and nursing staff to recognize signs of mental illness and awareness regarding referral services.
When the reason of referral was analyzed, it was found that unexplained physical symptom was the most common category, which accounted for about one-third of the total referral. Similar results were found in other studies.,, This can be explained on the basis of high prevalence of functional somatic symptoms in Indian patients who have psychiatric illnesses as they are the most commonly used idioms of distress.
In keeping with the reason for referral, neurotic, stress-related, and somatoform disorder was the most common psychiatric diagnoses, followed by mood disorders. In contrast to the prominence of delirium as the most common diagnosis in referred patients in previous studies,, our study found only 44 cases which were diagnosed as delirium. This could be because as it was a newly established hospital, serious and end-of-life patients were generally referred to higher centers. Furthermore, it might be possible that there might be cases of hypoactive delirium which would have gone unnoticed and resolved in the natural progression with correction of metabolic parameters.
Our study was one of the few studies exploring the referral pattern of a newly established psychiatry service, and it showed that measures more than systemic are needed to improve utilization of CLP services as the referral rates were almost similar to established GHPUs. It covered an adequate period of 20 months and a sample of 605 patients, comparable to previous studies.
One of the limitations of the study was that it was a retrospective review, and human errors in recording could have occurred. Moreover, no follow-up notes were recorded and thus not analyzed. Patients with missing data were not included in the study. In addition, due to the paucity of time and resources, a detailed evaluation beyond clinical assessment was not attempted, which might have led to underdiagnosis of personality disorders and intellectual disability.
There is a huge gap in the estimates of psychiatric comorbidity in medical and surgical estimates, and the referrals were seen in the CLP practice. Establishing GHPUs will not solve the purpose, it needs more changes, especially pertaining to patient awareness, stigma reduction, and sensitization of clinical and paraclinical staff in recognition of signs of mental illnesses. Referral rates represent only the tip of the iceberg of the potential of CL psychiatry. A multidisciplinary approach should be encouraged for the management of patients to facilitate early recognition and management of psychiatry problems.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]