An epidemiologic study of a psychiatric liaison service

An Epidemiologic Service

Study of a Psychiatric Liaison

Thomas J. Craig, M.D., M.P.H. Director, Clinical Systems Research and Development, information Sciences Division, Rockland Research Institute, Orangeburg, New York, and Research Associate Professor of Psychiatry, New York University Medical Center, New York, New York.

Abstract: An epidemiologic study

which the referrals come. Thus, for example, while some reports (2,8,11) have indicated that internists tend to be more likely to refer patients for psychiatric evaluation than surgeons, they fail to examine the differences in such referral patterns which might suggest explanations. The present study, provided an opportunity to examine epidemiologically the characteristics of referrals from a variety of nonpsychiatric inpatient services. The presence of an active liaison program serving two of the services (medicine and neurology) permits a further comparison of referral patterns across these services.

Over the past two decades, a number of reports have documented a high prevalence of emotional disorder among patients seeking care from nonpsychiatrist physicians. Lipowski (1) from a review of the literature, has estimated that 3040% of inpatients suffer from psychic distress or psychiatric illness sufficient to create a problem for the health professional. Recognition of this fact resulted in the rapid development of the relatively new subspecialty of liaison psychiatry. However, despite efforts to encourage nonpsychiatrists to refer such patients to these services, rates of such referrals have generally ranged from 1.0% in hospitals with only a consultation service to highs of 7 to 10% in hospitals with long-standing active liaison programs (2-10). Most reports have focused on relatively small numbers of patients primarily referred from medical services and have generally failed to relate referral rates to other specific nonpsychiatric services (e.g., surgery) or to the demographic characteristics of the total inpatient population from

Method

of 308 consultations revealed substantial diferences in referral rates related to the demographic, clinical, and programmatic characteristics of patients and services. Actual liaison was associated with substantially increased referral rates across all age groups. Female patients appeared to have differentially benefited by liaison activities in terms of obtaining appropriate psychiatric intervention. Across all services studied (medicine, neurology, surgery, and obstetrics/gynecology), consultation appeared mainly directed at establishing a specific psychiatric diagnosisand treatment. Markedly different patterns of emotional disturbance were noted across different medical disease categories (e.g., cancer, chronic renal disease).

General Hospital Psychiatry

4, 131-137, 1982 0 Elsevier Science Publishing Co., Inc., 1982 52 Vanderbilt Avenue, New York, NY 10017

This study was carried out in the Psychiatric Liaison Service (PLS) of a major university hospital with over 500 beds, located in a major east coast city. All psychiatric consultations performed during a consecutive IZmonth period were abstracted and coded for analysis from the written reports on file in the PLS. These reports consisted of a face sheet with demographic information recorded at the time a consultation request was initiated, plus one or more pages of the consultants’ narrative report. Ward staff initiated consultations either by calling the PLS secretary or, by directly contacting the liaison psychiatrist on wards where one was assigned. All consultations in this study were carried out by senior psychiatric residents assigned to the service for six-month periods. During the study period, active psychiatric liaison was provided to the nonprivate medical and neurology wards. Each resident was assigned to a 131 ISSN 0163-8343/82/020131-07/$02.75

T. J. Craig

specific ward for liaison work; this entailed making rounds with the ward staff a minimum of once per week and establishing an ongoing liaison relationship with ward staff, including carrying out all consultations to the assigned ward whenever possible. This study is limited to consultations to the nonprivate wards, since consultations to private patients were sometimes referred to private attending psychiatrists, and hence would not appear in the PLS files. Data on the referred patients formed the numerators of the prevalence rates in Table 1. The denominators (that is, all inpatients admitted to the selected services during the study period by age and sex) consisted of data obtained from the hospital department of medical records and statistics for the study period. Specific consultation data were abstracted from the written reports. Since the time period of this study antedated the introduction of the current psychiatric diagnostic classification system (DSMIII) (12), all diagnoses reported reflect the DSM-II diagnoses in use at the time. For purposes of the study, these diagnoses were combined into broad nosologic categories, similar to those in earlier reports (3,4) (Table 2), which were felt to be relatively unambiguous. Studies from other populations, however, have indicated the probability that some of these diagnoses may have been reclassified into other categories had DSM-III criteria been applied (13). Reports of the relative reliability of these broad categories suggest that this effect may be relatively minor in the present study.

Results During the study year, a total of 362 consultations were carried out by PLS; 308 (84.8%) of these involved patients from the four nonprivate services examined in this study. Of the latter group, 197 (64.2%) were from medicine, 38 (12.4%) from surgery, 36 (11.7%) from OB/GYN, and 37 (12.1%) from neurology. The proportion of all inpatients referred for psychiatric consultation from these four major services is presented in Table 1. As noted in earlier studies, the referral rate from the medical service is uniformly greater than that from surgical services or obstetrics and gynecology (OB/GYN), ranging from a six- to tenfold difference. However, not noted earlier is the substantial difference between referral rates from the two services for which active liaison services were present (medicine and neurology), with a two- to threefold excess of referrals from medicine. 132

Table 1. Proportion (%) of inpatients referred for psychiatric consultation for four major services by sex and age Service Medicine

Surgery

Ob/Gyn

Neurology

@I

@I

(%J

@)

Sex Male Female

4.3 7.8

0.7 0.9

0.6

1.5 3.1

Age o-19 Z&39 40-59 60+ Total

6.0 7.7 6.6 4.1 6.0

0.8 1.1 0.8 0.4 0.8

0.9 0.5 0.6 0.4 0.6

2.0 3.5 2.3 0.5 2.1

When examined by sex, referral rates from the two services with active liaison showed a consistent 2:l female to male ratio, as contrasted to that from surgery where the sex ratio is virtually equal. Referral rates by age, while showing the above noted differences by service, showed more uniform patterns across services; the lowest referral rates were among the oldest age group (60+), and the highest rates were among the 2&39 year age groups, with the exception of the OB/GYN referrals which peaked in the youngest group (O-19 years).

Reason for Consultation Table 2 contrasts three aspects of the consultation process (reason for consultation, primary psychiatric diagnosis, and primary psychiatric referral) among the four services. The reasons for consultation, as stated in the ward staff’s written requests, were as follows. Approximately one-fifth of referrals from all services except neurology were requested for diagnosis or evaluation; somewhat fewer neurologic consultations were in this category. In addition, about one-fifth of the referrals from medicine, surgery, and neurology were requested because of the ward staff’s perception of substantial depressive symptoms. In contrast, depression was not listed as a reason for referral among OB/GYN requests. The other listed reasons for referral showed more varied patterns. One-fifth of OBI GYN referrals resulted from the patients’ prior history of psychiatric disorder, a rate double or more that of the other services. In contrast, suicide attempts were more common among medicine and surgery referrals, while management of behavior

Epidemiologic Study of a Liaison Service

Table 2. Reason for psychiatric consultation, by major service, primary psychiatric diagnosis, and primary psychiatric recommendation Service Medicine Surgery Ob/Gyn Neurology (N=197) (N=38) (N=36) (N=37) % % % % Reason for consultation History of psychiatric disorder Suicide attempt Diagnosis-evaluation Psychosis Depression Management of behavior disorder Other Primarv txvchiatric diagnosis No psychiatric disorder Schizophrenia Organic brain syndrome Depression Neurosis/personality disorder/ situational reaction Alcohol/drug abuse Unstated and other Primary psychiatric recommendation Psychotropic medication Referral to other psychiatric services Psychotherapy Physical treatment with psychiatric followup Other Unstated

disorders were more common sources of referral from the medicine and neurology services. Relatively few requests indicated the ward staff’s perception of a psychotic process. A substantial proportion of referrals from all services, especially OB/ GYN and neurology, represented a wide range of “other” reasons, including social and medical management (lo), ambivalence about surgery (2), alcohol and drug problems (17), “anxiety” (4) and no listed reason (21). Interestingly, only four of the 308 patients were noted to have requested psychiatric consultation.

Psychiatric Diagnosis The primary psychiatric diagnosis represents the DSM-II diagnosis noted by the psychiatric consultant. Of interest is the fact that a very small proportion of consultations were indicated as having no mental disorder. Schizophrenia and depression

5.6 13.2 20.3 7.6 16.2 18.3 19.1

10.5 18.4 18.5 5.3 21.1 10.5 15.7

2.5 8.6 26.9 27.9

13.2 10.5 34.2

13.9 5.6 25.0

10.8 21.6 29.7

19.8 11.2 3.0

36.8 5.3 -

38.9 16.7

27.0 2.7 8.1

24.8 29.2 5.3 33.2 6.2 1.3

10.3 15.4 10.8 46.2 10.3 7.7

14.7 29.4 5.9 35.3 14.7 5.9

29.3 22.0 14.6 24.4 4.9 4.9

-

20.0 5.7 20.0 8.6 8.6 31.5 -

5.4 5.4 13.5 5.4 18.9 21.6 29.7 -

were relatively evenly distributed across all referring services. In contrast, organic brain syndrome (OBS) diagnoses were more common among the two liaison services while diagnoses in the neurosis/personality disorder/situational reaction category were more common among the surgery and OB/GYN referrals. Eleven percent of the medicine referrals had a primary diagnosis of alcohol or drug abuse, while almost one-fifth of the OB/GYN referrals had unstated or other diagnoses.

Psychiatric Recommendations The primary recommendation of the psychiatric consultant varied considerably across services. Psychotropic medication was recommended chiefly for patients on medicine and neurology, while psychotherapy was relatively infrequently recommended as a sole modality. Referral to other psychiatric services was recommended for 15 to 30% of the 133

T. J. Craig

patients, more commonly among medicine and OB/ GYN services. This recommendation was generally made for implementation at the time of discharge from the nonpsychiatric service. Among those patients in this category, 7% were referred to state hospitals, 33% to the psychiatric inpatient or outpatient services of the hospital in which the study was conducted, 9% to other psychiatric hospitals and 21% to other outpatient psychiatric facilities. The most common recommendation for all services except neurology was continued treatment for the physical condition, with followup by the psychiatric consultant which generally included brief supportive psychotherapy. A more detailed analysis of referral patterns within the specific services revealed that 23.4% of the referrals from medicine had evidence of alcohol problems related to admission including 18 (39.1%) experiencing delirium tremens, 6 (13.0%) with an alcoholic OBS, 5 (10.8%) with cirrhosis or gastrointestinal bleeding secondary to alcoholism, and 3 (6.5%) with severe physical deterioration secondary to alcohol abuse. In contrast, only 10.5% of surgery referrals, 5.6% of OB/GYN referrals, and 8.1% of neurology referrals had alcohol abuse as a contributory cause of admission. A subarea of particular interest was the medical intensive care unit (MICU) which had been established in the hospital shortly before the study year. A total of 17 referrals were received from this unit, 15 of which involved suicidal attempts by overdose. Interestingly, in contrast to the general pattern for medical referrals, more of the MICU referrals were men (9) than women (S), and 14 were aged 49 years or younger. The referral rate for men aged 1049 was 6/79 (7.6%) in contrast to a rate of 3/200 (1.5%) for men aged 50+ years. The contrast for women was even more dramatic, with 8/47(17.0%) women under age 49 being referred as compared to O/114 (0%) older women. Only one patient, a man in his 5Os, was diagnosed as having an organic brain syndrome. Among specific patient categories, nine referrals from medicine involved cancer patients, almost equally divided by sex, of whom five received a psychiatric diagnosis of depression, and two that of OBS. In contrast, eight patients with chronic renal disease were referred of whom six were women, and five were diagnosed as having OBS while two had depression. Twenty-five medical patients with heart disease were referred (eight men and 17 women) of whom seven were diagnosed as having depression and nine as having OBS. 134

Patients with classic “psychosomatic” disorders were relatively rarely referred, as follows: peptic ulcer (2), hypertension (9), thyroid disease (6), bronchial asthma (4), headaches (2), and rheumatoid arthritis (1). Only two of these patients received a DSM-II diagnosis of psychophysiological reaction (one patient with peptic ulcer disease and one with asthma). Fifteen (41.6%) OB/GYN patients were pregnant at the time of referral, while four manifested postpartum depressions, and one had depressive symptoms following a therapeutic abortion.

Discussion The referral rates reported in Table 1 are similar to those reported in the literature for services with and without active liaison programs (e.g., medicine and surgery, respectively) (2-11). However, this broad generalization must be substantially modified when demographic and service-specific variables are considered. Thus, for example, while the referral rates for women medicine patients approach the highest reported referral rates (5, 7), those for men exposed to the same active liaison service are only half these rates. The same phenomenon of an increased female to male referral ratio existed for the other service (neurology) with an active liaison program, but the rates were only about one-third those on medicine, indicating that psychiatric needs may differ by service even in the presence of active liaison. The reason for these differences must be studied further. The 2:l female to male ratio, however, is similar to the findings of a number of studies which have observed that women tend to report and seek care for psychiatric distress at a higher rate than men (14-16). If this reflects a true difference in morbidity, then a comparison of the increased female to male referral ratio among liaison services-in contrast to the almost equal ratio for the nonliaison service (surgery)-would suggest that a program of active liaison may differentially benefit women in obtaining appropriate intervention for their emotional distress. In addition, the difference in absolute referral rates between the two liaison services suggests that a real difference may exist in the prevalence of significant emotional distress in these two inpatient settings. At a minimum, this finding demonstrates that the rate differences reported in earlier studies cannot be attributed solely to the presence or absence of a liaison program. Furthermore, the relatively small numbers of patients from nonmedicine services suggests caution

Epidemiologic

in the interpretation of these data, and the need for replication in other settings. With respect to age, referral patterns appear similar for all services except OB/GYN, suggesting that active liaison efforts seem to primarily increase referrals proportionately across all age groups without any differentiated effect, as noted above for sex. The above inference, of course, must be considered in the context of the informal educational and consultation activities carried on by the liaison psychiatrists (17). The referrals reported here represent only those patients deemed to require a formal psychiatric evaluation. However, in the process of making rounds, the liaison psychiatrists provided considerable assistance to the ward staff in managing less severe behavioral manifestations (such as transient grief reactions). Thus, both staff and patients on the liaison wards were the recipients of an enriched psychosocial input which affected the care of many more patients than those reported here. In contrast, the nonliaison wards received only those services reported. Unfortunately, the impact of this enriched input could not be systematically assessed in the present study but might be indirectly inferred from the experience of the MICU. Here, as the result of a psychiatric resident’s specific interests, active liaison focused on the use of techniques aimed at preventing the development of sensory deprivation delirium which has been reported to be frequent among such units. As noted, only one patient from this unit required formal psychiatric intervention for an organic brain syndrome, suggesting that this liaison may have been effective in reducing the more severe aspects of this condition. Perhaps the most direct implication of the data presented in Table 1 is the fact that any such study of general hospital referral patterns must take into consideration the demographic characteristics (at least age and sex) of the patients served and the specific characteristics of the services provided (consultation versus active liaison), as well as the nonpsychiatric services involved before any meaningful comparisons can be made. As noted earlier, virtually no past studies have addressed more than one or two of these variables, thus accounting for much of the diversity of findings reported in the literature. In an attempt to further examine the differences noted across services in Table 1, three variables were examined in Table 2. When comparing reason for consultation with psychiatric diagnosis it would appear that a major function served by the psychiatric consultant is that of identifying the specific

Study of a Liaison Service

psychiatric pathology in order to prescribe an appropriate intervention. These results are similar to other studies (8) in suggesting that the ward staff tends to focus on behavioral reasons for consultation rather than identifying the underlying disorder. Thus, for example, relatively few referrals specified the presence of psychosis as the reason for the consultation whereas, combining the diagnostic categories of schizophrenia and OBS (most of whom presented a picture of delirium), a substantial proportion of the patients from both medicine and neurology exhibited this condition. While the presence of depression and/or its manifestations (such as suicidal behavior) appeared to be regularly recognized by staff of most services, this did not appear to be true for OBlGYN where only 5.7% of the referrals were for suicide attempts in contrast to a full 25% diagnosed as depressed. In contrast, OB/ GYN staff seemed particularly prone to request consultation on the basis of a prior history of psychiatric disorder rather than current manifestations. Interestingly, the overall rates for specific reasons for consultation are virtually identical to earlier reports (2, 8), suggesting a relative constancy in types of problems presented. These studies, however, fail to examine these data by service. The differences in diagnostic patterns between services with and without active liaison would, at face value, seem to reflect real differences in the populations served rather than the effect of liaison. Thus, the higher proportion of OBS among the liaison services and the conversely higher proportion of depression and neurosis/personality disorder/situational reaction among the nonliaison services appear to reflect the different age distribution and physical problems of these different services as opposed to differences in perception of problems. However, further systematic research of patients from these services is needed to test this assumption. Psychiatric recommendations were relatively similar across the four services although psychotropic medication tended to be more often recommended on the liaison wards, probably reflecting diagnostic differences mentioned earlier. Interestingly, approximately one-quarter of all patients seen on all but the surgery services were felt to require referral for continued psychiatric treatment after discharge from the nonpsychiatric service. The rate of recommendation of psychotherapy as a primary modality is artificially low since the most frequent recommendation (physical treatment plus psychiatric followup) generally entailed continued 135

T. J. Craig

brief supportive psychotherapy by the consultant. This study did not include an assessment of the outcome of these recommendations; other reports, however, have indicated varying rates of compliance with recommendations (18). The high proportion of patients from the medical service with alcohol problems contributing to their admission confirms earlier reports (19). However, the present figure may, in fact, underestimate this rate since, in this hospital at the time of the study, there was an active alcohol consultation service staffed by nurse practitioners and alcohol counselors to whom patients with uncomplicated alcoholism could be directly referred. Patients with specific medical diagnoses showed interesting variations in psychiatric pathology which would appear to reflect real differences since all were exposed to identical consultation conditions. Thus, cancer patients tended to show depressive symptoms, while chronic renal patients tended toward OBS. Cardiac patients were relatively evenly divided between these two psychiatric diagnoses, suggesting the relative impact of the presence of these conditionsin some instances leading to reactive depression, in others leading to organic impairment. The relative absence of referrals for “psychosomatic” illness has been noted elsewhere (B), and may reflect a relative absence of such patients from the services studied. More likely, this may represent a basic attitudinal change in which these conditions generally no longer are considered to have a psychogenic etiology for which intervention is necessary. The latter assumption is supported by the fact that only two of the 24 (8.3%) patients with one of these diagnoses received a psychiatric diagnosis of psychophysiologic reaction. This finding supports the action of the originators of DSM-III-the elimination of this category from the psychiatric nosology--despite the fact that the study antedated the development of DSM-III by several years. The proportion of consultation patients receiving a diagnosis of schizophrenia is somewhat higher than the 3.1% to 9.0% reported from earlier studies (2-4, &lo, 17, 20). The exact interpretation of this higher number of such patients is indeterminate, although it may reflect the diagnostic practices of the consultants at the time of the study, or represent a true increase in such patients in the sample. Finally, the relative absence of postpartum depressive states requiring psychiatric consultation is notable and suggests the need for a prospective 136

epidemiologic study of obstetric patients to determine the true prevalence of this frequently discussed condition.

Summary In summary, the present study illustrates the need to examine patterns of psychiatric referrals in the general hospital in much more detail than has been the practice in the past. Clearly, a variety of factors (demographic, clinical, and programmatic) combine to produce a demand for services which varies considerably both qualitatively and quantitatively. If previous reports of relatively increased rates of psychiatric pathology among women are valid, then the presence of an active liaison program appears to remedy a bias against women, suggested by the rates from services without such a program. Finally, research is indicated, preferably using a prospective longitudinal design, to further explore several issues raised by the present study. In particular, studies are needed to determine the true prevalence of diagnosable mental illness among patients receiving a variety of medical and surgical services, and to identify factors which may facilitate or impede the recognition and referral of these patients for psychiatric consultation. In this regard the almost total absence of patient requests for consultation is striking and warrants further study in view of its implications regarding compliance with psychiatric recommendations. Also, the fact that elderly patients had uniformly lower referral rates across all services demands further study to determine whether this reflects a lower need for services or a relative failure to recognize the presence of this need by ward staff and consultants as suggested by an earlier report (21). In addition, studies are needed to determine the relative prevalence of specific psychiatric conditions (e.g., depression or OBS) among patients with specific physical conditions (e.g., cancer or heart disease) as a prelude to educational efforts aimed at increasing the ability of treating staff to recognize and treat these conditions. The author ackmwledges the assistance of Frances Simpson in manuscript preparation.

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Epidemiologic Study of a Liaison Service

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Canadian general hospital. Can J Psychiatry 24: 717-723, 1979 Fleminger JJ, Mallett BL: Psychiatric referral from medical and surgical wards. J Ment Sci 108183190, 1962 Eilenberg MD: Survey of inpatient referrals to an American psychiatric department. Br J Psychiatr 111:1211-1214, 1965 Meyer E, Mendelson M: The psychiatric consultation in postgraduate medical teaching. J Nerv Ment Dis 130:78-81, 1960 Lipowski ZJ, Kiriakos RZ: Borderlands between neurology and psychiatry: Observations in a neurological hospital. Int J Psychiatr Med 3:131-147, 1972 Crisp AH: The role of the psychiatrist in the general hospital. Postgrad Med J 44:267-276, 1968 Ries RR, Kleinman A, Bokan JA, Schuckit MA: Psychiatric consultation-liaison service. Patients, requests, and functions. Gen Hosp Psychiatr 2: 204-212, 1980 Anstee BH: The pattern of psychiatric referrals in a general hospital. Am J Psychiatr 120:631-634, 1972 Shevitz SA, Silberfarb PM, Lipowski ZJ: Psychiatric consultations in a general hospital: A report on 1,000 referrals. Dis Nerv System 37:295-300, 1976 Edwards JE, Angus JWS: Inpatient psychiatric referrals in an American county hospital. Compr Psychiatr 9:517-524, 1968 Diagnostic and Statistical Manual of Mental Disorders (Third edition): DSM-III. American Psychiatric Association, Washington, D.C., 1980 Craig TJ, Goodman AB, Haugland G: Impact of DSMIII in clinical practice. Am J Psychiatry, in press

14. Dohrenwend BP, Dohrenwend BS: Sex differences and psychiatric disorders. Am J Sociology 81: 1447-1454, 1976 15. Radloff L: Sex differences in depression: The effects of occupation and marital status. Sex Roles 1:249-265, 1975 16. Phillips DL, Segal BF: Sexual status and psychiatric symptoms. Am Social Rev 34:58-72, 1969 17. Kramer BA, Spikes J, Strain JJ: The effects of a psychiatric liaison program on the utilization of psychiatric consultations: An evaluation by chart audit. Gen Hosp Psychiatr 1:122-128, 1979 18. Van Dyke C, Rice D, Pallett P, Leigh H: Psychiatric consultation: Compliance and level of satisfaction with recommendations. Psychother Psychosom 33:14-24, 1980 19. Beresford TP, Alcoholism consultation and general hospital psychiatry. Gen Hosp Psychiatry 1:293-300, 1979 20. Weddige RL: Psychiatric consultation on medicalsurgical wards. Hosp Community Psychiatr 30: 377-378, 1979 21. Taintor Z, Gise LH, Spikes J. Strain JJ: Recording psychiatric consultations: A preliminary report. Gen Hosp Psychiatr 1:139-149, 1979

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