Psychiatric consultation on an otolaryngology liaison service

Psychiatric Consultation on an Otolaryngology Liaison Service Harold Bronheim, M.D., James J. Strain, M.D., Hugh F. Biller, M.D., and George Fulop, M.D. Abstract: Otoluyngology

Introduction

From the Division and Behavioral Medicine and Consultation Psychiatry (H.B.; J.J.S.; G.F.) and the Department of Otolarvnerologv, Mount Sinai Medicine Center, One Gustave L. Levy%ac< New York, NY 10029. Address renrint reauests to: Harold Bronheim, M.D., Box 1229, Behavioial Medi&ne & Consultation Psychiatry, Mount Sinai Medical Center, One Gustave L. Levy Place, New York NY 10029.

Patients hospitalized on the Otolaryngology (ENT) Service experience intense psychologic stresses. In addition to the usual anxiety that surgical patients are subject to, ENT patients often have cancer and must confront the threat of facial mutilation [l-4]. They experience a variety of sensory and motor alterations in rapid succession, including taste, smell, swallowing, respiration, vision, or hearing. Many ENT patients undergo tracheostomy, which immediately interrupts their ability to speak and adequately communicate basic needs and somatic and emotional distress and to verbally “work through” their illness and surgical interventions. The majority of surgical patients react to the initial stress of surgery with loss of self-esteem and unpleasant affect; however, most achieve adequate psychologic adaptation. The factors predicting psychologic outcome in ENT patients are mainly unknown [3]. Hackett and Cassem as well as others have described the variety of pathologic reactions observed perioperatively, including anxiety, depression, and alterations in mental status and behavior, and have commented on the means to reduce postoperative complications with preoperative interventions [l-3,5]. Baudry and Weiner have commented on the general preoperative and postoperative concerns of the surgical patient [6]: preoperative psychologic uneasiness, postoperative delirium, anxiety, pain, and depression. Lipowski has estimated that 30%60% of medical/surgical general hospital inpatients suffer clinically significant psychologic distress [7l. Although many psychologic studies and that of Lipowski antedated DSM-III [8],

patients (especially those with tracheostomies) present a significant challenge to psychiatrists from both a diagnostic and therapeutic standpoint. To date, no study has been made of psychiatric disorders among this important group ofpatients. At the Mount Sinai Medical Center, a liaison psychiatrist has been involved with a specialized otoluyngology cluster unif since 1979. Using a 384-item computerized database protocol developed at Mount Sinai, data on 139 otolayngology patients were recorded and compared with 1662 “Other” inpatient psychiatric consultations on the medical and surgical services during 1980-1987. The otolayngology patients as a group were more likely to be male (p = O.OZl), married (p = 0.001) and employed (p < 0.002). Cancer was the most common medical disorder, and the average level of stress as reported on DSM-ZlI’s Axis IV (5.1, severe) was significantly greater (p < 0.0001) than that for the “Other.” The most common psychiatric response was adjustment disorder (36%). The length of stay of those ENT patients seen in psychiatric consulfution was 26.4 days, in contrast to 2 2.1 days for all ENT patients. However, the length of stay of those patients on ENT receiving a psychiatric consultation was not different from the “Other” psychiatric consultation cohort (26.3 days). Despite the higher level of stress, the incidence of significant psychiatric morbidity was lower for the ENT cohort. The primary effect of the liaison psychiatrist was to lower the threshold for case identification that enhanced the referral rate on the ENT unit.

Gemal Haspita Psychiatry 11, 95-102, 1989 Q 1989 Elsevier Science Publishing Co., Inc. 655AvenueoftheAmericas,NewYork,NYlOOlO

95 ISSN 0163~8343/89/$3.50

H. Bronheirn

more recent reports utilizing DSM-III confirm the presence of psychologic dysfunction and the common diagnoses of grief and adjustment disorders [9]. Despite the high rate of psychiatric disturbances observed by surgeons, few otolaryngology patients are referred for psychiatric consultation [lO,ll]. Fulop and Strain estimated the psychiatric referral rate from the general medical/surgical inpatient units at The Mount Sinai Hospital to be 4% [12], which was considerably higher than the 0.3%-1.3% referral rates reported in a recent national survey [13]. Reasons for the low rate of referral include a) failure to identify psychiatric disorders, b) minimal confidence in psychiatric interventions, and c) fear that such interventions might be counterproductive [2,14]. Although there have been numerous reports of psychologic disorders in surgical patients, few have reported specifically on otolaryngology patients. Ginsberg et al. found premorbid stressors in spastic dysphonia patients to be within the normal range; however, subsequent adaptation in their sample was more similar to that in cancer patients than to that in normals. In spastic dysphonia, a disorder that was previously considered to be a variant of conversion disorder, surgical intervention by recurrent laryngeal nerve section is more appropriate [15]. Wallack et al. [16] and Strain et al. [17] reported their experiences with the participation of a liaison psychiatrist in weekly otolaryngolic ombudsmen rounds for the accumulation of psychosocial data and formulation of optimal interventions. Since 1980 at The Mount Sinai Hospital, psychiatry has developed a unique relationship with the ENT Service. In contrast to the usual consultation for patients in a crisis setting, the liaison psychiatrist is part of the unit team and participates in otolaryngology functions, especially a weekly ombudsmen conference in which patients are presented, interviewed, and discussed. The team consists of the psychiatrist, the Chief of Service, ENT residents, nursing staff, social worker, and other involved personnel [16]. The present article compares the psychiatric morbidity observed in ENT inpatients with that of patients seen in psychiatric consultation on all other medical and surgical units. Such a comparison delineates the special characteristics of the ENT consultation patient and highlights the effectiveness of a psychiatric liaison intervention. 96

Method The study was conducted at The Mount Sinai Hospital (New York City), a 1200-bed university hospital with 37,000 medical/surgical discharges per year. One hundred thirty-nine consultations performed by the liaison psychiatrist on the 30-bed ENT Service inpatient unit were compared to 1662 “Other” psychiatric consultations completed by the Division of Behavioral Medicine and Consultation Psychiatry from 1980 to 1987. Patients seen by the general consult service were referred through a formal request initiated by the primary caretaking physician, the usual method employed in general hospitals to obtain specialist opinion. On the liaison service, consultation is informal since the psychiatrist is part of the ENT team. The request for consultation can be initiated by the primary caretaker, other team members, or the psychiatrist. Whereas a formal consultation may be requested to address a specific issue, the liaison psychiatrist remains involved with the patient’s caretakers throughout the hospitalization as manager of the patient’s psychologic needs. The study utilized a 384-item structured inventory developed over 7 years that collected data on demography, level of urgency, reason for the referral, DSM-III diagnoses on five axes, and management recommendations, including treatment by the ward staff, the consultation-liaison psychiatrist, psychotropic medications, and psychiatry aftercare. Data were recorded by attendings, fellows, and residents on the consultation forms. Each case was reviewed by the senior faculty of the Division of Behavioral Medicine and Consultation Psychiatry, and 50% of the cases were seen by an attending. Statistical significance was assessed by twotailed t tests for continuous variables and by chisquare analyses for polychotomous or categorical items.

Results Patient Demographics The ENT patients referred were significantly older (p = 0.023) and more likely to be male (p = 0.011) than the “Other” patients (Table 1). The ENT group had significantly more whites (p < 0.0001) than minorities, a higher proportion of patients

Otolaryngology

Table 2. Leading reasons for requesting consultation”

Table 1. Patient demographics Otolaryngology (N=139)

Age Sex Male Female Race White Black Hispanic Other Marital Status Married Divorced Widowed Not married Living situation Alone With adult Nursing home Other Employment Yes No Insurance Medicare Medicaid Other

Liaison Service

“Other” (N=1662)

55.2

51.0

p=O.O23

49.6 50.4

38.7 61.3

p=O.Oll

77.4 11.3 10.5 0.8

41.5 29.3 28.2 1.0

51.5 9.6 16.2 15.4

30.3 13.7 18.5 29.4

26.5 68.4 2.2 2.2

28.6 60.1 2.1 a.4

35.6 64.4

21.1 79.0

7.2 2.2 90.6

11.0 17.2 71.8

Otolaryngology Coping with chronic illness Depression Anxiety Behavior management Organicity “Others” Depression Coping with chronic illness Organicity General diagnosis Suicide

p<0.0001

64.0% b 28.1% 24.5% b 22.3% 14.4% b 36.3% 33.9% b 27.7%b 22.7% 22.4%b

p<0.0001

“Multiplereasons for referral per patient are noted. These reasons are selected from a list of 28 possibilities. bStatistically significant differences (pCO.05) between Otolaryngology and “Other” cohort.

NS

tation after 2 weeks of hospitalization (31.4% vs. 19.6%, p < 0.0001).

p
p<0.0001

currently employed, fewer who were receiving public assistance (p < O.OOOl),and more who were married (p < 0.0001).

Referral Rate The referral rate from the Otolaryngology Service was 7.3%, which was more than twice the 3.6% referral rate for the “Others.”

Consult Request On the ENT service, significantly more consultations were initiated by the nursing staff, 30.9% as compared to the “Other” 8.4% (p < O.OOOl), whereas house staff, attending, and social services referrals were similar in the two cohorts. There was a significant difference in the lag time from date of admission to date consult called: 9.1% on day 1 for ENT and 30.9% for the “Other” (p < 0.0001). More ENT patients than “Others” had a formal consul-

Reason for Consultation ENT consults were more likely to be called for copwith chronic illness (64.0% vs. 33.9%, p < 0.0001) and less likely to be requested for diagnostic problems (7.9% vs. 22.7%, p < 0.0001) and suicide (7.9% vs. 20.0%, p < 0.0001). The five leading reasons for consultation are presented in Table 2: coping was primary for ENT patients whereas concerns about differential diagnosis, organicity, and suicide were significantly greater for the “Others.”

ing

DSM-IZZMultiaxial Diagnoses ENT patients were more frequently diagnosed as having “No Disorder” (23% vs. lO.O%, p < 0.05) and as having Adjustment Disorders (36.0% vs. 22.2%) (Table 3). For all the other major DSM-III Axis-I Diagnoses, the otolaryngology patients were comparable to the “Others” except for the organic mental disorder (12.9% vs. 26.2%, p < 0.05). In addition, ENT patients more commonly had no personality disorder on Axis II at the time of initial contact than the “Others” (54.0% vs. 32.6%, p < 0.05), and fewer personality diagnostic decisions were deferred because of insufficient data (28.1% vs. 47.3%). The medical/surgical disorders (Axis III-ICD9CM) differed significantly (p < 0.0001): 45.5% of 97

H. Bronheim

Table 3. Diagnosis (DSM-III) Otolaryngology (N=139) AXIS 1 No disorder Major Affective Disorder Anxiety Disorder Somatoform/Factitious Psychotic Organic Substance Abuse Adjustment Disorders AXIS II-Personality Disorders No disorder Definite Personality Disorder Deferred or Unknown

“Other” (N = 1662)

23.0% 10.1% 1.4% 0.0% 1.4% 12.9% 18.0% 36.0%

(32) (14) ( 2) ( 0) ( 2) (18) (25) (50)

10.0% 9.9% 1.7% 1.7% 2.5% 26.2% 19.3% 22.2%

54.0%

(75) (25) (39)

32.6% 20.1% 47.3%

18.0% 28.1%

(188r (187) ( 32) ( 32) ( 47) (494) (365) (419) (615) (380) (893)

“Statisticallysignificant difference (pCO.05) between Otolaryngology and “Other” cohort.

all ENT diagnoses were cancer, in comparison to 11.1% for the “Others.” Thirty ENT patients had laryngeal cancer. The next largest group of disorders were respiratory (16.6% vs. 7.7%), reflecting increased involvement of the large airways, whereas significantly fewer ENT patients had circulatory disease (5.9% vs. 21.4%). The ENT sample had 5.4% of the diagnoses listed as endocrine, frequently related to thyroid and calcium metabolism, in contrast to 12.5% of the “Others,” who were more likely to present with diabetes mellitus. The ENT cohort experienced more severe psychosocial stress (Axis IV: 5.1 vs. 4.5, p = O.OOOl), although they functioned better (Axis V) in the year prior to hospitalization than the “Others” (3.2 vs. 3.8, p = 0.0001).

Hospital Course and Outcome Otolaryngology patients underwent significantly more operative procedures to the head and neck that were disfiguring and experienced a greater incidence of sensory impairment (p < 0.0001) (Table 4). The ENT patients, however, were less bedridden and, over time, improved medically (p = 0.003), with a significantly lower incidence of death (p < 0.0001). The average length of stay, however, was almost identical (26.3 vs. 26.4 days) for the two groups (Table 5). Significantly fewer ENT patients left against medical advice (p < 0.0001) or were transferred to inpatient psychiatry units (p = 0.05) (Table 6). Although fewer medical consultations (p = 0.004) or 98

diagnostic tests (p = 0.0001) were recommended by the psychiatric consultant for ENT patients, they were more commonly seen by the social work staff before the psychiatric consultant had arrived. There was no significant difference in the recommendation for psychotherapy or psychotropic medication or in the assessment of psychologic improvement between the two groups (Table 6).

Discussion There is always the question in consultation-liaison psychiatry as to the nature of the acquisition of the sample. For example, in the typical consultation services, patients are identified and referred by the ward staff without the guidance of the Department of Psychiatry. Some services (for example, renal dialysis and transplantation) may employ a “screen” method in which every patient (the denominator) is evaluated by a psychiatrist or member of the mental health care team. A more traditional liaison approach is to have the psychiatrist not only screen patients himself or herself but influence the ward staff member to identify psychosocial distress as well. Obviously then, the method of referral to psychiatry influences the case mix observed and is an additional important variable to describe in attempting to understand the characteristics of a particular patient population. No doubt the liaisonscreen method employed for the ENT sample has had an effect on who was seen by the psychiatric consultants.

Otolaryngology Liaison Service

Table 4. Surgical outcome Otolaryngology

“Other”

Significance

80.0% 4.5%

64.0% 10.3%

p=o.o03

91.4% 4.8%

67.3% 18.1%

p<0.0001

81.1% 10.8%

22.4% 8.55

p<0.0001

80.0%

24.3%

p
56.9%

16.1%

p
1.8%

7.7%

Medical condition Improved Worse Motility Can walk Bedridden Operative procedure Major Minor Disfigurement Yes Sensory impairment Yes Death Yes

Table 5. Length of stay” Otolaryngology referred for psychiatric consultation (N=76)

26.3 days

“Other” psychiatric consultations (N=520)

26.4 days N.S.

All otolaryngology patients not referred for psychiatric consultation (N = 1488)

11.1 days PC.01

“Length of stay data were incompletely available in the psychiatric data base prior to 1984. Results are based on a 2-year sample only (1984-1985).

The Otolaryngology Service at The Mount Sinai Hospital is also an example of a specialized medical or surgical cluster unit which has emerged in the past two decades (e.g., Dialysis Units, ICUs, etc.). The cluster provides intensive specialized care to a selected patient population and is commonly the site of liaison psychiatry involvement. The significant differences in the demographics of the ENT and “Others“ is primarily related to the nature of this cluster unit. For example, otolaryngology tumors are associated with alcohol and tobacco use and are known to be more common in men [18]. The higher frequency of males in the ENT sample and the deviation from the usual 21 female-male ratio observed on the consult service throughout The Mount Sinai Hospital for the last 6 years [19] reflect the high risk of males for ENT disorders. In

p<0.0001

addition, because this cluster unit enjoys a national reputation, its sources of referral are more regional than local, and consequently its patient population reflects more of the average regional-national mix than is encountered on the other medical/surgical services, which serve primarily the local community. This difference is also of paramount consequence for the psychologic adjustment of the patients discussed below. In keeping with the team structure of the liaison psychiatry approach, it is not surprising that a much higher percentage of consults were generated by nursing. Nurses are frequently the only medical staff who have extensive communication with the patients (especially those with tracheostomies) and therefore may be the first to detect psychologic distress. Housestaff are more isolated from the patients insofar as much of their effort and indeed their interest is in surgical procedures in the operating room. Also, the Chairman of the ENT Service has encouraged the nurses to call psychiatry directly whenever they feel it would be helpful. Because the liaison approach involves the daily presence of a psychiatrist on the ward, there is no waiting time for response to a consultation request. It is therefore surprising that the lag time from admission to psychiatric consultation was so extended: 31.4% ENT versus 19.6% “Others” were seen after at least 2 weeks’ stay. The increase in lag time on the ENT service is due to several factors. The rate of organic mental disorder, personality disorder, requests for transfer to psychiatry, and 99

H. Bronheim Table 6. Psychiatric outcome

Otolaryngology

“Other”

Psychologic Condition Improved Worsened

65.7% 1.9%

55.5% 5.7%

Left AMA Social service note Constant observation Other consuIts recommended Diagnostic tests recommended Transfer to psychiatry Psychotherapy recommended Drug treatment

0.0% 81.4% 5.8% 5.0% 5.8% 2.9% 20.1% 66.0%

3.4% 64.7% 6.7% 3.5% 17.6% 7.3% 18.5% 68.0%

evaluation for discharge AMA were lower. Patients with severe psychiatric psychopathology usually present earlier with obvious changes in behavior or agitation associated with a unit conflict that obstructs the normal routine. In contrast, the otolaryngology patients had fewer diagnoses associated with disordered behavior and were more accepting of medical/surgical treatments, as evidenced by the high rate of surgical intervention. Secondly, patients eventually recognized for referral were frequently not identified until weeks after surgery by the nursing staff during the long postoperative rehabilitation phase involved in partial laryngectomy cases. Lastly, the weekly ombudsmen rounds required an ongoing review of the patient population for psychiatric consideration and enhanced the identification of patients with psychosocial difficulties. However, since a failure of coping may be discerned only with the passage of time and fa-

miliarity with the patient, the identification often occurred later in the hospital course [20]. In the role of consultant, the psychiatrist facilitates patient management by assisting staff with behavioral symptoms such as grief, anger, agitation, anxiety, or noncompliance [ 1,191. The leading reason for psychiatric consultation (Table 2) on the ENT service (i.e., coping with chronic illness) reflects the interest of the ENT staff in seeing that patients receive help coping with the multiple simultaneous stresses of head and neck surgery. The “Other” consults were more often called for psychopathology (depression, suicide, organicity, diagnostic problem, and personality disorders). The surgical nursing staff initiated 30.9% of the consults on the ENT service, in contrast to 8.4% nursinginitiated consults for the “Others.” Their reasons 100

Significance

NS p
p
for referral were more likely to involve coping and behavioral management difficulties than diagnostic considerations. The improved medical outcome of the ENT patients as opposed to “Others” may reflect their younger age or the prehospitalization and preanesthesia health of the referred patients, which tended to be good except for the isolated otolaryngologic disorder or tumor, which was corrected surgically. An additional factor may be the constant direct involvement of the senior surgical attending staff on the service, enhancing supervision and early detection of untoward medical events. The ENT death rate approximates the hospital average (3%-3.5%) and is much lower than the 19% rate found in the “Other” cohort [21]. The “Others,” in addition, manifested more serious systemic disease, delirium, and increased utilization of hospital resources, including more time spent in intensive care unit settings and increased use of other medical and surgical consultations.

Conclusion Otolaryngology patients have for the most part been ignored in the psychiatric literature. This may be due to the nature of the condition, which has such a direct impact upon communication, but it also may be due to the powerful negative reactions that the uninitiated have to facial disfigurement. An awareness of the normal range of psychologic adjustment has not as yet been established, nor has an approach to appropriate interventions been formulated. This study is the first in the direction of characterizing this long-neglected but large group of patients.

Otolaryngology Liaison Service

The ENT patients had less intense and less pathologic reactions than expected for individuals under severe to extreme stress. As a group, these patients were more intact psychologically, with greater premorbid psychologic adjustment associated with more stable family and social supports, higher rates of employment, and lower frequency of organicity and severe character disorder. Our data, therefore, confirm the observation that psychologic adaptation is correlated with premorbid function and with previous experiences with loss [6]. At times on the basis of psychologic considerations, complex procedures were modified or even deferred in order to best serve the patient within his or her ability to tolerate loss and comply with postoperative care. The primary effect of the liaison psychiatry involvement was to lower the threshold for case-finding, resulting in the identification of ENT patients with less than obvious psychiatric and psychosocial morbidity. As a result, the referral rate on the ENT unit was more than twice that on the “Other“ service. This occurred because the liaison psychiatrist was regularly present on the otolaryngology ward and worked closely with the resident and nursing staff. As mentioned earlier, referrals from nursing were accepted and were numerous. In addition, because of the Chief of Service’s dedication to the proposition that any patient who could be emotionally assisted should be, the ENT staff actively participated as a team in the review and presentation of patients at the weekly patient staff conference. As a result of participating in these conferences, the housestaff have become more open in entering into discussion with their patients, more likely to identify psychologic distress, and more willing to obtain psychiatric evaluation and support [16]. Furthermore, the occasional disruptive and highly agitated or frankly suicidal patient was comfortably managed on the ENT Service without transfer to Psychiatry because of the greater overall familiarity with psychiatric psychopathology and the daily presence of a psychiatrist. Otolaryngology surgery, especially of laryngeal and oral-pharyngeal cancers, is complex and often involves multiple procedures, including tracheostomies, and a long postoperative and rehabilitation period. These patients are clearly subjected to a significantly greater amount of stress than is normally encountered in the inpatient setting. It is not surprising, therefore, that a significant amount of psychiatric morbidity was present, although much of it would have been overlooked if the liaison psy-

chiatrist had not been present. Although the most common reactions were Adjustment Disorders and No Disorder (i.e., normal grief), they were usually transitory and managed by brief supportive therapy alone. Lastly, this study indicates that the length of stay of otolaryngology patients referred to the liaison psychiatrist was considerably longer than for all other otolaryngology patients not referred (26.4 vs. 11.1 days). This finding is consistent with those of others who have found significantly increased lengths of stay in the medically ill who have concurrent psychiatric comorbidity [22,23]. Lyons et al. have demonstrated that psychiatric interventions are correlated with earlier hospital discharges than would otherwise have occurred [24]. Therefore, the effects of significantly greater lengths of stay on hospital resource use and total financial costs are such that prompt psychiatric evaluation and intervention may have important cost offset considerations in this patient population. We wish to thank Ms. Susan Michele Sonenreich for her assistance in the preparation of this manuscript and Dr. Cynthia Lezuin for her helpful comments.

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