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Psychiatric disorders, inappropriate health service utilization and the role of consultation-liaison psychiatry
Journal of Psychosomatic Research, Vol. 39, No. 7, pp. 799-802, 1995 Copyright © 1995 Elsevier Science Inc. Printed in Great Britain. All rights reserved. 0022-3999/95 $29.00 + 0.00
Pergamon 0022-3999(95)00019-F
EDITORIAL
PSYCHIATRIC DISORDERS, INAPPROPRIATE HEALTH SERVICE UTILIZATION AND THE ROLE OF CONSULTATION-LIAISON PSYCHIATRY A. HOUSE People with apparently similar physical illnesses use health service resources to differing extents, even when allowance is made for the effect of age and the coexistence of physical disorders other than those for which they are primarily seeking treatment. For example, the variability in complexity, duration and cost of a single episode of hospital care cannot be explained by physical diagnosis alone. The same variability appears when we examine the number of episodes of contact made by each individual. There are differences between hospitals, health districts and regions; this suggests that there is geographical variation either in the severity of disease, or in the way in which health services are delivered (e~g., see [1]). However, there is also variation within single clinical services, which can only be explained by differences between individual patients. One question that arises is whether some of this variability in health service use is accounted for by coexistent psychiatric disorder, and whether such disorder is amenable to treatment, with resultant saving in cost. This editorial is not an exhaustive review of the evidence, but an outline of the argument and an indication of the methodological problems that need to be overcome if convincing evidence is to be collected in future studies. The nature o f the evidence There are three main elements in the argument: (1) It is now widely accepted that psychiatric disorder is common in the general hospital. There is substantial published evidence that diagnosable psychiatric disorders are at least twice as common in the general hospital as they are in the population at large, with a concomitant increase in clinically important disorders that just fail to meet diagnostic criteria. The main problems are mood disorders [2-4]; cognitive impairment [5, 6]; substance misuse [7, 8]; and abnormal illness behaviour or somatization [9, 10]. (2) People identified as having psychiatric problems make more use of nonpsychiatric health services. Among medical clinic attenders, those with psychological problems have higher investigation and treatment costs. For example, in a study from the outpatient and walk-in clinics of Massachusetts General Hospital, Barsky and colleagues showed that the number of medical diagnoses accounted for 33°70 of the variance in subsequent health service utilization, while adding somatic symptoms, disease preoccupation and psychiatric diagnosis explained 56070 of 799
800
Editorial
the variance [11]. Even among the inpatient population, where one would expect to find the greatest burden of severe physical illness, patients with psychiatric comorbidity have increased costs [12, 13]. (3) If psychiatric disorder accounts for the increase in health service utilization, then psychiatric treatment should reduce subsequent costs. There are descriptive data to support this argument [14]. In two studies examining health insurance claims, Schlesinger and colleagues have shown that mental health treatment is followed by a reduction in claims for treatment of physical disorders [15]. Similarly, nonpsychiatric costs in fee-for-service [16] or prepaid medical services [17, 18] seem to be lower following an episode of psychiatric treatment. There is a suggestion that patients with a psychiatric disorder who are seen by a consultation-liaison service during their admission have a shorter overall length of stay [19], especially if they are seen early in the admission [20]. The acid test is the randomized controlled trial of psychiatric intervention, the results of which are unfortunately contradictory. TwO trials have suggested benefits in terms of reduced lengths of stay [21, 22], two have suggested reduction in indirect costs [23] or inpatient prescribing costs [24], and two have yielded negative results [25, 26].
Flaws in the evidence Although the evidence suggests that psychiatric disorder does indeed have clinically important effects on the outcome of treatment for physical illness, there are flaws, which means that none of its conclusions can be accepted absolutely: (1) Although psychopathology does seem to be associated with increased costs, it is not clear that the one explains the other. For example, it is difficult to adjust for confounders like severity of physical illness, poverty and social isolation. (2) If psychiatric disorder does lead to increased nonpsychiatric health service use, it does not follow that the physical care is necessarily inappropriate. People with psychiatric problems have less healthy lifestyles with increased smoking rates, more obesity and less physical exercise, and they are thereby more prone to physical illness than the general population. (3) If identification and treatment of psychiatric cases is followed by reduced costs, we cannot assume that the cost reduction is the result of treatment. Hankin and colleagues [27] found that if a psychiatric diagnosis was made and treatment was given, then subsequent nonpsychiatric health care utilization was reduced, but, disconcertingly, it was also reduced if no treatment was offered after diagnosis. It may be that psychiatric diagnosis leads to reduced access to care as a result of stigmatizing. (4) Even where randomized controlled trials have reported reduced psychopathology and associated nonpsychiatric costs, it has not always been easy to characterize or standardize the intervention so that the method can be applied elsewhere. A number of the intervention studies published to date have been flawed by a choice of active intervention that is so minimalist as to be implausible.
Developing a research agenda The methods used to explore these questions have become more rigorous over the
Editorial
801
years [28], but there are a number of outstanding design problems that need to be addressed in the next generation of research studies. First, we need a more systematic and comprehensive approach to literature searching and reviewing; otherwise there is a real possibility of reporting bias. In the United Kingdom, there are relevant systematic reviews underway under the auspices of the Cochrane Collaboration [29] and the N.H.S. Centre for Reviews and Dissemination [30]. Second, we need good quality prospective studies exploring the relationship between psychopathology and the extent or complexity of nonpsychiatric health care. The two key methodological issues are quantifying inappropriate nonpsychiatric costs attributable to psychiatric disorder, and making proper adjustment for nonpsychiatric confounders [28]. An interesting international venture in this area is the BOMED1 RF [risk factor] study [31]. Third, we must increase the number of well-conducted randomized controlled trials that evaluate competently delivered psychological interventions. The cost of a properly conducted psychological intervention is substantial, but is justified by the need to produce definitive answers in an area where the costs of doing nothing are even more substantial. It follows that such clinical trials should include an economic analysis. Finally, trials should be designed to answer an important question about whether the intervention needs to involve specific psychiatric treatment (which is expensive) or whether a less specific and less expensive form of social work or counseling would be as effective [32, 33]. Psychiatric treatment is expensive, but it is a false economy not to employ it if the alternatives are ineffective. This need not be a competitive or antagonistic comparison. It is likely that in some settings nonspecialist treatment will be as effective as psychiatric treatment, but cheaper. In other settings only psychiatric treatment will be effective. Developing and implementing this research agenda should be high among the priorities of all of those who work in consultation-liaison psychiatry. The issues involved are poorly understood by those who work outside the speciality, and our conviction that they are important must be backed by better empirical evidence than we can martial at the moment. REFERENCES 1. HAM C (Ed). Health Care Variations: Assessing the Evidence. (Research Report No 2). London: Kings Fund Institute, 1990. 2. MOFFIC HS, PAYKEL ES. Depression in medical in-patients. Br JPsychiatry 1975; 126: 346-353. 3. RODIN G, VOSHART K. Depression in the medically ill: an overview. Am J Psychiatry 1986; 143: 696-705. 4. MAYOU R, HAWTON K. Psychiatric disorder in the general hospital. Br J Psychiatry 1986; 149: 172-190. 5. JOHNSTON M, WAKELING A, GRAHAM N, STOKES F. Cognitive impairment, emotional disorder, and length of stay of elderly patients in a district general hospital. Br JMed Psychol. 1987; 60: 133-139. 6. THOMAS R, CAMERON D, FAHS M. A prospective study of delirium and prolonged hospital stay. Arch Gen Psychiatry 1988; 45: 937-940. 7. JONES K, VISCHI TR. Impact of alcohol, drug abuse and mental health treatment on medical care utilisation. Suppl Med Care 1979; 1"1 (12): 1-82. 8. LLOYD G, CHICK J, CROMBIE E. Screening for problem drinkers among medical inpatients. Drug Alcohol Depend. 1982; 10: 335-359. 9. BASSC (Ed). Somatization: Physical Symptoms and Psychological lllness. London: Blackwell, 1990. 10. CREED F, MAYOU R, HOPKINS A (Eds). Medical Symptoms Not Explained by Organic Disease. Royal College of Psychiatrists and Royal College of Physicians of London, 1992.
802
Editorial
11. BARSKY A J, WYSHAK G, KLERMAN G. Medical and psychiatric determinants of outpatient utilization. M e d Care 1986; 24: 548-560. 12. LEVENSON JL, HAMER RM, ROSSITER LF. Relation of psychopathology in general medical inpatients to use and cost of services. A m J Psychiatry 1990; 147: 1498-1503. 13. SARAVAY S, STEINBERG M, WEINSCHEL B, POLLACK S, ALOIS N. Psychological comorbidity and length of stay in the general hospital. A m JPsychiatry 1991; 148: 324-329. 14. JACOBS D. Cost-effectiveness of specialised psychological programs for reducing hospital stays and outpatient visits. J Clin Psychol. 1987; 43: 729-735. 15. SCHLESINGER H, MUMFORD E, GLASS G, PATRICK C, SHARFSTEIN S. Mental health treatment and medical care utilization in a fee-for-service system: outpatient mental health treatment following the onset of a chronic disease. A m J Public Health 1983; 73: 422-429. 16. BORUS J, OLENDZKI M, KESSLER L, BURNS B, BRANDT U, BROVERMAN C, HENDERSON P. The "offset effect" of mental health treatment on ambulatory medical care utilization and charges. Arch Gen Psychiatry 1985; 42: 573-580. 17. FOLLETTE W, CUMMINGS N. Psychiatric services and medical utilization in a prepaid health plan setting. Med Care 1967; 5: 25-35. 18. GOLDBERG I, KRANTZ G, LOCKE B. Effect of a short-term outpatient psychiatric therapy benefit on the utilization of medical services in a prepaid group practice medical programme. Med Care 1970; 8:419-428. 19. LEVITAN S, KORNFELD D. Clinical and cost benefits of liaison psychiatry. A m JPsychiatry 1981; 138: 790-793. 20. LYONS J, HAMMER J, STRAIN J, FULOP G. The timing of psychiatric consultation in the general hospital and length of hospital stay. Gen Hosp Psychiatry 1986; 8: 159-162. 21. GRUEN W. Effects of brief psychotherapy during the hospitalization period on the recovery process in heart attacks. J Counsult Clin Psychol. 1975; 43: 223-232. 22. STRAIN J, LYONS JS, HAMMER J e t al. Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. A m J Psychiatry 1991; 148(8): 1044-1049. 23. MAGUIRE P, PENTOL A, ALLEN D, TAIT A, BROOKE M, SELLWOOD R. Cost of counselling women who undergo mastectomy. Br Med J. 1982; 284: 1933-1935. 24. HENGEVELD M, ANCION F, ROOIJMANS H. Psychiatric consultations with medical inpatients: a randomized controlled cost-effectiveness study. Int J Psychiatry Med. 1988; 18: 33-43. 25. LEVENSON J, HAMER R, ROSSITER L. A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients. A m J Psychiatry 1992; 149: 631-637. 26. SURMAN O, HACKETT T, SILVERBERG E, BEHRENDT D. Usefulness of psychiatric intervention in patients undergoing cardiac surgery. Arch Gen Psychiatry 1974; 30: 830-835. 27. HANKIN J, KESSLER L, GOLDBERG I, STEINWACHS D, STARFIELD B. A longitudinal study of offset in the use of nonpsychiatric services following specialised mental health care. Med Care 1983; 21: 1099-1110. 28. SARAVAY S, LAVIN M. Psychiatric comorbidity and length of stay in the general hospital: a critical review of outcome studies. Psychosomatics 1994; 35: 233-252. 29. COCHRANE COLLABORATION. Preparing, maintaining and disseminating systematic reviews of the effects of health care. Oxford: UK Cochrane Centre, 1994. 30. NHS CENTRE FOR REVIEWS AND DISSEMINATION, University of York, Heslington, York, YO1 5DD. 31. BIOMEDI RF:Ascreeninginstrumeat for the detection of psychosocial risk factors in patients admitted to general hospital wards. Biomed and Health Research Programme (1990-1994) Proposal PL93-1180, Commission of the European Communities, Bruxelles, Belgium, 1993. 32. MUMFORD E, SCHLESINGER H J, GLASS G. The effects of psychological intervention on recovery from surgery and heart attacks: an analysis of the literature. A m JPublic Health 1982; 72:141-151. 33. MUMFORD E, SCHLESINGER H, GLASS G, PATRICK C, CUERDON T. A new look at evidence about reduced cost of medical utilization following mental health treatment. A m J Psychiatry 1984; 141:1145-1158.
Pergamon 0022-3999(95)00019-F
EDITORIAL
PSYCHIATRIC DISORDERS, INAPPROPRIATE HEALTH SERVICE UTILIZATION AND THE ROLE OF CONSULTATION-LIAISON PSYCHIATRY A. HOUSE People with apparently similar physical illnesses use health service resources to differing extents, even when allowance is made for the effect of age and the coexistence of physical disorders other than those for which they are primarily seeking treatment. For example, the variability in complexity, duration and cost of a single episode of hospital care cannot be explained by physical diagnosis alone. The same variability appears when we examine the number of episodes of contact made by each individual. There are differences between hospitals, health districts and regions; this suggests that there is geographical variation either in the severity of disease, or in the way in which health services are delivered (e~g., see [1]). However, there is also variation within single clinical services, which can only be explained by differences between individual patients. One question that arises is whether some of this variability in health service use is accounted for by coexistent psychiatric disorder, and whether such disorder is amenable to treatment, with resultant saving in cost. This editorial is not an exhaustive review of the evidence, but an outline of the argument and an indication of the methodological problems that need to be overcome if convincing evidence is to be collected in future studies. The nature o f the evidence There are three main elements in the argument: (1) It is now widely accepted that psychiatric disorder is common in the general hospital. There is substantial published evidence that diagnosable psychiatric disorders are at least twice as common in the general hospital as they are in the population at large, with a concomitant increase in clinically important disorders that just fail to meet diagnostic criteria. The main problems are mood disorders [2-4]; cognitive impairment [5, 6]; substance misuse [7, 8]; and abnormal illness behaviour or somatization [9, 10]. (2) People identified as having psychiatric problems make more use of nonpsychiatric health services. Among medical clinic attenders, those with psychological problems have higher investigation and treatment costs. For example, in a study from the outpatient and walk-in clinics of Massachusetts General Hospital, Barsky and colleagues showed that the number of medical diagnoses accounted for 33°70 of the variance in subsequent health service utilization, while adding somatic symptoms, disease preoccupation and psychiatric diagnosis explained 56070 of 799
800
Editorial
the variance [11]. Even among the inpatient population, where one would expect to find the greatest burden of severe physical illness, patients with psychiatric comorbidity have increased costs [12, 13]. (3) If psychiatric disorder accounts for the increase in health service utilization, then psychiatric treatment should reduce subsequent costs. There are descriptive data to support this argument [14]. In two studies examining health insurance claims, Schlesinger and colleagues have shown that mental health treatment is followed by a reduction in claims for treatment of physical disorders [15]. Similarly, nonpsychiatric costs in fee-for-service [16] or prepaid medical services [17, 18] seem to be lower following an episode of psychiatric treatment. There is a suggestion that patients with a psychiatric disorder who are seen by a consultation-liaison service during their admission have a shorter overall length of stay [19], especially if they are seen early in the admission [20]. The acid test is the randomized controlled trial of psychiatric intervention, the results of which are unfortunately contradictory. TwO trials have suggested benefits in terms of reduced lengths of stay [21, 22], two have suggested reduction in indirect costs [23] or inpatient prescribing costs [24], and two have yielded negative results [25, 26].
Flaws in the evidence Although the evidence suggests that psychiatric disorder does indeed have clinically important effects on the outcome of treatment for physical illness, there are flaws, which means that none of its conclusions can be accepted absolutely: (1) Although psychopathology does seem to be associated with increased costs, it is not clear that the one explains the other. For example, it is difficult to adjust for confounders like severity of physical illness, poverty and social isolation. (2) If psychiatric disorder does lead to increased nonpsychiatric health service use, it does not follow that the physical care is necessarily inappropriate. People with psychiatric problems have less healthy lifestyles with increased smoking rates, more obesity and less physical exercise, and they are thereby more prone to physical illness than the general population. (3) If identification and treatment of psychiatric cases is followed by reduced costs, we cannot assume that the cost reduction is the result of treatment. Hankin and colleagues [27] found that if a psychiatric diagnosis was made and treatment was given, then subsequent nonpsychiatric health care utilization was reduced, but, disconcertingly, it was also reduced if no treatment was offered after diagnosis. It may be that psychiatric diagnosis leads to reduced access to care as a result of stigmatizing. (4) Even where randomized controlled trials have reported reduced psychopathology and associated nonpsychiatric costs, it has not always been easy to characterize or standardize the intervention so that the method can be applied elsewhere. A number of the intervention studies published to date have been flawed by a choice of active intervention that is so minimalist as to be implausible.
Developing a research agenda The methods used to explore these questions have become more rigorous over the
Editorial
801
years [28], but there are a number of outstanding design problems that need to be addressed in the next generation of research studies. First, we need a more systematic and comprehensive approach to literature searching and reviewing; otherwise there is a real possibility of reporting bias. In the United Kingdom, there are relevant systematic reviews underway under the auspices of the Cochrane Collaboration [29] and the N.H.S. Centre for Reviews and Dissemination [30]. Second, we need good quality prospective studies exploring the relationship between psychopathology and the extent or complexity of nonpsychiatric health care. The two key methodological issues are quantifying inappropriate nonpsychiatric costs attributable to psychiatric disorder, and making proper adjustment for nonpsychiatric confounders [28]. An interesting international venture in this area is the BOMED1 RF [risk factor] study [31]. Third, we must increase the number of well-conducted randomized controlled trials that evaluate competently delivered psychological interventions. The cost of a properly conducted psychological intervention is substantial, but is justified by the need to produce definitive answers in an area where the costs of doing nothing are even more substantial. It follows that such clinical trials should include an economic analysis. Finally, trials should be designed to answer an important question about whether the intervention needs to involve specific psychiatric treatment (which is expensive) or whether a less specific and less expensive form of social work or counseling would be as effective [32, 33]. Psychiatric treatment is expensive, but it is a false economy not to employ it if the alternatives are ineffective. This need not be a competitive or antagonistic comparison. It is likely that in some settings nonspecialist treatment will be as effective as psychiatric treatment, but cheaper. In other settings only psychiatric treatment will be effective. Developing and implementing this research agenda should be high among the priorities of all of those who work in consultation-liaison psychiatry. The issues involved are poorly understood by those who work outside the speciality, and our conviction that they are important must be backed by better empirical evidence than we can martial at the moment. REFERENCES 1. HAM C (Ed). Health Care Variations: Assessing the Evidence. (Research Report No 2). London: Kings Fund Institute, 1990. 2. MOFFIC HS, PAYKEL ES. Depression in medical in-patients. Br JPsychiatry 1975; 126: 346-353. 3. RODIN G, VOSHART K. Depression in the medically ill: an overview. Am J Psychiatry 1986; 143: 696-705. 4. MAYOU R, HAWTON K. Psychiatric disorder in the general hospital. Br J Psychiatry 1986; 149: 172-190. 5. JOHNSTON M, WAKELING A, GRAHAM N, STOKES F. Cognitive impairment, emotional disorder, and length of stay of elderly patients in a district general hospital. Br JMed Psychol. 1987; 60: 133-139. 6. THOMAS R, CAMERON D, FAHS M. A prospective study of delirium and prolonged hospital stay. Arch Gen Psychiatry 1988; 45: 937-940. 7. JONES K, VISCHI TR. Impact of alcohol, drug abuse and mental health treatment on medical care utilisation. Suppl Med Care 1979; 1"1 (12): 1-82. 8. LLOYD G, CHICK J, CROMBIE E. Screening for problem drinkers among medical inpatients. Drug Alcohol Depend. 1982; 10: 335-359. 9. BASSC (Ed). Somatization: Physical Symptoms and Psychological lllness. London: Blackwell, 1990. 10. CREED F, MAYOU R, HOPKINS A (Eds). Medical Symptoms Not Explained by Organic Disease. Royal College of Psychiatrists and Royal College of Physicians of London, 1992.
802
Editorial
11. BARSKY A J, WYSHAK G, KLERMAN G. Medical and psychiatric determinants of outpatient utilization. M e d Care 1986; 24: 548-560. 12. LEVENSON JL, HAMER RM, ROSSITER LF. Relation of psychopathology in general medical inpatients to use and cost of services. A m J Psychiatry 1990; 147: 1498-1503. 13. SARAVAY S, STEINBERG M, WEINSCHEL B, POLLACK S, ALOIS N. Psychological comorbidity and length of stay in the general hospital. A m JPsychiatry 1991; 148: 324-329. 14. JACOBS D. Cost-effectiveness of specialised psychological programs for reducing hospital stays and outpatient visits. J Clin Psychol. 1987; 43: 729-735. 15. SCHLESINGER H, MUMFORD E, GLASS G, PATRICK C, SHARFSTEIN S. Mental health treatment and medical care utilization in a fee-for-service system: outpatient mental health treatment following the onset of a chronic disease. A m J Public Health 1983; 73: 422-429. 16. BORUS J, OLENDZKI M, KESSLER L, BURNS B, BRANDT U, BROVERMAN C, HENDERSON P. The "offset effect" of mental health treatment on ambulatory medical care utilization and charges. Arch Gen Psychiatry 1985; 42: 573-580. 17. FOLLETTE W, CUMMINGS N. Psychiatric services and medical utilization in a prepaid health plan setting. Med Care 1967; 5: 25-35. 18. GOLDBERG I, KRANTZ G, LOCKE B. Effect of a short-term outpatient psychiatric therapy benefit on the utilization of medical services in a prepaid group practice medical programme. Med Care 1970; 8:419-428. 19. LEVITAN S, KORNFELD D. Clinical and cost benefits of liaison psychiatry. A m JPsychiatry 1981; 138: 790-793. 20. LYONS J, HAMMER J, STRAIN J, FULOP G. The timing of psychiatric consultation in the general hospital and length of hospital stay. Gen Hosp Psychiatry 1986; 8: 159-162. 21. GRUEN W. Effects of brief psychotherapy during the hospitalization period on the recovery process in heart attacks. J Counsult Clin Psychol. 1975; 43: 223-232. 22. STRAIN J, LYONS JS, HAMMER J e t al. Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. A m J Psychiatry 1991; 148(8): 1044-1049. 23. MAGUIRE P, PENTOL A, ALLEN D, TAIT A, BROOKE M, SELLWOOD R. Cost of counselling women who undergo mastectomy. Br Med J. 1982; 284: 1933-1935. 24. HENGEVELD M, ANCION F, ROOIJMANS H. Psychiatric consultations with medical inpatients: a randomized controlled cost-effectiveness study. Int J Psychiatry Med. 1988; 18: 33-43. 25. LEVENSON J, HAMER R, ROSSITER L. A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients. A m J Psychiatry 1992; 149: 631-637. 26. SURMAN O, HACKETT T, SILVERBERG E, BEHRENDT D. Usefulness of psychiatric intervention in patients undergoing cardiac surgery. Arch Gen Psychiatry 1974; 30: 830-835. 27. HANKIN J, KESSLER L, GOLDBERG I, STEINWACHS D, STARFIELD B. A longitudinal study of offset in the use of nonpsychiatric services following specialised mental health care. Med Care 1983; 21: 1099-1110. 28. SARAVAY S, LAVIN M. Psychiatric comorbidity and length of stay in the general hospital: a critical review of outcome studies. Psychosomatics 1994; 35: 233-252. 29. COCHRANE COLLABORATION. Preparing, maintaining and disseminating systematic reviews of the effects of health care. Oxford: UK Cochrane Centre, 1994. 30. NHS CENTRE FOR REVIEWS AND DISSEMINATION, University of York, Heslington, York, YO1 5DD. 31. BIOMEDI RF:Ascreeninginstrumeat for the detection of psychosocial risk factors in patients admitted to general hospital wards. Biomed and Health Research Programme (1990-1994) Proposal PL93-1180, Commission of the European Communities, Bruxelles, Belgium, 1993. 32. MUMFORD E, SCHLESINGER H J, GLASS G. The effects of psychological intervention on recovery from surgery and heart attacks: an analysis of the literature. A m JPublic Health 1982; 72:141-151. 33. MUMFORD E, SCHLESINGER H, GLASS G, PATRICK C, CUERDON T. A new look at evidence about reduced cost of medical utilization following mental health treatment. A m J Psychiatry 1984; 141:1145-1158.