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The influence of psychiatric consultation on the course of illness of the general hospital patient
The Influence of Psychiatric Consuhation on the Course of Illness of the General Hospital Patient By
I { A F A E L N]OS-ES AND S t I O S I I A N A B.~IiZ1LAY
p
S Y C I t l A T R I C C O N S U L T A T I O N S in a g e n e r a l h o s p i t a l , or liaison psychi, atry, a r e b e c o m i n g m o r e a n d m o r e w i d e s p r e a d in m o d e r n m e d i c i n e all over the w o r l d . T h e l i t e r a t u r e in t h i s field is, howe~'er, o n l y b e g i n n i n g to a p p e a r m o r e r e g u l a r l y w i t h i n t h e l a s t 10 y e a r s . T h e r e is still a d e a r t h of r e p o r t e d i n v e s t i g a t i o n s . C o n s u l t a t i o n s in a g e n e r a l h o s p i t a l a r e b o t h a n o u t c o m e of i n c r e a s e d s p e c i a l i z a t i o n mad a u effort to c o u n t e r b a l a n c e t h e p r e s e n t overs p e e i u l i z a t i o n , a T h i s is c l e a r l y so for t h e p s y c h i a t r i c c o n s u l t a t i o n , w h i c h r e p r e sents a n a t t e m p t to v i e w b o t h b o d i l y a n d p s y c h o l o g i c a l d i m e n s i o n s of o n e a n d t h e s a m e i n d i v i d u a l a n d , h o p e f u l l y , to i n t e g r a t e t h e m . T h i s s t u d y w a s a i m e d a t a s s e s s i n g t h e i m p a c t of t h e p s y c h i a t r i c c o n s u l t a t i o n o n t h e p a t i e n t in a u o n p s y c h i a t r i c g e n e r a l h o s p i t a l sere, i c e a n d o n t h e c o u r s e o f h i s i ! l n e s s . T h i s i m p a c t w a s a s s e s s e d t)v its i n f l u e ~ c e o n t h e o v e r a l l d i a g n o s i s . o n t h e t h e n x p e u t i e r e c o m m e n d a t i o n s , a n d on t h e p a t i e n t ' s c o n d i t i o n a f t e r
d i s c h a r g e f r o m the h o s p i t a l . I n consultations are requested under to s t u d y t h e i n t e r r e l a t i o n b e t w e e n c o n s u l t a t i o n a n d t h e i n f l u e n c e of the patient.
addition, since experience shows that such a v a r i e t y of c i r e u m s t m ~ c e s , e.:~ it w a s p l a n n e d t h e c i r c u m s t a n c e s l e a d i n g to the r e q u e s t for t h e c o n s u l t a t i o n i t s e l f on w h a t h a p p e n e d to METHOD
All p a t i e n t s o v e r 15 ~,ears of a g e , h o s p i t a l i z e d a t t h e 14othsehild t t a d a s s a h U n i v e r s i t y I l o s p i t a l d u r i n g o n e c a l e n d ~ y e a r , w h o w e r e s e e n in p s y c h i a t r i c colt~ultations r e p r e s e n t t h e p o p u l a t i o n for this s t u d S. T h e list o f p a t i e n t s w a s t a k e n f r o m t h e Ps.vehiatrie C o n s l d t a t i o n R e g i s t e r , w h e r e all c o n s u l t a t i o n s h a d b e e n c h r o n o l o g i c a l l y e t l t e r e d , i n c l u d i n g p s y c h i a t r i c d i a g n o s i s a n d t h e d i s p o s i t i o n . F u r t h e r inform~ttion w a s p r o v i d e d b v w r i t t e n r e p o r t s o f t h e c o n s u l t a n t s to t h e t r e a t i n g p h y s i c i a n . W h e n ~leeessar~'. t h e p s y c h i a t r i c c o n s u l t a n t w a s inter~:iewed in a d d i t i o n . All h a s p i t a l r e c o r d s of patient.s in t h e s t u d y w e r e examined. The inclusion or exclusion of the psychiatric consultant's ret'ommendations in t h e d i s c h a r g e s u m m a r y w e r e particnlarl_v looke~l for. T h e p a t i e n t s " visits in t h e o u t p a t i e n t clinic~ a n d s u b s e q u e n t h o s p i t a l i z a t i o n s w e r e s i m i l a r l y c h e c k e d . A q u e s t i o n n a i r e , s i ~ q e d b y t h e p s y c h i a t r i s t w h o h a d inter~-iewe¢| t h e p a t i e n L w a s se~d o u t to all p a t i e n t s b e t w e e n 8 a n d 18 m o n t h s a~ter t h e consultations. P a t i e n t s w h o d i d not r e s p o n d w i t h i n 2 to 3 w e e k s w e r e s e n t t h e s a m e q n e s t i o m ~ a i r e w i t h a d i f f e r e n t p r e a m b l e . T h o s e w h o d i d n o t r e s p i r e d to t h e sec~rid q , , e s t i o n n a i r e w e r e s e n t a f u r t h e r q u t ~ t i o n n a i r e w i t h a c o v e r i n g l e t t e r a s s t w i n g t h e p a t i e n t o t anon,,anity, a n d n o t r e q t d r i n g hit** to e n t e r his n a m e . R.~,FAEL XIosE.',, M . D . : Dcpartmt~it o/ Psyt'hiatry. ltadttvsa]t Uz~iccr.s-ity llospital a,~d Hadassah tlebretc Unit'er.sily 31edical School, Jerrtsatem, lsrad. SuosH.~x'.-~ BARZILAY, NI.D.: Dcpartmerlt o] Psychiatry, llada~sah Urffcersity llospital atJtl lladassah ttebr~'tt~ VtHt~c,sity ,~ledical School, ]eru.salem. israel. 16 (~.O~,IPI~EHE'~.'~I~,'I-: PsYCI[IA'II~','.~'(~L. ,~. ;~',,'O. | (|:~-:IH~,t'AI;~Y). ].~)('17
PSYCII1ATRIC CONSULTATION AND "IliE GENEIIAI, HOSPITAL .PATIENT
Patients ~
17
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15 f
.
J I0
,5 Age ~ o ~ n 15 i0 J'
o
f e
Study ~Populatlon . . . . . . . . . . . . . . .
,~i"
ao
30
~,o
5o
6o
~e
H~9 p i t a l
Population
Fig. 1 . ~ P a t i c n t s by age: Comparison of study and hospital populations, FINDINGS
T h e Patients, Their lllne.sse.s a n d Their Reactions to the Consultation O n e h u n d r e d s e v e n t y - t h r e e p a t i e n t s were seen in p s y c h i a t r i c c o n s u l t a t i o n d u r i n g 1961, w h i l e 956 ° a d u l t p a t i e n t s w e r e a d m i t t e d to the H a d a s s a h Itospital. 4 After c o r r e c t i n g this figure to m a k e the p o t e n t i a l n e e d for p s y c h i a t r i c c o n s u l t a t i o n c o m p a r a b l e , a c o n s u l t a t i o n rate of z.36 p e r c e n t is f o u n d (16.5 consultations for 7002 patients h o s p i t a l i z e d ) . W h e n c o m p a r i n g this w e i g h t e d a v e r a g e for t h e different services w h i c h r e q u e s t e d p s y c h i a t r i c consultations, w e find t h a t it runs from 8.7 p e r cent for one m e d i c a l service t h r o u g h 3.8 p e r cent for the other to 0 for one of the surgical services, \ V h e n c o m p a r i n g the c o n s u l t a t i v e p o p u l a t i o n w i t h t h e hospital p o p u l a t i o n with r e g a r d to sex a n d age, no difference was f o u n d w i t h r e g a r d to sex alone. However, sex a n d age t o g e t h e r show peaks for b o t h m e n a n d w o m e n at the ages of 19 to 29, mad 40 to 50, after w h i c h t h e r e is a m a r k e d d e c r e a s e (Fig. l ) . A c o m p a r i s o n of our p o p u l a t i o n w i t h the-. J e w i s h p o p u l a t i o n of Israel s h o w e d a relative p r e p o n d e r a n c e of E u r o p e a n - b o r n a m o n g t h e st-ucly p o p u l a tion (44.6 p e r cent vs. 37,3 p e r cent). T h e only e t h n i c g r o u p a m o n g s t the Asiana n d A f r i c a n - b o r n w h i c h was o v e r r c p r e s e n t c d w e r e the I r a q i - b o n a (9.4 pea" cent vs. 6.4 per ¢:ent). Seniority in the count."3," was a r e l e v a n t factor ha t h a t i m m i g r a n t s w h o c a m e to Israel b e f o r e 1948 are ve~, m u c h o v e r r e p r e s e n t e d in o u r p o p u l a t i o n (32.4 per cent vs. 16.6 per c e n t ) . Possibly this s e g r a e n t of t h e p o p u l a t i o n , w h i c h shows less m e n t a l illness on statistics of h o s p i t a l admissions, ~ tends m o r e to show a d a p t a t i o n a l difficulties t h r o u g h p s y c h o s o m a t i c p h e n o m e n a . ,Marital status does not differentiate b e t w e e n the two groups. T h e only n o t e w o r t h y finding is that t h e r e are t h r e e times m o r e d i v o r c e d persons a m o n g the s t u d y g r o u p (4.6 per cent vs. ].4 p e r cent ).
318
MosEs AND BARZZLAY
V~Zhen looking at t h e distribution of d o m i n a n t systems involved in the p a tients" major complaint, w e find that, in line w i t h the findings of K a u f m a n a n d Bernstein, e' t h e system most involved is the gastrointestinal one. \,Vhile these authors l i s t multiple s y m p t o m s as the second largest group, the next tnvo most i m p o r t a n t systems are, as in o u r study, the museuloskeletal a n d r e s p i r a t o r y systems. In our population, a b o u t 45 p e r cent of the patients listed s y m p t o m s in one b o d y system only, a n d a b o u t 55 p e r c e n t of the patients listed s y m p toms in a n u m b e r of systems. This is in l i n e w i t h findings on a medical w a r d in israel ~r. 7 L e n g t h of hospitalization of t h e s t u d y population shows t h a t p a t i e n t s hospitalized for more t h a n a m o n t h h a v e a g r e a t e r t h a n a v e r a g e e h a n c e for referral for p s y c h i a t r i c consultation (27.4 p e r cent vs. 10.5 per c e n t ) , w h e r e a s patients hospitalized for u p to a w e e k h a v e a m u c h b e l o w a v e r a g e chance (20.7 p e r cent vs. 38.2 per cent). W h e n e x a m i n i n g the patients" histories for the d u r a t i o n of their illnesse; or complaints, the chronicity of illness in our p o p u l a t i o n b e c o m e s a p p a r e n t (125 patients s h o w chronic illness, 15 s u b a c u t e a n d 33 a c u t e illness); 94 patients, or 54.3 p e r cent, h a d previously b e e n hospitalized for the s a m e complaints. W e believe that the p r e p o n d e r a n c e of multiple-system involvement, of long hospitalization, a n d of ehronicity o f illness indicates m o r e than a p r e p o n d e r ance of emotional d i s t u r b a n c e in t h e s t u d y population. O t h e r studies 7.*~.~:~.aa indicate t h a t similar disturbaa~ces exist also in those hospitalized for shorter periods, b u t t h a t these patients a r e not r e f e r r e d to a psychiatrist b e c a u s e t h e shorter hospitalization does not foster s u c h referrals. O f t e n the decision for a referral did not r i p e n in t h a t time; at other times emotional factors are considered only p e r exclusionem, w h e n t h e p a t i e n t is a l r e a d y a b o u t to be discharged, a A n examiaaation of the psychiatric diagnoses ha our p o p u l a t i o n shows a p r e p o n d e r a n c e of p s y e h o p h y s i o l o g i c a ! r e a c t i o n s - - - 3 7 p e r cent. W h e n all patients, ineluding those with psychophysiologieal reactions, arc d i a g n o s e d psychiatrically, the largest p s y c h i a t r i e diagnostic g r o u p s are those of personality d i s o r d e r (28.9 per c e n t ) a n d neurosis (27.7 p e r cent), Neurosis is diagaaosed m u c h m o r e 1frequently in w o m e n than in men ( 6 : 1 , w h e n the t e m a l e : m a l e ratio in the p o p u l a t i o n is 10:7). T a b l e 1 presents the d e g r e e of emotional d i s t u r b a n c e in the s t u d y population a n d s h o w s t h a t a b o u t 80 p e r cent of those r e f e r r e d to the psychiatrist show a m o d e r a t e or severe d i s t u r b a n c e . T h e consultant's assessment of the relation of the patient's emotional state to the major complaint w a s t h a t for 100 patients (57.8 p e r cent), their emotional state w a s an etiological factor for the m a j o r m e d i c a l complaint. In 26 patients (15 p e r c e n t ) there w a s no evidence of a connection b e t w e e n the emotiolml state a n d t h e m a j o r complaint. ~Vhen we e x a m i n e d the d e g r e e of insight in o u r population, w e f o u n d that a large majority (65,9 p e r cent) of the patients h a d no insight. A l t h o u g h the occasional brevity a n d the small n u m b e r of interviews are clearly a fitctor, these figures are also in k e e p i n g with clinical experience a n d with the "psycho-
19
FSYCHIATlllC CONSULTATION AND T H E GENEBAL HOSPITAL PATIENT Table D~ree
1.~Degree
o f E m o t i o n a l D i s t u r b a n c e in Sttt~g Patie~ffs
of Disturbance
No. of Patient~
Severe Moderate
71 67
1
138
Slight None Unclear
"_95 ) 6 ~ 4
35
)
Total
173
T a b l e 2 . - - - T r e a t m e n t R e c o m m e n d e d for S t u d y P a t i e n t s Treatment
Recommended
No. of Patients
4
Psychiatric hospitalization on closed w a r d P~vchiatrie hospitaiizata'on on open w a r d
20
Total p~lchiatric lwspitaIizations Ambulatory psychotherapy Social casework
78 5
Total ambulatory treatmeut Tolal l}Sr.ldffalric healmellt recommended subsequent to hospitalization P s y c h o t h e r a p y on hospital service Drug t r e a t m e n t on hospital service Social casework on hospital service Total treatment cm hospital sercice after consultation Supportive trvahnent b y geDerM practitioner N o psychiatric t r e a t m e n t ]'sychiatrie t r e a t m e n t r e c o m m e n d e d b u t unspeeifled • Total
24
83 lot 9
I0 6
2.5 9 _08 4 173
somatic" patient's t e n d e n c y to d e f e n d against the recognition of his emotional difficulties b y "somatization." T h e reaction of patients to the psychiatric i n t e r v i e w is in line w i t h this last finding. L a c k of insight does n o t m e a n a lack of readiness to d i s c u s s oneself or one's p r o b l e m s as long as no c o m m i t m e n t to t h e i r recognition i s required. O n l y 21 (22.1 p e r cent) patients s h o w e d or voiced clear-cut objections to the p s y c h i a t r i c interxdew. Fifty-seven patients (.3,3 p e r e e n t ) : e x p r e s s e d "satisfaction'" w i t h the interview on our questionnaire.
Tile Consultant's Recommendation After h a v i n g e x a m i n e d the composition of our patiehts, their illnesses a n d their reactions to t h e psychiatric interview, w e will n o w look at the psychiatrist's r e c o m m e n d a t i o n s ( T a b l e 2). T h e most striking feature is the very h i g h p e r c e n t a g e of patients for w h o m a m b u l a t o r y p s y c h o t h e r a p y was r e c o m m e n d e d 45.1 p e r cent. This finding is identical with that of Spencer s and of M e y e r and M e n d e l s o n ? In all, i n c l u d i n g p s y c h i a t r i c hospitalization, about 60 p e r cent of the patients w e r e r e f e r r e d for regular p s y e h o t h e r a p e u t i c treatment.
20
~'IOSFkS AND BARZILAY Table 3,~Diagnosis and Treatment in Psychiatric Consultant's Report and in the Hospital Summary Reflection of Consultant's
O p i n i o n in H o s p i t a l S u m m a r y
S u m m a r y goes b e y o n d psychiatrist's r e p o r t A p p r o p r i a t e to r e por t E m o t i o n a l f a c t or only i n c i d e n t a l l y menticmt,d E m o t i o n a l f a c t or not m e n t i o n e d
Total
R e Dial~noals
Re T r t m ~ m c n t
9 80 20 64
2 8.C) ,5 77
173
173
In m o r e t h a n h a l f - - i . e . , 57.2 p e r c e n t of the p a t i e n t s ~ t h e specific reason for w h i c h the t r e a t i n g p h y s i c i a n r e q u e s t e d the p s y c h i a t r i c consultation comes u n d e r t h e general, if s o m e w h a t vague, h e a d i n g of help v,,itla diagnosis a n d c o m p r e h e n s i v e t r e a t m e n t . In 7 p e r cent of t h e patients, the r e q u e s t was for assistance with the m a n a g e m e n t of the patient. F o r 30 p e r cent of the patients, help w a s r e q u e s t e d for a p r o b l e m considered u n r e l a t e d to the medical illness. W e are n o w in the process of a n a l y z i n g in m o r e detail some of the reasons l e a d i n g to psychiatric referrals a c c o r d i n g to a questionnaire d e v e l o p e d after t h e p e r i o d d u r i n g w h i c h this stud), was carried out. TM Finally, w e wish to look at the d e g r e e to w h i c h the physician w h o summ a r i z e d the hospital course of his p a t i e n t took into a c c o u n t the psychiatric consultant's opinions a n d h o w he did this ( T a b l e 3). In a small p e r c e n t a g e , the t r e a t i n g physician gives g r e a t e r w e i g h t to the emotional factors t h a n the consultant h a d done. F o r example, Mr. A. w a s a 40-year-old m a n suffering f r o m B u r g e r ~ disease, all f o u r of v,qlose limbs h a d b e e n a m p u t a t e d to s o m e extent. T h e psychiatric consultant, called in-t~ecause of lack of cooperation on the patient's part, s a w him 12 times, l i e d i a g n o s e d p a r a n o i d trends as a reaction to the illness a n d r e c o m m e n d e d social investigation to m a k e a d e q u a t e provisions. A l t h o u g h the consultant specifically w a r n e d against psy'chiatrie hospitalization, w h i c h he t h o u g h t m i g h t lead to a psychotic regression in the patient, the t r e a t i n g physician included a r e c o m m e n d a t i o n for hospitalization on a closed w a r d in his s u m m a r y . O n tim o t h e r h a n d , it is g r a t i f y i n g to note that in a b o u t half the patients, the s u m m a r y a d e q u a t e l y reflects tile views of the p s y c h i a t r i c consultant. F o l l o w - U p a n d lts Results
T a b l e 4 shows t h e response to our written communications. Seventeen patients died, two o f ' t h e m b y their o w n h a n d . O f tile r e m a i n d e r , less those w h o w e r e a b r o a d or w h o could not b e located, 68.7 p e r ce12t r e t u r n e d the questionnaires. T h r e e of these w e r e filled in only partially a n d w e r e therefore d i s c a r d e d . Of the ,99 patients, 64 or two-thirds replied ill response to the first questionnaire: 26 replied in response to tile second questionnaire a n d 6 in reply to the third. A m o n g these 6, we l e a r n e d that three replied only b e c a u s e t h e y w e r e able to maintain their a n o n y m i t y . O n e of those called twice on the t e l e p h o n e from a distance of 100 miles. It m a y thus l,-e r e a s o n a b l e to a s s u m e that a
I~SYC/tIATRIC
CONSULTATION
AND
THE
GENERAL
HOSPITAL
2I
PATII~NT
Table 4 . ~ F o l l o w - u p O u t c o m e Follow-Up Outcome
Replies received Questionnaires not returned Questionnaires did not rcach destination: (1) Patient abroad (2) Incorrect address Died To~l
No. of Patient~
99 45 12 (3) (9) 17 173
n u m b e r of those w h o did not r e t u r n the questionnaires failed to do so b e c a u s e they- did not w a n t written d a t a on t h e m to b e available in t h e hospital. O f the 96 patients w h o s e questionnaires w e r e fully filled in, 41.7 p e r cent (40) s h o w e d subjective i m p r o v e m e n t of their m a j o r complaint, O v e r a third (37) continue to suffer from their complaint, a n d 7 (7.3 p e r c e n t ) feel subjectively worse. F o u r t e e n patients n o w suffer from o t h e r complaints. T h e 96 patients w h o filled in the questionnaire h a d been asked to assess the influence of the psychiatric eonsnltation: 36.5 p e r cent i n d i c a t e d a positive response to the psychiatric consultation; 45.9 p e r cent i n d i c a t e d t h a t the consultation h a d land no influence on theni; a n d 2 p e r cent s h o w e d a negative response. E l e v e n p e r c e n t of the patients w o u l d not assess the influence of the consultation. It is interesting to note t h a t 5 patients did not r e m e m b e r ~ i . e . , p r e s u m a b l y r e p r e s s e d ~ t h e consultation. As r e g a r d s the follow-up b y the p a t i e n t of the psychiatrist's r e c o m m e n d a tions, 32 of the 96 r e s p o n d e r s to the follow-up entered p s y c h i a t r i c t r e a t m e n t . Eleven of these w e r e hospitalized one on a closed w a r d a n d ten on open wards. O f these, eight received p s y c b o t h e r a p y ; t h e y a n d two others stated that they h a d b e e n helped. O n e p a t i e n t stated t h a t he felt worse. T h i r t e e n patients e n t e r e d a m b u l a t o r y p s y c h o t h e r a p y . T h r e e s t o p p e d after only 2 interviews. T h r e e continue in p s y c h o t h e r a p y . O n e patient land interr u p t e d t r e a t m e n t a n d r e s u m e d after she r e n e w e d contact with us t h r o u g h the questionnaire. F o u r p a t i e n t s h a d t e r m i n a t e d p s y c h o t h e r a p y hy m u t u a l agreem e n t with the therapist a n d s t a t e d t h a t the), feel well. O n e patient, w h o s e major complaint w a s a s t h m a , stated t h a t the number, of his a s t h m a t i c attacks decreased, h u t did not relate this i m p r o v e m e n t to the t e r m i n a t e d p s y c h o t h e r apy, The last p a t i e n t in this g r o u p i n t e r r u p t e d t r e a t m e n t a n d s a w no imp r o v e m e n t in h e r condition. F i v e patients w e r e t r e a t e d by casework; only one of these i n d i c a t e d an i m p r o v e m e n t of his condition. O n e p a t i e n t continued to receive " s u p p o r t i v e " t r e a t m e n t from his physician outside the hospital; he stated that his complaints continued as before. T w o patients did not accept Ithe r e f e r r a l for p s y c h o t h e r a p y at the time, T h e i r condition detr.,eioratcd; they s u b s e q u e n t l y r e q u i r e d hospitalization on a closed w a r d a n d indicate a w o r s e n i n g of their condition. O f those 55 patients w h o did not r e p l y to the questionnaire, we f o u n d from the hospital records that 19 e n t e r e d psychiatric t r e a t m e n t as a result of the
~2
.~.IOSI';S A N D B~klIZ1LAY
c o n s u l t a t i o n ~ 1 0 o n a p s y c h i a t r i c w a r d and 9 on an o u t p a t i e n t basis. I n f o r m a tion on these p a t i e n t s is g i v e n w i t h o u t an a t t e m p t to infer a n y valid conclusions, since t h e y r e p r e s e n t a p a r t of the s a m p l e on w h i c h o n l y p a r t i a l i n f o r m a tion is available. It is, h o w e v e r , of interest to be able to give some i n f o r m a t i o n on n o n r e s p o n d e r s . DtscussIox T h e l i t e r a t u r e is r e p l e t e w i t h reports from ditferent b r a n c h e s of m e d i c i n e , b o t h hapatient mad o u t p a t i e n t ; in different eountrie,s, w h i c h assess the n u m b e r of p a t i e n t s w i t h e m o t i o n a l d i s t u r b a n c e . T h e s e r a n g e from 26 p e r cent of 975 p a t i e n t s seen in an e m e r g e n c y r o o m in E n g l a n d , ~'' t h r o u g h 3 0 per c e n t on m e d i c a l mad surg'ical wards, 10 per c e n t w i t h severe a n d 20 per cent w i t h slight d i s t r u b a n e e s ; ~ 34 p e r cent in i n t e r n a l m e d i c a l practice;! 2 45.8 per cent of 602 h o s p i t a l i z e d m e d i c a l patients with "'serious e m o t i o n a l d i s t u r b a n c e . "'~:; Eighty-six p e r cent of a s a m p l e of 200 out of 3680 surgical p a t i e n t s were, f o u n d to be d i s t u r b e d e m o t i o n a l l y a n d a sig'nifieant r e l a t i o n s h i p b e t w e e n the surgical mad e m o t i o n a l d i s t u r b a n c e was f o t m d in 48.5 per c:ent34 In 500 p a t i e n t s on g e n e r a l hospital wards, e m o t i o n a l d i s t u r b a n c e was d i a g n o s e d in 62 per c e n t ~ a n d of these, p s y c h o g e n i c disease i n 22 p e r cent a n d a p s y c h o l o g i c a l comp o n e n t in the s o m a t i c disease in 40 p e r cent. ~:' Still h i g h e r figures w e r e f o u n d in 253 p a t i e n t s on g e n e r a l h o s p i t a l wards, w h e r e 68.8 per cent had d i a g n o s a b l e e m o t i o n a l d i s t u r b a n c e , a*~ T h e same a u t h o r s f o u n d t h a t in 8z.3 per c e n t of "'psychosomatic" diseases, the illness was f o u n d to be r e l a t e d to a p s y c h i a t r i c disorder. In f u n c t i o n a l disorders w i t h o u t o r g a n i c findings, these a u t h o r s found 89.5 p e r c e n t of the illnesses to be rebated to the complaints. For o t h e r illnesses, t h e c o m p a r a b l e figure was 60.9 per cent. On a m e d i c a l w a r d in a g e n e r a l h o s p i t a l h~ Israel, a r a n d o m s a m p l e of S0 p a t i e n t s s h o w e d 80 per cent to h a v e serious p s y c h o s o c i a l i n c a p a c i t a t i o n s 2 6 per c e n t of a severe, a n d .54 per c e n t of a m o d e r a t e , n a t u r e - - a n d 16.3 p e r cent to h a v e mild i n c a p a c i t a t i o n 3 O n a d i a ~ l o s t i e c o n s u l t a t i v e service at Nit. Sinai t lospital. N e w York, 814 out of 1000 p a t i e n t s ~ i . e . , 81.4 per c e n t ~ w e r e f o u n d to be suffering from e m o t i o n a l d i s t u r b a n c e clearly r e l a t e d to t h e i r s o m a t i c complaint.'; A l t h o u g h no figures on t h e p r e v a l e n c e of e m o t i o n a l d i s t u r b a n c e in the p a t i e n t s in our h o s p i t a l are available, there is no reason to assume t h a t the p a t i e n t p o p u l a t i o n here w o u l d be very m u c h different from elsewhere, particul a r l y since it is a t e a c h i n g hospital. T h e fact that o n l y :2.36 p e r c e n t of all p a t i e n t s h o s p i t a l i z e d in t h e t l a d a s s a h U n i v e r s i t y H o s p i t a l w e r e r e f e r r e d for p s y c h i a t r i c eorLsult~,Hon thus p r e s e n t s a clear i n d i c a t i o n of e i t h e r a low a w a r e n e s s of p s y c h i a t r i c p r o b l e m s in t h e h o s p i t a l or of the lack of readiness to, tr),- to do s o m e t h i n g a b o u t it. Since, h o w e v e r , the large m a j o r i t y of p a p e r s q u o t e d referred to s y s t e m a t i c studies of p a t i e n t p o p u l a t i o n s r a t h e r t h a n to t h e e x a m i n a t i o n of t h e r o u t i n e of c o n s u l t a t i v e ser~'iee, w e w o u l d assume that this a s t o n i s h i n g l y low figure is not so different from figures in m a n y o t h e r hospitals. ,and is p r o b a b l y h i g h e r t h a n in some. T a b l e 5 gives a c o m p a r i s o n b e t w e e n qae finditags in a n u m b e r of these
I~S't'CIIIATtllC
CONSULTATION
AND
"lqlE
ClgNEItAL
IIOSI-'ITAI.
23
PATIENT
Table 5.--Diagnostic Classification of l"atients in Diffq~ent Studies OverMl Diagnosis
Author
Pemberton 17 [lelshorgh-~ Payson ~:~ Kau fman et a l . ~ Kanlrman and Bcrnstein~; Moses and LothaneV Study l)opulation
Organic Psychoonly somatic
0 r K a n ie alqd FuncP'sychotional h~giea~?
3° 58 27
-19 11 13
3:3
20
8
.9.z,~
15
10 4
( Pereontage~ I
. . ~ --
. . ---
Psyehint tie Diagnosis
Person a I i ty Disorders and Psycho- Other Total Neuroses ~es Ding,
t Percentages)
lifo Enlot. Disordtr
T~*tal
8 o.27) 17
~ ~ ~
~ ---
~ --
l0 5 35
1 13 8
39
100
50
8
9
:3:3
103
~3
39
100
-t9
9
:~3 ~_.
19
1 f:O
18.5
54
17.5
i00
.
37
~
59
100
57
.
. 13
.
. 26
Overall Total
100 t 00 100
. 4
I GO
s t u d i e s w i t h o u r o w n . It b e c o m e s e v i d e n t f r o m this t a b l e t h a t t h e m a i o r i t y of p s y c h i a t r i c d i s t u r b a n c e s are p s y c h o n e u r o s e s a n d p e r s o n a l i t y d i s t u r b a n c e s , a n d t h a t m o s t of t h e s e p a t i e n t s suffer f r o m " f u n c t i o n a l " or " p s y e h o s o n a a t i c " di::ease. T h e s i m i l a r i t y b e t w e e n m o s t of t h e s e s t u d i e s a n d o u r o ~ m is striking, p a r t i c u larly t h e o n e of K a u f i n a n a n d B e r n s t e i n ~ c a r r i e d o u t on 1000 p a t i e n t s . \ V h e n e x a m i n i n g t h e factors l e a d i n g to p s y c h i a t r i c c o n s u l t a t i o n , w e find, in line w i t h M e y e r mad M ( n d e l s o n , - t h a t w h a t m o t i v a t e s t h e h o s p i t a l physieima to r e q u e s t at p s y c h i a t r i c r e f e r r a l is m o s t l y b e h a v i o r on t h e p a r t of t h e p a t i e n t w h i c h s e e m s o u t of p l a c e or d i s q u i e t i n g . It is this m u c h m o r e t h a n t h e a b s t r a c t k n o w l e d g e t h a t a c e r t a i n d i s e a s e is c o n s i d e r e d to b e "'psychosonmtie,'" or t h e wish to a p p r o a c h an illness b o t h f r o m t h e p h y s i c a l a n d t h e e m o t i o n a l aspect. T h e c o n n e c t i n g link betwc, en t h e b e h a v i o r a l d i s t u r b a n c e a n d t h e r e f e r r a l c a n safely b e a s s u m e d to b e this f e e l i n g of h e l p l e s s n e s s t o w a r d m a n i f e s t a t i o n s which the physician can neither explain nor influence. A l a r g e p r o p o r t i o n of c o n s u l t a t i o n s w e r e r e q u e s t e d for p a t i e n t s w i t h p s y c h o s o m a t i c a n d f u n c t i o n a l d i s o r d e r s ~ j n o u r s t u d y a total of 64 p a t i e n t s o r 3 7 p e r c e o t of t h e s t u d y p o p u l a t i o n . " T h e m a j o r i t y o f c o n s u l t a t i o n s (63 p e r c e n t ) w e r e r e q u e s t e d in o r d e r to o b t a i n h e l p w i t h d i a g n o s i s a n d c o m p r e h e n s i v e treatme~at. In o t h e r w o r d s , t h e m a i n a i m w a s to e v a l u a t e t h e e m o t i o n a l f a c t o r in c g m p l a i n t s of t h e p a t i e n t s w h i c h w e r e d i r e c t l y r e l a t e d to t h e p r e s e n t h o s p i t a l i z a t i o n . As an o v e r a l l find -~ • ing, this s e e m s to i n d i c a t e a f r u i t f u l u t i l i z a t i o n of p s y c h i a t r i c c o n s u l t a t i o n . ttowever, one must take into account that such a general formulation hides m a n y m o r e d e t a i l e d factors, p a r t i c u l a r l y in t h e d o c t o r - p a t i e n t r e l a t i o n s h i p o n t h e w a r d , w h i c h s h o u l d b e s t u d i e d a n d e v a l u a t e d m o r e closely. S u c h a s t u d y is n o w in p r o g r e s s in o u r d e p a r t n a e n t , lt~ A c t u a l figures f o r t h e p e r c e n t a g e of p s y c h i a t r i c c o n s u l t a t i o n s of h o s p i t a l i z e d p a t i e n t s a r e a v a i l a b l e o n l y f r o m t h e s t31~dies of M e y e r a n d ~ l e n d e l s o n 9 a n d P a r s o n . I~ At John's l-lopkil~s t h e figures b"ver a p e r i o d o f 5 y e a r s r a n g e f r o m 4.9
04
~ I O S E S A N D ]3AI1ZILAY
p e r cent to 8.8 p e r cent. At Yale a2 tile figure given for one y e a r is 13.3 per cent. I n c o n s i d e r i n g the differences b e t w e e n these fig'ures a n d our own, one m i g h t p e r h a p s w o n d e r w h e t h e r tile p r e v a l e n c e of emol~ional d i s t u r b a n c e in Israel is lower. F r o m the few figures a v a i l a b l e in Israel, ~ it is c e r t a i n l y clear that the n u m b e r of psychiatric hospitalizations here is r o u g h l y the same as in the U. S. a n d in E n g l a n d . F r o m w h a t is k n o w n about the relationship b e t w e e n social c h a n g e and m e n t a l illness, there is no reason to believe flint in a country of mass immigration from both XVesteni and O r i e n t a l countries into a conglomerate b u t \ V e s t e m i z e d cultural milieu, there should b e any less m a l a d j u s t m e n t than elsewhere, Since, in addition, our p o p u l a t i o n is c o m p a r a b l e both with the overall hospital p o p u l a t i o n for the s a m e y e a r a n d with the p o p u l a t i o n of Israel, it can be r e g a r d e d as representative. Therefore, there seems to h e every reason to b e l i e v e that the small n m n b e r of requests for psychiatric consultation does not reflect the p r e v a l e n c e of emotional disorder but rather the attitudes of the p h y s i c i a n s on our services to psychiatric diagnosis a n d treatment. True. w e only b e g a n to i n t r o d u c e a psychiatric liaison service in the y e a r d u r i n g w h i c h this s t u d y was carried out, a n d such liaison service is given only to a small n u m b e r of wards. W e h a d b e e n aware previously of the fact that t h e n e e d for psychiatric consultation is directly proportional to the quality and q u a n t i t y of service given in this area, a n d we f o u n d corroboration for this in the last few years. V~:hen e x a m i n i n g the influence of the consultative psychiatric i n t e r v i e w on the patient, the psychoanaiytie~dly oriented psychiatrist is again b r o u g h t up sh,-u'ply with the s o m e t i m e s u n e x p e c t e d fact that even one such interview m a y h a v e at least subjective t h e r a p e u t i c effects. T w e n t y - t h r e e of our patients who h a d experienced subjective i m p r o v e m e n t clearly do not relate this to the p s y c h i a t r i c consultation for reasons related to their own p s y c h o d y n a m i c equilibrium. In a n u m b e r of our patients the c o n s u l t a n t s ~ w h o , b y a n d large, did not hesitate to indicate the a b s e n c e of t h e r a p e u t i c effect of their consultat i o n s ~ f e l t sure t h a t the consultative interview h a d i n d e e d b e e n beneficial to t h e patient. I n the light of reports in the literature r e g a r d i n g the h i g h n u m b e r of rec o m m e n d a t i o n s for p s y c h o t h e r a p y g r o w i n g out of. consultative work a n d its d i s c r e p a n c y w i t h the very low n u m b e r of patients w h o actually continue in p s y c h o t h e r a p y afterwards, "~ it is interesting to view w h a t h a p p e n e d to the p a t i e n t s for w h o m a m b u l a t o W p s y c h o t h e r a p y or casework was r e c o m m e n d e d . T h e l a e t that 51 out of 107 patients h a d b e g u n p s y c h o t h e r a p y presents a figure w h i c h seems q u i t e h i g h a n d c o m p a r e s x'ery f a v o r a b l y with that q u o t e d b y Spencer in C h a p e l Hill, North Carolina. s O u r hospital s u m m a r i e s s h o w e d that the t r e a t i n g physicians w h o r e q u e s t e d p s y c h i a t r i c c o n s u l t a t i o n s ~ m o s t l y for patients with m o d e r a t e or severe emotional d i s t u r b a n c e s ~ i n d i c a t e this fact only in h a l f of the patients, w h e n rep o r t i n g to the treating p h y s i c i a n outside the hospital. H e r e a g a i n we encounter b a s i c attitudes toward the emotions a n d t o w a r d p s y c h i a t r y w h i c h affect doctors, a n d through them, their patients. T h e t e n d e n c y to invite a patient to
I ' S Y C I t l A T R I C C O N S U L T A T I O N AND "lqqtE G E N E R A L I t O S P 1 T A L P A T I E N T
25
"pull h i m s e l f together" or "to forget a b o u t it" has b e e n described, i.a., b y Berger as a n d is well known. E v e n in those s u m m a r i e s w h i c h i n c l u d e d a r e f e r e n c e to the emotional disturbance, w e f o u n d p h r a s e s such as "the psychiatrist was not able to convince the p a t i e n t . . . ' " w h i c h indicate the treating physician's desire to relegate the responsibility for his patient's emotions to the psychiatrist. Finally, as w e look at the results of psychiatric treatment, of the 32 k n o w n patients w h o e n t e r e d p s y c h o t h e r a p y as a direct result of the consultation, w e find t h a t if one leaves out those w h o c a m e for less t h a n 3 interviews a n d those who are still in t r e a t m e n t ~ a total of 15 p a t i e n t s ~ 1 5 out of the r e m a i n i n g 18 reported that t h e y were h e l p e d b y this h'eatment. CONCLUSION
Psychiatric consultations represent one route of access to emotionally dist u r b e d persons. I n most general hospitals w h i c h h a v e no tradition, or only a brief one, of a psychiatri c liaison service, such consultations are u s e d relatively sparsely. W h e n they are used, however, their share in the i m p r o v e m e n t of the symptomatolog3" related to the hospital admission a p p e a r s to w a r r a n t approval of the current t r e n d of increased psychiatric liaison services a n d i n c r e a s e d psychiatric consultation. SUhIXIARY
T h e data on psychiatric consultations in a general t e a c h i n g hospital in Israel for a period of one y e a r are a n a l y z e d in terms of the p e r c e n t a g e of hospitalized patients referred, its c o m p a r i s o n w i t h the hospital p o p u l a t i o n a n d the p o p u l a t i o n at large. Personal data of the s t u d y p o p u l a t i o n are looked at to d e t e r m i n e special "qaigh risk" groups. T h e p o p u l a t i o n is a n a l y z e d for type of symptoms, their relation to tile p r e s e n t i n g illness, the severity of their psychological disturbance, a n d psychiatric diagnosis. T h e s e variables are c o m p a r e d with other studies of m e d i c a l patients in the literature. A second area exa m i n e d was tile patient's reaction to the psychiatric extunination at the time and the extent to w h i c h the treating p h y s i c i a n m a d e use of the psychiatric consultant's r e c o m m e n d a t i o n . A w r i t t e n follov¢-up s t u d y was carried out on all patients, w i t h information received for two-thirds of the population. T h e patient's estimate of the usefulness of a consultation was recorded, as wa/s,4~he present state of the condition for w h i c h ]~e h a d b e e n hospitalized. S ' m ~ ' r l y , the extent to w h i c h the p a t i e n t followed the consultant's r e c o m m e n d a t i o n was studied. T h e £ n d i n g s of this s t u d y i n d i c a t e tlfat a small p e r c e n t a g e (2.36 p e r cent) of the general hospital p o p u l a t i o n was referred" a n d t h a t this s e e m e d to reflect the treating p h y s i c i a n ' s a t t i t u d e s r a t h e r t h a n an i n h e r e n t difference in ineidence. C e r t a i n p o p u l a t i o n glTo{;ps • s h o w e d ,an increased "referral rate, w h i c h m a y relate e i t h e r to their i n c r e a s e d i n c i d e n c e rate of emotional d i s t u r b a n c e Or to the p h y s i c i a n ' s i n c r e a s e d desire to refer :sick p a t i e n t s w h i c h are c u l t u r a l l y more distant to him. T h e overall r e s p o n s e to psychiatric consultations seems to show the n e e d for
26
3IOS'ES AND BARZILAY
such consultations, organized as a psychiatric liaison service, and an overall subjective assessment of its usefulness by the patients, Some of the problems inherent in this psychiatric consultative situation are discussed. REFERENCES Psychosom. Med. 7:22, 1945, 1. Balint, M.: The pyramid and the psychotherapeutic relationship. Lancet 12. ]-lanunan, L.: The relationship of" psy2:1051, 1961. chiatry to internal medicine. Ment. 2. Meyeri E., and Mendelson, M.i PsyHyg. 23:177, 1939. chiatric consultations with patients on 13. Payson, "H., et al.: Recognition and medical and surgical wards. Psychiatry referral of psychiatric illness on a 24:197, 1961. university medical inpatient service. 3. Moses, R., Noy, P., Kaplan-DeNour. A,, Read at Amer. Psychiat. Assn. Meeting, and Wollstein, S.: Defensive patterns 1961. of psychiatric consultants in the gen14. Zwerling, I.. et al.: Personality distureral hospital. Harefuah 68:18, 1965. bances and relationship to evaluation 4. Hadassah Medical Organization Annual of surgical illness in 200 surgical Statistical Report. 1961. patients. Amer. J. Psychiat. 112:270, 5. Halevi. H. S.: Psychiatric morbidity in 1955. Israel. (Psychiatric hospital admissions, 1958.) Jerusalem: 1960 (pp. 7, 8, 69). 15. Helsborg, H. C.: Psychiatric investigations of patients in a medical depart6. Kaufman, M, P~., and Bernstein, S.: ment. Acta Psychiat. Stand. 3.3:303, Psychatric evaluation of the problem 1958. patient. J.A.M.A. 163:108. 1957. 7. Moses, R., and Lothane. Z.: Psychoso- 16. Kaufinan, M. R., et al.: Psychiatric findings m admissions to a medical matic evaluation of medical inpatients. service in a general hospital. J. Mount To be published. Sinai Hosp. N. Y. 26:160, 1959. 8. Spencer, R. F.: Medical patients: Consultation and psychotherapy. Arch. 17. Pemberton, J.: A sociomedical study of 200 hospital medical patients. Lancet -9" I964. Cert. P~'chiat. t0:z,10, 260:224, 1951. 9. Meyer, E., and Mendelson, M.: The psychiatric consultation in post grad- 18. Berger. H.: Management of neurosis by the internal and general practitioner. uate medical teaching. J. Nerv. Ment. New York J. Med. 11:1783, 1956. Dis. 130:78, 1960. 10. Mestitz, P.: A series of 1817 patients 19. Noy, P., Kaplan De Nour, A., and Moses, R.: Discrepancy between exseen in a casual b, department. Brit. pectations and service in psychiatri c Med. J. 2:1108, 1957. consultation. Arch. Ca,n. Psvchiat. 14: 11. Mittelmann, B., et al.: Personali~." and 651, ] 96~q. psychosomatic disturbances in patients on medical and surgical wards.
I { A F A E L N]OS-ES AND S t I O S I I A N A B.~IiZ1LAY
p
S Y C I t l A T R I C C O N S U L T A T I O N S in a g e n e r a l h o s p i t a l , or liaison psychi, atry, a r e b e c o m i n g m o r e a n d m o r e w i d e s p r e a d in m o d e r n m e d i c i n e all over the w o r l d . T h e l i t e r a t u r e in t h i s field is, howe~'er, o n l y b e g i n n i n g to a p p e a r m o r e r e g u l a r l y w i t h i n t h e l a s t 10 y e a r s . T h e r e is still a d e a r t h of r e p o r t e d i n v e s t i g a t i o n s . C o n s u l t a t i o n s in a g e n e r a l h o s p i t a l a r e b o t h a n o u t c o m e of i n c r e a s e d s p e c i a l i z a t i o n mad a u effort to c o u n t e r b a l a n c e t h e p r e s e n t overs p e e i u l i z a t i o n , a T h i s is c l e a r l y so for t h e p s y c h i a t r i c c o n s u l t a t i o n , w h i c h r e p r e sents a n a t t e m p t to v i e w b o t h b o d i l y a n d p s y c h o l o g i c a l d i m e n s i o n s of o n e a n d t h e s a m e i n d i v i d u a l a n d , h o p e f u l l y , to i n t e g r a t e t h e m . T h i s s t u d y w a s a i m e d a t a s s e s s i n g t h e i m p a c t of t h e p s y c h i a t r i c c o n s u l t a t i o n o n t h e p a t i e n t in a u o n p s y c h i a t r i c g e n e r a l h o s p i t a l sere, i c e a n d o n t h e c o u r s e o f h i s i ! l n e s s . T h i s i m p a c t w a s a s s e s s e d t)v its i n f l u e ~ c e o n t h e o v e r a l l d i a g n o s i s . o n t h e t h e n x p e u t i e r e c o m m e n d a t i o n s , a n d on t h e p a t i e n t ' s c o n d i t i o n a f t e r
d i s c h a r g e f r o m the h o s p i t a l . I n consultations are requested under to s t u d y t h e i n t e r r e l a t i o n b e t w e e n c o n s u l t a t i o n a n d t h e i n f l u e n c e of the patient.
addition, since experience shows that such a v a r i e t y of c i r e u m s t m ~ c e s , e.:~ it w a s p l a n n e d t h e c i r c u m s t a n c e s l e a d i n g to the r e q u e s t for t h e c o n s u l t a t i o n i t s e l f on w h a t h a p p e n e d to METHOD
All p a t i e n t s o v e r 15 ~,ears of a g e , h o s p i t a l i z e d a t t h e 14othsehild t t a d a s s a h U n i v e r s i t y I l o s p i t a l d u r i n g o n e c a l e n d ~ y e a r , w h o w e r e s e e n in p s y c h i a t r i c colt~ultations r e p r e s e n t t h e p o p u l a t i o n for this s t u d S. T h e list o f p a t i e n t s w a s t a k e n f r o m t h e Ps.vehiatrie C o n s l d t a t i o n R e g i s t e r , w h e r e all c o n s u l t a t i o n s h a d b e e n c h r o n o l o g i c a l l y e t l t e r e d , i n c l u d i n g p s y c h i a t r i c d i a g n o s i s a n d t h e d i s p o s i t i o n . F u r t h e r inform~ttion w a s p r o v i d e d b v w r i t t e n r e p o r t s o f t h e c o n s u l t a n t s to t h e t r e a t i n g p h y s i c i a n . W h e n ~leeessar~'. t h e p s y c h i a t r i c c o n s u l t a n t w a s inter~:iewed in a d d i t i o n . All h a s p i t a l r e c o r d s of patient.s in t h e s t u d y w e r e examined. The inclusion or exclusion of the psychiatric consultant's ret'ommendations in t h e d i s c h a r g e s u m m a r y w e r e particnlarl_v looke~l for. T h e p a t i e n t s " visits in t h e o u t p a t i e n t clinic~ a n d s u b s e q u e n t h o s p i t a l i z a t i o n s w e r e s i m i l a r l y c h e c k e d . A q u e s t i o n n a i r e , s i ~ q e d b y t h e p s y c h i a t r i s t w h o h a d inter~-iewe¢| t h e p a t i e n L w a s se~d o u t to all p a t i e n t s b e t w e e n 8 a n d 18 m o n t h s a~ter t h e consultations. P a t i e n t s w h o d i d not r e s p o n d w i t h i n 2 to 3 w e e k s w e r e s e n t t h e s a m e q n e s t i o m ~ a i r e w i t h a d i f f e r e n t p r e a m b l e . T h o s e w h o d i d n o t r e s p i r e d to t h e sec~rid q , , e s t i o n n a i r e w e r e s e n t a f u r t h e r q u t ~ t i o n n a i r e w i t h a c o v e r i n g l e t t e r a s s t w i n g t h e p a t i e n t o t anon,,anity, a n d n o t r e q t d r i n g hit** to e n t e r his n a m e . R.~,FAEL XIosE.',, M . D . : Dcpartmt~it o/ Psyt'hiatry. ltadttvsa]t Uz~iccr.s-ity llospital a,~d Hadassah tlebretc Unit'er.sily 31edical School, Jerrtsatem, lsrad. SuosH.~x'.-~ BARZILAY, NI.D.: Dcpartmerlt o] Psychiatry, llada~sah Urffcersity llospital atJtl lladassah ttebr~'tt~ VtHt~c,sity ,~ledical School, ]eru.salem. israel. 16 (~.O~,IPI~EHE'~.'~I~,'I-: PsYCI[IA'II~','.~'(~L. ,~. ;~',,'O. | (|:~-:IH~,t'AI;~Y). ].~)('17
PSYCII1ATRIC CONSULTATION AND "IliE GENEIIAI, HOSPITAL .PATIENT
Patients ~
17
/ j Men
//
15 f
.
J I0
,5 Age ~ o ~ n 15 i0 J'
o
f e
Study ~Populatlon . . . . . . . . . . . . . . .
,~i"
ao
30
~,o
5o
6o
~e
H~9 p i t a l
Population
Fig. 1 . ~ P a t i c n t s by age: Comparison of study and hospital populations, FINDINGS
T h e Patients, Their lllne.sse.s a n d Their Reactions to the Consultation O n e h u n d r e d s e v e n t y - t h r e e p a t i e n t s were seen in p s y c h i a t r i c c o n s u l t a t i o n d u r i n g 1961, w h i l e 956 ° a d u l t p a t i e n t s w e r e a d m i t t e d to the H a d a s s a h Itospital. 4 After c o r r e c t i n g this figure to m a k e the p o t e n t i a l n e e d for p s y c h i a t r i c c o n s u l t a t i o n c o m p a r a b l e , a c o n s u l t a t i o n rate of z.36 p e r c e n t is f o u n d (16.5 consultations for 7002 patients h o s p i t a l i z e d ) . W h e n c o m p a r i n g this w e i g h t e d a v e r a g e for t h e different services w h i c h r e q u e s t e d p s y c h i a t r i c consultations, w e find t h a t it runs from 8.7 p e r cent for one m e d i c a l service t h r o u g h 3.8 p e r cent for the other to 0 for one of the surgical services, \ V h e n c o m p a r i n g the c o n s u l t a t i v e p o p u l a t i o n w i t h t h e hospital p o p u l a t i o n with r e g a r d to sex a n d age, no difference was f o u n d w i t h r e g a r d to sex alone. However, sex a n d age t o g e t h e r show peaks for b o t h m e n a n d w o m e n at the ages of 19 to 29, mad 40 to 50, after w h i c h t h e r e is a m a r k e d d e c r e a s e (Fig. l ) . A c o m p a r i s o n of our p o p u l a t i o n w i t h the-. J e w i s h p o p u l a t i o n of Israel s h o w e d a relative p r e p o n d e r a n c e of E u r o p e a n - b o r n a m o n g t h e st-ucly p o p u l a tion (44.6 p e r cent vs. 37,3 p e r cent). T h e only e t h n i c g r o u p a m o n g s t the Asiana n d A f r i c a n - b o r n w h i c h was o v e r r c p r e s e n t c d w e r e the I r a q i - b o n a (9.4 pea" cent vs. 6.4 per ¢:ent). Seniority in the count."3," was a r e l e v a n t factor ha t h a t i m m i g r a n t s w h o c a m e to Israel b e f o r e 1948 are ve~, m u c h o v e r r e p r e s e n t e d in o u r p o p u l a t i o n (32.4 per cent vs. 16.6 per c e n t ) . Possibly this s e g r a e n t of t h e p o p u l a t i o n , w h i c h shows less m e n t a l illness on statistics of h o s p i t a l admissions, ~ tends m o r e to show a d a p t a t i o n a l difficulties t h r o u g h p s y c h o s o m a t i c p h e n o m e n a . ,Marital status does not differentiate b e t w e e n the two groups. T h e only n o t e w o r t h y finding is that t h e r e are t h r e e times m o r e d i v o r c e d persons a m o n g the s t u d y g r o u p (4.6 per cent vs. ].4 p e r cent ).
318
MosEs AND BARZZLAY
V~Zhen looking at t h e distribution of d o m i n a n t systems involved in the p a tients" major complaint, w e find that, in line w i t h the findings of K a u f m a n a n d Bernstein, e' t h e system most involved is the gastrointestinal one. \,Vhile these authors l i s t multiple s y m p t o m s as the second largest group, the next tnvo most i m p o r t a n t systems are, as in o u r study, the museuloskeletal a n d r e s p i r a t o r y systems. In our population, a b o u t 45 p e r cent of the patients listed s y m p t o m s in one b o d y system only, a n d a b o u t 55 p e r c e n t of the patients listed s y m p toms in a n u m b e r of systems. This is in l i n e w i t h findings on a medical w a r d in israel ~r. 7 L e n g t h of hospitalization of t h e s t u d y population shows t h a t p a t i e n t s hospitalized for more t h a n a m o n t h h a v e a g r e a t e r t h a n a v e r a g e e h a n c e for referral for p s y c h i a t r i c consultation (27.4 p e r cent vs. 10.5 per c e n t ) , w h e r e a s patients hospitalized for u p to a w e e k h a v e a m u c h b e l o w a v e r a g e chance (20.7 p e r cent vs. 38.2 per cent). W h e n e x a m i n i n g the patients" histories for the d u r a t i o n of their illnesse; or complaints, the chronicity of illness in our p o p u l a t i o n b e c o m e s a p p a r e n t (125 patients s h o w chronic illness, 15 s u b a c u t e a n d 33 a c u t e illness); 94 patients, or 54.3 p e r cent, h a d previously b e e n hospitalized for the s a m e complaints. W e believe that the p r e p o n d e r a n c e of multiple-system involvement, of long hospitalization, a n d of ehronicity o f illness indicates m o r e than a p r e p o n d e r ance of emotional d i s t u r b a n c e in t h e s t u d y population. O t h e r studies 7.*~.~:~.aa indicate t h a t similar disturbaa~ces exist also in those hospitalized for shorter periods, b u t t h a t these patients a r e not r e f e r r e d to a psychiatrist b e c a u s e t h e shorter hospitalization does not foster s u c h referrals. O f t e n the decision for a referral did not r i p e n in t h a t time; at other times emotional factors are considered only p e r exclusionem, w h e n t h e p a t i e n t is a l r e a d y a b o u t to be discharged, a A n examiaaation of the psychiatric diagnoses ha our p o p u l a t i o n shows a p r e p o n d e r a n c e of p s y e h o p h y s i o l o g i c a ! r e a c t i o n s - - - 3 7 p e r cent. W h e n all patients, ineluding those with psychophysiologieal reactions, arc d i a g n o s e d psychiatrically, the largest p s y c h i a t r i e diagnostic g r o u p s are those of personality d i s o r d e r (28.9 per c e n t ) a n d neurosis (27.7 p e r cent), Neurosis is diagaaosed m u c h m o r e 1frequently in w o m e n than in men ( 6 : 1 , w h e n the t e m a l e : m a l e ratio in the p o p u l a t i o n is 10:7). T a b l e 1 presents the d e g r e e of emotional d i s t u r b a n c e in the s t u d y population a n d s h o w s t h a t a b o u t 80 p e r cent of those r e f e r r e d to the psychiatrist show a m o d e r a t e or severe d i s t u r b a n c e . T h e consultant's assessment of the relation of the patient's emotional state to the major complaint w a s t h a t for 100 patients (57.8 p e r cent), their emotional state w a s an etiological factor for the m a j o r m e d i c a l complaint. In 26 patients (15 p e r c e n t ) there w a s no evidence of a connection b e t w e e n the emotiolml state a n d t h e m a j o r complaint. ~Vhen we e x a m i n e d the d e g r e e of insight in o u r population, w e f o u n d that a large majority (65,9 p e r cent) of the patients h a d no insight. A l t h o u g h the occasional brevity a n d the small n u m b e r of interviews are clearly a fitctor, these figures are also in k e e p i n g with clinical experience a n d with the "psycho-
19
FSYCHIATlllC CONSULTATION AND T H E GENEBAL HOSPITAL PATIENT Table D~ree
1.~Degree
o f E m o t i o n a l D i s t u r b a n c e in Sttt~g Patie~ffs
of Disturbance
No. of Patient~
Severe Moderate
71 67
1
138
Slight None Unclear
"_95 ) 6 ~ 4
35
)
Total
173
T a b l e 2 . - - - T r e a t m e n t R e c o m m e n d e d for S t u d y P a t i e n t s Treatment
Recommended
No. of Patients
4
Psychiatric hospitalization on closed w a r d P~vchiatrie hospitaiizata'on on open w a r d
20
Total p~lchiatric lwspitaIizations Ambulatory psychotherapy Social casework
78 5
Total ambulatory treatmeut Tolal l}Sr.ldffalric healmellt recommended subsequent to hospitalization P s y c h o t h e r a p y on hospital service Drug t r e a t m e n t on hospital service Social casework on hospital service Total treatment cm hospital sercice after consultation Supportive trvahnent b y geDerM practitioner N o psychiatric t r e a t m e n t ]'sychiatrie t r e a t m e n t r e c o m m e n d e d b u t unspeeifled • Total
24
83 lot 9
I0 6
2.5 9 _08 4 173
somatic" patient's t e n d e n c y to d e f e n d against the recognition of his emotional difficulties b y "somatization." T h e reaction of patients to the psychiatric i n t e r v i e w is in line w i t h this last finding. L a c k of insight does n o t m e a n a lack of readiness to d i s c u s s oneself or one's p r o b l e m s as long as no c o m m i t m e n t to t h e i r recognition i s required. O n l y 21 (22.1 p e r cent) patients s h o w e d or voiced clear-cut objections to the p s y c h i a t r i c interxdew. Fifty-seven patients (.3,3 p e r e e n t ) : e x p r e s s e d "satisfaction'" w i t h the interview on our questionnaire.
Tile Consultant's Recommendation After h a v i n g e x a m i n e d the composition of our patiehts, their illnesses a n d their reactions to t h e psychiatric interview, w e will n o w look at the psychiatrist's r e c o m m e n d a t i o n s ( T a b l e 2). T h e most striking feature is the very h i g h p e r c e n t a g e of patients for w h o m a m b u l a t o r y p s y c h o t h e r a p y was r e c o m m e n d e d 45.1 p e r cent. This finding is identical with that of Spencer s and of M e y e r and M e n d e l s o n ? In all, i n c l u d i n g p s y c h i a t r i c hospitalization, about 60 p e r cent of the patients w e r e r e f e r r e d for regular p s y e h o t h e r a p e u t i c treatment.
20
~'IOSFkS AND BARZILAY Table 3,~Diagnosis and Treatment in Psychiatric Consultant's Report and in the Hospital Summary Reflection of Consultant's
O p i n i o n in H o s p i t a l S u m m a r y
S u m m a r y goes b e y o n d psychiatrist's r e p o r t A p p r o p r i a t e to r e por t E m o t i o n a l f a c t or only i n c i d e n t a l l y menticmt,d E m o t i o n a l f a c t or not m e n t i o n e d
Total
R e Dial~noals
Re T r t m ~ m c n t
9 80 20 64
2 8.C) ,5 77
173
173
In m o r e t h a n h a l f - - i . e . , 57.2 p e r c e n t of the p a t i e n t s ~ t h e specific reason for w h i c h the t r e a t i n g p h y s i c i a n r e q u e s t e d the p s y c h i a t r i c consultation comes u n d e r t h e general, if s o m e w h a t vague, h e a d i n g of help v,,itla diagnosis a n d c o m p r e h e n s i v e t r e a t m e n t . In 7 p e r cent of t h e patients, the r e q u e s t was for assistance with the m a n a g e m e n t of the patient. F o r 30 p e r cent of the patients, help w a s r e q u e s t e d for a p r o b l e m considered u n r e l a t e d to the medical illness. W e are n o w in the process of a n a l y z i n g in m o r e detail some of the reasons l e a d i n g to psychiatric referrals a c c o r d i n g to a questionnaire d e v e l o p e d after t h e p e r i o d d u r i n g w h i c h this stud), was carried out. TM Finally, w e wish to look at the d e g r e e to w h i c h the physician w h o summ a r i z e d the hospital course of his p a t i e n t took into a c c o u n t the psychiatric consultant's opinions a n d h o w he did this ( T a b l e 3). In a small p e r c e n t a g e , the t r e a t i n g physician gives g r e a t e r w e i g h t to the emotional factors t h a n the consultant h a d done. F o r example, Mr. A. w a s a 40-year-old m a n suffering f r o m B u r g e r ~ disease, all f o u r of v,qlose limbs h a d b e e n a m p u t a t e d to s o m e extent. T h e psychiatric consultant, called in-t~ecause of lack of cooperation on the patient's part, s a w him 12 times, l i e d i a g n o s e d p a r a n o i d trends as a reaction to the illness a n d r e c o m m e n d e d social investigation to m a k e a d e q u a t e provisions. A l t h o u g h the consultant specifically w a r n e d against psy'chiatrie hospitalization, w h i c h he t h o u g h t m i g h t lead to a psychotic regression in the patient, the t r e a t i n g physician included a r e c o m m e n d a t i o n for hospitalization on a closed w a r d in his s u m m a r y . O n tim o t h e r h a n d , it is g r a t i f y i n g to note that in a b o u t half the patients, the s u m m a r y a d e q u a t e l y reflects tile views of the p s y c h i a t r i c consultant. F o l l o w - U p a n d lts Results
T a b l e 4 shows t h e response to our written communications. Seventeen patients died, two o f ' t h e m b y their o w n h a n d . O f tile r e m a i n d e r , less those w h o w e r e a b r o a d or w h o could not b e located, 68.7 p e r ce12t r e t u r n e d the questionnaires. T h r e e of these w e r e filled in only partially a n d w e r e therefore d i s c a r d e d . Of the ,99 patients, 64 or two-thirds replied ill response to the first questionnaire: 26 replied in response to tile second questionnaire a n d 6 in reply to the third. A m o n g these 6, we l e a r n e d that three replied only b e c a u s e t h e y w e r e able to maintain their a n o n y m i t y . O n e of those called twice on the t e l e p h o n e from a distance of 100 miles. It m a y thus l,-e r e a s o n a b l e to a s s u m e that a
I~SYC/tIATRIC
CONSULTATION
AND
THE
GENERAL
HOSPITAL
2I
PATII~NT
Table 4 . ~ F o l l o w - u p O u t c o m e Follow-Up Outcome
Replies received Questionnaires not returned Questionnaires did not rcach destination: (1) Patient abroad (2) Incorrect address Died To~l
No. of Patient~
99 45 12 (3) (9) 17 173
n u m b e r of those w h o did not r e t u r n the questionnaires failed to do so b e c a u s e they- did not w a n t written d a t a on t h e m to b e available in t h e hospital. O f the 96 patients w h o s e questionnaires w e r e fully filled in, 41.7 p e r cent (40) s h o w e d subjective i m p r o v e m e n t of their m a j o r complaint, O v e r a third (37) continue to suffer from their complaint, a n d 7 (7.3 p e r c e n t ) feel subjectively worse. F o u r t e e n patients n o w suffer from o t h e r complaints. T h e 96 patients w h o filled in the questionnaire h a d been asked to assess the influence of the psychiatric eonsnltation: 36.5 p e r cent i n d i c a t e d a positive response to the psychiatric consultation; 45.9 p e r cent i n d i c a t e d t h a t the consultation h a d land no influence on theni; a n d 2 p e r cent s h o w e d a negative response. E l e v e n p e r c e n t of the patients w o u l d not assess the influence of the consultation. It is interesting to note t h a t 5 patients did not r e m e m b e r ~ i . e . , p r e s u m a b l y r e p r e s s e d ~ t h e consultation. As r e g a r d s the follow-up b y the p a t i e n t of the psychiatrist's r e c o m m e n d a tions, 32 of the 96 r e s p o n d e r s to the follow-up entered p s y c h i a t r i c t r e a t m e n t . Eleven of these w e r e hospitalized one on a closed w a r d a n d ten on open wards. O f these, eight received p s y c b o t h e r a p y ; t h e y a n d two others stated that they h a d b e e n helped. O n e p a t i e n t stated t h a t he felt worse. T h i r t e e n patients e n t e r e d a m b u l a t o r y p s y c h o t h e r a p y . T h r e e s t o p p e d after only 2 interviews. T h r e e continue in p s y c h o t h e r a p y . O n e patient land interr u p t e d t r e a t m e n t a n d r e s u m e d after she r e n e w e d contact with us t h r o u g h the questionnaire. F o u r p a t i e n t s h a d t e r m i n a t e d p s y c h o t h e r a p y hy m u t u a l agreem e n t with the therapist a n d s t a t e d t h a t the), feel well. O n e patient, w h o s e major complaint w a s a s t h m a , stated t h a t the number, of his a s t h m a t i c attacks decreased, h u t did not relate this i m p r o v e m e n t to the t e r m i n a t e d p s y c h o t h e r apy, The last p a t i e n t in this g r o u p i n t e r r u p t e d t r e a t m e n t a n d s a w no imp r o v e m e n t in h e r condition. F i v e patients w e r e t r e a t e d by casework; only one of these i n d i c a t e d an i m p r o v e m e n t of his condition. O n e p a t i e n t continued to receive " s u p p o r t i v e " t r e a t m e n t from his physician outside the hospital; he stated that his complaints continued as before. T w o patients did not accept Ithe r e f e r r a l for p s y c h o t h e r a p y at the time, T h e i r condition detr.,eioratcd; they s u b s e q u e n t l y r e q u i r e d hospitalization on a closed w a r d a n d indicate a w o r s e n i n g of their condition. O f those 55 patients w h o did not r e p l y to the questionnaire, we f o u n d from the hospital records that 19 e n t e r e d psychiatric t r e a t m e n t as a result of the
~2
.~.IOSI';S A N D B~klIZ1LAY
c o n s u l t a t i o n ~ 1 0 o n a p s y c h i a t r i c w a r d and 9 on an o u t p a t i e n t basis. I n f o r m a tion on these p a t i e n t s is g i v e n w i t h o u t an a t t e m p t to infer a n y valid conclusions, since t h e y r e p r e s e n t a p a r t of the s a m p l e on w h i c h o n l y p a r t i a l i n f o r m a tion is available. It is, h o w e v e r , of interest to be able to give some i n f o r m a t i o n on n o n r e s p o n d e r s . DtscussIox T h e l i t e r a t u r e is r e p l e t e w i t h reports from ditferent b r a n c h e s of m e d i c i n e , b o t h hapatient mad o u t p a t i e n t ; in different eountrie,s, w h i c h assess the n u m b e r of p a t i e n t s w i t h e m o t i o n a l d i s t u r b a n c e . T h e s e r a n g e from 26 p e r cent of 975 p a t i e n t s seen in an e m e r g e n c y r o o m in E n g l a n d , ~'' t h r o u g h 3 0 per c e n t on m e d i c a l mad surg'ical wards, 10 per c e n t w i t h severe a n d 20 per cent w i t h slight d i s t r u b a n e e s ; ~ 34 p e r cent in i n t e r n a l m e d i c a l practice;! 2 45.8 per cent of 602 h o s p i t a l i z e d m e d i c a l patients with "'serious e m o t i o n a l d i s t u r b a n c e . "'~:; Eighty-six p e r cent of a s a m p l e of 200 out of 3680 surgical p a t i e n t s were, f o u n d to be d i s t u r b e d e m o t i o n a l l y a n d a sig'nifieant r e l a t i o n s h i p b e t w e e n the surgical mad e m o t i o n a l d i s t u r b a n c e was f o t m d in 48.5 per c:ent34 In 500 p a t i e n t s on g e n e r a l hospital wards, e m o t i o n a l d i s t u r b a n c e was d i a g n o s e d in 62 per c e n t ~ a n d of these, p s y c h o g e n i c disease i n 22 p e r cent a n d a p s y c h o l o g i c a l comp o n e n t in the s o m a t i c disease in 40 p e r cent. ~:' Still h i g h e r figures w e r e f o u n d in 253 p a t i e n t s on g e n e r a l h o s p i t a l wards, w h e r e 68.8 per cent had d i a g n o s a b l e e m o t i o n a l d i s t u r b a n c e , a*~ T h e same a u t h o r s f o u n d t h a t in 8z.3 per c e n t of "'psychosomatic" diseases, the illness was f o u n d to be r e l a t e d to a p s y c h i a t r i c disorder. In f u n c t i o n a l disorders w i t h o u t o r g a n i c findings, these a u t h o r s found 89.5 p e r c e n t of the illnesses to be rebated to the complaints. For o t h e r illnesses, t h e c o m p a r a b l e figure was 60.9 per cent. On a m e d i c a l w a r d in a g e n e r a l h o s p i t a l h~ Israel, a r a n d o m s a m p l e of S0 p a t i e n t s s h o w e d 80 per cent to h a v e serious p s y c h o s o c i a l i n c a p a c i t a t i o n s 2 6 per c e n t of a severe, a n d .54 per c e n t of a m o d e r a t e , n a t u r e - - a n d 16.3 p e r cent to h a v e mild i n c a p a c i t a t i o n 3 O n a d i a ~ l o s t i e c o n s u l t a t i v e service at Nit. Sinai t lospital. N e w York, 814 out of 1000 p a t i e n t s ~ i . e . , 81.4 per c e n t ~ w e r e f o u n d to be suffering from e m o t i o n a l d i s t u r b a n c e clearly r e l a t e d to t h e i r s o m a t i c complaint.'; A l t h o u g h no figures on t h e p r e v a l e n c e of e m o t i o n a l d i s t u r b a n c e in the p a t i e n t s in our h o s p i t a l are available, there is no reason to assume t h a t the p a t i e n t p o p u l a t i o n here w o u l d be very m u c h different from elsewhere, particul a r l y since it is a t e a c h i n g hospital. T h e fact that o n l y :2.36 p e r c e n t of all p a t i e n t s h o s p i t a l i z e d in t h e t l a d a s s a h U n i v e r s i t y H o s p i t a l w e r e r e f e r r e d for p s y c h i a t r i c eorLsult~,Hon thus p r e s e n t s a clear i n d i c a t i o n of e i t h e r a low a w a r e n e s s of p s y c h i a t r i c p r o b l e m s in t h e h o s p i t a l or of the lack of readiness to, tr),- to do s o m e t h i n g a b o u t it. Since, h o w e v e r , the large m a j o r i t y of p a p e r s q u o t e d referred to s y s t e m a t i c studies of p a t i e n t p o p u l a t i o n s r a t h e r t h a n to t h e e x a m i n a t i o n of t h e r o u t i n e of c o n s u l t a t i v e ser~'iee, w e w o u l d assume that this a s t o n i s h i n g l y low figure is not so different from figures in m a n y o t h e r hospitals. ,and is p r o b a b l y h i g h e r t h a n in some. T a b l e 5 gives a c o m p a r i s o n b e t w e e n qae finditags in a n u m b e r of these
I~S't'CIIIATtllC
CONSULTATION
AND
"lqlE
ClgNEItAL
IIOSI-'ITAI.
23
PATIENT
Table 5.--Diagnostic Classification of l"atients in Diffq~ent Studies OverMl Diagnosis
Author
Pemberton 17 [lelshorgh-~ Payson ~:~ Kau fman et a l . ~ Kanlrman and Bcrnstein~; Moses and LothaneV Study l)opulation
Organic Psychoonly somatic
0 r K a n ie alqd FuncP'sychotional h~giea~?
3° 58 27
-19 11 13
3:3
20
8
.9.z,~
15
10 4
( Pereontage~ I
. . ~ --
. . ---
Psyehint tie Diagnosis
Person a I i ty Disorders and Psycho- Other Total Neuroses ~es Ding,
t Percentages)
lifo Enlot. Disordtr
T~*tal
8 o.27) 17
~ ~ ~
~ ---
~ --
l0 5 35
1 13 8
39
100
50
8
9
:3:3
103
~3
39
100
-t9
9
:~3 ~_.
19
1 f:O
18.5
54
17.5
i00
.
37
~
59
100
57
.
. 13
.
. 26
Overall Total
100 t 00 100
. 4
I GO
s t u d i e s w i t h o u r o w n . It b e c o m e s e v i d e n t f r o m this t a b l e t h a t t h e m a i o r i t y of p s y c h i a t r i c d i s t u r b a n c e s are p s y c h o n e u r o s e s a n d p e r s o n a l i t y d i s t u r b a n c e s , a n d t h a t m o s t of t h e s e p a t i e n t s suffer f r o m " f u n c t i o n a l " or " p s y e h o s o n a a t i c " di::ease. T h e s i m i l a r i t y b e t w e e n m o s t of t h e s e s t u d i e s a n d o u r o ~ m is striking, p a r t i c u larly t h e o n e of K a u f i n a n a n d B e r n s t e i n ~ c a r r i e d o u t on 1000 p a t i e n t s . \ V h e n e x a m i n i n g t h e factors l e a d i n g to p s y c h i a t r i c c o n s u l t a t i o n , w e find, in line w i t h M e y e r mad M ( n d e l s o n , - t h a t w h a t m o t i v a t e s t h e h o s p i t a l physieima to r e q u e s t at p s y c h i a t r i c r e f e r r a l is m o s t l y b e h a v i o r on t h e p a r t of t h e p a t i e n t w h i c h s e e m s o u t of p l a c e or d i s q u i e t i n g . It is this m u c h m o r e t h a n t h e a b s t r a c t k n o w l e d g e t h a t a c e r t a i n d i s e a s e is c o n s i d e r e d to b e "'psychosonmtie,'" or t h e wish to a p p r o a c h an illness b o t h f r o m t h e p h y s i c a l a n d t h e e m o t i o n a l aspect. T h e c o n n e c t i n g link betwc, en t h e b e h a v i o r a l d i s t u r b a n c e a n d t h e r e f e r r a l c a n safely b e a s s u m e d to b e this f e e l i n g of h e l p l e s s n e s s t o w a r d m a n i f e s t a t i o n s which the physician can neither explain nor influence. A l a r g e p r o p o r t i o n of c o n s u l t a t i o n s w e r e r e q u e s t e d for p a t i e n t s w i t h p s y c h o s o m a t i c a n d f u n c t i o n a l d i s o r d e r s ~ j n o u r s t u d y a total of 64 p a t i e n t s o r 3 7 p e r c e o t of t h e s t u d y p o p u l a t i o n . " T h e m a j o r i t y o f c o n s u l t a t i o n s (63 p e r c e n t ) w e r e r e q u e s t e d in o r d e r to o b t a i n h e l p w i t h d i a g n o s i s a n d c o m p r e h e n s i v e treatme~at. In o t h e r w o r d s , t h e m a i n a i m w a s to e v a l u a t e t h e e m o t i o n a l f a c t o r in c g m p l a i n t s of t h e p a t i e n t s w h i c h w e r e d i r e c t l y r e l a t e d to t h e p r e s e n t h o s p i t a l i z a t i o n . As an o v e r a l l find -~ • ing, this s e e m s to i n d i c a t e a f r u i t f u l u t i l i z a t i o n of p s y c h i a t r i c c o n s u l t a t i o n . ttowever, one must take into account that such a general formulation hides m a n y m o r e d e t a i l e d factors, p a r t i c u l a r l y in t h e d o c t o r - p a t i e n t r e l a t i o n s h i p o n t h e w a r d , w h i c h s h o u l d b e s t u d i e d a n d e v a l u a t e d m o r e closely. S u c h a s t u d y is n o w in p r o g r e s s in o u r d e p a r t n a e n t , lt~ A c t u a l figures f o r t h e p e r c e n t a g e of p s y c h i a t r i c c o n s u l t a t i o n s of h o s p i t a l i z e d p a t i e n t s a r e a v a i l a b l e o n l y f r o m t h e s t31~dies of M e y e r a n d ~ l e n d e l s o n 9 a n d P a r s o n . I~ At John's l-lopkil~s t h e figures b"ver a p e r i o d o f 5 y e a r s r a n g e f r o m 4.9
04
~ I O S E S A N D ]3AI1ZILAY
p e r cent to 8.8 p e r cent. At Yale a2 tile figure given for one y e a r is 13.3 per cent. I n c o n s i d e r i n g the differences b e t w e e n these fig'ures a n d our own, one m i g h t p e r h a p s w o n d e r w h e t h e r tile p r e v a l e n c e of emol~ional d i s t u r b a n c e in Israel is lower. F r o m the few figures a v a i l a b l e in Israel, ~ it is c e r t a i n l y clear that the n u m b e r of psychiatric hospitalizations here is r o u g h l y the same as in the U. S. a n d in E n g l a n d . F r o m w h a t is k n o w n about the relationship b e t w e e n social c h a n g e and m e n t a l illness, there is no reason to believe flint in a country of mass immigration from both XVesteni and O r i e n t a l countries into a conglomerate b u t \ V e s t e m i z e d cultural milieu, there should b e any less m a l a d j u s t m e n t than elsewhere, Since, in addition, our p o p u l a t i o n is c o m p a r a b l e both with the overall hospital p o p u l a t i o n for the s a m e y e a r a n d with the p o p u l a t i o n of Israel, it can be r e g a r d e d as representative. Therefore, there seems to h e every reason to b e l i e v e that the small n m n b e r of requests for psychiatric consultation does not reflect the p r e v a l e n c e of emotional disorder but rather the attitudes of the p h y s i c i a n s on our services to psychiatric diagnosis a n d treatment. True. w e only b e g a n to i n t r o d u c e a psychiatric liaison service in the y e a r d u r i n g w h i c h this s t u d y was carried out, a n d such liaison service is given only to a small n u m b e r of wards. W e h a d b e e n aware previously of the fact that t h e n e e d for psychiatric consultation is directly proportional to the quality and q u a n t i t y of service given in this area, a n d we f o u n d corroboration for this in the last few years. V~:hen e x a m i n i n g the influence of the consultative psychiatric i n t e r v i e w on the patient, the psychoanaiytie~dly oriented psychiatrist is again b r o u g h t up sh,-u'ply with the s o m e t i m e s u n e x p e c t e d fact that even one such interview m a y h a v e at least subjective t h e r a p e u t i c effects. T w e n t y - t h r e e of our patients who h a d experienced subjective i m p r o v e m e n t clearly do not relate this to the p s y c h i a t r i c consultation for reasons related to their own p s y c h o d y n a m i c equilibrium. In a n u m b e r of our patients the c o n s u l t a n t s ~ w h o , b y a n d large, did not hesitate to indicate the a b s e n c e of t h e r a p e u t i c effect of their consultat i o n s ~ f e l t sure t h a t the consultative interview h a d i n d e e d b e e n beneficial to t h e patient. I n the light of reports in the literature r e g a r d i n g the h i g h n u m b e r of rec o m m e n d a t i o n s for p s y c h o t h e r a p y g r o w i n g out of. consultative work a n d its d i s c r e p a n c y w i t h the very low n u m b e r of patients w h o actually continue in p s y c h o t h e r a p y afterwards, "~ it is interesting to view w h a t h a p p e n e d to the p a t i e n t s for w h o m a m b u l a t o W p s y c h o t h e r a p y or casework was r e c o m m e n d e d . T h e l a e t that 51 out of 107 patients h a d b e g u n p s y c h o t h e r a p y presents a figure w h i c h seems q u i t e h i g h a n d c o m p a r e s x'ery f a v o r a b l y with that q u o t e d b y Spencer in C h a p e l Hill, North Carolina. s O u r hospital s u m m a r i e s s h o w e d that the t r e a t i n g physicians w h o r e q u e s t e d p s y c h i a t r i c c o n s u l t a t i o n s ~ m o s t l y for patients with m o d e r a t e or severe emotional d i s t u r b a n c e s ~ i n d i c a t e this fact only in h a l f of the patients, w h e n rep o r t i n g to the treating p h y s i c i a n outside the hospital. H e r e a g a i n we encounter b a s i c attitudes toward the emotions a n d t o w a r d p s y c h i a t r y w h i c h affect doctors, a n d through them, their patients. T h e t e n d e n c y to invite a patient to
I ' S Y C I t l A T R I C C O N S U L T A T I O N AND "lqqtE G E N E R A L I t O S P 1 T A L P A T I E N T
25
"pull h i m s e l f together" or "to forget a b o u t it" has b e e n described, i.a., b y Berger as a n d is well known. E v e n in those s u m m a r i e s w h i c h i n c l u d e d a r e f e r e n c e to the emotional disturbance, w e f o u n d p h r a s e s such as "the psychiatrist was not able to convince the p a t i e n t . . . ' " w h i c h indicate the treating physician's desire to relegate the responsibility for his patient's emotions to the psychiatrist. Finally, as w e look at the results of psychiatric treatment, of the 32 k n o w n patients w h o e n t e r e d p s y c h o t h e r a p y as a direct result of the consultation, w e find t h a t if one leaves out those w h o c a m e for less t h a n 3 interviews a n d those who are still in t r e a t m e n t ~ a total of 15 p a t i e n t s ~ 1 5 out of the r e m a i n i n g 18 reported that t h e y were h e l p e d b y this h'eatment. CONCLUSION
Psychiatric consultations represent one route of access to emotionally dist u r b e d persons. I n most general hospitals w h i c h h a v e no tradition, or only a brief one, of a psychiatri c liaison service, such consultations are u s e d relatively sparsely. W h e n they are used, however, their share in the i m p r o v e m e n t of the symptomatolog3" related to the hospital admission a p p e a r s to w a r r a n t approval of the current t r e n d of increased psychiatric liaison services a n d i n c r e a s e d psychiatric consultation. SUhIXIARY
T h e data on psychiatric consultations in a general t e a c h i n g hospital in Israel for a period of one y e a r are a n a l y z e d in terms of the p e r c e n t a g e of hospitalized patients referred, its c o m p a r i s o n w i t h the hospital p o p u l a t i o n a n d the p o p u l a t i o n at large. Personal data of the s t u d y p o p u l a t i o n are looked at to d e t e r m i n e special "qaigh risk" groups. T h e p o p u l a t i o n is a n a l y z e d for type of symptoms, their relation to tile p r e s e n t i n g illness, the severity of their psychological disturbance, a n d psychiatric diagnosis. T h e s e variables are c o m p a r e d with other studies of m e d i c a l patients in the literature. A second area exa m i n e d was tile patient's reaction to the psychiatric extunination at the time and the extent to w h i c h the treating p h y s i c i a n m a d e use of the psychiatric consultant's r e c o m m e n d a t i o n . A w r i t t e n follov¢-up s t u d y was carried out on all patients, w i t h information received for two-thirds of the population. T h e patient's estimate of the usefulness of a consultation was recorded, as wa/s,4~he present state of the condition for w h i c h ]~e h a d b e e n hospitalized. S ' m ~ ' r l y , the extent to w h i c h the p a t i e n t followed the consultant's r e c o m m e n d a t i o n was studied. T h e £ n d i n g s of this s t u d y i n d i c a t e tlfat a small p e r c e n t a g e (2.36 p e r cent) of the general hospital p o p u l a t i o n was referred" a n d t h a t this s e e m e d to reflect the treating p h y s i c i a n ' s a t t i t u d e s r a t h e r t h a n an i n h e r e n t difference in ineidence. C e r t a i n p o p u l a t i o n glTo{;ps • s h o w e d ,an increased "referral rate, w h i c h m a y relate e i t h e r to their i n c r e a s e d i n c i d e n c e rate of emotional d i s t u r b a n c e Or to the p h y s i c i a n ' s i n c r e a s e d desire to refer :sick p a t i e n t s w h i c h are c u l t u r a l l y more distant to him. T h e overall r e s p o n s e to psychiatric consultations seems to show the n e e d for
26
3IOS'ES AND BARZILAY
such consultations, organized as a psychiatric liaison service, and an overall subjective assessment of its usefulness by the patients, Some of the problems inherent in this psychiatric consultative situation are discussed. REFERENCES Psychosom. Med. 7:22, 1945, 1. Balint, M.: The pyramid and the psychotherapeutic relationship. Lancet 12. ]-lanunan, L.: The relationship of" psy2:1051, 1961. chiatry to internal medicine. Ment. 2. Meyeri E., and Mendelson, M.i PsyHyg. 23:177, 1939. chiatric consultations with patients on 13. Payson, "H., et al.: Recognition and medical and surgical wards. Psychiatry referral of psychiatric illness on a 24:197, 1961. university medical inpatient service. 3. Moses, R., Noy, P., Kaplan-DeNour. A,, Read at Amer. Psychiat. Assn. Meeting, and Wollstein, S.: Defensive patterns 1961. of psychiatric consultants in the gen14. Zwerling, I.. et al.: Personality distureral hospital. Harefuah 68:18, 1965. bances and relationship to evaluation 4. Hadassah Medical Organization Annual of surgical illness in 200 surgical Statistical Report. 1961. patients. Amer. J. Psychiat. 112:270, 5. Halevi. H. S.: Psychiatric morbidity in 1955. Israel. (Psychiatric hospital admissions, 1958.) Jerusalem: 1960 (pp. 7, 8, 69). 15. Helsborg, H. C.: Psychiatric investigations of patients in a medical depart6. Kaufman, M, P~., and Bernstein, S.: ment. Acta Psychiat. Stand. 3.3:303, Psychatric evaluation of the problem 1958. patient. J.A.M.A. 163:108. 1957. 7. Moses, R., and Lothane. Z.: Psychoso- 16. Kaufinan, M. R., et al.: Psychiatric findings m admissions to a medical matic evaluation of medical inpatients. service in a general hospital. J. Mount To be published. Sinai Hosp. N. Y. 26:160, 1959. 8. Spencer, R. F.: Medical patients: Consultation and psychotherapy. Arch. 17. Pemberton, J.: A sociomedical study of 200 hospital medical patients. Lancet -9" I964. Cert. P~'chiat. t0:z,10, 260:224, 1951. 9. Meyer, E., and Mendelson, M.: The psychiatric consultation in post grad- 18. Berger. H.: Management of neurosis by the internal and general practitioner. uate medical teaching. J. Nerv. Ment. New York J. Med. 11:1783, 1956. Dis. 130:78, 1960. 10. Mestitz, P.: A series of 1817 patients 19. Noy, P., Kaplan De Nour, A., and Moses, R.: Discrepancy between exseen in a casual b, department. Brit. pectations and service in psychiatri c Med. J. 2:1108, 1957. consultation. Arch. Ca,n. Psvchiat. 14: 11. Mittelmann, B., et al.: Personali~." and 651, ] 96~q. psychosomatic disturbances in patients on medical and surgical wards.