- Email: [email protected]
The liaison clinic: A model for liaison psychiatry funding, training, and research
The Liaison Clinic: A Model for Liaison Psychiatry Funding, Training, and Research George E. Rowan, M.D. Instructor in Clinical Psychiatry, Columbia University, College of Physicians and Surgeons and Attending, Consultation Psychiatry Service, St. Luke’s Hospital, New York
James J. Strain, M.D. Professor of Clinical Psychiatry and Director, Liaison and Consultation Service, Mount Sinai School of Medicine, New York
Leslie Hartley Gise, M.D. Assistant Professor of Psychiatry and Associate Director, Liaison Consultation Service, Mount Sinai School of Medicine, New York
Abstract: Whileliaisonor similar clinics have existed since at least 2932, they remain uncommon. The Mount Sinai Medical Center Liaison Clinic is presented as a model for psychiatric evaiuntion and care of medical patients as well as training, research, and funding. In addition, it is a model for linking general and mental health systems in the tertiary care setting. Thefirsf year of operation of the clinic is described, including the sources of referral, demographic data, psychiatric, and medical diagnoses, and type of clinic contact. A total of 96 patients were seen in 390 visits, equaling three quarters of a liaison fellow’s
salary. Psychiatric disorder is commonly treated by nonmental-health professionals. Reiger et al. [l] report that 54% of the U.S. population with mental disorders are treated in the general health care sector. The failure to detect and treat mental disorders appears to exist at all levels of care. In the tertiary care setting, this failure is not due to the unavailability of appropriate professionals, but to the lack of a unit designated to link psychiatric and medical care. Pincus [2] describes conceptual models of linkage between general health and mental health systems of care, stating that a consultation and This work was supported in part by NIMH Grant MH 16438.
General Hospital Psychiatry 6, 109-115, 1984 0 Elsevier Science Publishing Co., Inc. 1984 52 Vanderbilt Avenue, New York, NY 10017
service model is suited to a tertiary care setting, where training is an important consideration. Information flow in this model tends to be informal and verbal, facilitating psychiatric liaison. Heretofore, consultation-liaison psychiatry has rarely applied this model to the outpatient setting, where the bulk of care is delivered. The Liaison Clinic described in this paper is a model for linking general and mental health systems of care at the tertiary level. In addition, the clinic is presented as a model of psychiatric care for medical patients as well as for training, research, and funding.
Background The clinic developed from a need to provide continuity of psychiatric care for the medically ill inpatient, initially assessed and treated by the consulting psychiatrist. Although the focus of psychiatric consultation is frequently the assessment and preparation of the patient for follow-up outpatient psychiatric treatment, the circumstances of acute medical illness and the time frame of brief hospitaiization often do not permit this process to reach resolution prior to discharge. Thus, the typical medical or surgical patient is discharged with unresolved ambivalence regarding psychiatric 109 ISSN 0163-8343/84/$3.00
G. E. Rowan, J. J. Strain, and L. Gise
treatment, which may result in broken appointments. The problem is further aggravated when such a patient is placed on a waiting list. He is likely to feel disappointed with the referral and angered that his medical condition is thought to be “in his mind.” Not infrequently, the consultant sees the patient during a subsequent hospitalization only to find the psychiatric condition untreated. In these cases, the medical staff may conclude that the psychiatrist had not provided continuity of care after discharge. The liaison psychiatrist has a unique advantage in treating psychologic dysfunction in the medically ill and in the medical setting. He is likely to be more adept at assessing and treating the psychosocial aspects of medical illness, and he is trained to communicate effectively with his medical colleagues and to aid them in the psychologic management of their patients. Another rationale for a liaison clinic is that the medically ill patient who would never seek treatment in the psychiatric outpatient department for fear of being labeled “crazy” may be more than willing to see a professional who specializes in the treatment of the psychologic stress related to medical illness. In addition to linking inpatient consultation psychiatry with outpatient care, the clinic provides a format for training and research in the psychologic dysfunction of the medically ill. The clinic was initiated as a liaison psychiatry fellow’s research project during a full-time year in training. The Mount Sinai Medical Center Liaison Clinic was reestablished in July, 1980. The original clinic had been an outgrowth of Kaufman’s emphasis on the liaison between medicine and psychiatry in the 1940s and early 1950s [3,4]. In spite of the enormous growth of specialty clinics in teaching hospitals during the 1960s and 197Os, liaison clinics remain uncommon. The Liaison Clinic at Mount Sinai Medical Center was the only one in operation in Manhattan when all major general hospitals were surveyed September, 1982. Included were all general hospitals offering training in at least psychiatry, medicine, surgery, and pediatrics. However, the concept of a psychiatric clinic for the medically ill is not new. At the University of Rochester, Clarke [5] described, in 1931, a child guidance clinic designed for medically ill children and operated in conjunction with the Department of Pediatrics. In 1950, Greenhill and Kilgore [6] reported the use of a psychosomatic clinic for the psychiatric training of Duke University medical house officers. In 1962, Lipsitt [7] initiated a clinic for the coordination of
110
medical and psychiatric outpatient treatment at Beth Israel Hospital. Termed “Integration Clinic,” it was located in the Medical Clinic and designed for the psychiatric evaluation of patients who were reluctant to accept the psychologic factors in their medical illness. Most recently, Kaplan [8] described a psychosomatic clinic within the setting of the Boston City Hospital Consultation-Liaison Service.
Description of the Clinic The Liaison Clinic opened in July, 1980 to assess and treat all patients with psychologic problems related to their physical complaints. The clinic’s population includes patients with somatoform disorders, as well as disorders characterized by difficulty coping with illness and/or treatment. The clinic was staffed by the Associate Director of the Liaison Division (LHG) and the liaison fellow (GER). In addition, during their consultation- liaison rotation, residents and medical students saw outpatients under the supervision of an attending liaison psychiatrist. While the availability of space and other liaison activities usually necessitate afternoon appointments, the Liaison Clinic has no formal hours of operation. The Liaison Clinic psychiatrist, through his daily work in the medical setting, publicized the new outpatient service. Such interpersonal contact with medical colleagues and social workers is the primary means of referral. The authors also publicized the clinic in liaison, inpatient, and general outpatient psychiatry staff meetings. During the first year of the clinic’s operation, the liaison fellow attended the weekly intake conference of the general psychiatry clinic to discuss potential referrals. In addition, a formal mechanism of referral to the Liaison Clinic is the triage by the general psychiatry clinic of all medically ill patients. Patients who also have schizophrenia or major affective disorder are exceptions and are usually retained in the general psychiatry clinic, which provides better comprehensive treatment for these disorders. Data collection of patient evaluation and treatment as well as liaison effectiveness is facilitated by the use of a computerized consultation form [9]. The revised form, which registers 386 items, is suitable for both inpatient and outpatient services and is described in greater detail later. Patient visits are recorded in the medical and surgical chart rather than on a separate psychiatric chart. A copy of the psychiatrist’s note is retained in the Liaison Clinic.
The Liaison Clinic
Table 2. Primary reason for referral
Table 1. Liaison clinic referral sources
Number of patients
Number of patients Medicine Medical and surgical clinics Medical group practice Psychiatry Consultation service Inpatient service Outpatient service Private attendings Community agencies
Patient
78 (81%) 69 (72%) 9 (09%) 16 (17%) 5 1 5 5
(05%) (01%) (05%) (05%) 2 (02%)
Data
The patients seen came primarily from several units in the hospital (Table l), and particularly from the medical and surgical clinics (n=69). In addition, two patients were referred by extramural agencies. A variety of consultees initiated requests for psychiatric evaluation, including the patients’ families. However, most cases were referred by a social worker (n = 30). Seventy-one percent of the patients were female and two-thirds were aged 30-60 (range 17-86). The most frequent marital status was separated or divorced (n=36). The patient population was nearly equally represented by the white (n=30), black (n=34), and hispanic (n=32) ethnic groups. Patients were referred most commonly (Table 2) for depression (n=24), anxiety (n=23), and diagnostic evaluation (n=14); that is, for the presence of a psychotic disorder or a psychogenic component to the patient’s medical illness. The patients’ chief complaints were anxiety (n=35), depression (n=34), pain or other somatic complaint (n=ll), sexual problem (n=4), hearing voices (n=4), and other (n=3). Five patients had no complaint and were brought to the clinic for evaluation of memory impairment and/or psychotic behavior. Of the twelve patients with no DSM III axis I diagnosis (Table 3), eight received an axis II diagnosis, which was most often mixed personality disorder. Furthermore, the patients showed a great diversity in ICD-9 medical (axis III) diagnoses. Forty-two specific primary diagnoses are summarized in 15 disease categories (Table 4). Hypertension, diabetes, and asthma were the most common specific disease entities. Sixteen patients were assigned no medical diagnosis and were often referred from
Anxiety Behavior management Coping (help dealing with illness) Depression Diagnosis Noncompliance Organic brain syndrome Pain Preoperative evaluation Psychiatric history of psychosis Psychotropic medication assessment Sexual problem Sleeping disorder Social performance impaired Suicidal risk evaluation Other Total
23 2 2 24 14 1 5 3 2 2 6 4 2 1 3 2 96
medical clinics after extensive diagnostic evaluation showed no somatic etiology for the patient’s complaints. The
Clinic Contact
The Liaison Clinic contact ranged from an initial evaluation to ongoing individual or group psychoTable 3. DSM III Axis I diagnosis Number of patients Major depressive illness Dysthymic disorder Adjustment disorder With anxious mood With depressed mood With mixed emotional features Posttraumatic stress disorder Generalized anxiety disorder Panic disorder Conversion reaction Somatoform disorder Heroin abuse Organic mental disorder Schizophrenia Schizophreniform disorder Atypical psychosis No axis I diagnosis Total
17 11 15 9 5 1 8 1 1 1 1 8 3 1 2 12 96
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G. E. Rowan, J. J. Strain, and L. Gise
Table 4. Primary. medical diagnosis Number of patients Disease of the circulatory system Hypertentsion Other Endocrine disorder Diabetes Hypothyroidism Disease of the nervous system Asthma Neoplasms Disease of the genitourinary systema Infectious diseases Disease of the sense organs Digestive system disorder Blood dyscrasia Osteoarthritis Disease of the skin and subcutaneous tissue Tension headache Abdominal pain, unknown etiology Hip fracture No medical diagnosis Total
10 10 9 2 11 8 7 4a 3 3 3 2 2 2 2 1 1 16 96
“This number does not include cases of end-state renal disease that were seen in the dialysis unit and not included in the liaison clinic data.
therapy.
Evaluations
were generally accomplished
in a single 45-60 minute visit. A recommendation for psychiatric treatment was made for 88 patients, who had an axis I and/or axis II DSM III psychiatric disorder. For the remaining eight of the 96 clinic patients, treatment was not indicated; they had either no axis I or II disorder (n=4), or an uncomplicated, stable organic mental disorder (n=4). Treatment in the Liaison Clinic was recommended for 68 patients, and included individual or group psychotherapy or counselling. In addition, 48 also received medication. Twenty of the 68, however, failed to keep their second appointment. Scheduled individual psychotherapy sessions ranged from twice weekly to biweekly and were of 45 minutes duration. A group psychotherapy for the medically ill met weekly for 90 minutes. Medication visits, which included supportive counselling, were monthly to quarterly and of 20-30 minutes duration. Formal behavioral treatment such as hypnosis or biofeedback was not available. For the patients needing treatment (n=88), the number of visits ranged from one (n=44) to 37 (n=l). The latter occurred for a patient seen in 112
weekly individual psychotherapy. Forty-four patients had a single visit for a variety of reasons: a) noncompliance (n=20); b) counselling or follow-up by the referring clinic’s social worker or psychiatric nurse-clinician alone was sufficient (n=7); c) the referral of patients with psychotic or major affective disorder to the general psychiatry clinic (n=7); d) the unavailability at the time of evaluation of the most appropriate treatment and consequent referral elsewhere (n=6); and e) subsequent medical hospitalization precluding treatment in the Liaison Clinic (n=4). In the last situation, except for one patient who was hospitalized outside of the Mount Sinai Medical Center, psychiatric consultation and treatment was continued by the Liaison Clinic psychiatrist in the inpatient medical setting. The treatment of the 68 clinic cases reflects the use of a multidisciplinary and liaison approach [Table 51. Sixty-four patients were followed in conjunction with the referring clinic. Of these, 32 were treated by the Liaison Clinic psychiatrist acting as primary therapist. Frequently, the psychiatrist saw the patient initially in the referring clinic, where he discussed the proposed psychiatric management with the physician, nurse, and/or social worker. If his physical presence in the medical setting was not immediately possible, the Liaison Clinic psychiatrist began the patient’s evaluation by a telephone contact with the referring health care professional. During treatment, the frequency of contact with the consultee depended mostly on the reason for referral and the patient’s psychiatric disorder. Contact ranged from weekly to quarterly. For example, the liaison clinic psychiatrist met weekly with the Hemophilia Clinic physicians and staff to develop a treatment strategy for a noncompliant hemophiliac with a severe personality disorder. Thus, his treatment of the patient with individual psychotherapy had an impact on health care delivery as well as the patient’s psychopathology. On the other hand, only occasional discussion with the referring neuTable 5. Liaison clinic treatment cases Number of patients Psychiatrist only Psychiatrist and medical/surgical clinic physician with psychiatric nurse-clinician with social worker Total
4 32 11 21 68
The Liaison Clinic
Table 6.
Liaison clinic income
Rate/visit
Number of visits Income
Medicaid $60.78 220 Medicare 37 Medicaid/Medicare . . z.9: 24 Self-pay $15:50 99 (average) Totals 380
$13,372 1,998 1,548 1,534 $18,452
rologist took place for a patient with multiple sclerosis with secondary organicity and anxiety. Here, the issue was the choice of the appropriate psychotropic medication, which required much less liaison effort. For another 32 patients, the identified primary therapist was the referring clinic’s social worker or psychiatric nurse-clinician. For the latter, the Liaison Clinic psychiatrist served as a consultant and prescribed medication when indicated. The psychiatrist’s contact with the social worker or nurseclinician was an integral part of the patient’s Liaison Clinic visit; usually, the contact was in person as the primary therapist accompanied the patient in the clinic visit. For this patient group, contact with the referring clinic’s physician was less frequent and usually confined to the need for medication change or additional consultations. The primary therapist was encouraged to provide not only counselling and social services, but also liaison to the referring clinic. Thus, the psychiatrist facilitated the coordination of the medical and psychologic care and encouraged a team approach.
year. NIMH had been a mainstay for many programs since the Second World War. In 1946, at the Mount Sinai Hospital in New York City, M. Ralph Kaufman employed a unique and successful approach to “funding” a liaison service [41. He relied on the services donated by a large group of dedicated voluntary attendings, each working 4-10 hours per week. Funding has also occurred directly from the consultation effort, and such fee-for-service reimbursement will become more important in the future. Third party payers may be willing to support consultation-liaison activities if off-set studies like that of Levitan and Kornfeld [lo] are pursued. They demonstrated that a liaison psychiatry service on an orthopedic unit was cost effective; it shortened the length of stay and encouraged discharge to home rather than to a health related facility. With the ever possible termination of training grants, funding for liaison fellowships has also been jeopardized. Strain et al. [ll] described funding of a liaison fellowship by a unique combination of consultation and “authentic” liaison effort in a renal dialysis unit. Similarly to a renal dialysis unit, the Liaison Clinic permits direct reimbursement of patient care and facilitates training in liaison psychiatry. The income generated from approximately 10 hours weekly of direct patient care provided by the associate director, fellow, and residents over the period of a year exceeded three-quarters of the liaison fellow’s salary of $24,000 per annum (a PGYS level). Since the clinic had generated a waiting list and requests for patient groups from diabetes, cardiac, and hemophiliac clinics, it was apparent that enough patient need had been identified to support a second fellow or half-time junior attending.
Income Three hundred and ninety patient visits from July 1, 1980 to June 30, 1981 yielded an income of $18,425, of which $13,372 was from Medicaid reimbursement (Table 6). The balance was derived from Medicare, Medicaid/Medicare, and self-pay visits.i
Discussion FWUfing Funding for consultation and liaison psychiatry has been problematic and is aggravated by the possible termination of training grants during any academic ‘Ten visits registration.
were
not
reimbursed
because
of
faulty
Training On the average, the liaison psychiatry fellow devoted 10 hours weekly to Liaison Clinic activities. These included weekly individual supervision and frequent case conferences. In addition, he evaluated more than half of the clinic patients and dealt with the liaison as well as treatment aspects of a case. The remainder of the fellow’s time was devoted to studying and participating in other paradigms of liaison practice: an inpatient medical unit, a psychiatric-medical inpatient unit 1121,a primary care setting, an ambulatory specialty clinic, and ongoing seminars, conferences, and supervision. The Liaison Clinic also provides a unique train113
G. E. Rowan, J. J. Strain, and L. Gise ing placement within psychiatry for residents and medical students. Psychiatry residents during the consultation-liaison rotation are encouraged to continue the psychiatric treatment of medically ill patients whom they initially evaluate on the medical and surgical inpatient services. The opportunity to evaluate and treat such patients challenges the residents’ liaison as well as psychiatric diagnostic and treatment skills. Senior medical students, during a consultation-liaison elective, enjoy a similar, although more intensely supervised experience; in addition to receiving formal supervision by the liaison faculty, they work closely with the liaison fellow. The Liaison Clinic allows the psychiatric trainee in a tertiary care center a much needed training opportunity in an outpatient setting where both medical and psychiatric dysfunction are emphasized and integrated.
Research Not only does the clinic serve as a source for access to funding and a format for training, but it permits the development of a patient population that can be studied for response to treatment, compliance, utilization of service, and recidivism in the medically ill. It also facilitates longitudinal study and the evaluation of psychiatric intervention in the outpatient setting. The high incidence of anxiety and depression in this population has several treatment and research implications. Behavioral treatment, particularly biofeedback, would be a valuable adjunct to the treatment of nonpsychotic anxiety and related somatic complaints that were present in 10% of the Liaison Clinic population. Because the effectiveness of tricyclic antidepressants in the medically ill has yet to be determined, patients with major affective disorders and significant medical illness are referred to a double blind randomized, controlled study assessing the use of tricyclic medication versus placebo. In addition, the relationship between age, sex, psychologic dysfunction and medical illness can be studied longitudinally. Since circulatory disease was the most frequent Axis III diagnosis in our population, it would be possible to study the kind of psychologic dysfunction present in this medical patient group. Statistical analysis of the data may help identify critical variable(s) in compliance. Examining the lack of concordance between reason for request and psychiatric diagnosis provides an opportunity for needs assessment, revealing those 114
areas of psychopathology less frequently identified by nonpsychiatric physicians, to which the liaison psychiatrist should direct his teaching effort. In time, the success of liaison teaching might be measured by the degree of concordance between the primary care physician’s reason for request and the consultant’s ultimate psychiatric diagnosis. These research pursuits in the Liaison Clinic are facilitated by-the use of the revised psychiatric consultation form. This encourages not only the longitudinal study of multiple variables, but also a comparison of an inpatient with an outpatient sample. Such a record-keeping method, utilizing a minicomputer system (CLINFO), permits evaluation of the effectiveness of liaison psychiatry in a) identification and description of the population, b) the education of the psychiatric trainee, c) consultee satisfaction, d) consultee learning, e) patient outcome, and f) cost-benefit analysis [9]. Since data from patient contacts on the consultation service and in the Liaison Clinic are recorded on the psychiatric consultation form and carefully maintained records are available on all patients from the psychiatric-medical inpatient unit and medical clinic, it is possible to follow the utilization of services for the medically ill and the recidivism from one service versus another. Furthermore, such a multiple service delivery system would permit off-set studies on the cost of caring for the psychologic and psychiatric needs of the medically ill by examining, for example: a) the frequency of rehospitalization in a patient group followed in a primary care clinic versus a liaison clinic; and b) the ability to keep patients in the ambulatory setting when psychologic and medical needs are handled conjointly, particularly in the tertiary phase of illness, that is, in the convalescent and posthospitalization phase. The examination of the alteration of morbidity and mortality with psychologic interventions is possible; for instance, Rahe et al. [13] have demonstrated the effectiveness of group interventions in postcardiac patients.
Conclusions The Liaison Clinic developed from the need to provide continuity of patient care and provided a missing link in a system of tertiary inpatient and outpatient care. The clinic provides funding and a format for liaison psychiatry training as well as a unique opportunity to study psychologic dysfunction in the medically ill. This ambulatory model is an approach to patient care, training, and funding
The Liaison Clinic
that could be employed in the tertiary care teaching hospital. In addition, the Liaison Clinic concept fosters the practice and teaching of a biopsychosocial orientation in a heretofore biomedical setting and establishes important linkages between general health and mental health in a tertiary care setting. More importantly, it serves as a teaching resource for the nonpsychiatric physician, medical students, and psychiatric residents on interface patients whom they confront in practice. It moves beyond the consultation and referral model to promote the nonpsychiatric physicians’ active participation in the detection and management of the psychologic morbidity of their patients. Finally, and most importantly, the Liaison Clinic incorporates nonpsychiatric professionals into the biopsychosocial care process and addresses the needs of the “de facto” mental health service, since it provides training to those physicians who are in contact with the majority of patients with mental disorder. Acknowledgment note The authors thank Dr. Ilona Mire& for assisting Dr. Rowan in developing and leading a group psychotherapy for the medically ill.
References Reiger DA, Goldberg ID, Taube CA: The de facto US mental health services system: A public perspective. Arch Gen Psychiatry 35:685-693, 1978 Pincus HA: Linking general health and mental health systems of care: Conceptual models of implementation. Am J Psychiatry 137:315-320, 1980 Kaufman MR, Margolin S: Theory and practice of psychosomatic medicine. Med Clin Am 32:611-616, 1948
4. Bernstein S, Kaufman MR: The psychiatrist in a general hospital: His functional relationship to the nonpsychiatric services. J Mt Sinai Hosp 29:385-394,1962 5. Clarke EK: The role of the psychiatric department in relation to the pediatric department in a general hospital. Am J Psychiatry 88:559-566, 1931 6. Greenhill MH, Kilgore SR: Principles of methodology in teaching the psychiatric approach to medical house officers. Psychosomatic Medicine 12:38-48, 1950 7. Lipsitt DR: Integration Clinic: An approach to the teaching and practice of medical psychology in an outpatient setting. Psychiatry and Medical Practice in a General Hospital. Zinberg NE (ed). International Universities Press, 1964 8. Kaplan KH: Development and function of a psychiatric liaison clinic. Psychosomatics 22:502-512, 1981 9. Taintor Z, Gise LH, Spikes J, Strain JJ: Recording psychiatric consultations: A preliminary report. Gen Hosp Psychiatry 1:139-149, 1979 10. Levitan SJ, Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am J Psychiatry 138:790-793,198l 11. Strain JJ, Vollhardt BR, Langer SJ: A liaison fellowship on a hemodialysis unit: A self-funded position. Gen Hosp Psychiatry 3:10-15, 1981 12. Goodman B, Kaplan MA, Schwartz M: A psychiatric-medical unit. Presented at the APA Meeting, Toronto, 1982 13. Rahe RH, Ward HW, Hayes V: Brief group therapy in myocardial infarction rehabilitation: Three to four year follow-up of a controlled trial. Psychosom Med 41:229-242, 1979 Direct reprint requests to: Dr. Strain, Director
Psychiatric Liaison Consultation Service, Mount Sinai School of Medicine One Gustave L. Levy Place New York, New York 10029
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James J. Strain, M.D. Professor of Clinical Psychiatry and Director, Liaison and Consultation Service, Mount Sinai School of Medicine, New York
Leslie Hartley Gise, M.D. Assistant Professor of Psychiatry and Associate Director, Liaison Consultation Service, Mount Sinai School of Medicine, New York
Abstract: Whileliaisonor similar clinics have existed since at least 2932, they remain uncommon. The Mount Sinai Medical Center Liaison Clinic is presented as a model for psychiatric evaiuntion and care of medical patients as well as training, research, and funding. In addition, it is a model for linking general and mental health systems in the tertiary care setting. Thefirsf year of operation of the clinic is described, including the sources of referral, demographic data, psychiatric, and medical diagnoses, and type of clinic contact. A total of 96 patients were seen in 390 visits, equaling three quarters of a liaison fellow’s
salary. Psychiatric disorder is commonly treated by nonmental-health professionals. Reiger et al. [l] report that 54% of the U.S. population with mental disorders are treated in the general health care sector. The failure to detect and treat mental disorders appears to exist at all levels of care. In the tertiary care setting, this failure is not due to the unavailability of appropriate professionals, but to the lack of a unit designated to link psychiatric and medical care. Pincus [2] describes conceptual models of linkage between general health and mental health systems of care, stating that a consultation and This work was supported in part by NIMH Grant MH 16438.
General Hospital Psychiatry 6, 109-115, 1984 0 Elsevier Science Publishing Co., Inc. 1984 52 Vanderbilt Avenue, New York, NY 10017
service model is suited to a tertiary care setting, where training is an important consideration. Information flow in this model tends to be informal and verbal, facilitating psychiatric liaison. Heretofore, consultation-liaison psychiatry has rarely applied this model to the outpatient setting, where the bulk of care is delivered. The Liaison Clinic described in this paper is a model for linking general and mental health systems of care at the tertiary level. In addition, the clinic is presented as a model of psychiatric care for medical patients as well as for training, research, and funding.
Background The clinic developed from a need to provide continuity of psychiatric care for the medically ill inpatient, initially assessed and treated by the consulting psychiatrist. Although the focus of psychiatric consultation is frequently the assessment and preparation of the patient for follow-up outpatient psychiatric treatment, the circumstances of acute medical illness and the time frame of brief hospitaiization often do not permit this process to reach resolution prior to discharge. Thus, the typical medical or surgical patient is discharged with unresolved ambivalence regarding psychiatric 109 ISSN 0163-8343/84/$3.00
G. E. Rowan, J. J. Strain, and L. Gise
treatment, which may result in broken appointments. The problem is further aggravated when such a patient is placed on a waiting list. He is likely to feel disappointed with the referral and angered that his medical condition is thought to be “in his mind.” Not infrequently, the consultant sees the patient during a subsequent hospitalization only to find the psychiatric condition untreated. In these cases, the medical staff may conclude that the psychiatrist had not provided continuity of care after discharge. The liaison psychiatrist has a unique advantage in treating psychologic dysfunction in the medically ill and in the medical setting. He is likely to be more adept at assessing and treating the psychosocial aspects of medical illness, and he is trained to communicate effectively with his medical colleagues and to aid them in the psychologic management of their patients. Another rationale for a liaison clinic is that the medically ill patient who would never seek treatment in the psychiatric outpatient department for fear of being labeled “crazy” may be more than willing to see a professional who specializes in the treatment of the psychologic stress related to medical illness. In addition to linking inpatient consultation psychiatry with outpatient care, the clinic provides a format for training and research in the psychologic dysfunction of the medically ill. The clinic was initiated as a liaison psychiatry fellow’s research project during a full-time year in training. The Mount Sinai Medical Center Liaison Clinic was reestablished in July, 1980. The original clinic had been an outgrowth of Kaufman’s emphasis on the liaison between medicine and psychiatry in the 1940s and early 1950s [3,4]. In spite of the enormous growth of specialty clinics in teaching hospitals during the 1960s and 197Os, liaison clinics remain uncommon. The Liaison Clinic at Mount Sinai Medical Center was the only one in operation in Manhattan when all major general hospitals were surveyed September, 1982. Included were all general hospitals offering training in at least psychiatry, medicine, surgery, and pediatrics. However, the concept of a psychiatric clinic for the medically ill is not new. At the University of Rochester, Clarke [5] described, in 1931, a child guidance clinic designed for medically ill children and operated in conjunction with the Department of Pediatrics. In 1950, Greenhill and Kilgore [6] reported the use of a psychosomatic clinic for the psychiatric training of Duke University medical house officers. In 1962, Lipsitt [7] initiated a clinic for the coordination of
110
medical and psychiatric outpatient treatment at Beth Israel Hospital. Termed “Integration Clinic,” it was located in the Medical Clinic and designed for the psychiatric evaluation of patients who were reluctant to accept the psychologic factors in their medical illness. Most recently, Kaplan [8] described a psychosomatic clinic within the setting of the Boston City Hospital Consultation-Liaison Service.
Description of the Clinic The Liaison Clinic opened in July, 1980 to assess and treat all patients with psychologic problems related to their physical complaints. The clinic’s population includes patients with somatoform disorders, as well as disorders characterized by difficulty coping with illness and/or treatment. The clinic was staffed by the Associate Director of the Liaison Division (LHG) and the liaison fellow (GER). In addition, during their consultation- liaison rotation, residents and medical students saw outpatients under the supervision of an attending liaison psychiatrist. While the availability of space and other liaison activities usually necessitate afternoon appointments, the Liaison Clinic has no formal hours of operation. The Liaison Clinic psychiatrist, through his daily work in the medical setting, publicized the new outpatient service. Such interpersonal contact with medical colleagues and social workers is the primary means of referral. The authors also publicized the clinic in liaison, inpatient, and general outpatient psychiatry staff meetings. During the first year of the clinic’s operation, the liaison fellow attended the weekly intake conference of the general psychiatry clinic to discuss potential referrals. In addition, a formal mechanism of referral to the Liaison Clinic is the triage by the general psychiatry clinic of all medically ill patients. Patients who also have schizophrenia or major affective disorder are exceptions and are usually retained in the general psychiatry clinic, which provides better comprehensive treatment for these disorders. Data collection of patient evaluation and treatment as well as liaison effectiveness is facilitated by the use of a computerized consultation form [9]. The revised form, which registers 386 items, is suitable for both inpatient and outpatient services and is described in greater detail later. Patient visits are recorded in the medical and surgical chart rather than on a separate psychiatric chart. A copy of the psychiatrist’s note is retained in the Liaison Clinic.
The Liaison Clinic
Table 2. Primary reason for referral
Table 1. Liaison clinic referral sources
Number of patients
Number of patients Medicine Medical and surgical clinics Medical group practice Psychiatry Consultation service Inpatient service Outpatient service Private attendings Community agencies
Patient
78 (81%) 69 (72%) 9 (09%) 16 (17%) 5 1 5 5
(05%) (01%) (05%) (05%) 2 (02%)
Data
The patients seen came primarily from several units in the hospital (Table l), and particularly from the medical and surgical clinics (n=69). In addition, two patients were referred by extramural agencies. A variety of consultees initiated requests for psychiatric evaluation, including the patients’ families. However, most cases were referred by a social worker (n = 30). Seventy-one percent of the patients were female and two-thirds were aged 30-60 (range 17-86). The most frequent marital status was separated or divorced (n=36). The patient population was nearly equally represented by the white (n=30), black (n=34), and hispanic (n=32) ethnic groups. Patients were referred most commonly (Table 2) for depression (n=24), anxiety (n=23), and diagnostic evaluation (n=14); that is, for the presence of a psychotic disorder or a psychogenic component to the patient’s medical illness. The patients’ chief complaints were anxiety (n=35), depression (n=34), pain or other somatic complaint (n=ll), sexual problem (n=4), hearing voices (n=4), and other (n=3). Five patients had no complaint and were brought to the clinic for evaluation of memory impairment and/or psychotic behavior. Of the twelve patients with no DSM III axis I diagnosis (Table 3), eight received an axis II diagnosis, which was most often mixed personality disorder. Furthermore, the patients showed a great diversity in ICD-9 medical (axis III) diagnoses. Forty-two specific primary diagnoses are summarized in 15 disease categories (Table 4). Hypertension, diabetes, and asthma were the most common specific disease entities. Sixteen patients were assigned no medical diagnosis and were often referred from
Anxiety Behavior management Coping (help dealing with illness) Depression Diagnosis Noncompliance Organic brain syndrome Pain Preoperative evaluation Psychiatric history of psychosis Psychotropic medication assessment Sexual problem Sleeping disorder Social performance impaired Suicidal risk evaluation Other Total
23 2 2 24 14 1 5 3 2 2 6 4 2 1 3 2 96
medical clinics after extensive diagnostic evaluation showed no somatic etiology for the patient’s complaints. The
Clinic Contact
The Liaison Clinic contact ranged from an initial evaluation to ongoing individual or group psychoTable 3. DSM III Axis I diagnosis Number of patients Major depressive illness Dysthymic disorder Adjustment disorder With anxious mood With depressed mood With mixed emotional features Posttraumatic stress disorder Generalized anxiety disorder Panic disorder Conversion reaction Somatoform disorder Heroin abuse Organic mental disorder Schizophrenia Schizophreniform disorder Atypical psychosis No axis I diagnosis Total
17 11 15 9 5 1 8 1 1 1 1 8 3 1 2 12 96
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G. E. Rowan, J. J. Strain, and L. Gise
Table 4. Primary. medical diagnosis Number of patients Disease of the circulatory system Hypertentsion Other Endocrine disorder Diabetes Hypothyroidism Disease of the nervous system Asthma Neoplasms Disease of the genitourinary systema Infectious diseases Disease of the sense organs Digestive system disorder Blood dyscrasia Osteoarthritis Disease of the skin and subcutaneous tissue Tension headache Abdominal pain, unknown etiology Hip fracture No medical diagnosis Total
10 10 9 2 11 8 7 4a 3 3 3 2 2 2 2 1 1 16 96
“This number does not include cases of end-state renal disease that were seen in the dialysis unit and not included in the liaison clinic data.
therapy.
Evaluations
were generally accomplished
in a single 45-60 minute visit. A recommendation for psychiatric treatment was made for 88 patients, who had an axis I and/or axis II DSM III psychiatric disorder. For the remaining eight of the 96 clinic patients, treatment was not indicated; they had either no axis I or II disorder (n=4), or an uncomplicated, stable organic mental disorder (n=4). Treatment in the Liaison Clinic was recommended for 68 patients, and included individual or group psychotherapy or counselling. In addition, 48 also received medication. Twenty of the 68, however, failed to keep their second appointment. Scheduled individual psychotherapy sessions ranged from twice weekly to biweekly and were of 45 minutes duration. A group psychotherapy for the medically ill met weekly for 90 minutes. Medication visits, which included supportive counselling, were monthly to quarterly and of 20-30 minutes duration. Formal behavioral treatment such as hypnosis or biofeedback was not available. For the patients needing treatment (n=88), the number of visits ranged from one (n=44) to 37 (n=l). The latter occurred for a patient seen in 112
weekly individual psychotherapy. Forty-four patients had a single visit for a variety of reasons: a) noncompliance (n=20); b) counselling or follow-up by the referring clinic’s social worker or psychiatric nurse-clinician alone was sufficient (n=7); c) the referral of patients with psychotic or major affective disorder to the general psychiatry clinic (n=7); d) the unavailability at the time of evaluation of the most appropriate treatment and consequent referral elsewhere (n=6); and e) subsequent medical hospitalization precluding treatment in the Liaison Clinic (n=4). In the last situation, except for one patient who was hospitalized outside of the Mount Sinai Medical Center, psychiatric consultation and treatment was continued by the Liaison Clinic psychiatrist in the inpatient medical setting. The treatment of the 68 clinic cases reflects the use of a multidisciplinary and liaison approach [Table 51. Sixty-four patients were followed in conjunction with the referring clinic. Of these, 32 were treated by the Liaison Clinic psychiatrist acting as primary therapist. Frequently, the psychiatrist saw the patient initially in the referring clinic, where he discussed the proposed psychiatric management with the physician, nurse, and/or social worker. If his physical presence in the medical setting was not immediately possible, the Liaison Clinic psychiatrist began the patient’s evaluation by a telephone contact with the referring health care professional. During treatment, the frequency of contact with the consultee depended mostly on the reason for referral and the patient’s psychiatric disorder. Contact ranged from weekly to quarterly. For example, the liaison clinic psychiatrist met weekly with the Hemophilia Clinic physicians and staff to develop a treatment strategy for a noncompliant hemophiliac with a severe personality disorder. Thus, his treatment of the patient with individual psychotherapy had an impact on health care delivery as well as the patient’s psychopathology. On the other hand, only occasional discussion with the referring neuTable 5. Liaison clinic treatment cases Number of patients Psychiatrist only Psychiatrist and medical/surgical clinic physician with psychiatric nurse-clinician with social worker Total
4 32 11 21 68
The Liaison Clinic
Table 6.
Liaison clinic income
Rate/visit
Number of visits Income
Medicaid $60.78 220 Medicare 37 Medicaid/Medicare . . z.9: 24 Self-pay $15:50 99 (average) Totals 380
$13,372 1,998 1,548 1,534 $18,452
rologist took place for a patient with multiple sclerosis with secondary organicity and anxiety. Here, the issue was the choice of the appropriate psychotropic medication, which required much less liaison effort. For another 32 patients, the identified primary therapist was the referring clinic’s social worker or psychiatric nurse-clinician. For the latter, the Liaison Clinic psychiatrist served as a consultant and prescribed medication when indicated. The psychiatrist’s contact with the social worker or nurseclinician was an integral part of the patient’s Liaison Clinic visit; usually, the contact was in person as the primary therapist accompanied the patient in the clinic visit. For this patient group, contact with the referring clinic’s physician was less frequent and usually confined to the need for medication change or additional consultations. The primary therapist was encouraged to provide not only counselling and social services, but also liaison to the referring clinic. Thus, the psychiatrist facilitated the coordination of the medical and psychologic care and encouraged a team approach.
year. NIMH had been a mainstay for many programs since the Second World War. In 1946, at the Mount Sinai Hospital in New York City, M. Ralph Kaufman employed a unique and successful approach to “funding” a liaison service [41. He relied on the services donated by a large group of dedicated voluntary attendings, each working 4-10 hours per week. Funding has also occurred directly from the consultation effort, and such fee-for-service reimbursement will become more important in the future. Third party payers may be willing to support consultation-liaison activities if off-set studies like that of Levitan and Kornfeld [lo] are pursued. They demonstrated that a liaison psychiatry service on an orthopedic unit was cost effective; it shortened the length of stay and encouraged discharge to home rather than to a health related facility. With the ever possible termination of training grants, funding for liaison fellowships has also been jeopardized. Strain et al. [ll] described funding of a liaison fellowship by a unique combination of consultation and “authentic” liaison effort in a renal dialysis unit. Similarly to a renal dialysis unit, the Liaison Clinic permits direct reimbursement of patient care and facilitates training in liaison psychiatry. The income generated from approximately 10 hours weekly of direct patient care provided by the associate director, fellow, and residents over the period of a year exceeded three-quarters of the liaison fellow’s salary of $24,000 per annum (a PGYS level). Since the clinic had generated a waiting list and requests for patient groups from diabetes, cardiac, and hemophiliac clinics, it was apparent that enough patient need had been identified to support a second fellow or half-time junior attending.
Income Three hundred and ninety patient visits from July 1, 1980 to June 30, 1981 yielded an income of $18,425, of which $13,372 was from Medicaid reimbursement (Table 6). The balance was derived from Medicare, Medicaid/Medicare, and self-pay visits.i
Discussion FWUfing Funding for consultation and liaison psychiatry has been problematic and is aggravated by the possible termination of training grants during any academic ‘Ten visits registration.
were
not
reimbursed
because
of
faulty
Training On the average, the liaison psychiatry fellow devoted 10 hours weekly to Liaison Clinic activities. These included weekly individual supervision and frequent case conferences. In addition, he evaluated more than half of the clinic patients and dealt with the liaison as well as treatment aspects of a case. The remainder of the fellow’s time was devoted to studying and participating in other paradigms of liaison practice: an inpatient medical unit, a psychiatric-medical inpatient unit 1121,a primary care setting, an ambulatory specialty clinic, and ongoing seminars, conferences, and supervision. The Liaison Clinic also provides a unique train113
G. E. Rowan, J. J. Strain, and L. Gise ing placement within psychiatry for residents and medical students. Psychiatry residents during the consultation-liaison rotation are encouraged to continue the psychiatric treatment of medically ill patients whom they initially evaluate on the medical and surgical inpatient services. The opportunity to evaluate and treat such patients challenges the residents’ liaison as well as psychiatric diagnostic and treatment skills. Senior medical students, during a consultation-liaison elective, enjoy a similar, although more intensely supervised experience; in addition to receiving formal supervision by the liaison faculty, they work closely with the liaison fellow. The Liaison Clinic allows the psychiatric trainee in a tertiary care center a much needed training opportunity in an outpatient setting where both medical and psychiatric dysfunction are emphasized and integrated.
Research Not only does the clinic serve as a source for access to funding and a format for training, but it permits the development of a patient population that can be studied for response to treatment, compliance, utilization of service, and recidivism in the medically ill. It also facilitates longitudinal study and the evaluation of psychiatric intervention in the outpatient setting. The high incidence of anxiety and depression in this population has several treatment and research implications. Behavioral treatment, particularly biofeedback, would be a valuable adjunct to the treatment of nonpsychotic anxiety and related somatic complaints that were present in 10% of the Liaison Clinic population. Because the effectiveness of tricyclic antidepressants in the medically ill has yet to be determined, patients with major affective disorders and significant medical illness are referred to a double blind randomized, controlled study assessing the use of tricyclic medication versus placebo. In addition, the relationship between age, sex, psychologic dysfunction and medical illness can be studied longitudinally. Since circulatory disease was the most frequent Axis III diagnosis in our population, it would be possible to study the kind of psychologic dysfunction present in this medical patient group. Statistical analysis of the data may help identify critical variable(s) in compliance. Examining the lack of concordance between reason for request and psychiatric diagnosis provides an opportunity for needs assessment, revealing those 114
areas of psychopathology less frequently identified by nonpsychiatric physicians, to which the liaison psychiatrist should direct his teaching effort. In time, the success of liaison teaching might be measured by the degree of concordance between the primary care physician’s reason for request and the consultant’s ultimate psychiatric diagnosis. These research pursuits in the Liaison Clinic are facilitated by-the use of the revised psychiatric consultation form. This encourages not only the longitudinal study of multiple variables, but also a comparison of an inpatient with an outpatient sample. Such a record-keeping method, utilizing a minicomputer system (CLINFO), permits evaluation of the effectiveness of liaison psychiatry in a) identification and description of the population, b) the education of the psychiatric trainee, c) consultee satisfaction, d) consultee learning, e) patient outcome, and f) cost-benefit analysis [9]. Since data from patient contacts on the consultation service and in the Liaison Clinic are recorded on the psychiatric consultation form and carefully maintained records are available on all patients from the psychiatric-medical inpatient unit and medical clinic, it is possible to follow the utilization of services for the medically ill and the recidivism from one service versus another. Furthermore, such a multiple service delivery system would permit off-set studies on the cost of caring for the psychologic and psychiatric needs of the medically ill by examining, for example: a) the frequency of rehospitalization in a patient group followed in a primary care clinic versus a liaison clinic; and b) the ability to keep patients in the ambulatory setting when psychologic and medical needs are handled conjointly, particularly in the tertiary phase of illness, that is, in the convalescent and posthospitalization phase. The examination of the alteration of morbidity and mortality with psychologic interventions is possible; for instance, Rahe et al. [13] have demonstrated the effectiveness of group interventions in postcardiac patients.
Conclusions The Liaison Clinic developed from the need to provide continuity of patient care and provided a missing link in a system of tertiary inpatient and outpatient care. The clinic provides funding and a format for liaison psychiatry training as well as a unique opportunity to study psychologic dysfunction in the medically ill. This ambulatory model is an approach to patient care, training, and funding
The Liaison Clinic
that could be employed in the tertiary care teaching hospital. In addition, the Liaison Clinic concept fosters the practice and teaching of a biopsychosocial orientation in a heretofore biomedical setting and establishes important linkages between general health and mental health in a tertiary care setting. More importantly, it serves as a teaching resource for the nonpsychiatric physician, medical students, and psychiatric residents on interface patients whom they confront in practice. It moves beyond the consultation and referral model to promote the nonpsychiatric physicians’ active participation in the detection and management of the psychologic morbidity of their patients. Finally, and most importantly, the Liaison Clinic incorporates nonpsychiatric professionals into the biopsychosocial care process and addresses the needs of the “de facto” mental health service, since it provides training to those physicians who are in contact with the majority of patients with mental disorder. Acknowledgment note The authors thank Dr. Ilona Mire& for assisting Dr. Rowan in developing and leading a group psychotherapy for the medically ill.
References Reiger DA, Goldberg ID, Taube CA: The de facto US mental health services system: A public perspective. Arch Gen Psychiatry 35:685-693, 1978 Pincus HA: Linking general health and mental health systems of care: Conceptual models of implementation. Am J Psychiatry 137:315-320, 1980 Kaufman MR, Margolin S: Theory and practice of psychosomatic medicine. Med Clin Am 32:611-616, 1948
4. Bernstein S, Kaufman MR: The psychiatrist in a general hospital: His functional relationship to the nonpsychiatric services. J Mt Sinai Hosp 29:385-394,1962 5. Clarke EK: The role of the psychiatric department in relation to the pediatric department in a general hospital. Am J Psychiatry 88:559-566, 1931 6. Greenhill MH, Kilgore SR: Principles of methodology in teaching the psychiatric approach to medical house officers. Psychosomatic Medicine 12:38-48, 1950 7. Lipsitt DR: Integration Clinic: An approach to the teaching and practice of medical psychology in an outpatient setting. Psychiatry and Medical Practice in a General Hospital. Zinberg NE (ed). International Universities Press, 1964 8. Kaplan KH: Development and function of a psychiatric liaison clinic. Psychosomatics 22:502-512, 1981 9. Taintor Z, Gise LH, Spikes J, Strain JJ: Recording psychiatric consultations: A preliminary report. Gen Hosp Psychiatry 1:139-149, 1979 10. Levitan SJ, Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am J Psychiatry 138:790-793,198l 11. Strain JJ, Vollhardt BR, Langer SJ: A liaison fellowship on a hemodialysis unit: A self-funded position. Gen Hosp Psychiatry 3:10-15, 1981 12. Goodman B, Kaplan MA, Schwartz M: A psychiatric-medical unit. Presented at the APA Meeting, Toronto, 1982 13. Rahe RH, Ward HW, Hayes V: Brief group therapy in myocardial infarction rehabilitation: Three to four year follow-up of a controlled trial. Psychosom Med 41:229-242, 1979 Direct reprint requests to: Dr. Strain, Director
Psychiatric Liaison Consultation Service, Mount Sinai School of Medicine One Gustave L. Levy Place New York, New York 10029
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