Utilization pattern of a Canadian psychiatric consultation service

Utilization Pattern of a Canadian Psychiatric Consultation Service* Edgardo L. Nrez, Stuff Psychiatrist, Ontario, Canada

M.D., M.P.H.,

Ottawa Civic Hospital,

Marvin Silverman,

F.R.C.P.

and, Assistant Professor,

M.D., F.R.C.P.

Director, Department of Psychiatry, School, Ottawa, Ontario, Canada

Abstract: The authors reviewed 255 psychiatric consultations in a Canadian teaching general hospital over a one-year period. The majority of the patients were referred from the medical and surgical services.The three most commonly stated reasons for referral were either parasuicidal behavior, depression, or psychological conflicts affecting physical illness. The three most common prima y psychiatric diagnoses were: affective disorders, organic brain syndromes, and transient situational disturbances. The factors influencing compliance among the patients referred for psychiatric ambulatory treatment were studied. Compliance was defined as attendance at the first appointment. Of the 42.8% of the patients referred for ambulatory psychiatric treatment, 54% complied.

Developments in psychosomatic medicine in the 1920s and 1930s played a significant role in providing a theoretical basis for consultation liaison psychiatry. Henry (1929) proposed a conceptual framework for this field (1). With the post-World War II increase in psychiatric units in general hospitals, psychiatrists became more involved in the psychological care of physically ill patients in nonpsychiatric departments (2). By 1968, 75% of psychiatric training centers in the United States provided education in consultation psychiatry (3,4), and by 1971, 5% to 10% of general hospitals in Canada had an

General Hospital Psychmfry 5, 185-190, 1983 0 Elsevier Science Publishing Co., Inc. 1983 52 Vanderbilt Avenue, New York, NY 10017

University of Ottawa Medical School, Ottawa,

(C)

Ottawa Civic Hospital,

*Presented at: The 6th World Congress of the International College of Psychosomatic Medicine, September, 1981, Montreal, Quebec.

(C)

Associate Professor,

University of Ottawa Medical

organized consultation service (5). These services have continued to expand and training in consultation liaison psychiatry is now a requirement for certification in Psychiatry by the Royal College of Physicians and Surgeons of Canada (6). A review of literature revealed few recent studies on the utilization of Canadian psychiatric consultation liaison services (7,8), and no information on the compliance for treatment among the consultation patients referred for psychiatric ambulatory care. There is need for more precise information on the interrelations of factors that influence compliance, particularly in consultation liaison psychiatry. Studies on compliance with referral from emergency room to psychiatric outpatient clinics and in the use of psychotropic medications (9,lO) led the authors to examine the factors influencing compliance of patients referred by a liaison service for psychiatric ambulatory treatment; the following review covers a one year period in a teaching hospital setting.

Methods Consultations to nonpsychiatric inpatients were done by psychiatric residents under a staff psychiatrist’s supervision. The resident completed a standard questionnaire with the details of: the time elapsed between admission to the hospital and the request for consultation, patient’s demographic 185 ISSN 0163~8343183B3.00

E. L. Perez

and M. Silverman

characteristics, whether the patient was informed that he was going to be seen by a psychiatric consultant, the source and the stated reasons for the referral. Also recorded were the patient’s attitude toward a psychiatric consultation, physical and psychiatric diagnoses of the patient, patient’s behavior on nonpsychiatric wards, consultant’s treatment recommendation, and compliance with the recommended plan for psychiatric ambulatory treatment. Patients were asked to make their own appointments for ambulatory treatment with a psychiatrist other than the consultant. Compliance was defined as attendance at the first ambulatory appointment. The patient, and the referral physician/agency were contacted either by letter or telephone approximately two weeks after discharge from the nonpsychiatric ward to assess compliance. Discriminant analysis was used to analyze the compliance data.

Results Referral Rates and Demographic

Characteristics

Ottawa Civic Hospital is an 850-bed (40 of which are psychiatric beds) general hospital serving a catchment area of seven hundred thousand people. Of 24,283 patients admitted during a 12-month period, 2% were referred to the general, cardiac, and palliative care psychiatric consultation services. Two hundred fifty-five of these referrals were to the general psychiatric service. We report only this latTable 1. Demographic characteristics of consultations

4F

%

Sex

%

< 20 20-29 30-39

6 19

Males

39

16 15 12 18 14

Females

61

40-49 50-59 60-69 2 70

Marital status Single Married Divorced Widowed Separated Common-law

%

1 2 3 4 5

1.2 12.0 37.2 32.8 16.8

OAccordingto Hollingshead and Redlich.

186

Source of Referral and Reasons for Referral Source of referral and reasons for referral are shown in Tables 2A and 2B. By department, the most frequently stated reasons for referral was as follows: Medicine: parasuicidal behavior; Orthopedic: assessment due to previous psychiatric illness; Neurology: possible psychological factors affecting physical illness; Obstetrics and Gynecology: depression; and Surgery: depression and psychotic disorder (psychotic disorder was diagnosed frequently by the psychiatrist as acute organic brain syndrome). Seventy percent of the patients said they were told, and 30% not told they were going to be seen by a psychiatric consultant. (There was no attempt to confirm this finding with the staff.) Patients were informed more frequently by staff physicians (56.4%) than by interns (26%), nurses (9.9%), residents (7.2%), or family members (0.6%) for all stated reasons for referral except parasuicidal behavior, in which case interns and residents informed patients more frequently (p < .OOl). When reasons for referral were more specifically defined (e.g. depression, marital maladjustment, and alcoTable 2A. Source of referral of consultation patients

Social classa 25.0 46.0 5.6 11.5 9.9 2.0

group. Forty-seven percent of the consultations were requested within the first four days after admission to the hospital, 27% between the fifth and eighth day, and 26%, nine days or more after admission. Age, sex, marital status, and social class appear in Table 1. The age distribution of all psychiatric consultation patients corresponds to that of all patients admitted to the hospital. Sixty-one percent of patients seen in consultation were female, in contrast to 57% for all hospital admissions. ter

Clinical department

Medical Surgical Neurological Obstetricalgynecological Other

% of consultation patients

% of total patients in each department referred for psychiatric consultation

65 17 8 4

4 1 3 .l

6

Canadian Psychiatric

Table 2B. Stated reason for referral to consultation service % of Reason

consultation

Parasuicidal behavior Depression Psychological factors affecting physical illness Other psychiatric disorders besides depression or psycho-

23.6 19.2

sis Psychotic state Assessment to rule out a psychiatric problem Previous history of psychiatric illness Alcoholism Marital and familial problems

11.2 8.8

patients

15.2

7.6

Patient’s Attitude Consultation

Toward a Psychiatric

five percent of patients felt they needed a psychiatric consultation and 35% felt they did not. Those acknowledging need for consultation agreed either that they had “psychological problems” or that they approved of their physician’s recommendation. Reasons given for not needing a psychiatric consultation were: they understood their emotional problems and did not need any help, that they had not benefitted from previous psychiatric treatment, or that they felt they did not have any emotional problems. Only 7% of the patients who felt they did not need psychiatric consultation did not have a psychiatric disorder (diagnosed by the psychiatrist). Sixty

Psychiatric

and PhysicaZ Diagnosis

The primary psychiatric diagnoses (made according to the Diagnostic and Statistical Manual of Mental Disorders DSM-II of the American Psychiatric Association) are shown in Table 3A.

Service

Some referring physicians offered a psychiatric diagnosis as part of their reason for referral. Concurrence rate between referring physician and psychiatric consultant was: affective disorders (64%), psychophysiological disorders (57%), organic brain syndrome (35%), and schizophrenia (12%). Fifty two percent of the consulted patients had a previous psychiatric illness but the majority were not receiving psychiatric treatment at the time of the consultation. In cases of overdose, more than 95% of the consultation patients had concurrent

Table 3A. Primary psychiatric diagnosis* consultation patients

of

% of

6.8 5.6 2.0

holism) patients more often acknowledged they were told they were to be seen by a psychiatrist (p < .OOl). When referral was for “assessment to rule out a psychiatric problem” or “suspect a psychotic disorder“ (mainly diagnosed by the psychiatrist as an organic brain syndrome) patients claimed they were informed the least.

Consultation

Diagnosis

consultation

27.2 18.8 15.6

Neurotic depression Organic brain syndromes Transient situational distur(Major Affective Disorders) Psychotic depressive reaction and Manic depressive illness Personality disorders Alcohol and drug dependency Schizophrenia Psychophysiological disorders Other neurotic disorders Marital maladjustment Sexual deviation No psychiatric problems ‘According

patients

9.2 8.0 7.2 3.2 2.8 2.8 0.8 0.4 4.0

to DSM-II

Table 3B. Primary physical diagnosis consultation patients

of

% of Diagnosis Overdose Neurological disorders Gastrointestinal disorders Cardiovascular disorders Endocrine and Metabolic disorders Musculoskeletal disorders Gynecological disorders Respiratory disorders Dermatological and Renal disorders Cancer No disorder Others

consultation 22.0 16.1 11.2 8.5 8.5 6.7 3.6 3.3 3.3 (each) 0.9 0.9 11.7

patients

E. L. Perez and M. Silverman

physical and psychiatric disorders; when overdose was excluded as a physical diagnostic category, the percentage of patients with concurrent physical and psychiatric disorders dropped to 75%. The primary physical diagnoses are shown in Table 3B.

Patient‘s Behavior on Nonpsychiatric

Wards

Although 59 of all patients seen in consultation were initially hospitalized and referred for parasuicidal behavior, only 20 were still considered a suicidal risk at time of psychiatric assessment. Of these patients, 12 were transferred to the psychiatric inpatient ward, and eight to psychiatric ambulatory care by our crisis intervention clinic. Of the 7% of patients seen in consultation for disruptive behavior (verbal and physical assault on the staff) in nonpsychiatric wards, the most common diagnosis was acute organic brain syndrome; followup visits by the psychiatrist were most common among these patients. Eighteen percent of the patients seen in consultation refused to follow medical or surgical treatment recommended by their treating physicians. The three most common diagnoses in this group were: acute organic brain syndrome, personality disorder, and transient situational disturbances.

Psychiatric

Treatment and Recommendations

The psychiatrist provided followup visits (which consisted mainly of supportive individual therapy) in the nonpsychiatric wards for 28% of the patients. Psychotropic medications for patients on a nonpsychiatric ward, were prescribed for 34% of all the patients seen. The majority received major tranquilizers or antidepressants. The recommendations for disposition provided by the psychiatric consultant are shown in Table 4. Three quarters of the patients transferred to the psychiatric inpatient unit were referrals from the Department of Medicine. The rest were evenly distributed among the other hospital departments. Major reasons for referral for those transferred were: parasuicidal behavior, depression, and psychotic states. Seventy percent of the group with a history of psychiatric illness prior to the psychiatric consultation, in contrast to 48% with no history of psychiatric illness, were either transferred to the psychiatric inpatient unit or referred for psychiatric ambulatory care upon discharge from the nonpsychiatric ward (p = .Ol). Twenty five percent of the patients with acute 188

Table 4. Recommendation for disposition provided by the consulting psychiatrist

Recommendation Referral for ambulatory psychiatric treatment No need for further psychiatric intervention on discharge from the nonpsychiatric ward Transferred to psychiatric inpatient unit Referral to family physician Referral to community social agency

% of consultation patients

42.8

38.4 14.4 2.8 1.6

organic brain syndrome were referred for ambulatory treatment of a concomitant psychiatric disorder.

Compliance Fifty four percent of the patients referred for ambulatory care complied. Patient characteristics and treatment factors which appeared to influence compliance were: 1. Age: Amongst patients 17 to 79, greatest compliance was among those 20 to 29, and least among those 40 to 49 (p = .05). 2. Ethnicity: Fifty seven percent of the English and French Canadians complied in comparison with 14.3% of other ethnic backgrounds (p = .05). Among those who complied, the 3. Diagnosis: ranking of psychiatric diagnostic categories (greatest to least) was: schizophrenia, organic brain syndrome, psychophysiologic disorders, major affective disorders, transient situational disturbance, neurotic depression, alcoholism, and personality disorders (p < .Ol). 4. Conflicts with staff: Patients who appeared to have conflicts with the medical and nursing staff on nonpsychiatric wards had a higher compliance than those who did not (p = .Ol). 5. Parasuicidal behavior: Patients considered to be a suicidal risk at the time of psychiatric assessment showed 90% compliance against 50.5% of those not considered at risk (p = .02). 6. Medical convalescence: Eighty percent of patients with delayed medical convalescence complied in contrast to 40% of those without delayed medical convalescence (p = .05).

Canadian Psychiatric Consultation Service

7. Followup: Increased number of followups by the psychiatrist led to higher compliance (p = .Ol)

Discussion In spite of a documented high proportion of concurrent physical and psychological problems seen in patients admitted to nonpsychiatric wards of general hospitals (11,12), referral rate for psychiatric consultation tends to be low. British studies (8) showed a range of 0.7% to 1.6% referrals from total hospital population while U.S. figures range from 2.2 to 6.9% (13-16). In a recently published Canadian study (8) 1.2% of all admissions to the hospital during a five year period were referred for psychiatric consultation. Our study showed a 2% overall referral rate. The reasons for referral in our study are similar to those reported in the literature (8,11,16-M). One-third of our patients perceived no need for a consultation. This group includes patients referred for “possible psychological component to the etiology of patient’s physical illness.” Because patients who somatize have a tendency to deny the importance of psychological factors in their illness, they may be less inclined to accept the need for psychiatric intervention. Furthermore, individuals referred for “parasuicidal behavior” often deny the need for psychiatric assessment and treatment. It is very important to recognize this group as they tend to be at higher risk for repeated attempts. Of interest is that one-third of the patients mentioned had not been informed about their psychiatric consultation. It is possible that of these, patients diagnosed having organic brain syndrome probably could not remember being informed, due to cognitive impairment. For others, reasons for referral were vague (e.g. “suspect a possible psychological component to the etiology of patient’s physical illness”), perhaps because some of these patients may deny their conditions and resist being informed; or, conversely patients with well defined psychiatric disorders may be more receptive to preparation for psychiatric consultation. The most common psychiatric and physical diagnoses among the patients seen by our consultation liaison service were similar to those of other investigators (8,11,15,16). There was a low concurrence between diagnoses of referring physicians and psychiatric consultants, especially of organic brain syndrome and schizophrenia. Nonpsychiatrist physicians may have greater difficulty differentiating

organic from functional psychosis, an area of considerable challenge to the liaison psychiatrist’s educational role. Evans (19) maintains that treatment of the medical patient presenting with psychological conflicts should be undertaken on the nonpsychiatric ward whenever possible. Considerable reassurance and support should be given to the nursing staff. In our study 14% of the patients seen were transferred to the psychiatric ward. Shevitz et al. (11) report a 16%, and Taylor et al. (8) a 6% transfer rate. One year after completion of our study the number of patients transferred has decreased to approximately 2 to 3%, partly due to increased involvement by the psychiatrists in providing more education and support for the nursing and medical staff, and partly to improved communication between psychiatrists and referring physicians, the importance of which has been described by Evans (19) for an effective consultation service. Karasu (16), writing of compliance of consultation patients referred for ambulatory psychiatric care, expressed the need for studies of variables which influence compliance. Our study showed 54% compliance. Higher compliance (statistically significant) correlated positively with younger patients and with increased psychiatric followup on nonpsychiatric wards. Followup may be perceived by patients as a sign of the psychiatrist’s concern and also as an opportunity for clarification of patients’ misperceptions and fear. In contrast to our findings,studies by Wilder (9) and Jellinek (20) showed a higher compliance in emergency consultations of older patients referred for ambulatory psychiatric treatment. In our service, patients with schizophrenia and organic brain syndrome had a higher compliance rate in comparison to other diagnostic categories. This differs from other studies (9,10,20) in which depressive disorders had the highest compliance and schizophrenia the lowest. The most likely explanation for this high compliance rate for schizophrenics in our study was that most were receiving psychiatric ambulatory treatment prior to the consultation and were merely told to continue seeing their psychiatrist on discharge from the hospital. Higher compliance among patients with organic brain syndrome may be due to previous history of psychiatric illness and treatment and increased followup psychiatric visits. Though our study found suicidal patients compliant with referral, Del Gaudio et al. (10) report that patients with high suicidal potential were less

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E. L. Perez and M. Silverman

likely to comply with referral for ambulatory psychiatric treatment. Although our study showed that there was a fairly high compliance rate, we feel that there are two administrative factors which may help to increase compliance. Firstly, appointments should be given for ambulatory follow up, rather than asking patients to make contact on their own. Secondly, the patient should be assigned to the same psychiatrist who conducted the initial assessment. Craig et al. (21) reported a threefold increase in completion rate of referrals to psychiatric outpatient clinics when an appointment was given at the time of the psychiatric emergency room assessment. Wilder et al. (9) also found that giving the patient an appointment for ambulatory treatment with the same psychiatrist seen in the emergency room led to higher compliance. In summary, our findings support some of the benefits of a consultation liaison service in a general hospital, as described by Hales and Fink (22), including improved communication between services, appropriate diagnosis of psychiatric disorders in medical and surgical patients and improved compliance with treatment recommendations. Levitan and Kornfeld (23) documented the effectiveness of liaison psychiatry in reducing the length of hospital stay. Further research in consultation liaison psychiatry with controlled studies of effectiveness and cost benefit of liaison services, is essential. Data from such investigations will be useful to third party payors in understanding, assessing and appropriately reimbursing consultation-liaison services.

References 1. Henry GW: Some modern aspects of psychiatry in general hospital practice. Am J Psychiatry 86:481-499, 1929 2. Lipowski ZJ: Consultation liaison psychiatry: An overview. Am J Psychiatry 131:623-630, 1974 3. Lipowski ZJ: Consultation liaison psychiatry in the general hospital. Compr Psychiatry 12:461-465,197l 4. Mannino FV: Consultation Research in Mental Health and Related Fields. U.S. Public Health Monograph No. 79, NIMH Public Health Service Publication 2122, U.S. Gov’t Printing Office, 1971 5. Krakowski AJ: Consultation Psychiatry: Present Global Status. Psychother Psychosom 23:78-85,1974 6. The Royal College of Physicians and Surgeons of Canada. Specialty training requirements in Psychiatry. June 1977.

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7. Marcus AM: A pilot study of the psychiatric consultation service in a general hospital setting. Can Psychiatr Assoc J 9:9-17, 1964 8. Taylor G, Doody K: Psychiatric consultation in a Canadian general hospital. Can Psychiatric Assoc J 24:717-723, 1979 9. Wilder J, Plutchnik, KR, Conte H: Compliance with psychiatric emergency room referrals. Arch Gen Psychiatry 34:930-933, 1977 10. Del Gaudio A, Carpenter P, Stein L, Morrow G: Characteristics of patients completing referrals from an emergency department to a psychiatric outpatient clinic. Compr Psychiatry 18:301-307, 1977 11. Shevitz SA, Silberfarb PM, Lipowski ZJ: Psychaitric consultations in a general hospital, A report on 1,000 referrals. Dis Nerv Syst 37295-300, 1976 12. McKegney FP: The incidence and characteristics of patients with conversion reaction, A general hospital consultation service sample. Am J Psychiatry 124:542-545, 1967 13. Edwards JG, Angus JW: Inpatient psychiatric referrals in an american county hospital. Comp Psychiatry 9:517-524, 1968 14. Eilenberg MD: Survey of inpatient referrals to an American psychiatric department. Br J Psychiatry 111:1211-1214, 1965 15. Kligerman MJ, McKegney FP: Patterns of psychiatric consultation in two general hospitals. Int J Psychiatry Med 2:126-132, 1971 16. Karasu TB, Plutchik R, Steinmuller R, Conte H, Siegal B: Patterns of psychiatric consultation in a general hospital. Hosp Community Psychiatry 38:291-294, 1977 17. Karasu TB: Utilization of a psychiatric consultation service. Psychosomatics 19:467-470, 1978 18. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine, I. General principles, Psychosom Med 29:153-169, 1966 19. Evans L: Consultation-liaison psychiatry. Austr N Zeal J Psychiatry 11:95-100, 1977 20. Jellinek M: Referrals from a psychiatric emergency room: Relationship of compliance to demographic and interview variables. Am J Psychiatry 135:209212, 1976 21. Craig T, Huffine C, Brooks M: Compliance of referral to psychiatric services by inner city residents. Arch Gen Psychiatry 31:353-357, 1974 22. Hales R, Fink I’: A modest proposal for consultationliaison Psychiatry in the 1980’s. Am J Psychiatry 139:1015-1021, 1982 23. Levitan S, Kornfeld B: Clinical and cost benefits of liaison psychiatry, Am J Psychiatry 138:790-793,198l Direct reprint requests to: Edgardo L. Perez, M.D. Department of Psychiatry Ottawa Civic Hospital 1053 Carling Avenue Ottawa, Ontario Canada KlY 4E9