Psychiatric Consultation Service Research Articles

Psychiatric co-morbidities and patients with head and spinal cord trauma: Effects on acute hospital care

Three hundred twenty-one patients with traumatic head and spinal cord injuries were studied. Forty-two of these patients (13.1%) received psychiatric consultation services. Two types of consultation patients were identified—one receiving psychiatric consultation services in the acute-care hospital and one receiving psychiatric services in the post-acute care, long-term rehabilitation center. In order to assess the impact of psychiatric co-morbidities on hospital length of stay and changes, 40 consultation patients (23 acute and 17 rehabilitation) were matched to 87 control patients who received no psychiatric services. Matching was done on severity of injury, age, and sex. Psychiatric consultation cases had significantly longer stays than did matched controls. There were no differences on total charges.

Comparison of two cognitive rating scales in medically ill patients.

Patients with acute, complex behavioral syndromes combined with impaired comprehension and communication are difficult diagnostic challenges. Using a structured mental status interview can significantly reduce the chance of overlooking the presence of cognitive dysfunction. The authors tested the applicability of the cognitive portion of the Alzheimer's Disease Assessment Scale (ADAS-COG) as a screening instrument on a psychiatric consultation service. The ADAS-COG compared favorably with the Mini-Mental State Exam (MMSE), but appeared to be less influenced by educational level. The advantages and disadvantages of using each of these tests on a psychiatric consultation service are discussed.

Delirium: 100 cases.

One hundred consecutive cases of delirium seen in a psychiatric consultation service of a general hospital are discussed. Two thirds of the patients came from pneumology and cardiology since the hospital serves as a regional thoracic center. The frequency of delirium was 12.6% of consultations: three men were seen for every one woman; 80% of cases were over fifty years of age. The clinical aspects of delirium are studied according to DSM-III criteria to evaluate: a) the frequency of the symptoms, b) the temporal course of the disorder, c) any clinical characteristic of delirium linked with potential etiological factors, d) the role of anxiety.

Management of anxiety and panic attacks in immediate care facilities

The records of all patients entering the Emergency Department of a large general hospital and an adjacent walkin medical clinic were reviewed for a 4-week period. Information was gathered on the assessment and treatment of patients given a final diagnosis of anxiety or panic disorder. The majority of patients receiving these diagnoses in both settings presented with physical complaints. In the Emergency Department, where psychiatric consultation services were available, psychiatric appointments were arranged for 80% of patients with anxiety as an entrance complaint and none of those with physical entrance complaints.

Factors associated with the use of psychiatric consultations in short-term general hospitals.

A significant number of patients in general hospitals suffer from psychiatric distress or illness, but not all receive psychiatric consultation. This study examined several potential predictors of such consultation. These included patient characteristics (age, sex, race, insurance, disease stage, and number of medical diagnoses), characteristics of hospital stay (number of procedures, other consultations, length of stay, discharge destination), hospital characteristics (size, percent occupancy, teaching status, presence of a psychiatric unit, type of control), and community characteristics (region, urban/rural setting). Data were derived from a national sample of 327 hospitals. Parallel analyses using stepwise logistic regression were carried out across four samples: patients determined at discharge to have been hospitalized for diabetes, hip fracture, chronic obstructive pulmonary disease, and coronary artery bypass surgery. Results show a wide variation in the use of psychiatric consultations across different subgroups. Longer lengths of stay, urban setting. Northeast region, younger patient age, and other consultations were the most consistent predictors of the probability of psychiatric consultation. These variations may reflect differences in the need for consultation, differential recognition of these needs by providers, or differential availability of psychiatric consultation services. Moreover, they may have implications for equity and/or quality of hospital care.

Consultation-liaison outcome evaluation system (CLOES): Resident or private attending physicians' concordance with consultants' recommendations

Systematic investigation of consultee concordance with the recommendations of the psychiatric consultant in general medical settings can enhance the role of the consultant as well as measure the efficacy of the psychiatric consultation service. Two hundred psychiatric consultations in a community based teaching hospital were studied for concordance with suggestions for psychotropic medications and diagnostic tests as well as the representation of the psychiatric diagnosis in the discharge summary. Results indicated that orders for medications and suggestions for diagnostic tests had a greater yield if the consultant personally wrote such orders. There was no difference in concordance rates between consultees who were private practitioners or resident physicians. Finally psychiatric diagnoses of dysthymic disorders and adjustment disorders were more likely to be omitted from the discharge summary than other psychiatric disorders.

Patterns of referral for psychiatric consultation at a VA Medical Center.

Psychiatric consultation and liaison services at Veterans Administration (VA) hospitals are likely to become more important in the coming years as the VA population grows older and more veterans with psychiatric problems need medical treatment. The VA already manages more than 10 percent of the psychiatric beds in the United States (1), and psychiatric beds constitute 32 percent of all the beds in the VA system (2). One study found that 64 percent of veterans seeking psychiatric care at a VA hospital had at least one prior psychiatric admission (3). Despite the extensiveness of the VA’s psychiatric program and the likelihood that demand for psychiatric consultation and liaison services at VA hospitals will increase, a review of the literature indicates that consultation and liaison referral patterns in the VA system have not been examined. This paper reviews requests for psychiatric consultation at the VA Medical Center in Louisville over a two-yea penod. The medical center is a 369bed teaching hospital affiliated with the University of Louisville School of Medicine.

Psychiatric consultation for acute amputees: Report of a ten-year experience

Eighty-six patients receiving amputations (59 scheduled surgical amputations and 27 at the accident scene) were referred, usually after the amputation, to the psychiatric consultation service. Reasons for referral included assistance in coping, evaluation for depression, management of pain medication, behavioral problems, and suicidal ideation. Major reactions to amputation included flashbacks to the accident, body-image disturbances, a sense of helplessness, and grieving. Successful treatment interventions included psychotherapy, appropriate psychotropic or pain medication, grief counseling, and peer-group support. Psychiatric consultation also focused on improving the patient's relationship with other caregivers, and it reduced the length of hospitalization somewhat.

Self-Destructive Behavior in Hospitalized Medical and Surgical Patients

This article reviews the literature and presents data from the Psychiatric Consultation Service of the Medical University of South Carolina on self-destructive behavior in hospitalized medical and surgical patients. Fatal suicide attempts are rare and usually occur in patients with severe, painful chronic illnesses, psychosis, or dementia. Less overt forms of self-destructive behavior include refusal of medical treatment and uncooperative behavior.

Cognitive screening at the bedside: Usefulness of a structured examination

A structured, brief bedside test of cognition, the Cognitive Capacity Screening Examination (CCSE), was used to evaluate 50 consecutive patients seen on a psychiatric consultation service. This test showed statistical reliability (K=0.62) upon independent examinations. It appeared statistically valid as a screening device in its association with delirium or dementia diagnosed independently. The presence of psychotic symptoms was a confounding variable, whereas sex, educational level, and length of time between serial examinations had no effect on reliability or validity. Likewise, age had no statistical effect, although the number of elderly patients in this sample was small. The CCSE appears to be a useful brief mental status examination.

Reflections on the current psychiatric consultation and referral pattern and on the state of the art, at Oxford Regional Centre, an adult mental retardation facility.

This paper investigates the utilization pattern of the psychiatric consultation and referral service provided by the author in an Adult Mental Retardation Facility over a three-year period. The services, their history and locale are described against a background of changes in attitudes towards the problems of the retarded. Rising interest by psychiatrists in the field is placed in context. A spectrum of variables is used for a statistical analysis of factors (Chi2) influencing psychiatric referrals or non-referrals of all new admissions over the period indicated (N = 98). Against a background of increasing normalization and de-institutionalization, the character and composition of the shrinking institutional population has changed. Administration and direct-care staff are now confronted with management and care problems of lower functioning retardates, presenting difficult-to-manage behaviours and severe, often multiple, handicaps. Several factors with resource and care implications are considered, affecting institutionalized as well as community placed retardates, especially in hard economic times. Findings are discussed; recommendations are made concerning the application of scarce psychiatric resources to meet changing psychiatric needs of the population, maximize services and continue community directed normalization efforts. Some caveats are sounded and further research suggested.

Part II: A ospective DSM-III study of 100 consecutive somatization patients

In this study the authors defined somatization and prospectively studied the prevalence of somatizing patients referred to a psychiatric consultation service. Included are the demographic characteristics and five-axis DSM-III diagnoses of 100 consecutive somatizing patients. A comparison of these patients was made to a control group (N = 161) of nonsomatizing patients also referred for consultation. There were significantly more patients with depression, panic disorder, personality disorders and psychophysiologic illness in the somatization patient sample and significantly more patients with schizophrenia, manic depressive illness, organic brain syndromes, adjustment disorder and serious medical illness in the non-somatization control group. Age, sex, and DSM-III axes IV and V did not significantly differentiate the two groups. The role of somatization as a process as distinguished from a DSM-III somatoform disorder is discsssed, and the importance of somatic symptoms as they relate to an underlying mental disorder is reviewed.

Sleep disorders on a psychiatric consultation service

Of 100 consecutive patients on a psychiatric consultation service, 80 had sleep disorders; 72 had insomnia. Disturbed sleep was not mentioned in the records of 54% of the 80 patients, indicating a need for more physician education in sleep disorders.

Implementation of psychosocial services in managing emotional stress.

Psychological services for breast cancer patients call for several elements in the inpatient, outpatient, and home settings. In the inpatient setting, comprehensive services include Reach-to-Recovery, social work, and psychiatric consultation services, and structured psychological support available to the staff. In the outpatient setting, comprehensive services include social work and psychiatric consultation and support for the staff, but in addition programming for the patient's family is crucial, with a balance of services which include both education and emotional support in regard to the patient's disease. In the home setting, when dying breast cancer patients are to be considered, the needs for psychological consultation and emotional support for the visiting nursing personnel becomes paramount.

Adult psychiatric disorders in psychiatrically ill young adolescents.

Adolescents aged 12-15 years, randomly selected from a psychiatric outpatient clinic, psychiatric consultation service, and general pediatric outpatient clinic, were given a complete psychiatric evaluation and structured diagnostic interview. Of 121 subjects studied, 100 satisfied Rutter and associates' criteria for a childhood psychiatric disorder. When these subjects were rediagnosed according to Feighner and associates' research diagnostic criteria (similar to DSM-III criteria), 52 fulfilled the criteria for an adult disorder. Diagnoses included antisocial personality, hysteria, schizophrenia, depression, mental retardation, anxiety neurosis, and undiagnosed psychiatric illness. There was a correlation between diagnosis according to Rutter and associates' criteria and adult diagnosis.

Evaluation and management in consultation-liaison psychiatry.

The subjects were 95 medical and surgical inpatients referred to Kyushu University Hospital Psychiatric Consultation Service. The authors studied the mental status of each referred patient and elicited some Unclassified mental status cases. It was recommended, therefore, to bring in new concepts of normal condition and polymorphous condition in dealing with those Unclassified mental status cases which are often recognized as problematic both by the patient's primary physician and the psychiatric consultant. The ordinary style Single contact consultation was also compared with the Active follow-up consultation regarding the function of psychiatric consultations. The authors confirmed that most referring physicians who were supported by the Active follow-up consultation appreciated highly the evaluating function of a psychiatric consultant.

Utilization pattern of a Canadian psychiatric consultation service

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 primary 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.

Psychiatric consultation: A survey and review of utilization

Regardless of what has been written of the need for evaluation of the psychiatric consultation service in the general hospital, there is a dearth of such studies. 1 In a 400-bed university-affiliated general hospital, we have recently increased the staffing and scope of consultation service. In a period of 2 mo, two and one-half staff positions were added. Here was a point at which to take stock of prior performance and future course. One evaluative approach herein involves a survey of recipients of the consultation service, staff physicians of the hospital. We were also interested in the relationship between the findings of such a survey instrument and the actual clinical practice. To that end, we used our service records to explore the following possible associations: Would concurrent use of consultation services by various subgroups within the staff reflect survey support and approval? How would survey respondents' declared profile of reasons to request consultation compare with actual practice?

The mortality of delirium: An underappreciated problem?

The author reviewed 116 charts of medical-surgical inpatients evaluated by a university hospital psychiatric consultation service. Five of 15 consultation patients with delirium died within three months after the consultation, whereas only one of 43 depressed patients died. Neither consultees nor psychiatric consultants usually considered patient prognosis, according to chart notations. Mortality associated with delirium may be underappreciated in the assessment of delirious patients.

Psychiatric components of medical and surgical practice: a survey of general hospital physicians.

A questionnaire was sent to 206 internists and surgeons asking them to estimate the following: the frequency of psychiatric disorders and behavioral problems among their patients, the type and frequency of psychiatric medication they prescribed, the psychiatric consultation services they most valued, and the type of psychiatric problems they considered emergencies. These physicians estimated that 14% of their patients had significant psychiatric problems; the most frequently mentioned was depression. More than 25% of the physicians prescribed minor tranquilizers, sedatives, and antidepressants at least once a week. Violent behavior was considered a psychiatric emergency by the majority of physicians. There were significant differences between the responses of internists and those of surgeons.