Need Assessment of Consultation Liaison Psychiatry amongst the Clinical Faculty

Introduction

Rapid changes in social structure and lifestyles have resulted in a surge in the prevalence of psychological conditions, particularly common mental disorders. Depression is now the second commonest cause of morbidity worldwide (1). In a general hospital setting, most of such patients initially present to medical and surgical departments, with only a small number presenting directly to psychiatry. Nearly 20-40% of patients attending various outpatients and in-patients clinical services for various medico-surgical problems also suffer from psychiatric illnesses like anxiety and stress-related disorders, depression, functional somatic syndromes, and substance use disorders or have psychosocial issues complicating their primary illness. Many of these remain unidentified and have a potential to increase physical morbidity, prolonging hospital stay and incurring increased cost to the system. Consultation liaison (CL) psychiatry is a speciality of psychiatry, in which a psychiatrist works in liaison with the primary clinical team and helps in diagnosis and management of patients with psychiatric problems in non-psychiatric settings. It includes collaborative teaching and research activities with health professionals in non-psychiatric divisions (2). Taken together, CL psychiatry thereby provides the interface for collaborative management, training and research between psychiatry and other clinical departments and can, therefore, be of significant value in a general hospital setup. CL psychiatry derives its roots from psychosomatic medicine, a discipline concerned with the interplay of biological and psychosocial factors in the causation, course and outcome of various diseases (3).

Worldwide, although various models of CL services were developed in the 1970s and early 80s (4) evaluative research in training of CL psychiatry is currently lacking (5). In India too, though the first general hospital psychiatric units (GHPUs) was set up as early as 1933 and there may be more than 500 GHPUs in the country, there are very few CL psychiatry units in the country (6). The number of papers published on this topic from India are also few and leave much to be desired.

A survey in a major teaching hospital in Delhi found that 87% of physicians and surgeons were of the opinion that they would have been benefitted if their undergraduate training in psychiatry had been better (7). Similar findings were noted in another study involving 86 general practitioners and specialists (8). Several studies have found that timely referral and care of psychiatric problems in patients admitted in other wards improves quality of life and promotes early discharge. Alhuthail (9) demonstrated that nature of comorbid psychiatric diagnosis influenced the duration of stay in the ward. The referral time was noted as crucial and accounted for 22% variance of duration of ward stay. de Jonge et al (10) assessed the impact of psychiatric interventions on both the duration of ward stay as well as the quality of life of patients admitted in a medical ward. Psychiatric interventions were found to reduce duration of ward stay, particularly in the elderly. The quality of life was also enhanced by such interventions.

A recent study from Iran exploring the roadblocks in CL psychiatry reported that the most common reasons of physicians for not requesting psychiatric consultation were lack of time, access to psychiatrist and belief in the need for psychiatric consultation (11). A similar study from Saudi Arabia reported that poor psychiatric knowledge of medical doctors negatively influenced the referral rates to psychiatry and reflected the lack of integration of psychiatry and medicine at the training level (12). Poor psychiatric knowledge is also reflected in another study where majority of the medical specialists believed that the main task of the visiting psychiatrist was to advise them on psychosocial issues, while leaving clinical responsibility in their hands (13). Even in the Western countries like the UK, clinicians consider emotional assessment of routine patients impractical and referrals are avoided because of 'stigmatisation' (14). Underestimation of psychiatric morbidity by clinicians from different specialities is common and there is a general reluctance to refer patients to a psychiatrist for varied reasons (15).

A major problem for lack of integration of psychiatric services is considered to be the focus on brief consultations only in absence of liaison activities. Indeed, literature suggests that psychiatric liaison on medical wards produce a more positive attitude towards psychiatry and a higher consultation request rate. A study comparing CL as against consultation only model found that liaison activities were more favourably received by consultees than consultation alone and increased the consultation rate (16). Such liaison services have found more benefit in focussed departments like geriatrics and critical care medicine where delirium, dementia and psychiatric symptoms occur very frequently (17, 18), and also in oncology services where end of life care, depression and anxiety form a major focus of patients (19, 20). For most other clinical departments, specific conditions like suicidality, aggression and depression might be topics of focussed liaison discussions.

In India, we have very few CL psychiatry units. It is important to know the awareness, attitude and perceived needs of non-psychiatric clinicians about the need of CL psychiatry services in GHPUs. The present study was planned in this background to assess the perception of non-psychiatric clinical faculty regarding the nature and extent of mental health problems in their patients; to understand the factors influencing referral to a mental health specialist and, to assess their perceived needs for CL psychiatry services.

Methods

The Department of Psychiatry, All India Institute of Medical Sciences, New Delhi has started a dedicated CL psychiatry service in 2008. The service is provided by one senior resident, 2 junior residents on rotational posting, supervised by two faculty members. The study was conducted by the CL Psychiatry Team using a questionnaire-based survey approach with a cross sectional design.

For the purposes of this study, a semistructured 27 item questionnaire was developed by the authors. The contents of this questionnaire have been taken from literature review and clinical experience. The questionnaire was intended to be answered in a self-report fashion by the participants. The questionnaire collects non-identifying details such as subject of specialization, department of work, year of completing post-graduation and years of experience as faculty. The rest of the items in the questionnaire were intended to obtain data pertaining to the three broad areas of interest including the kind of psychiatric symptoms/illness seen by them in their clinical practice, reasons for seeking psychiatric referrals, their general awareness about psychiatric symptomatology, psychiatric medications and non-pharmacological treatments, and their awareness about CL psychiatry. The complete questionnaire can be obtained from the authors on request.

At the time of study, there were 239 faculty members working in various clinical disciplines excluding psychiatry. All clinical faculty members working currently at the institute (n=239) were sent mail giving background of the study with an online version of the questionnaire created using the free platform of Google Documents and Google Survey. The faculty members were requested participation in the study. Two reminders were sent after one and three months. The questionnaire took about 10 minutes to fill and submit. Every participant was informed of the nature of the study and informed consent was obtained.

The study was approved by the Institute Ethics Committee. Full confidentiality was maintained. Individual characteristics of the respondents were tabulated and a content analysis of the responses was conducted.

Results

Responses were received from only 46 faculty members. Average experience of the participant faculty members from different disciplines varied from 14-22 years as faculty. The participant characteristics are given in Table 1. Thirty five respondents were not aware that CL Psychiatry was a separate sub-speciality with a designated workforce. Most of the participants saw about 10 inpatients and 50-100 outpatients per week. All but two of them agreed that focussed training of residents in this area would be useful.