Psychological comorbidity and length of stay in the general hospital

The impact of psychiatric comorbidity on length of stay of medical inpatients

The aim of the study was to determine the impact of psychiatric comorbidity (PC) on length of hospital stay (LOS) of medical inpatients. A prospective cohort study was conducted. A series of 317 medical inpatients consecutively admitted to the general medical wards of a University Hospital composed the sample, after excluding those who refused or who could not be evaluated due to their physical illnesses or treatments (n=78). Data on demographic and medical variables were collected. A psychiatrist categorized subjects into two cohorts (with and without PC), according to DSM-IV, using the Schedule for Affective Disorders and Schizophrenia, except in patients cognitively impaired who were diagnosed by clinical interview. Mortality and length of stay during the index hospitalization were recorded. At admission, 156 (49%) inpatients had a current psychiatric comorbidity. After controlling for confounders (age and physical severity), in the multivariate analysis of covariance, the patients with cognitive impairment had a significantly prolonged LOS (F=17.8; P<.01) compared with those without cognitive impairment. No difference existed in LOS for the patients with depressive disorders (F=0.36; P=.55), Anxiety disorders (F=1.48; P=.22) or Substance related disorders (F=1.05; P=.30). These results suggest an independent effect of cognitive impairment increasing LOS of medical inpatients.

Psychiatric morbidity and impact on hospital length of stay among hematologic cancer patients receiving stem-cell transplantation

PURPOSE

To determine the prevalence of psychiatric disorders during hospitalization for hematopoietic stem-cell transplantation (SCT) and to estimate their impact on hospital length of stay (LOS).

PATIENTS AND METHODS

In a prospective inpatient study conducted from July 1994 to August 1997, 220 patients aged 16 to 65 years received SCT for hematologic cancer at a single institution. Patients received a psychiatric assessment at hospital admission and weekly during hospitalization until discharge or death, yielding a total of 1,062 psychiatric interviews performed. Psychiatric disorders were determined on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Univariate and multivariate linear regression analyses were used to identify variables associated with LOS.

RESULTS

Overall psychiatric disorder prevalence was 44.1%; an adjustment disorder was diagnosed in 22.7% of patients, a mood disorder in 14.1%, an anxiety disorder in 8.2%, and delirium in 7.3%. After adjusting for admission and in-hospital risk factors, diagnosis of any mood, anxiety, or adjustment disorder (P =.022), chronic myelogenous leukemia (P =.003), Karnofsky performance score less than 90 at hospital admission (P =.025), and higher regimen-related toxicity (P <.001) were associated with a longer LOS. Acute lymphoblastic leukemia (P =.009), non-Hodgkin's lymphoma (P =.04), use of peripheral-blood stem cells (P <.001), second year of study (P <.001), and third year of study (P <.001) were associated with a shorter LOS.

CONCLUSION

Our data indicate high psychiatric morbidity and an association with longer LOS, underscoring the need for early recognition and effective treatment.

Complexity of care and mental illness in medical inpatients

We investigated the complexity of medical inpatient care to learn it was associated with the presence and type of mental disorders, and with emotional distress and somatization. Six indicators of care complexity, including length of stay (LOS), were assessed for 294 consecutive medical inpatients. Patients rated their own health and physical disability, and medical consultants assessed them for chronic and life-threatening diseases. A subsample of 157 patients was assessed for ICD-10 psychiatric diagnoses by means of an extensive semi-structured interview known as Schedules for Clinical Assessment in Neuropsychiatry (SCAN). With a few exceptions, the indicators of complexity of care were not statistically significantly associated to ICD-10 mental disorders; psychological distress, measured by the SCL-8 rating scale; or somatization, measured by the Whiteley-7 rating scale. On the other hand, four of six complexity indicators were significantly associated with self-rated physical disability or health, or both, when controlling for the severity of the medical condition. In conclusion, complexity of care, including LOS, was substantially associated with the patient's own health perception but only marginally with the presence of mental illness. This is noteworthy, as previously published results concerning the same patients have shown a clear association of mental illness with utilization of admissions to nonpsychiatric departments, and with utilization of primary care resources.

A health services perspective on delivery of psychiatric services in primary care including internal medicine

Serious problems persist in the recognition and treatment of psychiatric problems in primary care despite multiple interventions directed at correcting these problems. Improved outcomes depend on improved recognition, and screening instruments need to be streamlined tremendously to be accepted by primary care providers. Publication of guidelines and physician education, although essential for improved care, are probably insufficient to implement guidelines-based care. Improvements in psychiatric outcome appear to depend on the level of intensity of the intervention employed. Continued research is needed to determine the most effective type of educational intervention and more widely applicable quality improvement processes. Broad-based changes in health service delivery focusing on the true integration of mental health services with general medical care are required to bring about meaningful, effective change. Ongoing changes in physician training programs (combined primary care/psychiatry programs) may facilitate implementation of guideline-based psychiatric care in medical settings, but the full impact of these changes is not likely to be felt for several years.

Does psychiatric comorbidity increase the length of stay in general hospitals?

Several studies reported that in non-psychiatric hospital departments mentally ill patients have a longer length of hospital stay than mentally well. But their methods are often limited because other predictors of length of stay were excluded from statistical analyses. Using the Clinical Interview Schedule, research psychiatrists interviewed 993 patients of medical, surgical, gynecological, and rehabilitation departments in Austria. Using several multiple regression analyses, the influence of psychiatric comorbidity and other variables on length of stay was analyzed. 32.2% of all patients suffered from psychiatric morbidity. Of all psychiatric cases, 6.2% received more than one psychiatric diagnosis. Presence of psychiatric disorders, age, a diagnosis of neoplasms, number of all somatic diagnoses, and the number of previous non-psychiatric hospital admissions predicted length of stay. Patients with dementia, with substance abuse disorders, and with alcohol- and drug-related psychiatric disorders showed a significantly increased length of stay, while other psychiatric diagnoses did not differ from the mentally well. Even after controlling for confounding variables, dementia and substance related diagnoses increase the length of hospital stay. It is important to investigate interventions for early recognition and treatment of these disorders.

[Multinational European project and multicenter Spanish study of quality improvement of assistance on consultation-liaison psychiatry in general hospital: clinical profile in Spain]

BACKGROUND

In the frame of the European study on quality assurance in consultation liaison psychiatry and psychosomatics (supported by the BIOMED 1 program), the clinical <<process>> of consultation-liaison psychiatry units pertaining to six Spanish general hospitals is analyzed.

PATIENTS AND METHOD

A sample of 3. 608 consecutive patients referred to the consultation-liaison psychiatry units of five public general hospitals (Clínico of Zaragoza, Clínico of Barcelona, General of Alicante, Ramón y Cajal of Madrid, Princesa of Madrid) and one private gynecological hospital (Dexeus of Barcelona) was studied. The data were recorded with a standardized instrument (CL-BDoK-P), validated in a previous study.

RESULTS

Consult request took place 10.6 days (on average) after the patients admission (<<lagtime 1>>), half the requests were urgent, and psychiatric consultants examined the patients 1.9 days (on average) after the request (<<lagtime 2>>). The most frequent reasons for referral were current psychiatric symptoms (50.3%), unexplained physical symptoms (15.2%), substance abuse (9.2%), psychiatric history (8.5%), suicide risk (6%) and coping with illness (5.8%). The main referral services were internal medicine (17.5%), traumatology (7.5%) and general surgery (7.3%). An important clinical activity is documented in patients frequently considered to be <<complex>>, with broad spectrum diagnostic and interventions processes and both in-hospital and out-patient follow-up. However, some problems were also detected in the clinical <<process>>.

CONCLUSIONS

The results outline the clinical importance of Spanish consultation-liaison psychiatry in the general hospital, but the possibility of improving its efficiency through the implementation of integrative models, organizational changes and modern models of <<quality assurance>> is also emphasized.

Psychiatric comorbidity and the long-term care of people with AIDS

OBJECTIVES

To examine the association of comorbid psychiatric disorders with admission and discharge characteristics for patients residing at a long-term care facility designated for acquired immunodeficiency syndrome (AIDS).

METHODS

Demographic and clinical characteristics were obtained by systematic chart review for all patients (N = 180) admitted to the facility from its opening in October 1995 through December 1999. Lifetime history of severe and persistent psychiatric disorders (major depression, bipolar and psychotic disorders) was determined by current diagnosis on baseline clinical evaluation or a documented past history.

RESULTS

Forty-five patients (25%) had comorbid psychiatric disorders. At admission, patients with comorbidity were more likely to be ambulatory (80% vs. 62%, P = .03) and had fewer deficits in activities of daily living (27% vs. 43%, P = .05). After controlling for human immunodeficiency virus (HIV) disease severity, patients with comorbidity had significantly lower discharge rates (relative risk = 0.43, 95% confidence interval 0.23-0.78, P = .0001) and death rates (relative risk = 0.53, 95% confidence interval 0.42-0.68, P = .009).

CONCLUSIONS

Patients with AIDS and comorbid psychiatric disorders at this facility had more favorable admission characteristics and were less likely to be discharged or to die. They may have been admitted earlier in their disease course for reasons not exclusively due to HIV infection. Once admitted, community-based residential alternatives may be unavailable as a discharge option. These findings are unlikely to be an anomaly and may become more pronounced with prolonged survival due to further therapeutic improvements in HIV care. Health services planners must anticipate rising demands on the costs of care for an increasing number of patients who may require long-term care and expanded discharge options for the comanagement of HIV disease and chronic psychiatric disorders.

Comorbidity of depression among physically ill patients and its effect on the length of hospital stay

This study was carried out to demonstrate the prevalence of depression among physically ill patients and to investigate its effects on the length of hospital stay. Out of 65 inpatients (44 male, 21 female; 51 with benign and 14 with malignant diseases), 14 (21.5%) met the criteria for major depression in the DSM-IV. The average length of hospital stay was compared according to the comorbidity with major depression. Among the patients with benign diseases, those with major depression stayed longer (P<0.05) at the hospital than those without it (82.2 vs. 36.0 days). Likewise, among the cancer patients, those with major depression stayed longer than those without it (83.8 vs. 51.4 days), although this was not significantly different. The duration of hospitalization needs to be shortened because of the reduction in national medical costs, the economics of hospital administration and the quality of life of patients and their families. Further research is needed to demonstrate the role of consultation-liaison psychiatry in the shortening of hospitalization.

Anxiety and depression disorders 5 years after severe injuries: a prospective follow-up study

Individuals with severe injuries were investigated 5 years after the traumatic events, and predictors of anxiety and depression disorders were identified. Trauma victims were selected who had an Injury Severity Score of > or = 16 and were brought to all hospitals in the Mersey region and North Wales over 1 year. The 212 patients aged > or = 15 years who left the hospital alive and lived within an accessible distance of the study hospital in Warrington were contacted 5 years later and 158 (74.5%) received follow-up assessment. Thirty-eight subjects (36.9%) reported "definite" anxiety and/or depression disorders and, of these, only 21.1% reported taking psychotropic medications. Factors associated with anxiety and/or depression disorders at follow-up were: sequelae of head injury (i.e., cognitive problems, posttraumatic seizures, facial pain): writing impairment: disability due to thorax problems; and a new trauma during follow-up. Initial severity or types of injuries and overall residual disability rated by the investigator were not strong predictors of anxiety and/or depression disorders at follow-up.

Delirium in hospital: does it increase length of stay?

OBJECTIVE

To determine the effect of delirium, as a comorbid diagnosis in hospitalised patients, on patient length of stay (LOS).

METHOD

Prospective study comparing LOS of delirious patients with controls matched by age, gender, principal diagnosis and date of admission. Medical and surgical inpatients of Westmead Hospital with delirium were identified from a Consultation Liaison (CL) psychiatry database and were matched with controls from the hospital medical records.

RESULTS

Delirious patient LOS was found to be significantly longer (2.2-fold; 95% confidence interval 1.5-3.3) than matched controls.

CONCLUSIONS

Delirium, as a comorbid diagnosis in general hospital patients, is associated with an increased use of resources. Its early diagnosis may limit this and morbidity.

Depression and social functioning in general hospital in-patients

Impairment of social functioning is often associated with depression and contributes to an unfavorable course of the disease. Although it must be suspected that both social maladaptation and depression could obstruct recovery from somatic diseases, little attention has been paid to their interaction in general hospital patients. To assess social integration in depressive and psychiatrically healthy general hospital in-patients, 250 patients were studied with the Composite International Diagnostic Interview (CIDI), a structured clinical interview, and the Social Interview Schedule (SIS). From clinical interviews, it was established that 16.4% of the patients suffered from depressive disorders (ICD-10). When these patients were compared with patients without psychiatric disorder, only a tendency to social dysfunctioning with regard to social management and satisfaction with social situations was observed. But when the depressive sample was divided into three diagnostic groups (depressive episode, dysthymia, depressive adjustment disorder), significant social impairments were found in the dysthymia subsample. Family and other interpersonal problems were most prominent. When depression preceded somatic illness, a higher level of impairment was observed. The majority of dysthymia patients suffered from long-term somatic diseases, often cancer, which were preceded by depression. The results of this study single out a small group of patients who seem to be at an extensive risk of chronic psychiatric and somatic illnesses and should therefore be a focus of consultation/liaison (C/L) interventions.

A prospective study of the impact of psychiatric comorbidity on length of hospital stays of elderly medical-surgical inpatients

To determine the difference in length of hospital stay for geriatric medical-surgical inpatients with or without psychiatric comorbidity, the authors prospectively interviewed 467 admissions by using the Structured Clinical Interview for DSM-III-R and the Mini-Mental State Exam. At admission, 208 (44.5%) inpatients had a current psychiatric comorbidity, 51 (10.9%) had an anxiety disorder, 88 (18.8%) had a depressive disorder, and 126 (27%) had cognitive impairment. The patients with cognitive impairment had a significantly prolonged hospital stay compared with those without cognitive impairment (14.6 vs. 10.6 days). No difference existed in length of stay for the patients with and without anxiety disorders (11.6 vs. 11.6 days) or depressive disorders (11.0 vs 11.8 days). In view of the limited resources available for screening elderly medical-surgical inpatients for psychiatric comorbidity, this study suggests the utility of identifying cognitive impairment and targeting it for interventions to reduce the clinical burden and to decrease hospital stays.

The effectiveness of the mental health nursing interventions in a general hospital

The purpose of the study was to investigate: a) how mental health nursing interventions were provided to general hospital patients, who during their hospitalization presented psychological/pyschiatric problems and b) how the patients actually evaluate the effectiveness of the care given to them. We interviewed 95 medical-surgical patients, who were referred to the psychiatric consultation-liaison service of a general hospital. During the interview, a nursing evaluation of the patients' psychological problems took place, followed by appropriate mental health nursing interventions which were taken from the NOSIE scale and the standards of the Psychiatric Mental Health Nursing Practice. Anxiety was the most common problem 41.1% in the referrals. The comparison of the mean value of the patients' problems before and those after the mental health nursing interventions, showed statistically significant reduction of the problems. Also, the comparison of the mean value in the fourth assessment of the patients' problems with the mean value of the patients' opinion, showed an achievement in facilitating the verbal expression and comforting the physical and psychological symptoms to a point statistically significant.

Psychiatric interventions in the medically ill. Outcome and effectiveness research

This article reviews the current status and emerging trends of outcome data from research studies of psychiatric and psychosocial interventions for mental disorders in patients in the general medical sector. Although data from such studies have had limited success to date in influencing health policy, legislators and administrators are increasingly likely to turn to outcome data to inform their decisions. The impact of psychiatric disorders, the recognition and treatment or referral of psychiatric-disordered patients by general medical practitioners, and the outcome results of psychiatric intervention programs are examined for both the inpatient and outpatient general medical sectors.

Patterns of diagnoses, comorbidities, and treatment in late-middle-aged and older affective disorder patients: comparison of mental health and medical sectors

OBJECTIVE

To compare the diagnoses, psychiatric and medical comorbidities, and prior and current treatment received by late-middle-aged and older affective disorder patients in mental health and medical service settings and to identify predictors of these patients' length of inpatient care.

DESIGN

Department of Veterans Affairs (VA) nationwide databases are used to examine the prevalence, diagnoses, and inpatient and outpatient treatment received by affective disorder patients in mental health and medical units in Fiscal Year 1990.

RESULTS

Compared with late-middle-aged and older index medical patients (n = 11,701), index mental health patients (n = 9039) were more likely to have affective psychoses and major depressive disorder and less likely to have depressive disorder NOS. Almost 60% of affective disorder patients in mental health settings had comorbid psychiatric diagnoses; this was true of 30% of patients in medical settings. Moreover, more than 80% of affective disorder patients in mental health settings had concomitant medical disorders. Affective disorder patients also had very high rates of prior mental health and medical care. Patients who had more severe affective disorders and comorbid psychiatric and medical diagnoses had longer episodes of inpatient care; in contrast, more intensive prior medical and mental health outpatient care was associated with shorter episodes of inpatient care.

CONCLUSIONS

The findings highlight affective disorder patients' high rates of comorbidity and intensive use of health care resources, emphasize the value of outpatient care in reducing the amount of subsequent inpatient care, and underscore the need for closer integration of mental health and medical care.

Consultation-liaison psychiatry in an Australian oncology unit

OBJECTIVE

To provide an overview of the work of a consultation-liaison (C-L) psychiatry service to an oncology unit in a university affiliated teaching hospital, with the aid of a comprehensive clinical database.

METHOD

The MICROCARES prospective clinical database system was used to record data on all oncology inpatients referred to C-L psychiatry, and the hospital clinical database was used to compare referred inpatients with all oncology inpatients.

RESULTS

Two hundred and seventy-one referrals were made in the 3 years from 1991 to 1993, a referral rate of 10.4%. The referred patients were younger but there was no bias in sex and marital status. The mean length of stay was twice that for all other oncology admissions, day cases excluded. The most frequent reasons for referral were coping problems, depression, terminal illness issues and anxiety. The most common psychiatric diagnoses were Systemic Family Problems (V codes, 24%), Mood Disorders (23%), Adjustment Disorders (16%) and Organic Mental Disorders (10%). Management involved family conferences in half of the patients and antidepressant medication in one-quarter. Concordance with pharmacological recommendations was 98%. Existential issues and family-centred care are discussed.

CONCLUSIONS

Both individual and family-centred care is required in an oncology service; a dedicated liaison attachment offers considerable staff support. Psycho-oncology is underdeveloped in Australia compared to many overseas services; there is scope for substantial growth in preventive and supportive work.

Comorbidity as a correlate of length of stay for hospitalized patients with acute chest pain

OBJECTIVE

To determine whether comorbid medical conditions as measured with the Charlson Comorbidity Index are independent correlates of length of stay after adjusting for other clinical and socioeconomic data.

DESIGN

Prospective cohort study.

SETTING

Urban teaching hospital.

PATIENTS

All 1,261 patient aged 30 years or more who were admitted to this hospital after coming to the emergency department with acute chest pain between October 1990 and May 1992.

MEASUREMENTS AND OUTCOMES

Clinical data including comorbid medical conditions used in the Charlson index were prospectively recorded by the evaluating physician at the time of admission or by a research nurse who was blinded to the subsequent events. History of myocardial infarction was excluded from the calculation of the Charlson index score. Charlson index scores were 0 to 1 for 921 patients (73%), 2 to 3 for 263 (21%), and greater than 3 for 77 (6%). Unadjusted means (+/- SD) lengths of stay in these groups were 4.4 +/- 5.2, 5.2 +/- 5.9, and 7.5 +/- 9.3 days, respectively. In multiple linear regression analysis, compared with Charlson index scores of 0 to 1, scores of 2 to 3 and greater than 3 were significant (p < .01) independent correlates of the log transformation of length of stay after adjusting for clinical data from the initial presentation and subsequent course (model R2 = .510). In an analysis restricted to the 795 patients without clinical complications, a Charlson index score greater than 3 was an independent correlate of length of stay compared with scores of 0 to 1 (p < .01). Individual comorbid conditions were not significant correlates of length of stay after controlling for Charlson index score.

CONCLUSIONS

In this population of patients with acute chest pain, comorbidity as measured with the Charlson index was independently associated with length of stay after adjustment for other clinical data. After adjusting for the Charlson index, no separate comorbid condition was significantly correlated with length of stay. These findings suggest that the Charlson index can be used to adjust for comorbidities in analyses of length of stay for patients with this condition.

Consultation-liaison psychiatry to renal medicine: work with an inpatient unit

OBJECTIVE

To provide an overview of the work of a liaison psychiatry service to a renal medicine inpatient unit, based on a comprehensive clinical database, in order to provide a basis for comparison with similar units and to identify issues of concern.

METHOD

The MICRO-CARES prospective clinical database system was used to obtain data on all patients referred to the Liaison Psychiatry Service, and the hospital clinical database was used to compare referred patients with total Renal Unit admissions in a large, suburban, university-affiliated hospital.

RESULTS

Two hundred and ninety-nine inpatient referrals were made in the three years from 1990 to 1992: a referral rate of 17%. There was no bias in referral on age, sex or marital status. Coping problems (27%), depression (20%) and noncompliance (11%) were the most frequent reasons cited. Forty-five per cent of referrals required a pre-dialysis assessment. There was good agreement between consultee and consultant about noncompliance, but poorer agreement about organic brain syndromes, depression, anxiety and alcohol problems. The highest prevalence of DSM-III-R diagnoses was for V Codes (35% of Mental Disorders (23%). Referred patients had a length of stay significantly longer than that of the total admissions (20.5 days +/- 20.6 SD compared with 8.7 +2- 12.5 SD, p < .001). Psychotropic drugs were prescribed in 25% of referrals, and liaison psychiatry staff spent a mean of 181 +/- 148 SD minutes per patient, reflecting the emphasis on psychological management. The systems issues are discussed.

CONCLUSIONS

The high level of complex physical/psychiatric comorbidity present and the systemic issues involved suggest that the management of patients in a renal medicine inpatient unit requires a dedicated attachment of a consultant psychiatrist-led, multidisciplinary, liaison psychiatry team which is well trained in psychodynamic issues and is comfortable with the complexity of biological issues which arise. The data provide a reliable basis for comparison with other services.

Consultation-liaison psychiatry in an obstetric service

OBJECTIVE

The aim of this paper is to provide an overview of the work of a consultation-liaison (C-L) psychiatry service to an obstetric inpatient unit in a university affiliated teaching hospital, with the aid of a comprehensive clinical database.

METHOD

The MICRO-CARES clinical database system was used for prospective recording of data on all obstetric inpatients referred to the C-L psychiatry service and the hospital clinical database was used to compare referred inpatients with all obstetric inpatients.

RESULTS

Ninety patients were referred in 3 years, a referral rate of 1.2% of obstetric admissions. There was no bias in referral on age, but there were significantly more unmarried patients in the referred group (p < 0.001). Referred patients had a significantly prolonged length of stay: a mean of 9 days for referred patients, with 6 days for all obstetric patients (p < 0.001). The most frequent reasons for referral were: coping problems, depression, anxiety/fear and past history of major psychiatric illness. The most common DMS-III-R psychiatric diagnoses were: Personality Disorders (19%), Mood Disorders (17%), Schizophrenic Disorders (15%) and Adjustment Disorders (13%). At least one confirmed diagnosis was made in 77% of patients, but 42% of diagnoses remained differential. There were significantly more patients with diseases of the nervous system, endocrine and circulatory disorders in the referred group (p < 0.001). Recommendations of psychosocial interventions predominated over psychopharmacological interventions, and concordance with these was 97% and 98%, respectively. Issues in the relationship of obstetrics and psychiatric C-L services are discussed and future directions indicated.

CONCLUSIONS

The referral rate was low compared with other specialty units. This is probably due to factors inherent in obstetric practice. A wide spectrum of psychiatric disorders was referred, including a higher than expected number of women with postpartum psychotic disorders, the majority of whom were managed successfully in the obstetric ward. There is a need for increased liaison with obstetric and community services and for collaborative research, with a particular emphasis on the prevention of psychiatric morbidity associated with pregnancy.

[Mood disorders among inpatients in ambulatory and validation of the anxiety and depression scale HAD]

The revised Clinical Interview Schedule (CIS-R) and the Hospital Anxiety and Depression (HAD) Scale were used to estimate the prevalence of mood disorders among 78 consecutive admissions to a general medical ward in a university general hospital in Brazil (43 males and 35 females; mean age = 43.2yr). Interviewers also completed a 5-point symptom severity scales for anxiety and depression. The definition of cases of anxiety [and depression] was based on two criteria: a. score > or = 2 on the CIS-R section of anxiety [> or = 4 on the CIS-R sections of depression and depressive ideas]; and b. score > or = 2 on the clinical severity scale for anxiety [score > or = 2 on the clinical severity scale for depression]. A 39% prevalence rate of affective disorders was found. Sixteen (20.5%) patients met criteria for anxiety, most of the disorders being of mild severity. Twenty-sic patients (33%) were depressed, 7 of them in a moderate degree. The HAD was easily understood by the patients. Anxiety and depression subscales had internal consistency of 0.68 and 0.77, respectively. At a cut-off point of 8/9 sensibility and specificity were 93.7% and 72.6% for anxiety, and 84.6% and 90.3% for depression. HAD items correlated positively with the respective subscales. To a lesser degree, they also correlated with the alternative subscale. Our findings confirm the high prevalence of mood disorders among medical in-patients. In clinical practice, the HAD may have a useful role in detecting those patients requiring further psychological care.

Consultation-liaison psychiatry in general medical units

The activities of a consultation-liaison psychiatry service to general medical units in a university affiliated suburban teaching hospital are described, with a report from the MICRO-CARES clinical database on 165 consecutive referrals over a 12 month period. The referral rate was 4.2% of admissions. The data confirm the association of psychiatric referral and prolonged length of hospital stay (mean of 18 days for referred patients, 9 days for non-referred patients). The most common reasons for referral were depression, suicide risk evaluation, organic brain syndrome and suspected psychological component to illness. The most common psychiatric diagnoses were Mood Disorders (55%), Organic Mental Disorders (35%), Adjustment Disorders (19%), Somatoform and other Somatic Disorders (16%) and Personality Disorders (15%). Although 67% of patients received at least one confirmed diagnosis, 39% of all diagnoses remained "differential", or unconfirmed, at discharge. Concordance with drug recommendations was 97% and with non-drug recommendations 95%. Two groups of patients were prominent among the referrals: the young self-poisoning patient, and the older patient living alone. The issues involved in providing a liaison psychiatry service to general medical units with these characteristics are described.

Impact of the interaction of depression and physical illness on a psychiatric unit's length of stay

Prior literature suggests that length of stay (LOS) on medical inpatient units is increased by the coexistence of depression and physical illness. The present study examined 532 psychiatric inpatient admissions to determine if physical illness increased LOS for patients grouped by diagnostic categories of psychosis, depression, personality disorder, anxiety disorder, adjustment disorder, bipolar disorder (not depressed), and other psychiatric disorders. LOS for depressed patients was significantly longer for those with any physical final diagnosis (mean = 20.08 days) than for depressed patients with no physical diagnosis (mean = 11.48 days). LOS was also longer for all patients with physical diagnoses (mean = 19.31 days) than all patients with no physical diagnosis (mean = 13.13 days). No other specific diagnostic group (psychosis, personality disorder, and so forth) showed significant differences in LOS for any associated physical illness vs no physical illness. The study results tend to indicate that physical illness is associated with increased LOS for depressed psychiatric patients but not for other specific diagnostic groups. Depressed patients may 1) mask physical illness by depression-generated physical complaints; 2) prioritize mood symptoms over physical symptoms; and/or 3) may suffer from feelings of hopelessness or be pessimistic that their physical symptoms will be effectively treated and, therefore, not report their physical symptoms.

General hospital psychiatry and the new behavioral health care delivery system

Mental health care delivery has undergone substantial changes in recent years. This article reviews the evolution of managed care in the mental health care field and outlines managed behavioral health care techniques used in providing access to high-quality, cost-effective care. The expansion of general hospital psychiatry over the last 25 years is also reviewed. Current strengths of general hospital psychiatry which make it well positioned for an expanded role in behavioral health care delivery are examined. Recommendations are made for further improvements in the clinical, administrative, and financial aspects of general hospital psychiatry care delivery to prepare it for the integrated behavioral health care systems of tomorrow.

Effects of psychiatric consultation on medical consumption in medical outpatients with abdominal pain

A randomized controlled clinical trial was conducted in an outpatient clinic of internal medicine to test the hypothesis that a protocol of cooperation and communication between internist and general practitioner, sustained with psychiatric consultation, would reduce medical consumption in a group of medical outpatients with abdominal pain (N = 106). A reduction in medical consumption could not be demonstrated. However, a great variation in protocol adherence was found, partly related to the severity of the psychological problems. There is some evidence that the protocol, if restricted to cases with more severe psychiatric comorbidity, might reduce medical consumption.

Cognitive impairment in psychiatric patients and length of hospital stay

The purpose of this study was to determine whether brief neuropsychologic screening at the time of admission to an acute-care psychiatric unit predicts the length of inpatient hospital stay (LOS). Over a 4-month period, 41 consecutively admitted patients on a general psychiatric inpatient unit were administered the Mini-Mental State Examination (MMSE), the Trails A and B subtests from the Halstead-Reitan Neuropsychological Battery, and the Visual Reproduction subtest (VR) of the Wechsler Memory Scale within 72 hours of admission. A setwise, hierarchic multiple regression model examined the contributions of demographic factors, clinical features, and the four neuropsychologic tests to LOS variance. VR and Trails A were the best predictors of LOS, responsible for 21.6% and 16.3% of outcome variance, respectively. The independent variables (IVs) comprising the best-fitting model include Trails A, VR, MMSE, and patient diagnosis. These variables collectively accounted for 48.8% of the variance in LOS, and predicted 70.4% of patients with LOS < 21 days and 82.4% of patients with LOS > 21 days. The results of this study support the hypothesis that LOS is related to cognitive impairment associated with psychiatric illness, and suggest that neuropsychologic testing upon admission to an inpatient unit can be useful in predicting LOS.

Depression in the medically ill. Critical issues in diagnostic assessment

Diagnosing depression in the medically ill is a difficult diagnostic task that will not be clarified appreciably by DSM-IV. The author reviews diagnostic validity as it relates to depressive disorders in the medically ill. Suggested guidelines for using the DSM-IV to diagnose depressive disorders in the medically ill also are reviewed.

Staffing and funding of consultation-liaison psychiatry services in Australia and New Zealand

The aim of the study was to establish the current and desired levels of staffing and funding of the 52 consultation-liaison (C-L) psychiatry training units in Australian and New Zealand general hospitals. Administration of a questionnaire and follow-up verification provided data on referral rates, existing and preferred staffing levels, and staff workloads. The referral rates and staffing levels in most cases fall below those quoted for Europe and the USA, and those considered optimal by the respondents. This, together with the large variation in referral rates and workload, has implications for the type of clinical activity conducted and quality of the training experience in different units.

Developing a financially viable consultation-liaison service

As reimbursement for psychiatry changes, general hospital psychiatry divisions, specifically consultation-liaison (C-L) services, will take on increasingly important roles. This article shows how a variety of funding mechanisms have applications in different hospital systems. Although every recommendation does not apply to each hospital, certain important contributions that C-L psychiatry can make, such as updating diagnosis-related group codes and enhancing hospital reimbursement for services appropriately delivered, are reviewed. Specific recommendations that may be helpful in various hospital systems are offered that, individually and in the aggregate, should enhance the position, as well as the financial, research, and clinical base for an effectively managed C-L service.

Psychiatric comorbidity and length of stay in the general hospital. A critical review of outcome studies

The authors critically reviewed 26 international and American outcome studies that assessed the effect of psychiatric comorbidity on length of stay for medical/surgical inpatients. Three generations of American studies were defined according to the rigorousness of the methodology. Eighty-nine percent of all studies with sample sizes greater than 110 and 75% of the prospective, rigorously controlled, American studies found a significant association between psychiatric comorbidity and increased length of stay. The findings lead to the conclusion that impaired cognition associated with delirium and dementia, depressed mood, and other personality variables contributes to prolonged hospital stays and greater utilization of hospitals and other health resources after discharge. Recommendations for future research are suggested.

Nursing care hours of patients receiving varying amounts and types of consultation/liaison services

Psychiatric comorbidities in the general hospital population have been found to increase the cost of health care. This descriptive study provides an in-depth analysis (including nursing hours), of general hospital patients receiving low, medium, and high intensity consultation/liaison (C/L) services from C/L psychiatrists and C/L nurses using computerized databases and the medical record. The results show that there are significant differences among the subgroups receiving varying amounts of C/L services. This study has particular significance for C/L nursing as many C/L nursing interventions are focused on both the patient and the delivery of nursing care by the staff nurse.

A comparative study of screening instruments for mental disorders in general hospital patients

OBJECTIVE

Self-administered questionnaires are frequently used in studies of hospitalized physically ill patients to identify and measure psychiatric morbidity. This study examines the validity of some commonly used questionnaires in this context.

METHOD

One hundred and seventy-nine patients in a general hospital completed the GHQ, HAD, BDI and STAI and were interviewed using the SCID-R. The findings were evaluated against DSM-III-R diagnoses using the QROC curve.

RESULTS

Thirty-eight percent of patients obtained one or more DSM-III-R diagnoses; 25 percent mood disorder, 12 percent anxiety disorder, 11 percent drug abuse or dependence, 2 percent a somatic syndrome. Eleven percent had more than one diagnosis. As screening instruments for general psychiatric morbidity there were no statistically significant differences between versions of the GHQ and the HAD. With respect to identifying depression, the GHQ tended to perform better than the other instruments.

CONCLUSIONS

The questionnaires identified general morbidity and depression satisfactorily but anxiety and drug abuse and dependence syndromes poorly. The results also support the notion that the DSM-III-R classification has a number of deficiencies when used in this population.

Future directions for mental health services in Australia

The last decade has seen a marked increase in the attention given to mental health policy and services at both a state and national level. Mental health consumers, carers, service providers, and a number of professional bodies have contributed to the scrutiny of what had been a relatively neglected area. The release of Australia's first National Mental Health Policy is a milestone in the development of a national focus on mental health promotion, prevention and the provision of enhanced services for persons with mental disorder and mental health problems. This paper discusses briefly the directions promoted in the national policy, including mental health promotion, reorientation of mental health services, the nongovernment sector, consumer rights, intersectoral links, service quality, research and evaluation.

Psychosocial interventions in chronic medical illness. An overview of outcome research

Previous studies have shown that psychopathology is common in the medically ill, affects the course of medical illness, and is associated with increased health care costs. Recent controlled trials have demonstrated that psychosocial interventions in the medically ill can improve both psychosocial and medical outcomes. Although an important aim of current research is to assess the cost effectiveness of such interventions, the meaning and significance of "cost effectiveness," "cost benefit," and "cost offset" are frequently misunderstood. An overview of outcome research will be used to illuminate the promise and the limitations of such studies, with special attention to bias in research design.

Natural history of symptoms of depression and anxiety during inpatient treatment on general medicine wards

OBJECTIVE

To establish the frequency of criteria-based depression and anxiety in newly admitted medical inpatients and to determine the natural history of depressive and anxiety symptoms during hospitalization.

DESIGN

Prospective structured assessment of criteria-based depression and anxiety diagnoses within 24 hours of hospitalization with routine follow-up depression and anxiety questionnaires until discharge.

SETTING

A tertiary care university hospital and an affiliated Veterans Administration hospital.

PATIENTS

One hundred twenty-eight adult patients admitted to internal medicine inpatient units between May 1990 and August 1990.

MAIN RESULTS

On admission, 43 of the 128 patients inducted met the DSM-III criteria for major depression, while an additional six met the criteria for adjustment disorder with depressed mood. Only six patients met the criteria for panic disorder, generalized anxiety disorder, or adjustment disorder with anxious mood at the time of admission to the study. Patients with high symptom scores on the anxiety and depression scales showed significant decreases in these scores without specific psychiatric intervention. Those who remained in the hospital 20 days or longer showed initial improvement and subsequently returned to baseline symptom levels of depression and anxiety. In approximately 9% of patients, symptoms of depression persisted or worsened.

CONCLUSIONS

Major depression occurs more commonly than anxiety disorder in newly admitted medical inpatients but both resolve spontaneously in the majority during the course of hospitalization without specific psychiatric intervention unless the hospitalization is prolonged. One in ten will continue to show symptoms of depression.