Evaluative research in consultation-liaison psychiatry. Review of the literature: 1970-1981

Performance measurement tools for consultation-liaison psychiatry services must consider feasibility

This editorial describes an effort by 9 consultation-liaison (C-L) psychiatry service leaders in the United States to incorporate routine performance measurement into their service workflows. Although C-L psychiatry is an essential clinical service in general hospitals, performance metrics for this service have not been broadly accepted or implemented. Meanwhile, the performance metrics that have been developed rely on an investment in resources and/or new workflows that C-L psychiatry services may not be prepared to make on a widespread level. Our group sought to determine the feasibility of incorporating routine performance measurement into the workflows of a diverse sample of C-L psychiatry services using only existing resources via three collection methods: timestamp review, chart auditing, and survey administration. No methods were broadly successful across the 9 services. We argue that for routine performance measurement to gain wider traction in the field of C-L psychiatry, the ready availability-or automatability-of performance data must be taken into account.

Wand A. Quality indicators for a consultation-liaison psychiatry service

Purpose

– Consultation-liaison psychiatry (CLP) researchers have not yet developed accepted quality indicators to measure efficiency or effectiveness. The purpose of this paper is to combine objective and subjective quality indicators to assess hospital-based CLP service utilisation, efficiency and effectiveness.

Design/methodology/approach

– Service utilisation rate was calculated over the service's first four years. Patient characteristics and objective quality indicators relating to response timeliness in 2012 were examined. Totally, 41 staff and 52 consecutive patients completed evaluation surveys to subjectively evaluate effectiveness.

Findings

– The utilisation rate increased initially and then slightly declined to 1.03 per cent of all hospital admissions. In 2012, 91.5 per cent were seen on the same referral day and 99.4 per cent by the next day. The benchmark for urgent referrals was not met (77.4 per cent). Patients rated involvement with the CLP service a positive experience (90 per cent), but were less clear about follow-up plans (68 per cent). Staff believed that the service improved the patients’ hospital course (98 per cent) and was communicated well (93-95 per cent). Only 63 per cent agreed that relevant CLP education was provided and 76 per cent rated follow-up plans as clear.

Originality/value

– This CLP service was evaluated by measuring utilisation rates, referral response timeliness and consumer feedback. Referral to contact time is a useful objective quality indicator but should be combined with subjective yet standardised measures surveying service recipients (patients and referring staff) to be comprehensive and meaningful.

The effectiveness of consultation-liaison psychiatry in the general hospital setting: a systematic review

OBJECTIVE

The aim of this study was to review how the effectiveness of consultation liaison psychiatry (CLP) services has been measured and to evaluate the strength of the evidence for effectiveness.

METHODS

Systematic review of medical databases using broad search terms as well as expert opinion was sought. The literature search was restricted to studies of general, whole-of-hospital inpatient CLP services.

RESULTS

Forty articles were found and grouped into five measurements of effectiveness: cost effectiveness including length of stay, concordance, staff and patient feedback, and follow-up outcome studies. All measurements contributed to the evaluation of CLP services, but no one measure in isolation could adequately cover the multifaceted roles of CLP. Concordance was the only measurement with an established, consistent approach for evaluation. Cost effectiveness and follow-up outcome studies were the only measures with levels of evidence above four, however the three follow-up outcome studies reported conflicting results. Subjective evidence derived from patient and staff feedback is important but presently lacking due to methodological problems. The effectiveness of CLP services was demonstrated by cost-effectiveness, earlier referrals to CLP predicting shorter length of stay, and concordance with some management recommendations.

CONCLUSION

There is evidence that some CLP services are cost-effective and reduce length of stay when involved early and that referrers follow certain recommendations. However, many studies had disparate results and were methodologically flawed. Future research should focus on standardising patient and staff feedback, and short-term patient outcomes.

PSYCHIATRIC EVALUATION OF LIMB FRACTURE PATIENTS

The study included 70 consecutive patients with fracture of the lower and upper limbs each and an equal number of age and sex matched normal control subjects. All the subjects were screened using the General Health Questionnaire (GHQ), the Michigan Alcoholism Screening Test (MAST), Carroll Rating Scale for Depression (CRSD), State-Trait Anxiety Inventory (STAI), Impact of Events Scale (IES), Fatigue Scale (FS) and the Perceived Stress Questionnaire (PSQ). Probable "Psychiatric cases" identified by the questionnaires underwent diagnostic psychiatric evaluation. As compared to normal controls, the limb fracture patients obtained significantly higher scores on the GHQ, MAST, CRSD, IES & FS but not on the STAI & PSQ. Psychiatric evaluation revealed significantly higher prevalence of psychiatric disorders in lower limb fracture patients (n=31) as compared to upper limb fracture patients (n=18) and control subjects (n=6). Limb fracture patients had a high prevalence of alcohol dependence/abuse (243%) and depressive disorders (6.4%). The results indicate that psychological intervention would greatly facilitate the management of these patients.

Use of a routine outcome measure in a consultation-liaison mental health service

OBJECTIVE

The problem severity of patients seen by a psychiatric consultation- liaison service was studied through the use of a routine outcome measure.

METHODS

Ratings on the Health of the Nation Outcome Scales (HoNOS) over nearly 3 years in the emergency department, general hospital, and on admission to the acute psychiatric unit were compared.

RESULTS

Mean HoNOS total scores in the emergency department were not significantly different from those at admission to the acute psychiatric unit, but were significantly higher than those in the general hospital. Mean scores in all three settings were higher than those obtained at case review of psychiatric patients in the community. Despite differences in age, sex, and psychiatric diagnosis between the three hospital settings, differences in mean HoNOS total scores remained substantially unchanged after adjustment for these factors. Most HoNOS assessments were performed by medical staff.

CONCLUSIONS

The suspected high levels of problem severity and comorbidity of patients seen by a psychiatric consultation-liaison service were confirmed through the use of a routine outcome measure.

A systematic review of studies of the cost-effectiveness of mental health consultation-liaison interventions in general hospitals

A systematic review of cost-effectiveness analyses of mental health consultation-liaison interventions in general hospitals was conducted. Few studies have evaluated the cost-effectiveness of consultation-liaison interventions, and only two articles met the criteria for inclusion in the review. The comparable variable was length of the hospital stay. It could not be concluded that psychiatric consultation had an effect on the duration of hospital stays. In one of the studies, the group that received psychiatric consultation showed improvement in depressive symptoms. Additional studies would have been relevant to this review if they had replicated clinical practice by using a naturalistic research design.

Medical inpatients at risk of extended hospital stay and poor discharge health status: detection with COMPRI and INTERMED

OBJECTIVE

To detect the patients in medical wards at risk of extended LOS and poor discharge health status with the use of complexity prediction instrument (COMPRI) and interdisciplinary medicine (INTERMED) instruments.

METHODS

STUDY 1: In a sample of 275 consecutively admitted medical inpatients, a hierarchical cluster analysis on INTERMED variables was performed. The clusters were compared on length of hospital stay (LOS) and Short Form 36 (SF-36) at discharge. STUDY 2: Receiver operating characteristic (ROC) analysis was used to optimal cut-off points for the COMPRI and INTERMED. Patients detected with COMPRI and INTERMED were then compared with undetected patients on LOS and SF-36.

RESULTS

STUDY 1: In concordance with previous findings, a cluster of patients with high biopsychosocial vulnerability was identified with significantly higher scores on LOS (p <.05) and lower scores on SF-36 (p <.001) than patients in other clusters. STUDY 2: A cut-off point for the COMPRI of 5/6 was found to detect patients at risk of long LOS. A cut off score for the INTERMED of 20/21 was found to detect patients at risk of poor discharge health status. Patients detected with COMPRI and INTERMED had a significantly longer LOS (p <.001) and a poorer discharge health status (SF-36 MCS: p <.001; SF-36 PCS: p =.05) than nondetected patients. Of the detected patients, 37% had an extended hospital stay and poor discharge health status; of the nondetected patients, this was only 7%.

CONCLUSIONS

The COMPRI-INTERMED can help to detect complex patients admitted to medical wards within the first days of admission, and rule out those with a small chance of poor outcomes.

A review of research on the structure, process and outcome of liaison mental health services

Liaison mental health services (LMHS) developed originally to address the mental health needs of people with physical illnesses in general hospitals and more recently to work also with people with mental health problems presenting at non-mental health services. The purpose of the present paper was to review empirical research on the structure, process and outcome of liaison mental health services using systematic review methods. Following a comprehensive search strategy, the authors reviewed 48 papers published between 1975 and 2001. There is an extensive international literature on LMHS, much of which describes the structure and process of liaison work. Studies evaluating the outcomes of liaison mental health services are fewer, and handicapped by methodological flaws, some of which are serious enough to cast doubts on the reported results. Professionals and clients value LMHS. LMHS based in accident and emergency (A & E) departments appear to ease the burden of general A & E staff, help clients access mental health services and reduce re-admission rates of people with mental health problems. There is little evidence supporting one model of configuring LMHS over another.

Consultation-liaison psychiatry and psychosomatic medicine: the company they keep

OBJECTIVE

The objectives of this review are 1) to briefly describe the parallel historical developments of consultation-liaison (C-L) psychiatry and psychosomatic medicine [corrected]; 2) to analyze the extent to which the literature of C-L psychiatry and psychosomatic medicine relate to each other, given that both fields have evolved simultaneously in the history of psychiatry; and 3) to propose possible explanations for observed publication patterns in selected C-L resources and the journal Psychosomatic Medicine.

METHODS

The quasi-citation analysis includes two segments: 1) a review of selected key C-L psychiatry references to determine the extent to which classic articles from Psychosomatic Medicine are cited; and 2) an analysis of 60 years of Psychosomatic Medicine, sampling issues from the first 5 years of each decade and all issues of the year 2000 for articles of potential relevance to C-L psychiatry. References to Psychosomatic Medicine articles in C-L resources are tallied as percentages of total references in each source. Articles in Psychosomatic Medicine are assigned to one of three categories (A, B, or C) according to their perceived relevance to C-L psychiatry, from most (A) to least (C) relevant.

RESULTS

The review of C-L sources ("basic" reading lists and reference lists of seminal articles and textbooks) revealed a wide range of Psychosomatic Medicine citations, from 0% to 27.4% (average, 7.5%). The survey of Psychosomatic Medicine sorted 1705 articles for their relevance to C-L psychiatry into category A (9.5-40.6%, average 21.3%), category B (70.4-86.3%, average 72.3%), and category C (0.7-12.1%, average 6.4%) for each half-decade for the past 60 years. The lowest number of category A articles appeared in the years 1970 to 1975, and the highest number appeared in 1950 to 1955; reciprocal results were found for category B articles. The lowest number of category C articles appeared in 1980 to 1985, and the highest number appeared in 1940 to 1945. For the six issues of 2000, the distributions of articles in categories A, B, and C are similar, continuing an upward trend beginning in 1975 of core (category A) articles. Explanations for publication patterns are speculatively related to various factors, such as a paucity of C-L research and researchers, the broad definition of C-L psychiatry, editorial policies, and the impact of World War II.

CONCLUSIONS

Although C-L psychiatry and psychosomatic medicine have common roots, the reliance of the C-L literature on classic Psychosomatic Medicine articles has varied markedly, from none to about one-quarter of its references. Nevertheless, Psychosomatic Medicine has consistently published articles of theoretical and clinical interest to C-L psychiatrists, with more than 90% of published articles considered to be of high or moderate relevance to C-L psychiatry. A far higher percentage of articles in Psychosomatic Medicine would seem to be relevant to the field of C-L psychiatry than are cited in significant C-L literature. Psychosomatic Medicine's essential focus on empirical research may dissuade the more clinically oriented C-L psychiatrists.

A model for evaluating the impact of consultation-liaison psychiatry activities on referral patterns

A method for evaluating the change of the referral patterns in consultation-liaison (C-L) psychiatry is described. The method is applied to the study of the 528 requests received by a C-L team for a 2-year period, following the creation of the C-L service. Five types of C-L request are isolated and related to DSM-III-R diagnosis and other clinical variables. Final data show how the referral patterns in a general hospital can change in a positive way as a result of C-L psychiatry activity, moving from a "mending" and secondary view of psychiatric work to a collaborative and primary conceptual model.

The efficacy of intensive biopsychosocial teaching programs for residents: a review of the literature and guidelines for teaching

OBJECTIVE

To review research evaluations of intensive biopsychosocial training programs for nonpsychiatry residents, and determine whether this research showed sufficient rigor and consistent beneficial impact to allow initial research-based teaching guidelines.

DATA SOURCES

An English-language literature search used MEDLINE (1966-93), Psychological Abstracts (1967-93), and Educational Resource Information Clearinghouse (1966-93) as well as bibliographic reviews from prominent peer-reviewed articles and consultation with an expert.

STUDY SELECTION

From among several hundred articles about biopsychosocial training, only 12 studies met the selection criteria: at least 100 contact hours of training for nonpsychiatry residents and an evaluation of efficacy.

DATA EXTRACTION

The three authors independently assessed these 12 studies and made a consensus decision based on explicit criteria. Successful and unsuccessful programs were distinguished from among those classified as quasi-experimental or experimental to identify programs of sufficient rigor to meet the study objective; success was defined as learning beyond knowledge and residents' acceptance of teaching.

DATA SYNTHESIS

Four successful quasi-experimental or experimental programs showed the following uniquely beneficial features: 1) protected time for residents; 2) teaching that was required, structured, multidimensional, and balanced between learner-centered and teacher-centered approaches; 3) teaching methods that used normal as well as psychosocially disturbed patients, nonpsychiatrist teachers, and special teaching techniques; and 4) inclusion in the curriculum of interviewing, interpersonal skills, doctor-patient relationship, and patient education. Two unsuccessful quasi-experimental or experimental programs were unidimensional and unstructured, and used predominant or isolated teacher-centered approaches. Features found in both successful and unsuccessful programs were experiential teaching, psychiatrist and other mental health professional teachers, use of disturbed patients, training to manage patients' psychosocial problems, teaching directed toward knowledge acquisition, teaching about treatment, and university affiliation.

CONCLUSIONS

Four rigorously studied, successful programs showed a common pattern of intensive biopsychosocial teaching that produced, in aggregate, improvement in residents' knowledge, attitudes, skills, and self-awareness. Although there is need for more definitive research, these data are sufficiently compelling and consistent to provide initial, research-based teaching guidelines.

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 retrospective study on the perceived need for and actual use of psychiatric consultations in older medical patients

OBJECTIVE

The authors examined the (under) utilization of the psychiatric consultation service for patients aged sixty to seventy-five who were hospitalized for medical reasons, and explored whether one could retrospectively document and identify a greater need for psychological support than the one reflected in the number of actual consultations requested. Three questions were addressed: 1) the psychiatric consultation rate; 2) the frequency of unrecognized medical, psychiatric, and psychosocial complicating factors; and 3) whether the distribution of these factors differed by gender.

METHOD

Records of 203 consecutively-admitted elderly patients hospitalized on medical wards were reviewed by two experienced general hospital psychiatrists for any indication of medical, psychiatric, and psychosocial risk factors. The frequency of actual psychiatric consultations was also recorded.

RESULTS

Three or more risk factors were noted in the records of 36 percent of all patients. Consultation was sought for only 3 percent. Gender differences in type and distribution of risk factors were identified.

CONCLUSIONS

Indicators and profiles that define probable need for psychiatric consultation were identified and briefly discussed. More well-designed, prospective studies testing these indicators and profiles are needed.

Concordance with recommendations in a consultation-liaison psychiatry service

We studied the concordance of physicians with the recommendations of psychiatric consultants in a sample of 270 consultations in a 400-bed general hospital. Of the patients about whom a consultation was sought, 37% had a past psychiatric history, and 67% were on psychotropic drugs. Twelve percent had Organic Mental Disorder, 35% Affective Disorder, and for 24% no DSM-III diagnosis could be made. The psychiatrist made psychotropic drug recommendations in 62%, and the physicians' concordance with this recommendation was 86%. The physician's discharge summary included a diagnosis which concorded with the psychiatrist's diagnosis in 53% of files. The psychiatrist recommended further investigations in only 5.2% of files.

Methodology in consultation-liaison research: a classification of biases

Methodology is receiving overdue attention in psychiatric research. This article focuses on biases encountered in studies in consultation-liaison psychiatry. A classification of biases derived from epidemiology is presented, and the expected impact of each bias is discussed. Methods to minimize bias in the design and implementation of consultation-liaison research are suggested.

Training of primary health care medical officers in mental health care. Errors in clinical judgment before and after training

This investigation examined the nature and frequency of errors in clinical judgment that were displayed by primary health care medical officers before and after short-term training in mental health care. Thirty-nine medical officers who underwent inservice training for 2 weeks were evaluated using standardized case vignettes. Before the training, doctors displayed a sizable percentage of major and minor errors, which dropped significantly following training. Errors were not unique to psychiatric presentations alone, but occurred with respect to vignettes representing physical disorders as well. The results on the whole demonstrate a satisfactory gain in clinical skills of medical officers following the training and highlight the need for continuation of a program of this nature.

Follow-up of psychiatric comorbidity in the general hospital

Although appropriate follow-up is an important task in the consultation setting, little attention has been directed to its frequency, or the risk profile for minimal or maximal follow-up. Eight hundred twenty-three patients from 1983 to 1986 were examined at the Mount Sinai Hospital using a computerized psychiatric consultation database that recorded demographic information, reason for referral, DSM-III 5 Axes diagnosis, recommendations and number of follow-up interviews. Forty-two percent of the consultations had three or less (minimum) follow-up visits. The minimum follow-up group were significantly less often referred for depression or diagnosed as depression (p = .01), had fewer psychosocial stressors (Axis III) (p = .03), and recommendations for psychosocial treatment by the psychiatric consultant (p = .0001), but had significantly more personality disorders (Axis II) (p = .04). Sixty-two percent of the consultation patients were correctly classified into the follow-up groups by the variables: 1) marital status; 2) living situation; 3) problem assessed as chronic illness or pain; 4) absence of an Axis I diagnosis or diagnostic uncertainty; and 5) number of recommendations by the consultant.

Psychiatric assessment of leg fracture patients: a pilot study

Of 200 consecutively admitted leg fracture patients, 101 consented to be screened for psychopathology using the BSI and SMAST questionnaires. Probable cases of psychopathology were referred for diagnostic psychiatric evaluation. Of the participants, 80.2 percent were identified as possible psychiatric cases. Diagnostic evaluation revealed high prevalence of substance abuse (66.0%), depression (46.8%), and personality pathology (38.3%). Accident victims tended to be single young males. Accidents occurred mostly during leisure hours, and were often associated with alcohol use. Psychiatric assistance appears essential in the management of such patients. Psychiatrists need to be especially knowledgeable about chemical dependency, interpersonal issues and psychotherapy.

The evaluation of a consultation-liaison service

The demographics, referral patterns, and diagnoses of a psychiatric consultation-liaison service during a 1-year period are reported. A comparison with data from a similar evaluation of the same service 10 years previously showed stability in most variables. The data suggest that mere availability of a consultation-liaison service does not necessarily lead to increased utilization and highlights the need to forge specific links with other specialties. The use of DSM-III diagnoses in a consultation-liaison service is discussed.

Psychiatric consultations with depressed medical inpatients: a randomized controlled cost-effectiveness study

Nonspecific, supportive psychiatric consultations were performed with a random sample of thirty-three general medical inpatients scoring thirteen or more on the Beck Depression Inventory. The control group consisted of thirty-five patients, matched for sex, marital status, somatic history, and seriousness of illness. The number of patients receiving no analgesic and/or psychotropic medication in the consult group (39%) was significantly greater than that in the control group (17%). When compared with their mean BDI score on admission, the BDI score just before discharge had decreased significantly in the consult group (from 20 to 13), but not in the control group (from 19 to 16). Probably because the patient sample was too heterogeneous, with too low a prevalence of mental disorders (45%), a significant reduction in other medical care expenditures and in length of hospital stay could not be demonstrated.

Ambulatory mental health liaison research: a review and preview

Mental health liaison in primary care is a complex technology requiring scientific study and validation if we are to know when, where, and how to utilize it. Earlier studies have raised as many questions as they have resolved. Recommendations for future research are presented in relation to such issues as: How should mental health consultation/liaison be defined? How should consultation/liaison studies be prioritized? What aspects of consultation/liaison should be studied? What methodologies are appropriate?

The effectiveness of mental health consultation and referral in ambulatory primary care: a research lacuna

This article reviews the research literature on referral to and consultation with mental health specialists for patients in ambulatory medical settings. Very few controlled trials measuring the efficacy of such liaison could be located. They were mainly from the British literature, usually involved psychologists, and (with the exception of one study) tested only the model of referral to the mental health specialist for treatment. More research needs to be done in this important area. Methodologic issues and topics for further study are discussed.

Consultation-liaison psychiatry: the first half century

Consultation-liaison psychiatry is over 50 years old. Its main goal has been to bring medicine and psychiatry closer together so as to improve patient care in its psychosocial and psychiatric aspects. The history of this field may be divided into four overlapping phases: the beginnings, the organizational phase, the phase of conceptual development, and the phase of rapid growth. The highlights of each phase are outlined. The author concludes that C-L psychiatry has achieved the status of a full-fledged subspecialty of psychiatry, one whose main contribution has been to draw attention of clinicians and researchers to psychosocial aspects of physical illness, and to the psychiatric complications of such illness and of the medical and surgical therapies.

Recent research developments in consultation-liaison psychiatry

With the major changes in health care and general hospital practice in the last decade, practice and research in consultation and liaison psychiatry have also changed dramatically. The authors present a selected review of recent advances and implications for five important topics in consultation-liaison research: diagnosis, disease mechanisms, biologic treatments, health services, and psychosocial treatments for medical disorders.

Ombudsman rounds revisited--a controlled study of attitudinal change in response to liaison psychiatry teaching

The authors tested the hypothesis that the attitudes of interns in internal medicine could be positively altered by a weekly medical-psychiatric conference (ombudsman rounds) that is given for 4 months on the inpatient medical service. In order to diminish the effects of simulation a 48-item questionnaire using a Q-sort design was employed. It was given both before and after the PGY-1 year to three groups of house staff: 1) an on-site experimental group (29 subjects), 2) an on-site control group (11 subjects), and 3) an off-site control group from a sister institution (13 subjects). When compared with either control group a statistically significant number of subjects in the experimental group changed positively. When the control groups were combined even greater statistical significance was achieved. The data suggest that attitudes of internal medicine trainees may be favorably altered by medical-psychiatric conferences on inpatient wards.

The timing of psychiatric consultation in the general hospital and length of hospital stay

Four hundred nineteen consecutive consult cases were studied to determine the relationship of the timing of the consult to hospital length of stay. Results indicated that earlier consultations predicted shorter lengths of stay. Applications of the present methodology to more complex evaluations of psychiatric consultation are discussed.

Consultation psychiatry in a Japanese general hospital: patients referred to psychiatric consultation

A total of 164 (47%) out of 350 new psychiatric patients in a general hospital in Japan were those referred to psychiatric consultation. In 47% of the cases, concurrent physical and psychiatric disorders were reported. In the referred patients, neurosis (38%) was the most common psychiatric disorder, followed by other nonorganic psychoses (9%), schizophrenic psychoses (8%), alcoholic psychoses (8%), transient organic psychotic conditions (7%), affective psychoses (6%) and others. The high frequency of psychiatric emergency cases (23%) including cases with suicide attempts (12%) indicated that psychiatrists play an important role in psychiatric emergency crisis intervention in the general hospital emergency service. In suicide attempts, depression was most prominent, but schizophrenic psychoses were also involved in a third of the cases.

Referrals to psychiatrists in a general hospital--comparison of two methods of liaison psychiatry: preliminary communication

Patients on a general medical ward were offered a liaison psychiatric service with 'unlimited' access, in which referrals were accepted from nurses, other paramedical staff and junior doctors in addition to senior medical staff. This new service (method II) was compared with the usual liaison service (method I, referrals initiated or approved by senior medical staff only) which was continued in parallel on a comparable general medical ward. Method II resulted in a threefold increase in referral rate and led to a significant alteration in the types of problem attracting referral. Despite the much higher rate of method II referrals, however, similar percentages of referrals by both methods were offered psychiatric follow up. The results do not support the commonly held belief that it is the failure of ward staff to recognize psychiatric morbidity which accounts for the low rate of referrals to many psychiatric liaison services.

Some methodological issues in consultation-liaison psychiatry research

This is a research methodologic design model that may be useful to consultation-liaison psychiatrists. It is intended to facilitate such researchers in setting up and executing carefully controlled studies of the effectiveness (in psychiatric, medical, surgical, functional, cost, or other areas) of consultation-liaison interventions. The specific variables discussed are areas of particular interest to the authors, but many other variables may be readily substituted into this basic model. The design may be expanded or contracted relatively easily as would be appropriate for particular projects. The overall purpose of this paper is, hopefully, to serve as a catalyst for consultation-liaison psychiatrists to consider such research in their academic settings and to foster increased discussion and critical thinking regarding such research. The authors consider such research efforts important for the future regarding the scientific basis, proven effectiveness, and funding of consultation-liaison and general hospital psychiatry.

Making the case for consultation-liaison psychiatry: issues in cost-effectiveness analysis

There is an increasing need to rationally allocate scarce resources to improve the efficiency of health care and reduce costs. Evidence suggests that consultation-liaison psychiatry has important clinical and economic benefits. This article defines cost-effectiveness and cost benefit analyses, describes basic principles for CEA and in that context critiques recent literature relevant to consultation-liaison psychiatry, and discusses potential contributions and dangers that such studies might offer. There is a need within the health care field for systemic and sophisticated decisions by policy makers. Well designed and comprehensively analyzed studies of the cost-effectiveness of consultation-liaison programs will not only contribute toward advancing the field of consultation-liaison psychiatry but also toward informing the decisions of health policy makers.

Current trends in consultation-liaison psychiatry

Consultation-psychiatry has grown rapidly and become a subspecialty of psychiatry in the past decade. The author reviews the history of this field at the interface of psychiatry and medicine, offers its definition, and discusses current trends pertaining to the organization of liaison services and to the teaching and research activities of liaison psychiatrists. He concludes that a liaison service has become a recognized division of a general hospital psychiatric unit for the provision of psychiatric consultation and teaching to the nonpsychiatric departments of the hospital. Consultation-liaison psychiatry (or liaison psychiatry for short) has emerged in the past decade as a subspecialty of psychiatry, one concerned with mental health problems among medical and surgical patients. Diagnosis, treatment, study and prevention of psychiatric disorders in those patients constitute the proper domain of liaison psychiatry. I will review in this article the major current trends in this field as they pertain to matters of organization, education, and research. A brief historical note and a definition of liaison psychiatry will introduce my review.