Methodology in consultation-liaison research: a classification of biases

Is depression a risk factor for mortality in chronic hemodialysis patients?

OBJECTIVE: The present study was conducted to assess the association between depressive symptomatology and mortality in chronic hemodialysis. METHOD: A cohort of 40 patients was followed for a median period of 10.5 months. The Beck Depression Inventory was used to classify patients as exposed to depression (Beck Depression Inventory score > 14) or not (Beck Depression Inventory < 14). Kaplan-Meier survival curves were used to compare the mortality rate between the two groups. The effects of potential confounding factors were adjusted using Cox proportional hazards model. RESULTS: After 24 months of follow-up, survival rates were 39% for exposed and 95% for non-exposed patients (p = 0.029). The Cox proportional hazards model showed results similar to those of the bivariate analysis, indicating that depressive symptomatology tended to be associated with mortality (HR = 6.5, 95%CI: 0.8-55.6; p = 0.085). Other study variables, including age, concurrent systemic diseases, and biochemical markers, were not significantly associated with mortality. Exposed patients remained on dialysis longer and received kidney transplants less frequently (9% vs. 50% for non-exposed patients). When kidney transplantation was included in the Cox regression model, the hazard ratio of mortality for exposed as compared to non-exposed patients lost statistical significance (HR = 4.5; 95%CI: 0.5-40.0; p = 0.17). CONCLUSIONS: Our study suggests that the presence of depressive symptoms may act as an independent risk factor for mortality in chronic hemodialysis patients. However, this finding needs further investigations.

The ECLW Collaborative study II: patient registration form (PRF) instrument, training and reliability. European Consultation/Liaison Work group

This paper describes the development and testing of the Patient Registration Form (PRF), a standardized instrument for the description of patients seen by consultation-liaison (C-L) psychiatrists and psychosomatists in general hospitals, the referral patterns, the C-L interventions and their outcomes. The PRF study is part of a large multi-centre. European investigation on the effectiveness of mental health service delivery, conducted by the European C-L Workgroup for General Hospital Psychiatry and Psychosomatics (ECLW) and performed in the framework of the of the E.C. 4th Medical and Health Research Program. The final version of the PRF consists of 68 items. It was developed by the Program Management Group (PMG) and National Coordinators (NC) after long preparatory studies to assure both face and content validity and pilot testing. Two hundred and twenty consultants, who required 40 hours of training and came from 14 different European countries and 90 different sites, participated in the final reliability study. The PRF was tested in 13 written case histories. A "gold standard' for the correct answers in each item was decided by "consensus ratings' of the PMG and a subsequent 80% agreement by the NCs. A high standard (average kappa (k) > or = 0.70; at least 2/3 of the PRF items, kappa > or = 0.70) was required for the rater to be considered as "reliable' (RR). The consultants considered the PRF both "feasible' and 93.2% of them fulfilled the RR criteria. The calculated rater-"gold standard' reliability was satisfactory: only four PRF items were identified with low agreement coefficients and no biases were observed cross-nationally in the ratings. Given the implications of misclassification for evaluating C-L effectiveness and services, these results are important and the achievement unprecedented.

Psychiatric consultation for somatizing patients in the family practice setting: a feasibility study

OBJECTIVE

The purpose of the study was to assess the feasibility of a psychiatric consultation intervention for somatizing patients in the family practice setting in terms of 1) patient compliance, 2) patient satisfaction, and 3) compliance and satisfaction of general practitioners (GPs).

METHOD

In a period of nine months, forty-six patients were selected for psychiatric consultation in six solo family practices in a semi-urban area in the Netherlands. The consultation included an interview with the consulting psychiatrist, the patient, and the GP. A written summary of the consultation was provided to the GP and the patient. A booster session with a GP and psychiatrist was included to evaluate and reinforce the recommendations.

RESULTS

The majority of the selected patients agreed to participate after informed consent. An intervention was implemented containing interpersonal techniques, reattribution, clarification, and structuring. GP compliance with recommendations was 100 percent, patient compliance 75 percent.

CONCLUSION

A standardized psychiatric consultation for somatizing patients in a family practice setting can be implemented. Several levels of implementation can be distinguished.

The European Consultation-Liaison Workgroup (ECLW) Collaborative Study. I. General outline

Previous C-L psychiatric service research is seriously limited by its parochial nature; very few results can be generalized outside of the hospital in which the original study was performed because of differences in the nature of the hospital and the type of C-L service. This article presents the general outline and methodology of a European multicentered C-L service delivery study effected by the European Consultation-Liaison Workgroup for General Hospital Psychiatry and Psychosomatics (ECLW). The study is unique in its kind as it allows the comparison of very different C-L services; for example, some services are run by C-L psychiatrists, others are run by C-L psychosomaticists and the study encompasses a large variety of different settings. As a result, both common factors in C-L service delivery and specific local patterns can be explored. The overall hypothesis tested in this study was that the most developed services would see (as well as more patients) a wider variety of clinical problems than small services. The implication is that the absence of well-developed C-L services in a general hospital may mean that there are patients with unmet mental health needs. In separate articles the training and reliability testing of the new Patient Registration Form (PRF) and the Institutional and Provider characteristics will be described. The former includes the use of ICD-10 in the general hospital setting. This study is a collaborative effort made by 226 consultants from 56 psychiatric C-L services in 11 countries. Each consultant recorded details of 1 year's caseload leading to a thorough description of 14,717 patients collected between 1991 and 1993. The advanced methodology included a multicentered international approach, rigid training for all participating consultants, and the development and testing of new instruments. This will allow us to assess the impact of important structural and process variables on the outcome of C-L service delivery in several European countries. These results will be reported in papers both in the international and national literature of the participating countries.

Psychological distress and cognitive impairment in neurological in-patients: its prevalence and its recognition by residents

OBJECTIVE

This pilot study investigated the prevalence of psychological distress and cognitive impairment in neurological in-patients by means of three widely accepted questionnaires. We examined residents' recognition of corresponding disturbances.

METHOD

We interviewed fifty-five consecutively admitted in-patients of a neurological unit with the MMSE, GHQ-28 and BDI. We asked the neurological residents whether they found cognitive impairment or psychological disturbances in their patients and to indicate the extent of those abnormalities.

RESULTS

Fifteen percent of patients showed cognitive impairment, but as many as one-third showed psychological problems warranting further work-up. Recognition of such by residents as well as specification of psychiatric diagnoses and important psychosocial factors in the final reports was poor.

CONCLUSION

Psychological problems are common in neurologic in-patients. They are insufficiently recognized by residents and usually not taken into consideration in patient-care. We suggest the improvement of neurologic training to include appropriate interview techniques, providing the integration of biological, psychological and social factors in diagnosis and therapy.

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.

Exploration of anatomical dolls by nonreferred preschool-aged children: comparisons by age, gender, race, and socioeconomic status

The contributions of age, gender, race, and socioeconomic status (SES) to differences in nonreferred (i.e., presumably nonabused) preschool-aged children's interactions with anatomical dolls were explored. Significant age findings included a decrease with age in manual exploration, an increase in showing doll-to-doll kissing and an increase in demonstrating suggestive intercourse between the dolls. Although 2-year-olds were active in undressing the dolls and exploring the genitals, anus, and breasts, no 2-year-old displayed any sexualized behaviors with the dolls. Six percent (6%) of the children demonstrated clear intercourse positioning. Only low SES black males, ages 4 and 5, demonstrated clear intercourse positioning when the interviewer was present in the room. However, such demonstrations were seen across gender and race and SES when the children were left alone with the dolls. The implications of the findings for evaluators who interview children using anatomical dolls are discussed.

Psychiatric consultations in medical outpatients with abdominal pain: patient and physician effects

OBJECTIVE

The purpose of the study was to assess the effect of a psychiatric consultation intervention in terms of changes in 1) the patients' psychological symptoms, and 2) satisfaction of general practitioners (GPs) concerning their cooperation with the internists.

METHOD

In a randomized controlled design, the effect of a psychiatric consultation intervention in medical outpatients with abdominal pain (n = 106) has been assessed. The goal of the intervention was 1) a holistic approach toward the patients' symptoms, and 2) the improvement of the cooperation between primary and secondary medical health services. The intervention was designed at the health care provider level; the psychiatrist did not see or examine the patient. The 106 patients were subdivided in an index group (N = 49) and a control group (N = 57). The major outcome measures were the psychological status of the patient and degree of satisfaction of the GPs about the cooperation with the medical specialists.

RESULTS

At six months follow-up, there was a significantly greater decline in depressive symptoms assessed by SCL-90 in the patient index group compared with the control group. The GPs of the index group were significantly more satisfied with the cooperation and communication with the internists compared with the control group.

CONCLUSIONS

An experimental psychiatric consultation intervention did effect the patients' well-being to a certain degree, and especially the GPs were affected in terms of satisfaction. The relevance of improving the communication between health care providers in the management of somatizing patients is discussed.

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.

Psychological factors affecting end-stage renal disease. A review

This review summarizes recent systematic research literature regarding psychological factors as they affect chronic renal disease. Special attention is devoted to depression, quality of life, noncompliance, outcome studies, withdrawal from dialysis, and directions for future research.

Hospital utilization and readmission rates for geriatric and young adult patients with major depression: results from a historical cohort study

Late-life depression may have different clinical features, hospital utilization patterns, and natural history, depending on whether the illness begins in midlife or late life. This historical cohort study examined three patient groups, late-onset geriatric depressed patients, early-onset geriatric depressed patients, and young adult depressed patients, to determine hospital utilization patterns, readmission rates, and whether specific clinical symptoms on admission predisposed patients to readmission. The two geriatric patient groups had similar demographic, medical comorbidity, and hospital utilization profiles, except that the early-onset geriatric depressed group had longer hospital lengths of stay. Hospital utilization patterns for the young adult patients were different from the geriatric patients, but in the expected direction, ie, less medical comorbidity and shorter lengths of stay. Patients with late-onset geriatric depression had the highest 24-month readmission rate (47.4%), followed by early-onset geriatric depression patients (23.1%) and young adult patients (16.7%). Delusional symptoms and agitation were similar across the three patient groups and, as expected, somatic complaints were more frequent in the geriatric patient groups. The relative risk for readmission was greatest for geriatric patients who were somatic. Readmission risk was increased for agitated late-onset geriatric depressed patients and young adult patients, but not for early-onset geriatric depressed patients. Delusional symptoms did not predict readmission for any patient group.