Who gets referred? Child psychiatric consultation in a pediatric hospital

Child psychiatry consultations to pediatric inpatients: a literature review

While the prevalence of psychiatric disorders in clinical pediatric populations is high, only a few studies have systematically examined child psychiatry consultations to pediatric inpatients. This paper reviews this body of literature and indicates important areas for further study. Some of the studies did not report basic data such as the number of consults, age, sex, or race of referrals, and referral rate. Without such basic data, it is impossible to make adequate comparisons between studies. Several studies did not report economic status or admission diagnosis of the child, psychiatric intervention/treatment on the ward, or psychiatric referral after discharge. Mostly the samples were small, including data on less than 100 inpatient consults. There is a need for greater consistency in the classification of reasons for referral, so that accurate and meaningful comparisons can be made across sites. The examination of psychiatric diagnoses was complicated by the wide range of diagnostic classifications that have been used. Standardization on the DSM-III-R/IV diagnostic system would make for greater comparability between studies. It would be useful in planning for services if future studies included cost as well as efficacy studies with a randomized control group.

The general hospital psychiatrist: too many tasks and too few roles?

What should the general hospital psychiatrist do, and how should he do it? In psychiatric settings, psychiatrists may legitimately confine their attention to those patients whose disorders can be classified according to ICD-9, but in general hospital settings, the same approach defines a very restricted range of activities. Evidence is reviewed which highlights the differences between psychiatric disorders encountered in psychiatric hospitals and those found in primary care or general hospital settings. Different activities proposed for the general hospital psychiatrist, and the results of research comparing these, are reviewed. A recent study is discussed in which alteration of the psychiatrist's method of practice in a general medical unit produced considerable changes in the pattern of psychiatric referrals. Evaluation of the efficacy of their interventions should remain the ultimate goal of general hospital psychiatrists. This can be adequately undertaken only by means of better understanding of the process by which general hospital patients attract psychiatric referral.

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.

The relationship between attitudinal and behavioral change in pediatric residents in a psychiatric liaison teaching program: a pilot study

Two behavioral measures--chart audits and requests for psychiatric consultations--and two attitudinal measures--case conference comments and a case management questionnaire--were used to assess changes in pediatric residents' approaches to psychosocial issues over the course of liaison training. Both attitudinal measures showed changes in the residents' approaches, including an increased attention to patients' and families' feelings and an expanded awareness of the options available in dealing with psychosocial problems. These changes in attitude, however, did not result in increases in the amount of psychosocial data recorded in the charts or increases in resident-initiated consultation requests. The authors use their observations on the wards and in case conferences and interviews with pediatric residents to explain why chart contents and psychiatric consultation practices are resistant to change. Their findings indicate a gap between attitudinal and behavioral change that requires further research on how pediatric residents identify psychosocial problems, and how liaison training is integrated with the needs and expectations of nonpsychiatric physicians.

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

In the last decade, the biopsychosocial concept of medicine had flourished clinically in the form of consultation-liaison (C-L) psychiatry. However, full acceptance by the medical profession will depend, in part, upon scientific demonstration that psychological and social factors influence biological medical illness, and that C-L psychiatric teaching and patient intervention can improve the medical treatment of patients. This review surveys the literature over the last 10 years that describes and evaluates C-L activities as they impact upon clinical medicine and medical education. A conceptual grid for organizing research in the field is presented that distinguishes decision-oriented, or descriptive studies, from conclusion-oriented, or outcome studies. Further, this grid specifies the focus of the C-L activity, either the patient or health care professional. It seems clear that the very recent shift from descriptive studies to more outcome-oriented research, particularly regarding patient outcomes, should be the direction of the future. A greater emphasis on defining the exact components of C-L work that are most useful is also indicated. Several other specific recommendations for evaluative research in C-L psychiatry conclude this review.