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

Major depression in elderly medical inpatients in Greece, prevalence and identification

BACKGROUND

The aim of this study was to report the prevalence of episodes of DSM-IV major depression, as well as their identification rates, in elderly inpatients in a general hospital in Greece.

METHODS

200 selected patients, 65 years old and over, hospitalized in Surgery and Internal Medicine Departments, were assessed for major depression over a period of 12 months (October 2006-November 2007) by means of SCID-I/P, HADS, BDI and GDS-15. During the same period, liaison calls from the same departments were evaluated and findings were compared.

RESULTS

When psychiatric screening was performed, 28 patients (14%) were diagnosed as suffering from a major depressive episode. During the same period, there were only 20 liaison calls from the same departments for patients over 65 years old, from which 4 patients were found to be suffering from major depression. Comparison between the two periods showed significant underestimation of depression. All psychometric scales detected depression sufficiently.

CONCLUSIONS

In general hospital elderly inpatients, depression still remains underestimated. Depression symptom scales could be used as routine tests for screening major depression.

The impact of two changes in service delivery on a geriatric psychiatry liaison service

BACKGROUND

The impact of two changes in service delivery (alteration in the admission policy of the medical unit and the introduction of a formal liaison component to a 'consultation only' liaison geriatric psychiatry service) on the associated liaison geriatric psychiatry service was examined in a naturalistic study. The main null hypothesis was that the referral rate would not be influenced by either change in service delivery.

METHOD

The 30-month study period was divided into three phases defined by the two changes in service delivery. The impact of the two changes in service delivery on the (i) referral rate, (ii) reasons for referral, (iii) demographic and clinical characteristics of the referrals and (iv) advice offered after assessment was examined with a retrospective design.

RESULTS

There was a significant decline in the number of referrals for each month across the three study phases exclusively accounted for by a decline between phase 2 and phase 3. The number of reasons for referral and management advice offered for social treatments per patient were greater in phase 1 compared to phase 2. The total number of management advice offered for medical treatments per patient was greater in phase 2 compared to phase 3. The cost of a specialist registrar attending a geriatric medicine ward round was more than offset by the associated decline in the number of referrals per month.

CONCLUSION

Although this study was not designed as a cost-effectiveness study, the results suggest that the liaison component has the potential to be cost-effective. There is a need for more formal clinical effectiveness and cost-effectiveness studies in liaison geriatric psychiatry.

The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. The Academy of Psychosomatic Medicine

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the field, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and revised prior to final approval. Some of the topics discussed include qualifications of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations.

Reference to psychiatric consultation in the discharge letter of general hospital inpatients

OBJECTIVE

The consultation-liaison psychiatrist is frequently confronted with the consultees' lack of adherence to the consultants' recommendations. The aim of this study was to investigate the question if and how the C-L psychiatrist's diagnoses and recommendations are mentioned in the consultee's final medical report and thus communicated to the physician responsible for the aftercare.

METHOD

Psychiatric consult reports of a consecutive sample of 144 patients of the departments of neurology, internal medicine, and gynecology and obstetrics at the University Hospital of Zurich were compared to the content of the respective discharge letters.

RESULTS

Some kind of information about the psychiatric consultation was found in 84 percent of the discharge letters (consultation as such: 71.5%; psychiatric diagnosis: 66.7%; recommendations: 76.2%. Length of stay, timing of the consultation, length of the consult report and type of recommendation correlated significantly with the mention of psychiatric aspects in the final medical report. Psychotropic medication and psychiatric hospitalization were the recommendations most reliably mentioned.

CONCLUSIONS

Psychiatric consultation seems to be taken seriously by attending physicians and is communicated in a high percentage to the physicians responsible for the aftercare. Nevertheless, in patients where active post-discharge management is needed the C-L psychiatrist should actively manage referral to outpatient settings and/or instruct primary care providers.