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

Towards the development of a reciprocal liaison service

Aims and Method

The aim of this survey was to determine attitudes among consultants in different specialities towards the development of a reciprocal liaison service providing access for psychiatric patients to medical and surgical liaison services equal to the access of medical and surgical patients to psychiatric liaison services. All medical, surgical and psychiatric consultants in a district health service were surveyed, with a total response rate of 48%.

Results

The mean number of medical and surgical patients requiring a psychiatric liaison service was 6%. The mean number of psychiatric patients requiring medical and surgical liaison services was 11%. Ratings overall for various components of the two types of liaison service were generally similar, with acute assessments and follow-up being given a high priority for both types.

Clinical Implications

As liaison services are developed, the notion of equity of access for all patients is paramount. Commissioning of such services should thereby specify the reciprocal nature of development. This survey shows that generally there is a positive attitude to the development of such a service.

Psychiatry in the renal unit

Consultation–liaison psychiatry in renal medicine provides a unique experience for the psychiatrist. There is the opportunity to work with a specialist multi-disciplinary team managing patients with chronic and complex physical problems in in-patient and out-patient settings. We aim to consider the common psychiatric problems experienced by renal patients and the particular problems that face the renal team and the liaising psychiatrist in relation to assessment and treatment.

Psychotropic Drugs in Terminally Ill Patients: A Review of the Clinical and Research Literature

The principal psychopharmacological drugs used with terminally ill persons were briefly reviewed, and special consideration for various terminal illnesses were discussed. Sections on the analgesic effects of psychotropic drugs, the psychotropic properties of opioids, the beneficial effects of marijuana, and the use of LSD in terminal cancer patients are included.

Marital Quality in Kidney Transplant Recipients: Easy to Predict, Hard to Neglect

BACKGROUND

Given the significant role of post-renal transplant familial support in the patient's adherence to treatment, a study into the contributors to marital quality in this population seems necessary. This study sought to identify the predictors of poor post-renal transplant marital quality.

METHODS

This cross-sectional study was conducted in 2006 on 125 married kidney transplant recipients. Marital quality was evaluated using the Revised Marital Adjustment Scale (RMAS). A score below the fourth-quartile MAS score of a group of age- and sex- matched healthy controls was interpreted as poor marital relationship. Multiple logistic regression analysis was utilized to evaluate the predictors of poor marital relationship.

RESULTS

The mean time interval between transplantation and assessment of marital quality was 43 +/- 15 months. Poor post-renal transplant marital quality can be predicted by the kidney transplant recipient's sex (M/F) (odds ratio [OR]; 0.31; 95% confidence interval [CI], 0.11 to 0.90; P=.031), age at transplantation (OR, 0.93; 95% CI, 0.89 to 0.98; P=.005), educational level (OR, 0.67; 95% CI, 0.44 to 1.03; P=.067), and monthly family income (OR, 2.20; 95% CI, 1.09 to 4.44; P=.028).

CONCLUSION

Presenting a simple prediction model for poor post-renal transplant marital relationship, this study will make it possible to detect patients at a higher risk of poor marital quality and thus avoid treatment noncompliance. At the time of transplantation, using simple demographic variables and providing couple-based health education programs as a part of a familial approach to renal transplantation may improve the outcome of such high-risk patients.

Psychiatric disorders in children with chronic renal failure

Psychiatric assessment was done according to the DSM-IV TR criteria in 19 children with predialysis chronic renal failure (CRF) and 19 children with end-stage renal disease on regular hemodialysis. The prevalence rate of psychiatric disorders in all the studied patients was 52.6%. Adjustment disorders were the most common disorders (18.4%), followed by depression (10.3%) and neurocognitive disorders (7.7%). Anxiety and elimination disorders were reported in 5.1 and 2.6%, respectively. The disorders were more prevalent (P=0.05) in dialysis (68.4%) than in predialysis patients (36.8%). The presence of psychiatric disorders was not significantly correlated with sex, severity of anemia, duration of CRF or the efficiency or the duration of hemodialysis. In conclusion, psychiatric disorders were prevalent in our patients, especially in those on hemodialysis. Both adjustments with depression and depressive disorders were the most common psychiatric disorders. This array of disorders was more likely explained by the difficulties encountered in living with CRF rather than by demographic or physical factors.

Data collection in consultation-liaison psychiatry: an evaluation of Casemix

OBJECTIVE

To evaluate the usefulness of Casemix as a data collection system for consultation-liaison psychiatry services.

METHOD

Health information staff were requested to code psychiatric assessments and diagnosis prospectively for admissions to the Alfred Hospital, Melbourne, between July 2002 and June 2004 using Casemix.

RESULTS

Psychiatric assessments were requested on 2.5% of all hospital admissions (n = 2575). Casemix provided extensive demographic and hospital unit data for referred patients, is easy to set up, and is cost-free for the psychiatry service.

CONCLUSIONS

Casemix can provide extensive meaningful data for consultation-liaison psychiatry services that could assist in the argument for greater funding of these services.

Development of a Taiwanese computerized database for psychiatric consultation in a general hospital

OBJECTIVE

The aim of this study was to evaluate the applicability of a modified questionnaire in psychiatric consultation and a new computerized software at one general hospital in Taiwan.

METHOD

The Micro-Cares Clinical Information System for Consultation/Liaison Psychiatry (CISCL), an English language-based patient management application, has multiple clinical variables that were translated into Mandarin Chinese. The Mandarin Chinese version of the Micro-Cares Questionnaire (MCMQ) was further modified after extensive testing and clinical use by two staff psychiatrists and eight senior resident doctors. In addition, the structure of the Mandarin Chinese version of the Micro-Cares CISCL Program (MCMP) was created for direct information entry through a specialized Microsoft Access-based support module.

RESULTS

The MCMQ has been adapted to regular medical practice. Up to 66% of the consultation cases (618/913 patients) were recorded in 2003. Among those registered, 519 (84%) received psychiatric diagnoses. Eight of the 10 participants evaluated agreed that the MCMQ was clinically applicable.

CONCLUSION

MCMQ and MCMP have been routinely applied in the clinical, administrative, research and educational services of our psychiatric consultation.

Psychophysiological comorbidity and computerized biofeedback

Our previous research on basic and applied psychophysiology comprised the quantum model for subcellular brain processes, the psychosomatic health risk assessment and management, as well as the electrodermal biofeedback psychometrics and therapy. Based on this experience, in the present paper the stress-related psychophysiological disorders in patients dependent on hemodialysis and insulin are considered. The most frequent comorbid psychological disorders appeared to be anxiety and depression, and they are generally under-diagnosed and under-treated. It is concluded that the quality of life of these patients needs to be considerably enhanced. The application of biofeedback, as a complementary cost-effective and non-invasive psychophysiological tool is recommended. In terms of ESAO vocabulary, this technique could be viewed as some kind of artificial ANS/CNS support. Simultaneously, the concept of biocompatibility may be viewed in a larger perspective as "psychobiocompatibility".

A 12-month follow up of the implementation of clinical indicators in a consultation-liaison service

OBJECTIVES

This paper reviews the use of clinical indicators in a consultation-liaison (C-L) service over a 12-month period at the Royal Melbourne Hospital, Melbourne, Australia.

METHOD

Clinical indicators and C-L data were collected during the 1999 calendar year. A review of the process was conducted during and after completion of the 12-month period.

RESULTS

The system was found to be practical and useful. The use of clinical indicators led to the identification of problems and stimulated effective interventions. The use of the clinical indicators was associated with improvement in communication between C-L staff, parent units and practitioners providing follow-up.

CONCLUSIONS

The implementation of a database and clinical indicators was a useful addition to the C-L service. The use of clinical indicators was effective in improving clinical performance. These benefits need to be balanced against increased administrative burden.

Consultation-liaison psychiatrists' management of somatoform disorders

The authors studied interventions recommended by consultation-liaison (C-L) psychiatrists when they diagnosed somatoform disorder prospectively in a cohort of 4,401 consecutive inpatients referred to the C-L psychiatry service of a general teaching hospital, using standardized MICRO-CARES methodology. A DSM-III-R somatoform disorder was diagnosed in 2.9%, somatoform pain disorder in 1.4%, conversion disorder in 0.7%, hypochondriasis or somatization disorder undifferentiated/not otherwise specified in 0.6%, and somatization disorder in 0.2%. In 3.4%, somatoform disorder was considered a differential diagnosis. Psychiatric comorbidity included mood disorder (39%), personality disorder (37%), and psychoactive substance use disorder (19%). Recommendations were made about antidepressants in 40% of the patients, anxiolytics in 18%, sedatives in 18%, and antipsychotics in 10%. Psychiatrists recommended the following: more laboratory tests for 14%; additional medical/surgical consultations for 11%; an increase in the vigor of medical treatment for 13%; and psychological treatment for 76%; also they stressed an earlier discharge of 16%. Psychiatrists were more likely to request a prolongation of inpatient stay for patients with comorbid somatoform, mood, anxiety, and personality disorder. Differences in characteristics and treatment of the subgroups tended to be consistent with their constructs and comorbid psychiatric diagnoses.

The development of clinical indicators for a consultation-liaison service

OBJECTIVE

The aim of this paper is to describe the development and implementation of clinical indicators in the consultation-liaison service at Royal Melbourne Hospital (RMH).

METHOD

A working party lead by the University of Melbourne was established in 1998 to develop clinical indicators and a database for the RMH consultation-liaison service. Core parameters for measuring service functioning and six clinical indicators were developed. The system was implemented using a data collection form and computerised database operating within a system of regular clinical reviews.

RESULTS

The clinical indicators, database and review system were found to be a feasible, useful and efficient addition to a consultation-liaison service at a major general hospital.

CONCLUSIONS

Clinical indicators may be used within specialist psychiatry services to enhance clinical care and aid in service development and teaching.

Application of the Zung self-rating depression scale to patients before and after introduction to haemodialysis

In the present study we applied the Zung self-rating depression scale (SDS) to 19 renal failure patients who were introduced to haemodialysis in the Nagoya Daini Red Cross Hospital, Nagoya, Japan. The patients were divided into two groups: the emergent introduction (EI) group, who underwent unanticipated and sudden introduction to haemodialysis, and the ordinary introduction (OI) group, who experienced a more systematic introduction to haemodialysis following recommendation by medical specialists. The patients' Zung SDS responses were collected twice, just before and 2 weeks after haemodialysis introduction. The total SDS score of the EI group was significantly higher than that of the OI group, both before and after haemodialysis introduction. The total SDS scores for the EI and OI groups were significantly reduced after haemodialysis introduction. The SDS scores for the EI group were significantly higher in the mood of depression and cognitive symptoms categories, both before and after haemodyalysis introduction. Before introduction, SDS scores of the EI group were significantly higher in the categories of motor and vegetative symptoms. The SDS scores for vegetative symptoms in the EI group significantly decreased after introduction to haemodialysis. These results suggest that haemodialytic excretion of uremic toxins helps to reduce SDS scores.

Survivor guilt and chronic illness

OBJECTIVE

To examine the grief reactions that may result in patients after a death occurs within a treatment setting for chronic illness, and in particular to look at the applicability of the concept of survivor guilt in these situations.

CLINICAL PICTURE

Two patients with endstage renal disease are described. Both presented states of pathological grief for fellow patients. Vulnerability existed in both patients in terms of previous unresolved mourning and in terms of strong feelings of comradship with the dead patients. Both demonstrated features reminiscent of what has been termed the 'survivor syndrome'.

TREATMENT

The treatment involved supportive psychotherapy allowing exploration of grief and its relationship to current psychosomatic crises.

OUTCOME

Supportive psychotherapy successfully aided the resolution in one patient and made some difference in the other.

CONCLUSION

The impact of death within a treatment unit is emphasised. Surviving patients may have significant distress relating to such bereavement and may need appropriate intervention.

Liaison psychiatry in an HIV/AIDS unit

OBJECTIVE

To provide an overview of the work of a liaison psychiatry service to an HIV/AIDS inpatient unit, and particularly to examine the identification of mood and related disorders by referring doctors.

METHOD

The MICRO-CARES prospective clinical database system was used to obtain data on all patients referred to the HIV/AIDS consultation-liaison psychiatry service in an infectious diseases hospital in Melbourne.

RESULTS

Three hundred and ninety-two inpatient referrals were made in the 2 years from 1993-1995: a referral rate of 16.7%. The most frequent reasons for referral were evaluation of coping problems (42%), assessment of possible depression (31%), and assessment of psychotropic medication (24.5%). The most common psychiatric diagnoses were mood disorders (36.5%), psychoactive substance use disorders (22.7%) and organic mental disorders (18.1%). Overall concordance of recognition of depression by the referring doctor and diagnosis of depression by the consultant psychiatrist was 79%; 20% false positive rate, 23% false negative rate.

CONCLUSIONS

Psychiatric comorbidity is common in patients with HIV/AIDS. Reasons for referral vary from those seen in other inpatient settings. Previously noted problems such as the misdiagnosis of psychiatric disorder and the mislabelling of the syndrome recognised by psychiatrists as depression were noted here.

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.