Tackling the global mental health challenge: a psychosomatic medicine/consultation-liaison psychiatry perspective

BACKGROUND

Consultation-liaison (C-L) psychiatry, informed by principles of psychosomatic medicine, is well-positioned to address the global impact of mental disorders through primary care C-L models.

OBJECTIVE/METHOD

The authors review the international burden of mental disorders, highlighting medical comorbidity, undertreatment, and the rationale for enhancing primary-care management.

RESULTS

C-L psychiatry fosters the skills required for global mental health work. The authors describe successful C-L models developed in a low-income country (Ethiopia) and an under-resourced region of a high-income country (Australia).

CONCLUSION

C-L psychiatrists have the potential to marshal their unique skill-set to reduce the global burden of mental disorders.

The value of consultation-liaison interventions to the general hospital

Changes in health care funding have greatly enhanced the value of consultation-liaison services to their parent hospitals. This paper reviews representative studies showing that consultation-liaison interventions improve patient care, enhance patients' satisfaction with treatment, and reduce polypharmacy, adverse drug reactions, and subsequent hospitalizations. Reductions in costs of hospitalization realized by consultation-liaison interventions are also described, including average reductions in hospital stays of one to one and a half days, upgrades in diagnosis-related group (DRG) codes, and timely patient transfers to inpatient medical-psychiatric units or inpatient psychiatric facilities. These data suggest that consultation-liaison services will become increasingly important over the next few years.

Fellowship training in consultation-liaison psychiatry. Education goals and standards

Consultation-liaison (C-L) psychiatry, which focuses on the psychiatric care of patients in medical-surgical settings, has evolved into an increasingly recognized subspecialty. The Academy of Psychosomatic Medicine, using consultants and a database created from 49 extant C-L fellowship programs, has specified goals and standards for C-L fellowship training. These standards include organizational issues, clinical skills, a didactic curriculum, research training, and evaluation issues. The important contributions of C-L psychiatry to medical education are emphasized.

Teaching a biopsychosocial approach on medical attending rounds

The ascent of the biotechnical, disease-oriented model of medicine threatens to relegate the integrated, patient-oriented approach to a secondary position. In response to this, a program to teach medical housestaff a biopsychosocial approach was implemented in a setting of attending rounds by having a psychiatrist participate regularly as a member of the rounding team. The effectiveness of this program's teaching effort was significantly influenced by the psychological styles and level of training of the housestaff officers. Residents were the most teachable and potentially the most effective teachers with respect to the biopsychosocial model. Interns, appearing to respond to the stresses of internship with defensive behavior, e.g., turning passive into active and isolation of affect, were less receptive. The medical attending's attitude, however, was the most important factor affecting the teaching of this approach on rounds. Three medical-attending-teaching styles were characterized, one of which appeared incompatible with teaching a biopsychosocial approach on rounds. The psychiatrist had to learn to specifically adapt his teaching efforts to each of these three attending styles, as well as to the training level related needs and the defensive styles of the housestaff.

A comparison of relaxation techniques with electrosleep therapy for chronic, sleep-onset insomnia a sleep-EEG study

Two methods of relaxation therapy, electromyograph biofeedback and autogenic training, were compared to a nonrelaxation treatment, electrosleep therapy, in reducing sleep latency among 22 chronic, sleep-onset insomniacs. While none of the electrosleep patients improved on all-night laboratory electroencephalographic sleep records or daily home sleep logs, approximately one-half of the relaxation-treated patients showed marked improvement, which was sustained over a 1-month follow-up period. Although some sleep and treatment variables differentiated relaxation therapy responders from nonresponders, external stress appeared to be the most salient factor. Successful and unsuccessful patients could not be differentiated on any of the psychological variables studied.

Successful separation of depressed, normal, and insomniac subjects by EEG sleep data

Data from all-night EEG sleep studies were used to distinguish normal subjects, primary depressed patients, and primary insomniac patients. In part 1, we compared 41 normal subjects, 56 depressed patients, and 18 insomniacs. In a univariate comparison with normal subjects, depressed patients showed less total sleep, longer sleep latency, more early morning awake time, more intermittent awake time, less delta sleep, less sleep efficiency, and shorter rapid eye movement (REM) latencies; compared with insomniacs, depressed patients showed greater early morning awake time, shorter REM latency, greater REM index, and greater REM density. Using multivariate discriminant analysis, 82% of the sample were correctly classified by diagnosis: 100% of the normal subjects, 72% of the depressed patients, and 77% of the insomniacs. Eight variables contributed to the multivariate separation of depressed individuals from insomniacs and normals: total sleep time, total recording period, sleep efficiency, sleep latency, early morning awake time, awake time, REM time and REM%. When the discriminant functions were applied to a second group of 18 primary depressed patients, 82% were correctly classified as depressed. These results suggest that primary depressed patients and primary insomniac patients may show relatively characteristic patterns of sleep abnormality.

Treatment of hypertension with biofeedback and relaxation techniques

The present study describes a 16-week trial of the use of a combination of biofeedback and relaxation techniques for the treatment of hypertension. Twenty-two hypertensive patients were randomly allocated to one of three groups: (1) diastolic blood pressure feedback, electromyographic feedback, and verbal relaxation; (2) sham blood pressure feedback; and (3) no treatment. For the 14 patients completing active treatment during an initial or crossover period, the average changes in blood pressure as measured outside the laboratory were minimal (0/-1 and +1/0 mm Hg, supine and standing, respectively). Average blood pressure reduction in the laboratory was no greater with active than with sham blood pressure feedback (-3/-2 vs. -5/-2 mm Hg). One subject, however, after showing no change in blood pressure during sham feedback, achieved pronounced and prolonged improvement following active treatment. Overall results do not support the usefulness of these techniques as primary therapy in most hypertensives.

Novelty-seeking, fantasy, and sensitization in chronic insomniacs

13 chronic primary insomniacs and a matched group of normal sleepers were studied in terms of their level of novelty-seeking, ability to fantasize, and cognitive rumination. All-night electroencephalographic patterns confirmed insomniac-control sleep differences. Chronic insomniacs differed from normal sleepers on a measure of cognitive activity as a defense pattern (Byrne's Repression-Sensitization Scale) but did not differ on measures of need for cognitive stimulation (Pearson's Internal and External Cognition Scales), ability to fantasize (Betts' imagery task), or preference for fantasy (Pearson's Internal and External Sensation Scales).

Recorded and reported sleep in chronic primary insomnia

Sleep polygraph and questionnaire data of 18 chronic primary insomniacs were compared with those of 18 age- and sex-matched controls. The insomniacs had significantly longer sleep latencies, less total sleep, less sleep efficiency, more terminal wake time, and less delta sleep. There were significant discrepancies between the insomniacs' and controls' subjective assessments of their sleep and the sleep-polygraph data, but in opposite directions. The insomniacs' recorded sleep also showed more night-to-night variability than that of the controls. However, the controls, in contrast to the insomniacs, reported sleeping worse in the laboratory than at home. Significant differences between insomnia subtypes validly reflected the insomniacs' subjective complaints and were generally in accord with expectations based on them.