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Attitudinal impediments in the practice of consultation-liaison psychiatry

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Attitudinal impediments in the practice of consultation-liaison psychiatry
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  Original Research Article Attitudinal impediments in the practice of consultation-liaison psychiatry Nilamadhab Kar P.S.V.N. Sharma Abstract Context:  Psychiatric morbidity in the medically ill prolongs hospital stay of these patients and influences the prognosis of physical conditions. However, utilization of consultation liaison  psychiatric services is marginal in general hospitals. Aims: We attempted to study the attitude of non-psychiatric medical professionals and 30 nurses compared with that of psychiatrists to reflect upon the factors associated with inadequate utilization of psychiatric liaison services. Settings and Design: It was a cross-sectional study in a Medical College Hospital. Methods and Material: A self-rated, semi-structured 13-item, 5-point scale was used. Perceptions of the psychiatrists on the attitude of physicians and surgeons were also assessed. Statistical analysis: Percentages, Chi-Square and t-tests Results:   Most clinicians felt that having a psychiatric label is disadvantageous. Physicians and surgeons were aware of their lack of awareness regarding psychiatric problems. Psychiatrists more often than physicians and surgeons felt that the poor physical health status of patients  precluded referral reflecting their own uncertainty in assessing and handling physical illness. Poor working relation between psychiatrists and the physicians and surgeons was also reported. The patients’ emotions were perceived as difficult to handle by considerable proportion of non- psychiatric professionals. They also believed that psychiatric disorders were incurable, and reported that many patients refused psychiatric referral. Conclusions: There was a concern how the physician and surgeons perceived psychiatric illnesses and interventions. It is also worrying to observe how psychiatrists perceived the attitude of their colleagues in general hospital. Need for interactive multi-disciplinary physician education in liaison psychiatry can not be overemphasized. Key words:  liaison psychiatry, perception of doctors, psychiatric illness, attitude, general hospital Introduction Prevalence of psychiatric morbidity is high in general hospital inpatients. Two major epidemiological studies using standardized instruments for diagnosis have revealed that the prevalence of mental disorders in general hospital inpatients range from 41.3% to 46.5%. [1]  Another study reported a 68.5%  prevalence rate of psychiatric disorders in medicine, surgery and obstetrics wards. [2]  Psychiatric morbidity influences the prognosis of many medical conditions and prolongs hospital stay of these patients. A review of 26 articles found that in 80% there was significant correlation between psychiatric or psychological comorbidity and increased length of stay in general hospital inpatients. [3]  A general hospital admission provides window of opportunity to identify and initiate treatment Archives of Indian Psychiatry 14(1) April, 2012 45  for a previously unrecognized mental di sorder. Unrecognized comorbid psychiatric disorders adversely affect both the immediate hospital course and the post-discharge prognosis of the physical disorders; [4,5,6]  and contribute to higher rehospitalisation rates and use of outpatient medical services after discharge. [7,8]  This results in higher management costs in hospitals and outpatients. [3]  It is known that  psychiatric treatments are clinically effective and these interventions are cost effective in the management of psychiatric morbidity of the  physically ill patients. [9]  These will decrease overuse of general medical services and in some cases provide cost offset. [3]  However, utilization of consultation liaison psychiatric services is marginal in most general hospitals settings. A major obstacle to such endeavors has  been the stubborn fact that most psychiatric disorders in general hospital are under-recognized and under-referred. [10,11,12]  In nearly half of the studied general hospital inpatients receiving a psychiatric diagnosis, consultation-liaison psychiatry interventions were found to be necessary. However,  psychiatric consultation rates found in most recently presented studies in Germany and Austria range from 2.66% to 3.30%, and remain low when compared to the reported  prevalence figures of psychiatric disorders. [1] It another study it was found that while 30-60% of admitted patients have diagnosable  psychiatric disorders only 1-3% of admissions are likely to be referred. [3]  On the above background, it was intended to evaluate the attitude of the non-psychiatric clinicians on the psychiatric illness, to compare it with that of psychiatrists and to find out the attitudinal factors affecting the psychiatric liaison services in a general hospital. Method The study was conducted in the Kasturba Hospital, Manipal, India. It is a multi-specialty tertiary level hospital attached to Kasturba Medical College. A self-rated, semi-structured questionnaire with 5-point Likert type of responses was used for the survey. The questionnaire had 13 statements. There was scope for expression of further open ended views. Medical faculties, postgraduate medical trainees of various clinical departments in the university level teaching hospital involved in referral of patients to psychiatry and nurses in that hospital participated in the study. Responses from the psychiatrists and  postgraduate psychiatric trainees on these statements were also assessed. In addition,  psychiatric group were also asked to provide their perceptions of other clinicians’ attitudes  based on the same statements. Besides age and gender of the responders, years of experience in clinical practice were noted. Anonymity of the responses was maintained. For statistical reasons all the referring departments were considered as either medicine or surgery. The ‘agree’ and ‘strongly agree’ responses were clubbed together; so also the disagreeing responses. The do-not-know responses were not considered during the statistical evaluation. Most of the results were provided in percentages, the categorical variables were compared by chi-square tests and the means in t-tests. Significance level was set at standard 0.05 levels. Results The sample consisted on 54 from medical departments (14 faculties and 40 postgraduate trainees); 37 from surgical departments (27 faculties and 10 postgraduate trainees); 22 from  psychiatry (8 faculties and 14 postgraduate trainees); and 30 nurses. There was male  preponderance (84%) in all three groups of doctors. The mean age of the doctors did not differ in the groups. Years of experience in clinical practice were comparable between medical and psychiatric participants, whereas it was more in the surgery group (p< 0.05). Archives of Indian Psychiatry 14(1) April, 201246  Table 1.  Statements and percentages of agree responsesStatements PMSNPP Patient is disadvantaged by being labeled as psychiat-ric case.68.272.275.7100.095.5Psychiatric service is dissatisfactory.13.67.424.330.036.4Psychiatric language is incomprehensible.4.514.816.20.059.1ere is unawareness of the need for psychiatric intervention.77.361.170.0100.072.7Psychiatric disorders are incurable.31.844.432.410.059.1Patient’s emotions are diffi cult to handle.9.142.656.8100.081.8Physicians/surgeons do not know the patient well enough.54.431.532.483.340.9e significance of the psychological issue is denied by physicians and surgeons.72.737.054.173.363.6ere is poor working relationship between physi-cians / surgeons and psychiatrists.50.042.656.836.754.5e patients in medicine/surgery departments refuse psychiatric referral.50.051.835.160.077.3Physicians / surgeons consider patients are too physi-cally ill to be referred to psychiatry. 27.322.221.650.050.0Every doctor should be able to treat psychiatric disor-ders.22.750.043.246.731.8Physicians and surgeons can not spare time for psy-chological issues.63.635.240.576.781.8M: Medicine; N: Nurses; P: Psychiatry; PP: Perception of Psychiatrists; S: Surgery;e response to various statements in the questionnaire is given in table 1. Open ended  views were expressed by 18.2% of psychiatrists, 16.7% of medicine specialists and 32.4% of surgeons which formed the basis of the qualitative analysis. ere were many areas where consensus was evident; however there were considerable differences in opinion and attitude in other areas. Areas of agreement ere were no significant differences among clinicians (psychiatrists, physicians and surgeons) in the following areas. Most of the clinicians felt that it was disadvantageous for the patient to be labeled as psychiatric patient. Only a small minority felt that psychiatric services were unsatisfactory. Most of the doctors agreed to the fact that there is lack of awareness regarding the need for psychiatric intervention. A considerable proportion (39.6%) of the physicians and surgeons believed that psychiatric disorders are incurable. Almost half (48.4%) of the physicians and surgeons felt that there was poor working relationship with psychiatrists. One of the reasons for non-referral to psychiatry was brought forward as 46% of clinicians felt that patients refuse psychiatric referral. However, about one- fih Archives of Indian Psychiatry 14(1) April, 2012 47  (21.9%) of physicians and surgeons felt that patients are too physically ill to be referred. Areas of disagreement Difference in opinion was evident in the following areas. Significantly more number of physicians and surgeons felt that patient’ emotions are diffi cult to handle. While more psychiatrists (54.5%) felt that physicians and surgeons do not know the patient well enough; only 31.5% of physicians (p<0.05) and 32.4% of surgeons felt so. Most (72.7%) of the psychiatrists felt that the significance of psychological issue is denied in contrast to 37% (p<0.05) of physicians and 54.1% of surgeons. While only 22.7% of psychiatrists felt that every doctor should be able to treat psychological disorders 50.0% (p<0.05) of physicians and 43.2% of surgeon considered so. More (63.6%) psychiatrists felt that physicians and surgeons can not spare time for psychological issues in contrast to 35.2% (p<0.05) of physicians and 40.5% of surgeons. How psychiatrists perceived the attitude of the physicians and surgeons Most (95.5%) of psychiatrists perceived that physicians and surgeons consider it is disadvantageous for their patients to be labeled as psychiatric case in contrast to 73.6% of physicians. Significantly more (36.4%) psychiatric professionals perceived that physicians consider psychiatric service is dissatisfactory as against 7.4% of the later; and similarly 59.1% of psychiatrists believed that physicians and surgeons feel psychiatric language is useless and incomprehensible compared to much lower proportions (14.8% and 16.2% respectively) of the later groups. Compared to 81.1% of psychiatrists who thought that physicians and surgeons consider patient’s emotions are diffi cult to handle; only 42.6% physicians (p<0.05) and 56.8% surgeons reported so. Psychiatrists perceived that 77.3% of other clinicians feel that patients refuse psychiatric referral against only 35.1% (p<0.05) of surgeons. Only 22.2% of physicians and 21.6% of surgeons felt that patients are too ill to be referred against 50% of psychiatrist who considered this as the reason of non-referral by the physicians and surgeons. Majority (81.8%) of psychiatrists perceived that physicians and surgeons can not spare time in contrast to 35.2% physicians (p<0.001) and 40.5% surgeons (p<0.01). In summary, perceptions of psychiatrists regarding views of medical and surgical consultants interestingly differed significantly from the actual observations of these non-psychiatric professionals in many areas. e areas were: i. patient is disadvantaged by being labeled as psychiatric case; ii. psychiatric service is dissatisfactory; iii. psychiatric language is incomprehensible; iv. psychiatric disorders are incurable; and v. patient’s emotions are diffi cult to handle by the physicians and surgeons. Nurses’ observations e attitude of nurses were mostly similar to the doctors with a few interesting differences. Most striking was their optimistic view regarding curability of psychiatric disorder; and none of them felt psychiatric language was incomprehensible. Poor working relationship was noted in a relatively smaller proportion of nurses compared to doctors. Discussion e present study explored the attitudes of clinicians related to liaison psychiatry in a general hospital set up. ere are various interesting observations which would explain reported inadequacy in recognition and referral for psychiatric illnesses in medically ill inpatients. Most clinicians felt that having a psychiatric label is disadvantageous; however, psychiatrists felt the physicians and surgeons subscribe to the disadvantageous effects of labeling to a greater extent than it was felt by the physicians and surgeons. is leaves one wondering whether psychiatrist themselves contribute to the labeling to an extent? It is important to Archives of Indian Psychiatry 14(1) April, 2012 48  be aware of inadvertent contribution to the prevailing stigma against mental illness. A considerable proportion of physicians and surgeons acknowledged their lack of awareness regarding psychiatric problems. ey also felt that many psychiatric disorders were incurable, and psychiatric patient refused help or referral. ey recognized the inadequate interaction with psychiatrists. Psychiatrists less oen than physicians and surgeons believed that all doctors should deal with psychological problem. Psychiatrists felt that the surgeons and physicians can not spare time for psychological issues; considering how busy they are dealing with other physical conditions. As more than half of the psychiatrists felt that physicians and surgeons do not know the patient well enough, it reflected that considering the nature of psychiatric assessments, psychiatrists believed that other physicians were unaware of emotional issues. It was interesting that more psychiatrists felt it difficult for physicians and surgeons to handle patient’s emotions than the physicians and surgeons themselves! It could be the attributions by psychiatrists to the perceived lack of interest of physicians and surgeons in  psychological problems of the patients.Psychiatrists more often than physicians and surgeons felt that the poor physical health status of patients precluded referral reflecting their own uncertainty in assessing and handling  physical illness. It has been a recurring theme in recent years that the psychiatrists do lose touch with medical disorders and the assessment of their seriousness. It has been stressed that the psychiatrists retain the skills for physical examinations; 13 , 14  and remain involved in evaluations for physical illnesses. Belief of incurability of psychiatric disorders;  poor working relation by the physicians and surgeons; psychiatrists’ notion that other clinicians do not want to handle emotions or having psychiatric label is disadvantageous were identified as the core issues in the  practice of liaison psychiatry. These attitudinal differences between psychiatrists and other clinicians may affect consultation-liaison  practices in a general hospital set up.A combination of interactive discourse on psychiatric disorders in physically ill, continuing medical education of all clinical departments on site, maintaining knowledge  base and assessment skills for physical disorders by the psychiatrists, and active  psychiatric liaison will in all likelihood be needed to change the attitudinal impediments to recognize and refer appropriate patients to  psychiatric intervention in general hospital setting. References 1.Rothenhäusler HB. Mental disorders in general hospital patients. Psychiatr Danub. 2006; 18(3-4):183-92. 2. de Almeida JM, Xavier M, Nabais F, Santos F, Morais J. Psychiatric morbidity in general hospital inpatients. Acta Med Port. 1992; 5(11):575-9.3. Saravay SM. Psychiatric interventions in the medically ill: Outcome and effectiveness research. Psychiatric Clinics of North America, Consultation Liaison Psychiatry, 1996, 19(3): 467-480. 4. Carney RM, Freedland KE, Jaffe AS. Insomnia and depression prior to myocardial infarction. Psychosom Med. 1990; 52(6):603-9.5. Dalack GW, Roose SP. Perspectives on the relationship  between cardiovascular disease and affective disorder. J Clin Psychiatry. 1990;51 Suppl:4-9.6. Goodnick PJ, Henry JH, Buki VM. Treatment of depression in patients with diabetes mellitus. J Clin Psychiatry. 1995; 56(4):128-36.7. Mayou R, Hawton K, Feldman E, Ardern M. Psychiatric problems among medical admissions. Int J Psychiatry Med. 1991; 21(1):71-84.8. Saravay SM, Pollack S, Steinberg MD, Weinschel B, Habert M. Four-year follow-up of the influence of  psychological comorbidity on medical rehospitalization. Am J Psychiatry. 1996; 153(3):397-403.9. Parsonage M and Fossey M. Economic evaluation of a consultation-liaison psychiatry service. London: Archives of Indian Psychiatry 14(1) April, 2012 49
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