Article

Communication between psychosomatic C-L consultants and general practitioners in a German health care system

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Abstract

A randomized and prospective study examined the effects of intensive communication between treatment providers on physician behavior and patient care using a representative sample of patients referred to a German psychosomatic consultation-liaison (C-L) service (1998-1999). Sixty-seven patients were grouped (ICD-10) and randomized into intervention (n=33) and control groups (n=34). In the control group (CG), only the inpatient referring physicians were informed of consultation findings, as is standard practice in Germany. In the IG, the consultant directly reported the consultation findings to the general practitioner (GP). Patients were examined at 6-month (T2) and 3.5-year (T3) follow-up. Physician feedback and requests regarding the nature of communication were also assessed at T2. A significant reduction in symptoms was revealed at both follow-ups for the IG and CG. No significant group differences were found for acceptance of psychotherapy (59.1% IG and 42.3% CG at T3). The utilization of medical services remained stable across time. Patients who began psychotherapy were shown to have greater baseline symptom levels and "openness for new experiences" (NEO Five-Factor Inventory, NEO-FFi). Regular GP integration of psychosocial aspects into primary care differed between IG (44.0%) and CG (25.0%). Ninety-one percent of the GPs requested the option for a telephone conversation with the consultant or a case conference involving the patient at either their practice (37.7%) or the clinic (24.5%). We conclude that GPs are interested in a differentiated and more intensive cooperation concerning the integration of psychosocial aspects in their outpatient treatment. The patient's acceptance to follow a recommendation for psychotherapy, however, is related to the level of symptom severity and openness for new experiences.

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... Psychische Störungen treten bei statio när behandelten Patienten deutlich häu figer auf als bei Patienten in der Primär vorsorgung. Man geht davon aus, dass bis zu einem Drittel aller Krankenhaus patienten an psychischen Störungen lei det [1,2]. Dies bringt sowohl für die Be troffenen und die Behandler als auch für das Medizinalsystem besondere Heraus forderungen mit sich. ...
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However, the overall quality of trials was low particularly in regards to performance and attrition bias and may have resulted in an overestimation of effectiveness. More evidence is needed to determine the effectiveness of consultation liaison for people with mental disorders particularly for those with mental disorders other than depression.
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Mental health service delivery in the general health care sector is restricted with regard to understanding the magnitude and impact of mental illness in the medically ill (co-morbidity), as well as the significance of current mental health service delivery. A new model in development in the framework of a Biomed2 grant is presented. It consists of case-finding through complexity of hospital care prediction (COMPRI) followed by an integral health service needs assessment (INTERMED). It might serve to develop a more structural relation with the general health care sector for the management of mentally co-morbid high utilizing patients.
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Presents a research perspective on the importance of integrating mental health professionals into the treatment of primary care patients. Recent studies that have developed models for collaboration between mental health clinicians and primary care physicians, which have improved the satisfaction and clinical outcomes of patients with major depression are described. Results suggest 2 major findings: (1) a model of collaborative management with people with major depression dramatically improves adherence, satisfaction with treatment, and depressive outcomes, and (2) collaborative models provide a role for mental health practitioners, by potentiating the role of the primary care physician in treating depression. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Examined the diagnosis of general practitioners (GPs) on the treatment of psychological disorders. Human Ss: 18 male and female German adults (GPs) (mean age: 42.3 yrs) and 572 male and female German adults (patients of the GP Ss) (mean age 42.7 yrs). GP Ss rated the patient Ss using a global diagnostic rating. The GPs recorded their treatment. Patients filled out checklists during treatment. Agreement between doctor and researchers on mental health during treatment was examined. The prescription of psychotherapy by the GPs was addressed. Tests used: The Inpatient Scores (H. Schepank, 1995), Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R), Symptom Checklist-90-Revised (SCL-90-R), and the General Health Questionnaire (D. P. Goldberg, 1978). (English abstract) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
30–40% der Patienten eines Hausarztes leiden an psychogenen Erkrankungen. Nur 50% dieser Patienten werden vom Hausarzt ausreichend diagnostiziert. Für die Diagnose und Therapie ist die Qualität des Arzt-Patienten-Gesprächs von ausschlaggebender Bedeutung. Während in den 70er Jahren der Gesprächsstil des Arztes als Persönlichkeitsvariante betrachtet wurde, legen aktuelle empirische Studien zum Arzt-Patienten-Gespräch nahe, das Gesprächsverhalten des Arztes als einen interaktiven Prozeß zu verstehen, indem beide Kommunikationspartner (Arzt-Patient) ihr Gesprächsverhalten aufeinander abstimmen. Schulungsprogramme zur Verbesserung der hausärztlichen psychosomatischen Basiskompetenz zeigen oftmals nur geringe Erfolge, da sie der Bedeutung der Verbesserung der interaktiven Kompetenz nicht ausreichend Rechnung tagen. Diese steht im Zentrum des Düsseldorfer Trainings- und Schulungsprogramms zur Psychosomatischen Grundversorgung. Das Fortbildungskonzept sowie Erfahrungen mit diesem werden abschließend dargestellt und diskutiert. 30–40% of the patients of a general practitioner (GP) suffer from a psychogenic disorder. Only 50% of these patients are sufficiently diagnosed by their GPs. The quality of the doctor-patient interaction is of outstanding importance for the diagnostic process. The quality of the physician’s conversation with the patient is the result of a reciprocal attunement between physician and patient. Training programmes aiming at improving the basic psychosomatic competence did not show the expected effect possibly due to their failure to take into account the importance of improving the interactional competence. Improving the interactional competence is a central issue in the Düsseldorf training program for psychosomatic basic care. This program will be explained amd discussed.
Article
Previous C-L psychiatric service research is seriously limited by its parochial nature; very few results can be generalized outside of the hospital in which the original study was performed because of differences in the nature of the hospital and the type of C-L service. This article presents the general outline and methodology of a European multicentered C-L service delivery study effected by the European Consultation-Liaison Workgroup for General Hospital Psychiatry and Psychosomatics (ECLW). The study is unique in its kind as it allows the comparison of very different C-L services; for example, some services are run by C-L psychiatrists, others are run by C-L psychosomaticists and the study encompasses a large variety of different settings. As a result, both common factors in C-L service delivery and specific local patterns can be explored. The overall hypothesis tested in this study was that the most developed services would see (as well as more patients) a wider variety of clinical problems than small services. The implication is that the absence of well-developed C-L services in a general hospital may mean that there are patients with unmet mental health needs. In separate articles the training and reliability testing of the new Patient Registration Form (PRF) and the Institutional and Provider characteristics will be described. The former includes the use of ICD-10 in the general hospital setting. This study is a collaborative effort made by 226 consultants from 56 psychiatric C-L services in 11 countries. Each consultant recorded details of 1 year's caseload leading to a thorough description of 14,717 patients collected between 1991 and 1993. The advanced methodology included a multicentered international approach, rigid training for all participating consultants, and the development and testing of new instruments. This will allow us to assess the impact of important structural and process variables on the outcome of C-L service delivery in several European countries. These results will be reported in papers both in the international and national literature of the participating countries.
Article
Medical, psychiatric and social outcome were examined in medical in-patients previously identified as suffering from psychiatric disorder. One third of patients with an affective (emotional) disorder on admission were still psychiatrically ill four months after discharge. Persistent disorder was associated with continuing physical illness. During the year following admission those with affective disorder on admission continued to make greater demands on medical, social and psychiatric services than matched controls and had double the mortality rate (not significant). Patients with organic mental states on admission had a high mortality and morbidity, and made considerable continuing use of general hospital social and psychiatric services. Improved recognition of psychiatric disorder during hospital admission could result in better overall care of medical patients' psychiatric and social difficulties and more effective use of medical resources.
Article
Four hundred nineteen consecutive consult cases were studied to determine the relationship of the timing of the consult to hospital length of stay. Results indicated that earlier consultations predicted shorter lengths of stay. Applications of the present methodology to more complex evaluations of psychiatric consultation are discussed.
Article
The authors hypothesized that psychiatric liaison screening of elderly patients with hip fractures would shorten the average length of hospital stay and increase the proportion of patients who returned home after discharge. The study was performed at Mount Sinai Medical Center in New York and Northwestern Memorial Hospital in Chicago. The subjects were 452 patients 65 years or older who were consecutively admitted for surgical repair of fractured hips. During a baseline year the patients received traditional referral for psychiatric consultation. During the experimental year all the patients at Mount Sinai and the patients on one Northwestern Unit were screened for psychiatric consultation. The patients who received psychiatric liaison screening had a higher consultation rate than those who received traditional consultation. The rates of DSM-III disorders in the experimental year were 56% at Mount Sinai and 60% at Northwestern. The mean length of stay was reduced from 20.7 to 18.5 days at Mount Sinai and from 15.5 to 13.8 days at Northwestern, resulting in reductions in hospital costs ($647/day) of $166,926 and $97,361, respectively. Fees generated from Medicare service delivery could have paid for the $20,000 psychiatric intervention cost at each site. There was no difference, however, between the two years in the discharge placement of patients. Admission psychiatric liaison screening of elderly patients with hip fractures results in early detection of psychiatric morbidity, better psychiatric care, earlier discharge, and substantial cost savings to the hospital.
Article
56 patients with an average age of 55 years have been interviewed about their psychosocial situation at the 3rd till 5th day of treatment in a medical department of a hospital. They were more disturbed by their illness than by the medical therapy, although some were even stressed hardly by routine investigations like taking blood or sonographies. The hospital atmosphere was also found to be a source of disturbances (tying away from home, immobilisation). Especially patients older than 60 years, patients who were ill for the first time and those, who were not sufficiently informed had difficulties in adaptation. Female patients had more problems than male patients to cope with the changes. In further studies the different distressing factors and the strategies of coping of the ill should be investigated more exactly during the whole stay in hospital, to develop specific offers to help the patients.
Article
Between 1981 and 1986 we took a random sample of patients in internal wards of 9 out of 11 General Hospitals. This study serves to determine the prevalence of psychosomatic diseases of in-patients and to ascertain the planned demand for psychosomatic care. We used a psychodynamically oriented half-standardized interview as well as questionnaires about the patients' opinion of the etiology respectively on their therapeutic expectations and on life events. 11.1% of the in-patients had been admitted due to psychiatric problems such as alcohol, suicidal tendencies. 38.4% of the thoroughly examined patients were identified as psychosomatic in accordance with the evaluation of the interview. Items of the lay-etiology and of the therapeutic expectations correlate with this identification; psychosomatic patients have more critical life events.
Article
Over a period of 35 month patients with psychic disorders were treated by a psychological consultation-liaison-service during their stay at a general hospital. A follow-up investigation using a questionnaire was carried out in 1990 in patients with somatization. 66.6% of the patients with somatization took part in the investigation. 47.6% of these patients initiated a psychosomatic treatment after discharge from hospital. 62.8% of the patients described their general state of health as improved. The frequency of symptoms and the amount of restrictions in cause of symptoms could be explained by two factors: Patients without an opportunity to continue a psychosomatic treatment and patients who anticipated negative consequences in case of a psychosomatic treatment reported significantly more complaints and a worse health status.
Article
The psychosocial problems of a random sample of 100 patients in a medical department of a general hospital have been explored. About 15 to 20% of these patients suffered from terminal illness. About half of the patients felt physically and emotionally severely stressed. Besides the illness itself problems resulting of their life situation were the most important stressors, especially difficulties in family or partnership, loneliness and suicidal trends. Psychosocial factors seemed to influence the illness or the decision for hospital treatment at about 2/3 of the patients, at 21% this could be clearly concluded from the diagnosis made at the end of hospital treatment, mostly concerning alcoholism. Coping problems were found at 12 to 26% of the patients. The demands for psychosomatic treatment are high in general hospital, they differ much from those in specialized psychosomatic institutions.
Article
Patients who somatize but who do not meet criteria for somatization disorder are common in the community. Virtually no research has been conducted to determine how to treat these patients. We conducted a randomized controlled clinical trial of a psychiatric consultation intervention we had previously shown to improve the management of somatization disorder. The study population included 51 physicians treating 56 somatizing patients who had a history of seeking help for six to 12 lifetime unexplained physical symptoms. At the onset of the experiment, physicians randomized to the treatment condition received a consultation letter recommending a specific management approach; physicians randomized to the control/crossover condition received the consultation letter after 12 months. Data on health outcomes and charges were collected every 4 months for 2 years after randomization for 96% of subjects who entered the study. Patients of physicians who received the intervention reported significantly increased physical functioning, an improvement that remained stable during the year after the intervention. The intervention reduced annual medical care charges by $289 (95% confidence interval, $40 to $464) in 1990 constant dollars, which equates to a 32.9% reduction in the annual median cost of their medical care. Somatizing patients with a lifetime history of six to 12 unexplained physical symptoms reported better physical functioning after their primary care physician was provided appropriate treatment recommendations via a psychiatric consultation. Such a consultation is cost-effective because it reduces subsequent charges for medical care, while improving health outcomes in a chronically impaired population.
Article
The field of consultation-liaison (C-L) psychiatry has developed a variety of research interventions to try to improve the recognition and treatment of mental disorders in primary care. The authors review the results of three generations of randomized trials of mental health interventions developed by C-L psychiatrists. In general, these trials have been more successful in improving detection of mental illness and increasing the application of mental health treatments by primary care physicians than in changing patient outcomes. The results of these randomized trials are interpreted by using models developed in the health services field.
Article
Patients with somatization disorder (SD), subthreshold somatization, and somatization that is comorbid with another mental or physical disorder use a remarkably high level of general medical services. Because these patients view themselves as more seriously ill than do patients in the general medical population, their use of health care services may be as high as nine times greater than that of the general population. It is important to understand the course and prevalence of SD because 1) these patients tend to overuse health care resources and services, and 2) the associated costs are enormous. It is vital that expert clinical care and research be directed at this important patient group so that appropriate treatment regimens can be developed to help these patients and control the overutilization of limited health care resources.
Article
Several investigations of interventions with psychiatric and medical comorbidity (CM) in the medical inpatient setting have been reported. These studies include psychiatric liaison screening and interventions, psychosocial screening, and standard consultation. The studies had a variety of outcome variables: 1) altered psychiatric morbidity; 2) lag time to identification of CM; 3) lag time to referring to mental health disciplines; 4) cost offset; and 5) discharge placement. Methodological and design problems confound many of the results, in particular, the lack of random control procedures. However, similarity of findings of the frequency of CM in the inpatient setting and patient response to early detection and treatment should stimulate further research into the effects of psychiatric interventions in the acute inpatient medical setting.
Article
The authors critically reviewed 26 international and American outcome studies that assessed the effect of psychiatric comorbidity on length of stay for medical/surgical inpatients. Three generations of American studies were defined according to the rigorousness of the methodology. Eighty-nine percent of all studies with sample sizes greater than 110 and 75% of the prospective, rigorously controlled, American studies found a significant association between psychiatric comorbidity and increased length of stay. The findings lead to the conclusion that impaired cognition associated with delirium and dementia, depressed mood, and other personality variables contributes to prolonged hospital stays and greater utilization of hospitals and other health resources after discharge. Recommendations for future research are suggested.
Article
Persistent somatization patients put a serious burden on the health care system with multiple admissions, tests, surgeries, and medications. This study reports on factors relevant to the health-seeking behavior of somatizing patients and aspects of the health care system that facilitate their overutilization of health resources. Individuals (age 17-49 years) from the general population of two Danish municipalities with at least 10 general admissions during an 8-year period were studied comparing persistent somatizers with other high utilizers of medical admissions. Results are reported on geographical mobility, change in family doctors, route and distribution of admissions by time of day or week, discharges against medical advice, physical disease overlooked, and distribution of admissions to specialties. Although the health-seeking behavior of persistent somatizers may in part explain their overutilization of health care resources, such overutilization could be reduced and much suffering avoided if physicians displayed the same enthusiasm in diagnosing somatization as in ruling out organic pathology.
Article
The discharge letter is the primary means of communication between the inpatient and the outpatient treatment providers in the German health care system. The inclusion of psychosomatic consultation findings within the discharge letter is a critical step for impacting the psychosocial aspects of patient care following discharge. The present retrospective study measured the extent to which psychosomatic consultations conducted at the University of Heidelberg Medical Hospital were mentioned in the discharge letter during a 2-year index period. Psychosomatic consultations (N=605) were requested by a total of 101 inpatient physicians and conducted by 9 consultants. Of the 528 discharge letters that were reviewed, 67.8% referenced the psychosomatic consultation. Results from a stepwise logistic regression analysis found that a reason for referral due to "presumed psychiatric etiology of unexplained physical complaints" was the strongest predictor of whether the consultation was mentioned in the discharge letter (odds ratio=2.27). In contrast, a referral due to "coping and compliance problems" or the identification of psychosocial problems secondary to a somatic illness significantly decreased the chance of communication. The high rate of communication when physicians are confronted with a complex diagnostic picture involving presumed psychiatric comorbidity underscores the perceived usefulness of the consultation. However, consultants may need to take an active role in facilitating the management of psychosocial aspects of care during the inpatient stay and following discharge in an effort to improve concordance.
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Psychische Stoerungen bei internistischen und chirurgischen Krankenhauspatienten Praevalenz und Behandlungsbe-darf [Psychiatric disorders in hospitalized internal medicine and surgical patients: prevalence and treatment demand]
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Psychische Stoerungen bei internistischen und chirurgischen Krankenhauspatienten Praevalenz und Behandlungsbedarf
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Psychosomatic consultation in the discharge letter. Reporting psychosomatic consultations in the discharge letter: an examination of communication between inpatient and primary care physicians
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Effekte psychologischer Behandlung im Allgemeinkrankenhaus: Verlaufsuntersuchung an Patienten mit Somatisierungsverhalten
  • Lupke
Psychosomatik im allgemeinen Krankenhaus: Problemspektrum bei einer Zufallsstichprobe von 100 internistischen Patienten
  • Schmeling-Kludas
Eine Praevalenzstudie zum Bedarf an psychosomatischer Versorgung in den Allgemeinen Krankenhaeusern Hamburgs
  • Stuhr
Zur hausaerztlichen Diagnose und Versorgung psychogen Kranker Ergebnisse einer Feldstudie
  • Kruse
APM task force on psychosocial interventions in the general hospital inpatient setting: a review of cost–offset studies
  • Strain
Die psychosoziale Lage internistischer Patienten nach der Aufnahme im Krankenhaus Eine empirische Untersuchung
  • Schmeling-Kludas
Psychiatric comorbidity and length of stay in the general hospital: a critical review of outcome studies
  • Saravay
APM task force on funding implications of consultation–liaison outcome studies. Special series introduction: a review of outcome studies
  • Saravay