Quality assurance in liaison psychiatry. European Consultation-Liaison Workgroup

As far as we know, there is no experience of quality management in mental health care in Portugal. This study fills a gap in the area of consultation-liaison psychiatry. Due to its multidisciplinarity and to the complexity of the problems it deals with, consultation-liaison psychiatry seems a privileged field for the development of this kind of programme. The authors describe the different steps necessary for the implementation of a quality management study in one of the national centres and report some preliminary results that show the success it has attained.     

An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice

OBJECTIVE: This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices. METHOD: Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments. RESULTS: Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls. CONCLUSIONS: The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services.     

Primary care in psychiatry residency training

The author summarizes patient perspectives and government initiatives that have fostered closer medicine-psychiatry cooperation and more comprehensive treatment of patients. Despite the growing numbers of people requiring more formal mental health care, most patients are being treated by primary health care providers. This trend will continue as long as there is a decline in the number of medical students entering psychiatry. The author summarizes several general principles that psychiatry residency program directors should consider in designing primary care experiences for their residents and for medical students rotating on their services: longitudinal primary care experiences in organized medical care settings, training in basic medical principles and techniques, and instruction in the biopsychosocial model of disease. The author also recommends there specific training experiences for psychiatry residents that would enhance their ability to provide more effective mental health services to primary care physicians and their patients: consultation psychiatry, primary mental health care, and general psychiatry. The author concludes that medical students, through their contact with primary care-oriented psychiatry residency programs, would be more attracted to psychiatry as a specialty choice and that residents, upon completion of training, would be more inclined to practice in primary care settings.     

A psychology intern on a psychiatric consultation team: An intern's perspective.

A rotation on a consultation-liaison team can provide the intern with a varied experience and exposure to the diversity of psychological concomitants of medical illness as well as more purely psychological problems. The intern's training also provides the opportunity to teach other team members about psychological factors that may be operative in their patients. Potential conflicts arising from differences between the training of psychiatry and psychology team members and the divergence between the medical and behavioral or social-developmental models are noted. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship between etiology and phenomenologic profile in delirium

This study describes the symptom profile of 46 patients with delirium seen as consecutive referrals to a consultation-liaison psychiatry service. The relationship between symptoms rated on the Delirium Rating Scale (DRS) and delirium subtypes defined according to three putative etiologic groups are described. The relationship between etiologic groups and motoric subtype of the delirium episode is also described. Drug-related cases had the highest total DRS score and higher scores than the anticholinergic group for perceptual changes, delusions, psychomotor disturbance, and mood lability. Drug-related cases had higher scores than both the anticholinergic and infectious/electrolyte group for changes in sleep-wake cycle and fluctuation of symptoms. Those from the anticholinergic etiologic group were more likely to fit the hypoactive motoric subtype. Although our findings are tentative, etiologic categories may present with different symptom profiles, which may be associated with differing treatment responsiveness and course.     

The value of administrative experience for the clinician: opportunities of the chief residency in psychiatry

Administration has been traditionally contrasted with clinical work; experiences such as the chief residency in psychiatry are viewed as clinically-based training for unfamiliar administrative activity. In contrast to these viewpoints we propose that recognition of tasks common to clinical work and administration leads to a broader understanding of both activities, and that administrative experience can make specific contributions to the development of a clinician.     

Pediatric consultation: New concepts in training.

Consultation-liaison has become increasingly important to the diversification of psychological practice. With the advent of national health proposals, the ability to service individuals (including the youth of this nation) in a variety of settings will be critical. This article describes a comprehensive training program in consultation-liaison child and adolescent psychology and encourages its adoption in other training programs. Psychology training programs will need to provide practice experiences in a variety of settings for psychologists to remain viable in an increasingly competitive mental health market place. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Defining the role of the consultant psychiatrist in a public mental health service

OBJECTIVE: The aim of this paper is to clarify elements of the role of a psychiatrist working in the public sector. METHOD: The relevant literature was examined to help clarify some of the reasons psychiatrists have been leaving the public sector and to help define the key roles of a psychiatrist working in the public sector. RESULTS: Two principal roles for the consultant psychiatrist in the public sector are identified: the psychiatrist as a clinician and the psychiatrist as a manager. The management role is contrasted with the role as an administrator and important differences between these roles are identified. The management role includes planning, advocacy and managing human resources. The importance of professional development in the career path for the newly qualified psychiatrist is discussed. CONCLUSIONS: The role of the psychiatrist in public sector psychiatry is a challenging and exciting one. Psychiatrists will start to return to the public sector when they recognise this new role for the consultant psychiatrist. This will be to the advantage of public sector psychiatry in general and to the job satisfaction of psychiatrists. The key features of the clinical role are the demonstration of sophisticated clinical skills, providing clinical leadership via supervision, being accountable for patient care and providing consultant opinion on complex clinical problems.     

Restoration of tumor oxygenation after cytotoxic therapy by a perflubron emulsion/carbogen breathing

Thirty-six psychiatric patients with completed suicide, 162 with attempted suicide and 154 patients referred for suicidal behavior, four of whom died, were investigated and classified according to the ICD-10. Thirty-six patients with completed suicide among 9085 new psychiatric patients (1969-92) gave a suicide rate of 82.6/100 000 per year. Schizoaffective and depressive disorder in psychiatric patients with completed suicide and schizophrenia, depressive disorder and adjustment disorders in patients with attempted suicide were significantly more frequent than in 312 controls. Intrafamilial conflicts, divorce or loss of love and death or severe disease of family member were the most common precipitants. Loneliness from living alone in males, losing a spouse and intrafamilial conflicts within a large family of three generations in females were supposed to be risk factors. A high referral rate of 48% in attempted suicide indicated the important role of consultation-liaison psychiatry in emergency medicine.     

Images of psychiatry in recent Australian and New Zealand fiction

Psychiatry is variously portrayed in Australian and New Zealand fiction. This paper describes mental health professionals, settings, conditions, treatments, and social themes essayed in 128 works by 103 authors, published between 1957 and 1992. The predominant images are negative or markedly ambivalent: possible reasons for this are discussed. The perception of psychiatry by the culture in which it is formed and located, as mediated by its creative artists, has important implications for psychiatrists' understanding and explication of their social role, and has an impact on patients' expectations and experiences of psychiatry.     

The supervision relationship: Variables contributing to positive versus negative experiences.

We present pilot data on variables that influence interaction between trainees and supervisors and contribute to positive versus negative experiences in psychotherapy supervision. Subjects were two groups of supervisor/trainee dyads in which trainees had reported very positive or very negative supervision experiences. We found agreement on the quality of supervision experience between pair members. Trainees had positive supervision experiences when they were seen as interested in the supervisor's feedback. Trainees preferred supportive, instructional, and interpretive supervisors. Similarity in theoretical orientation and interpretive style contributed to positive experiences. A model combining variables to predict the quality of supervision experiences is presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Child psychiatry education for general residents

There is continuing debate about what child psychiatry experiences should be included in a general residency. The author describes the program at the University of Michigan in an effort to provide some insights into the interface between child psychiatry and general residency training. This program is unique in several respects: a 12-month rotation in child psychiatry is offered, and the faculty size and budget of the youth services are comparable to those of the adult services. A survey of all residents and faculty pointed up numerous disagreements as to the length of the rotation and priorities in curriculum. The author discusses the influence of the various competitive processes on the educational program.     

Assessment of therapy outcome within the scope of quality assurance in a psychiatric clinic. A report of experiences

A recent modification of German law requires quality assurance of inpatient treatment, i.e., of the quality of therapy, allowing comparison of different hospitals. In this paper a program developed to assess the outcome by means of international, frequently applied psychopathometric scales is presented. This program was evaluated in a study of 258 psychiatric inpatients. This study emphasized the identification of patients with long-term hospitalization and/or worse outcome. A concept to disclose these so-called 'problematic' patients by means of easily administered scales like the SCL90-R, GAF and WHO-Disability-Diagnostic-Scale (DDS) has been developed. Patients with a very long hospital stay (> 70 days) show a higher number and more severe symptoms in the self-rating (SCL90-R) at admission than the subjects with a short hospital stay. This pilot study demonstrated that a routine outcome analysis can be used for quality management in psychiatry.     

Obsessive-compulsive disorders in children. A review based on recent research and clinical experiences

This article describes obsessive-compulsive disorder in childhood through a review of some recent research topics and the author's own clinical experiences with the disorder. Among the topics discussed are diagnosis, differential diagnosis, phenomenological characteristics and treatment recommendation. The article concludes that although recent research on obsessive-compulsive disorders in children has lead to important advances in our understanding and treatment of the disorder, much remains to be addressed. Research on childhood obsessive-compulsive disorder in Norway seems to be non-existent, and the author calls attention to the need for empirical studies at Norwegian research institutions. These should include research on treatment preferences in Norwegian child psychiatry clinics.     

Relationship between response to interferon therapy and detection of hepatitis C virus RNA by differential flotation centrifugation

Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.     

The utility of interdisciplinary training and service: Psychology training on a psychiatry consultation-liaison service.

Increasing numbers of psychologists work in medical settings because of the growing acceptance of a biopsychosocial approach to illness. Do training programs prepare sufficient numbers of graduates to function effectively in medical settings? The authors describe the process of adding an inpatient medical-surgical consultation-liaison (C-L) service to a psychology internship's training rotations, the learning objectives used, and issues in the preparation of trainees for work in medical settings. Psychology trainees added significant capacity to the C-L service. These data may help facilitate the development of C-L training experiences for other programs (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of depression. Presentation of an integrated therapeutic model

In clinical work, research data must be integrated in the daily handling of patients. At the same time, symptoms must be treated and respect paid to the different personalities of the patients. Based on clinical experience and research data I present an integrated model for the treatment of patients with moderate to severe depression. I used the main principles in the model over 4 to 5 years, and where research has pointed to new, clinically relevant findings, these have also been included. The model can be used in psychiatric out-patient-clinics, on emergency wards and for general practitioners with a special interest in psychiatry. After 5 to 8 sessions spread over 8 to 12 weeks, the condition of most patients will have stabilized and improved, and the psychological part of the treatment can than be terminated.     

Osteoarthritis of the hip and occupational lifting

OBJECTIVES: The purpose of this study was to determine the effect on quality of care through the implementation of a clinical path for patients receiving transurethral prostatectomy. METHODS: We selected ten quality indicators with important clinical relevance as representative elements of the clinical path. These quality indicators were monitored during the entire hospitalization period of 100 consecutive patients who received transurethral prostatectomy. Monitoring data obtained from these patients were compared to data from 100 patients who received transurethral prostatectomy prior to implementation of the clinical path. Data was assessed to determine the relationship between quality indicators and management processes. RESULTS: Implementation of the clinical path for transurethral prostatectomy significantly decreased the percent of patients with incomplete preoperative tests on admission day, the duration of intravenous antibiotics administration, the percent of patients who required acute pain management postoperatively, the percent of patients who received postoperative bladder irrigation with normal saline and the percent of patients who had their Foley catheter removed after postoperative day 2. Three of the quality indicators had a significant relationship with management processes and may have directly affected the total admission charges. CONCLUSIONS: To evaluate the effect of the transurethral prostatectomy clinical path implementation on the quality of medical care, we compared ten quality indicators before and after implementation of this path. We concluded that implementation of the clinical path resulted in a statistically significant improvement in the quality of medical care.     

Development of a Quantification Proposal for Hidden Quality Costs: Applied to the Construction Sector

This study develops a quantification proposal for those quality costs that construction companies cannot estimate through objective criteria, known as hidden quality costs. This proposal will later be the object of validation through a real case: the quantification of the cost of loss of image that a construction company experiences as a consequence of a delay in the completion of a certain building. This proposal is of relevance to researchers in that it demonstrates how hidden cost quantification based on a fuzzy logic model can be developed and tested, and it provides the basis for future investigations. It is of relevance to professionals as it describes how fuzzy logic and quality costs can be used to effectively model industrial construction quality management.     

Subject and object of psychiatric research. On the history of concepts of a controversy

The relationship between subject and object is one of the philosophical questions that are of direct relevance for understanding psychiatry as a clinical and scientific field. Characteristic examples from the history of psychiatry are analyzed, including the "romantic era", the clinical concepts in Germany at the turn of the century, and twentieth century theories associated with the linguistic turn in philosophy. The practical implications of these theoretical considerations are often underestimated; this is clarified by a critical look at operationalized diagnostic criteria in psychiatry and at one of the most influential modern epistemological theories, "Evolutionary epistemology."