A framework for the implementation of consultation-liaison psychiatry from the characteristics of psychosomatic consultations at a general hospital in China

Abstract

Objective

To describe the characteristics of a consultation-liaison psychiatry (CLP) service at a general hospital in China, compare the literature on CLP in other hospitals in China and abroad, and identify reasons for the differences.

Methods

The medical records of all inpatients who received liaison consultations in the first year of the establishment of Xi’an International Medical Center Hospital were reviewed. Demographic data, specific department, number of consultations, reasons for consultation, outcome of consultation, and follow-up information on patients was collected.

Results

A total of 630 patients were enrolled during the first year of the hospital’s opening, of which 45.2% were male and 54.8% were female. A total of 89.2% of non-psychiatric departments requested a psychosomatic consultation. The percentage of middle-aged and elderly patients was 75.6%, of whom 61.6% were aged 45 to 74 years. The internal medicine department requested the highest number of consultations (48.2%), including those from respiratory medicine (12.1%), neurology (12.1%), gastroenterology (12.1%), and cardiology (12.1%). Among surgical patients, orthopedic patients (6.5%) comprised the majority of consults. The main reasons for requesting a psychosomatic consultation were depressive symptoms (139 cases, 22.8%), anxiety symptoms (137 cases, 22.5%), sleep problems (111 cases, 18.2%), and hallucinations, delusions, or behavioral problems (68 cases, 11.2%), accounting for a total of 74.6% of consultations (455/630).

Conclusion

A significant gap exists between the level of CLP services in China and developed regions in Europe and the United States, mainly due to low psychiatric consultation rates and poor quality CLP services.

Keywords

Consultation-liaison psychiatry general hospital psychosomatic department

Introduction

Consultation-liaison psychiatry (CLP) is based on theories of psychosomatic diseases and requires an understanding of disease development from multiple bio-psycho-social perspectives; its implementation has improved psychiatric services in general hospitals. Currently, CLP is an important part of mental health service development as it focuses on the relationship between somatic disorders and psychosocial factors and emphasizes the process or type of psychiatric consultation by psychiatrists and related personnel for patients in all departments of general hospitals.¹ In 1997, the European Association for Consultation-Liaison Psychiatry and Psychosomatic Medicine (EACLPP) was established. Since then, multiple countries developed guidelines² for CLP implementation and standardized technical training.³ In China, CLP was introduced in the 1980s, the CLP Collaborative Group was established in Beijing in 2003, and the Chinese Medical Association in 2006. At present most tertiary hospitals in China have established psychiatry or psychosomatic departments to provide CLP.⁴

Since mind-body unification is the guiding principle of CLP, it mainly serves patients with somatic or brain diseases accompanied by psychiatric disorders or co-morbidities in general hospitals. Its core service is the assessment and management of psychiatric symptoms by psychiatrists.⁵ Analyzing and determining the cause of the psychiatric symptoms by the psychiatric consultation physician is crucial. Since psychiatric symptoms can be multi-factorial, the CLP team should comprise an attending physician, a nurse, and personnel from the comprehensive unit. Moreover, if a patient requires multiple consultations or psycho-behavioral treatment, the involvement of the psychiatric team is necessary and should be a part of the CLP.

Currently, for consultation and liaison treatment in general hospitals in China, a non-psychiatrist submits a request for consultation after which a psychiatrist carries out the consultation. This is similar to the early CLP practices in Europe and the United States wherein general practitioners usually requested psychiatric consultations only for common psychiatric problems, including the differential diagnosis and management of psychotic symptoms and prescription of antipsychotic medications.⁶ Presently, in Europe and the United States, in addition to medical staff from general departments and psychiatry, CLP services invite patients, family members, nurses, and social workers to participate in the development of treatment plans; moreover, even ethical reviewers and hospital administrators sometimes participate in complex case management.¹ In addition to the delayed introduction of CLP and lack of trained personnel, there is a huge gap between domestic and foreign CLP services. Thus, the existing CLP service model and level need to be improved. Although most large general hospitals have psychiatric departments, their main purpose is to treat patients with severe mental disorders, which is beyond the scope of CLP. Practically, the improvement of the CLP service model in general hospitals can swiftly improve the level and quality of medical services and reduce medical costs and is also consistent with the guiding ideology of China's medical system reform.

In this study, we analyzed the psychiatric consultation cases in a general hospital within one year through retrospective analysis and examined the general demographic characteristics of the consulted patients and the consultation-related data. Thus, we aimed to have a clear understanding of the current status of consultation work development in the general hospitals of China, compare relevant research results, identify the gaps in the current services, recommend strategies for targeted consultation development, and provide a reference basis for the development of CLP in China.

Materials and Methods

Study Settings and Sample

In September 2019, the Psychosomatic Department of Xi'an International Medical Center Hospital started providing hospital-wide CLP services. All inpatients who underwent psychosomatic liaison consultation from September 1, 2019, to September 1, 2020, at Xi'an International Medical Center Hospital, China, were included in this study, including inpatients from all departments and patients from emergency holding rooms throughout the hospital.

Measures

Physicians from all department request consultation when their treatment requires the assistance of a psychiatrist. The physicians who conduct the consultation are psychiatrists who are attending physicians. The consultation comprises recording the patient’s medical and family histories, and the medical staff performs psychiatry-related examinations, diagnosing the patient according to the ICD-10, making treatment recommendations, and filling consultation notes.¹

Analysis

This study is a cross-sectional, retrospective study wherein the relevant data were extracted from the hospital’s information system. The general demographic data (age, gender), source department, reasons for consultation, consultation diagnosis, medication, and patient psychotherapy were systematically classified and analyzed. Specifically, the following formulae were used:

The proportion of consultation = the number of times a department applied for psychosomatic consultation / the number of times the whole hospital applied for psychosomatic consultation × 100.0%

The number of follow-up consultations proportion = the number of patients who applied for psychosomatic consultation more than once in a department / the number of patients who applied for psychosomatic consultation in a department × 100.0%.

SPSS25.0 software (IBM) was used for statistical analysis. The measurement data were described by $\bar{x} \pm s$ description, percentage, and composition ratio and were compared using the analysis of variance ANOVA and chi-square tests. p < 0.05 indicated a statistical difference.

Results

General Demographic Information

n this study, data from 630 inpatients who underwent psychosomatic liaison consultation in a 1-year cycle at Xi'an International Medical Center Hospital, China, were collected. Among them, 285 cases (45.2%) were males (mean age, 55.86 ± 18.34 years), and 345 cases (54.8%) were females (mean age, 56.43 ± 16.55 years). According to the World Health Organization's criteria for classifying people by age limits, there were three elderly patients (0.5%) aged ≥90 years, 85 patients (13.5%) aged 75–89 years, 206 patients (32.7%) aged 60–74 years, 182 patients (28.9%) aged 45–59 years, 135 patients (21.4%) aged 18–44 years, and 19 patients (3.0%) aged <18 years.

Source Department and Consultation Rate

Internal medicine had the highest percentage of psychosomatic consultations. Among surgical departments, orthopedics (rehabilitation) more frequently requested CLP. The top five departments that requested CLP were respiratory medicine (12.1%), neurology (12.1%), gastroenterology (12.1%), cardiology (12.1%), and rehabilitation (6.4%). There were 36 departments in the hospital, among which 26 departments (74.3%) requested psychosomatic consultation.

Main Reasons for Consultation

The reasons for requesting a psychosomatic consultation included depressive symptoms (139 cases, 22.8%), anxiety symptoms (137 cases, 22.5%), sleep problems (111 cases, 18.2%), and hallucinations and delusions or behavioral disorders (68 cases, 11.2%) and these accounted for 74.6% (455/630) of all reasons. Other reasons included unexplained somatic symptoms (51 cases, 8.4%), history of psychiatric disorders (43 cases, 7.1%), cognitive problems (41 cases, 6.7%), difficulty in classification (28 cases, 4.6%), and adjustment of medication (12 cases, 1.8%).

Consultation Diagnosis and Treatment

Among patients who underwent psychosomatic consultations, 23 cases (3.7%) did not have any psychiatric disorder. The most common psychiatric disorders were sleep disorders (67 cases, 10.6%) followed by anxiety disorders (191 cases, 30.3%), depressive disorders (209 cases, 33.2%), somatoform disorders (8 cases, 1.3%), stress-related disorders (13 cases, 2.1%), other psychotic disorders (11 cases, 1.8%), schizophrenia (5 cases, 0.8%), delirium state (42 cases, 6.7%), organic mental disorder (57 cases, 9.0%), and bipolar disorder (4 cases, 0.6%). Except for the 23 patients who did not have any psychiatric disorders, all patients received treatment recommendations from psychiatrists, and 94.1% of them required medication change. Additionally, 9.1% of the patients required psychological counseling and psychotherapy, and 1.3% were referred to the psychosomatic department.

Discussion

In terms of the proportion of gender ratio and age distribution of patients, the results of this study show a similar distribution pattern with relevant studies at home and abroad. Internal medicine is the main department of consultation, and orthopedics (rehabilitation department) is the main department of surgery. There is a significant gap between the domestic CLP service level and the developed regions in Europe and the United States, mainly reflected in the low rate of consultation and referral and the imperfect service model.

The proportion of females in this study was slightly higher than that of males (45.2% for males and 54.8% for females). A study by Shuo Li et al. (2018) on 1339 patients showed similar gender distribution as ours.⁷ Another study by Junhui Guo et al. (2016) on 688 patients, reported more male than female patients (51.2% male and 48.8% female).⁸ DaisukeShinjo1 (2022) investigated 46,171 patients from a 5-year national CLP effort at various general hospitals in Japan and presented an overall male-to-female ratio of 53:47 with patients aged 75–84 years receiving more CLP than any other age groups (29.7%).⁹ Moreover, 75.6% of the patients consulted in our study were old, with 61.6% of patients aged 45–74 years. The age distribution of consultation patients in related domestic studies showed similar trends.^7,8,10 The high proportion of middle-aged and elderly patients may be associated with declining physiological function, a high prevalence of somatic diseases involving multiple systems, more stressful events, greater psychological changes, and excessive concern for health.

This study revealed that the requests for CLP were predominantly placed by the internal medicine department (48.24%). A Study by Li Guike (2021) suggested that the digestive system is a response board for emotions, and the highest prevalence of psychosomatic disorders is noted in internal medicine consultation; however, only 19.0% of patients with combined anxiety and depression in the digestive system in their study received pharmacological treatment or referral, and in the present study, only 12.1% of gastroenterology patients received consultative treatment, both of which are significantly lower than the prevalence of psychiatric disorders in patients with digestive system issues. The low identification rate significantly impairs the quality of life of such patients, worsens the clinical prognosis, and increases the cost of treatment.¹¹ The highest percentage of CLP requests in the orthopedic department among all surgical departments is explained by the high rate of self-injurious suicidal behavior in patients with psychiatric disorders and the possibility of delirium after major orthopedic surgery.¹²

A related study conducted in Portugal revealed a high prevalence of psychiatric comorbidity in patients with heart failure, and these psychiatric symptoms were not adequately diagnosed. CLP can fill this gap and weaken the impact of psychiatric disorders on heart failure through timely diagnosis and appropriate treatment, thus contributing to improved survival rates and quality of life of patients and reduced public health expenditures.¹³ Studies in China have also reported that psychiatric consultations based on comprehensive assessment and multidisciplinary team visits compared with psychiatric consultation only can significantly shorten patients' hospitalization days and lower hospitalization costs.¹⁴ Therefore, general hospitals should pay attention to the development of CLP, take initiative to focus on the psychiatric health status of non-psychiatric patients, and conduct regular joint consultations to optimize medical resource utilization.

It is also critical to improve the efficiency of CLP. Hannah Kim¹⁵ discovered that improved patient outcomes were significantly associated with the cumulative level of contact by the CLP team. CLP teams in general hospitals usually contact the junior physicians of the referral team after receiving the referral. Moreover, 68.9% of CLP referrals in hospitals are initiated by junior physicians, who play a key role in hospital care delivery.¹⁶ Hartz uncovered that 44.0% of physicians across clinical departments were confident in managing anxiety or depressive disorders, while only 14.0% of physicians were confident in managing patients with unexplained somatic disorder (MUS).¹⁷ Therefore, proper management of somatoform disorders or MUS in collaboration with clinical departments should be explored in depth in CLP.

There is a significant gap between CLP services in China and foreign countries, this gap is correlated with the short history of CLP development, the lack of resources for psychiatric/psychological treatment, and the influence of social culture. The clinical significance of CLP is being gradually recognized by healthcare workers with the accumulation of practical experience with CLP and increased awareness of its importance in developed countries, such as Europe and the United States.

There are few studies on CLP in China. The psychiatric consultation rates reported in the relevant studies (1.0%–2.3%)^7,11 are lower than those reported in other countries (2.6%–3.3%).^18,19 The overall follow-up rate in this study was 8.7%, compared with 7.1% in the study by Guo Junhui (2016). Meanwhile, the majority of patients only had one consultation. It is suggested that the patient’s psycho-behavioral abnormality may be transient and then return to normal. Furthermore, non-psychiatrists are aware of the importance of mental health and request specialist intervention if there is a suspected psychiatric behavioral abnormality. In this study, the departments with the highest rate of follow-ups were obstetrics and gynecology, urology, and neurosurgery, and accounted for a relatively small number of consultations but a high rate of patient follow-ups.

Regarding service models, some hospitals in the United States have started to form professional teams that include psychiatrists to provide specialized CLP services and comprise hospice teams (palliative care). CLP services in Europe and the United States, in addition to medical staff from comprehensive departments and psychiatry, also invite patients' family members, nurses, and social workers to participate in formulating medical plans and even involve ethical reviewers and hospital administrators to solve some complex problems.¹³ The current CLP practice in China is similar to that during the early period in Europe and the United States, wherein psychiatrists were invited to consult primarily for disease diagnosis and guidance on medication, and some hospitals performed follow-up services Objectively, most general hospitals have set up psychiatry or psychosomatic departments due to a shortage of mental health professionals and lack of training. Nevertheless, their main purpose is to provide medication services for patients with mental disorders, failing to satisfy the demand for CLP consultation in general hospitals. Subjectively, the idea of "doctors not knocking on the patients’ door" still exists in our medical environment, and the initiative of CLP might not be actively accepted by the physician and the patient. Meanwhile, many CLP efforts are not effectively implemented owing to insufficient knowledge about CLP among non-psychiatrists about CLP and the introverted attitude of the national population toward psychological/psychiatric issues. Many patients with psychiatric/psychological disorders, especially those with unexplained somatic symptoms, are frequently referred back and forth to various departments in hospitals. This is mentally and financially draining, leading to negative feelings toward the healthcare system and hospitals owing to the lack of accurate diagnosis.

The biopsychosocial model lacks a clear scheme and does not provide sufficient clinical guidance or a framework for scientific advancement.²⁰ As the healthcare system enters a digital health era, the biopsychosocial model should be concretized into the practical work of CLP in conjunction with the application of rapidly evolving healthcare technologies to serve the patients’ needs. Improvement in the CLP service model in general hospitals will not only improve the level and quality of healthcare services but also reduce healthcare costs, in line with the ideology of domestic healthcare system reforms. Concerning the implementation of CLP in general hospitals, the staged, specific, and modular management of CLP is not only an extended practice of the biopsychosocial model but also an experience for the broader and deeper development of CLP in China.

Guidelines created by the American Psychiatric Association (APA) breaks down the development of active CLP efforts into four main elements: (1) systematic screening of admitted medical cases for psychiatric disorders; (2) patient-centered, early intervention; (3) a multidisciplinary team-based approach; and (4) clinical collaboration with the primary care team. The APA guidelines help conceptualize various aspects of active CLP psychiatric practice; however, it does not provide a framework to develop and implement active CLP services. Instead, a more explicit framework for practically implementing CLP is required. In our study, an implementation framework for active CLP work was developed under this guidance and the behavioral healthcare integration framework proposed by Sarah.²¹

Limitations

There are some shortcomings in this study. First, the psychiatric diagnoses were derived from psychiatrists during consultations, which lacked uniform objective information. Second, the study data came from only one hospital and the sample size was small.

Conclusions and Suggestions

There is a significant gap between the level of CLP services in China and developed regions in Europe and the United States mainly due to the low consultation and referral rates and the imperfect service model. Existing studies have found that effective implementation of CLP can improve patients' experience, optimize medical resource utilization, and reduce the systemic expenditure of health insurance. (See Table 1)

Table 1.

The proportion between the number of consultation patients and follow-up patients in each Department

Department	Number of consultations/Proportion	Number of follow-ups/proportion
Ultrasound intervention	1/0.2%	0/0%
Pediatrics	1/0.2%	0/0%
Otorhinolaryngology	10/1.6%	0/0%
Division of rheumatology	8/1.4%	0/0%
Obstetrics and gynecology	3/0.5%	1/33.3%
Orthopedics	44/7.0%	1/2.3%
Respiratory medicine	76/12.1%	8/10.5%
Emergency department	10/1.6%	0/0%
Nail surgery	5/0.8%	0/0%
Recovery unit	50/8.0%	7/14.0%
Geriatrics	20/3.3%	0/0%
Urology	11/1.8%	3/27.3%
Endocrinology	11/1.8%	0/0%
Dermatology	7/1.1%	1/14.3%
Burn plastic surgery	1/0.2%	1/100.00%
Neurology	76/12.1%	5/6.6%
Neurosurgery	33/5.2%	7/21.2%
Nephrology	6/1.0%	1/16.7%
Gastroenterology	76/12.1%	7/9.2%
Digestive surgery	14/2.2%	1/7.1%
Cardiology	76/12.1%	3/4.0%
Cardiac surgery	23/3.7%	2/8.7%
Thoracic surgery	8/1.3%	0/0%
Hematology	7/1.1%	0/0%
Oncology	28/4.4%	3/10.7%
Critical care	25/4.0%	4/16.0%
Total	630/100.0%	55/8.7%

Based on the statistical comparison of consultation patient data in this study, combined with the behavioral healthcare integration framework proposed by Sarah et al.,¹⁸ we propose the following framework for proactive CLP efforts in large general hospitals in China in terms of improving patient identification, treatment adherence of consultation patients, and patient follow-up levels, which includes six key points.

1. A survey of the science of psychological/psychiatric disorders and basic emotional levels by nurses/receptionists at admission, initial screening of patients who may be troubled by psychological/psychiatric disorders, and submission of the screened information to the attending physicians.

2. Establishment of a dedicated CLP team in hospitals and screening for junior physicians in each department for CLP training in hospitals with insufficient means to meet daily CLP service needs.

3. Adoption of a dual pathway management for the follow-up treatment of patients who have undergone consultation to guarantee that the patient's case is kept under observation post-consultation regardless of whether the patient is followed up.

4. Relevant treatment history and cases of patients with a history of psychiatric/psychological treatment can be inquired within a certain range.

5. In CLP for patients, feedback on problematic behaviors and treatment records is added to the daily management reports.

6. For outpatients, a protocol process is added for informing family members so that they can aid the treatment; for patients with insufficient family support, community leaders or service providers are introduced for out-of-hospital services.

Proactive CLP is an emerging model of collaborative care. This implementation framework will serve more patients and conserve healthcare resources. However, its standardization and effectiveness need further improvement due to limited clinical experience and application practices. Hopefully, the framework adaptations proposed by the study will contribute to the progress and improvement of the work in this area.

Footnotes

Author Contributions

Zou xue, Wang Ying: Conceptualization.

Liu Yanwen, Li Mei: Formal analysis and Writing.

Liu Ning, Han Le, Han Xueyan, Zhang Wenwen, Jing Huihui: Data Curation.

Hou Yitong, Ma Mingxiao: Investigation.

Zou xue: Validation.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Xi'an International Medical Center Hospita; (2022007).

Author’s Note

Liu Yanwen. Who is an intern in the Department of Adolescent Mental Health, Mental Hospital, Xi'an International Medical Center Hospital of Northwest University. The corresponding author Zou Xue guides her internship.

IRB Approval

The study protocol was approved by the Institutional Review Board of the Xi'an International Medical Center University (No: 20221103). In September 2019, the Psychosomatic department of Xi'an International Medical Center began providing hospital-wide CLP services

ORCID iD

Zou Xue

References

Zimbrean

Ernst

Forray

, et al. The educational value of outpatient consultation-liaison rotations: a white paper from the Academy of consultation-liaison psychiatry residency education subcommittee. Psychosomatics. 2020;61:436–449.

Leentjens

AFG

van Baalen

Kuijpers

HJH

, et al. The revised guideline on consultation-liaison psychiatry of the Netherlands Psychiatric Association. J Psychosom Res. 2018;110:12–14.

Smith

Hewison

West

, et al. Liaison psychiatry-measurement and evaluation of service types, referral patterns and outcomes (LP-MAESTRO): a protocol. BMJ Open. 2019;9:e032179.

Hao

. Psychiatry. Beijing, China: People's medical publishing House; 2018:254–265.

J A

Tsai

C S

Hung

T H

Chou

. Change in accuracy of recognizing psychiatric disorders by non-psychiatric physicians: Five-year data from a psychiatric consultation–liaison service. Psychiatry Clin Neurosci. 2011;65:618–623.

Siegel

Bleier

. The role of negotiation in consultation-liaison psychiatry. Psychosomatics. 2017;58:187–190.

, et al. Analysis of the characteristics of psychiatric liaison consultation in general hospitals. Chinese Journal of Modern Medicine. 2018;20:5–8.

Guo

Wang

Bai

, et al. Analysis of psychiatric liaison consultations in general hospitals. Journal of Clinical Psychiatry. 2016;009:195–196.

Shinjo

Tachimori

Maruyama-Sakurai

Fujimori

Inoue

Fushimi

. Consultation-liaison psychiatry in Japan: a nationwide retrospective observational study. BMC Psychiatry. 2021;21:1–13.

10.

Deng

. Review of consultation-liaison psychiatry. Journal of Neuroscience and Mental Health. 2020;20:533–536.

11.

Sun

Liang

. Clinical characteristics of inpatients with gastroenterology in general hospital psychiatric liaison consultation and factors influencing follow-up consultation. Guangxi Med. 2021;43:11–15.

12.

Wang

. Analysis of risk factors for postoperative delirium in common orthopedic surgeries. Chinese Journal of Orthopaedics. 2015;35:650–655.

13.

FerrariMarchiMattei

SMG

Moscara

Galeazzi

Pingani

. Past, present and future of the modena consultation-Liaison psychiatry service. Journal of Psychosomatic Research. 2021;144:110411.

14.

Zhao

Xia

Shi

, et al. A 3-year analysis of psychiatric consultation data of inpatients in a tertiary care general hospital. Chinese Mental Health Journal. 2011;1:30–34.

15.

Kim

Khanna

Olver

Norman

. Diagnostic agreement and concordance between consultation-liaison psychiatry and non-psychiatric (medical and surgical) doctors: changes within junior doctor's terms. Australas Psychiatry. 2022;30:60–63.

16.

Grover

Sahoo

Aggarwal

Dhiman

Chakrabarti

Avasthi

. Reasons for referral and diagnostic concordance between physicians/surgeons and the consultation-liaison psychiatry team: An exploratory study from a tertiary care hospital in India. Indian J Psychiatry. 2017;59:170–175.

17.

Muriel

Tarquini

Morris

. The “liaison” in consultation-liaison psychiatry: Helping medical staff cope with pediatric death. Child Adolesc Psychiatr Clin N Am. 2018;27:591–598.

18.

Rothenhusler

H B

Stepan

Kreiner

, et al. Patterns of psychiatric consultation in an Austrian tertiary care center - results of a systematic analysis of 3,307 referrals over 2 years. Psychiatria Danubina. 2008;20:301–309.

19.

Wand

APF

Corr

Eades

. Liaison psychiatry with Aboriginal and Torres Strait Islander peoples. Aust N Z J Psychiatry. 2009;43:509–517.

20.

Lee

Oldham

. The biopsychosocial model and consultation-liaison psychiatry: Legacy of George Engel and John Romano. J Acad Consult Liaison Psychiatry. 2022;63:187–188.

21.

Asuquo

Goodman

Gaynes

Nakamura

. A proactive consultation-liaison psychiatry implementation framework for the management of medical and surgical inpatients with psychiatric comorbidities. Gen Hosp Psychiatry. 2022;74:149–151.