[Consultation-liaison psychiatry and general hospital psychiatry in the Netherlands: on the way to psychosomatic medicine]. / Consultatieve en ziekenhuispsychiatrie in Nederland: op weg naar psychosomatische geneeskunde.

Consultation-liaison psychiatry and general hospital psychiatry have played a major role in promoting the concept of integrated care. New models for care have been developed and policy assurances about the quality of care have been expressed in the form of guidelines and indicators relating to procedure and performance. General hospital psychiatry is playing an increasingly important role in the training of psychiatrists. Due to the ageing population there is greater awareness of the importance of comorbidity and more support for the concept of integrated care. These changes will promote the further development of general hospital psychiatry.

[Measures for patients taking psychotropic drugs who undergo elective surgery]. / Maatregelen bij patiënten die psychofarmaca gebruiken en die een electieve operatie moeten ondergaan.

Psychotropic drugs can increase the risk of perioperative complications when given in combination with anaesthesia. Evidence-based guidelines that address this issue are lacking. Consensus-based recommendations were formed for the perioperative management of these patients based on the available literature and a systematic evaluation of perioperative risks by the medical specialists directly involved. Patients who use lithium, monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants or clozapine are at risk of experiencing adverse interactions. The anaesthesiology literature recommends discontinuing irreversible MAOIs and lithium in all cases, and tricyclic antidepressants in patients with systemic disorders. With the exception of lithium, the risks of psychiatric relapse or recurrence associated with discontinuation necessitate intensive integrated psychiatric treatment. Continuation of treatment under strict haemodynamic observation may also be an option in some cases. Patients taking selective serotonin reuptake inhibitors (SSRIs) should be observed carefully for psychological instability and physical abnormalities, and clinicians should be aware of medications that could increase the risk of haemorrhage when used in combination with SSRIs. In these cases, a psychiatrist should be consulted. The same is true for patients taking antipsychotic or other antidepressant medication who develop psychological instability or have a systemic disorder. Given the widespread use ofpsychotropic drugs and the seriousness of the associated risks, it is recommended that the decision whether to continue or discontinue psychotropic medication should become a standard component of preoperative assessment.

[Lithium use and perioperative management]. / Lithiumgebruik en het beleid bij een operatieve ingreep.

A 62-year-old man presented with diminished consciousness, hypotension, hypoglycaemia and agitation. He had undergone heart surgery 1.5 weeks earlier. Due to a stroke as a postoperative complication, antihypertensive medication had been added. His lithium medication had been interrupted only on the first postoperative day. The presenting complaints were due to delirium as a result of lithium intoxication. The delirium faded away after interruption of the lithium medication and treatment with haloperidol and oxazepam. The patient and his family were informed as to the nature of the delirium and the precautions to be taken in case of any future disease or operation. Lithium should be discontinued preoperatively in all patients. If necessary, alternative psychiatric medication must be prescribed. After restarting lithium, the serum levels of lithium must be monitored.

[Guideline 'Delirium']. / Richtlijn 'Delirium'.

The Dutch Association of Psychiatry, together with the Dutch Association of Clinical Geriatrics and with methodological support from the Dutch Institute for Healthcare Improvement (CBO) has developed a guideline for the optimal diagnosis, treatment and prevention of delirium. Delirium is caused by somatic illness or the use of medication, drugs or alcohol. Delirium is common among the somatically ill admitted to a general hospital and is associated with increased morbidity and mortality. Important predisposing factors for delirium are: age > or =70 years, cognitive disturbances, sensory impairments, problems in daily activities, and the use of alcohol and opiates. Precipitating factors that may provoke delirium are: infection, fever, dehydration, serum electrolyte imbalance, polypharmacy, and the use of psychotropic medication, particularly anticholinergic drugs. Detection, diagnosis, and assessment of the severity of delirium are based on clinical examination, case history, observation, mental status examination including tests of cognitive function, and diagnosis of underlying somatic diseases. For daily practice, measurement tools are not necessary, nor are laboratory or imaging tests, such as electroencephalography. Haloperidol is the treatment of first choice for delirium due to somatic illness, except in patients with delirium due to drug use or medication, Parkinson's disease or Lewy body dementia. In cases of concurrent alcohol withdrawal syndrome, delirium may be treated with haloperidol and a benzodiazepine and B-vitamins. Medical and environmental interventions have been shown to reduce the incidence and duration of delirium.

[Chronic heart failure and depression: the limitations of specialization-specific multidisciplinary guidelines]. / Chronisch hartfalen en depressie: beperkingen van specialisme-specifieke multidisciplinaire richtlijnen.

Recently two monodisciplinary guidelines, 'Mood disorders' and 'Chronic heart failure', were upgraded to multidisciplinary guidelines in order to guarantee an appropriate long-term care trajectory for these patients. Neither guideline mentions clinically relevant interactions despite the extensive research in this area over the past decade. The guideline for chronic heart failure should include information on how to detect patients who are depressed or at risk of depression and that depressed patients are at risk of non-compliance with the cardiac treatment. In the guideline for mood disorders excess mortality and the need for combined treatment with cardiologists should be mentioned.

Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disorders.

Consultation-liaison (C-L) psychiatry has an important role in the management of somatoform disorders (SD). Characteristics of SD patients in C-L psychiatry are largely unknown and are presented in this paper. We analyzed 13,314 Dutch psychiatric consultations from 1984 to 1991 and compared patients diagnosed with SD to patients with other mental disorders and to those without a mental disorder. The comparison included socio-demographic variables, consult characteristics, medical history, current somatic morbidity, information about additional diagnostic tests, hospital admission time and aftercare management. Of the 544 SD patients 39.5% (n = 215) were diagnosed with a conversion disorder that illustrates the highly selected nature of SD patients in C-L psychiatry. Employment among SD patients decreased significantly from 58% in the group aged 20-29 years to 6% in the group aged 50-59 years. This decrease was significantly larger as compared to other mental disorders and no mental disorders and was virtually unaffected by correction for potential confounding by gender. Contrary to our expectation no difference between the three groups was observed in claims for disability benefits. Of the SD patients 74.5% were referred for aftercare management, significantly more than the other two groups which is considered a promising development in C-L psychiatry.

The INTERMED: a screening instrument to identify multiple sclerosis patients in need of multidisciplinary treatment.

OBJECTIVE: To analyse the value of the INTERMED, a screening instrument to assess case complexity, compared with the Expanded Disability Status Scale (EDSS) and the Guy's Neurological Disability Scale (GNDS) to identify multiple sclerosis (MS) patients in need of multidisciplinary treatment. METHODS: One hundred MS patients underwent INTERMED, EDSS, and GNDS examinations. Patient care needs were assessed by a multidisciplinary team and a goal oriented treatment plan was defined. Correlations between INTERMED, individual INTERMED domains, EDSS, GNDS sum score, and total number of proposed disciplines involved in the treatment plan were studied. RESULTS: Mean (SD) age was 40.6 (10.1) years. Median scores were 14.0 for the INTERMED, 4.0 for the EDSS, and 13.5 for the GNDS sum score. Moderate correlations were found between the INTERMED sum score and EDSS (r=0.59) and GNDS sum score (r=0.60). The number of disciplines as proposed by the multidisciplinary team showed the highest statistically significant correlation with the INTERMED sum score (r=0.41) compared with EDSS (r=0.32) and GNDS sum score (r=0.34). No significant or only weak correlations were found between the psychological domain of the INTERMED and EDSS or GNDS. CONCLUSION: The findings in this study show that there is an additional value of the INTERMED compared with the EDSS and GNDS in identifying MS patients in need of multidisciplinary treatment. The INTERMED domains show the area of the patient's vulnerability and care needs: especially the INTERMED's psychological and social domains may guide the clinician to deal with specific problems that complicate healthcare delivery.

Complexity of care and mental illness in medical inpatients.

We investigated the complexity of medical inpatient care to learn it was associated with the presence and type of mental disorders, and with emotional distress and somatization. Six indicators of care complexity, including length of stay (LOS), were assessed for 294 consecutive medical inpatients. Patients rated their own health and physical disability, and medical consultants assessed them for chronic and life-threatening diseases. A subsample of 157 patients was assessed for ICD-10 psychiatric diagnoses by means of an extensive semi-structured interview known as Schedules for Clinical Assessment in Neuropsychiatry (SCAN). With a few exceptions, the indicators of complexity of care were not statistically significantly associated to ICD-10 mental disorders; psychological distress, measured by the SCL-8 rating scale; or somatization, measured by the Whiteley-7 rating scale. On the other hand, four of six complexity indicators were significantly associated with self-rated physical disability or health, or both, when controlling for the severity of the medical condition. In conclusion, complexity of care, including LOS, was substantially associated with the patient's own health perception but only marginally with the presence of mental illness. This is noteworthy, as previously published results concerning the same patients have shown a clear association of mental illness with utilization of admissions to nonpsychiatric departments, and with utilization of primary care resources.

Mental disturbances and perceived complexity of nursing care in medical inpatients: results from a European study.

AIMS AND OBJECTIVES: The relationship between mental disturbances - anxiety and depression, somatization and alcohol abuse - on admission to internal medicine units and perceived complexity of care as indicated by the nurse at discharge was studied. The goal was to study the utility of short screeners for mental disturbances to select patients for case-management on admission. DESIGN: The study had a cohort design: patients were included on admission and followed through their hospital stay until discharge. The study was conducted within the framework of the European Biomed 1 Risk Factor study. RESEARCH METHODS AND INSTRUMENTS: In the first 3 days of admission the patients were interviewed by a trained health care professional, who scored the SCL-8D, a somatization questionnaire based on the Whiteley-7 and the CAGE. At discharge, nurses rated the complexity of the patient's care. RESULTS: Patients with high scores on anxiety and depression (SCL-8D) and on somatization received higher ratings on perceived nursing complexity than those with low scores, with and without control for age, severity of illness and chronicity. The actual nursing intensity and medical care utilization, as measured daily by means of a checklist, could not explain these relations. No differences were found between patients with high or low scores on alcohol abuse. CONCLUSIONS: The study shows a potential use of screeners for mental disturbances to detect patients for whom nurses might need additional help. However, mental disturbance is not the sole criterion: functional status and other variables that predict medical and nursing care utilization should be included in a screening strategy for case-management programmes.

Consultation-Liaison psychiatric service delivery: results from a European study.

The reported findings of the European Consultation-Liaison Workgroup (ECLW) Collaborative Study describe consultation-liaison service delivery by 56 services from 11 European countries aggregated on a C-L service level. During the period of 1 year (1991), the participants applied a standardized, reliability tested method of patient data collection, and data were collected describing pertinent characteristics of the hospital, the C-L service, and the participating consultants. The consultation rate of 1% (median; 1.4% mean) underscores the discrepancy between epidemiology and the services delivered. The core function of C-L services in general hospitals is a quick, comprehensive emergency psychiatric function. Reasons to see patients were the following. deliberate self-harm (17%), substance abuse (7.2%), current psychiatric symptoms (38.6%), and unexplained physical complaints (18.6%) (all means). A significant number of patients are old and seriously ill. Mood disorders and organic mental disorders are most predominant (17.7%). Somatoform and dissociative disorders together constitute 7.5%. C-L services in European countries are mainly emergency psychiatric services and perform an important bridge function between primary, general health, and mental health care.

Referral pattern of neurological patients to psychiatric Consultation-Liaison Services in 33 European hospitals.

The referral pattern of neurological patients to 33 European psychiatric consultation-liaison (C-L) services in the general hospital was examined. Analyses were conducted on the ECLW CS data set, which consists of 14,717 psychiatric C-L referrals made in 56 European hospitals during 1991. Psychiatric referrals of patients admitted to neurological wards were compared to referrals from other wards. Information was obtained from 33 neurological wards, consisting of 34,506 neurological admissions. Of these admissions, 839 were referred to C-L psychiatry. The median consult rate among the hospitals was 1.8%. Compared to other hospital wards, patients referred from neurology were more frequently diagnosed as suffering from somatoform (P<.01) and dissociative disorders (P<.01), and less from substance abuse (P<.01) and delirium (P<.01). Referral to C-L psychiatry from neurological wards is characterized by an underestimation of psychiatric co-morbidity and a late detection, comparable to other medical specialties. An appeal is made for a standardized referral procedure including admission screening method, detecting patients at risk for nonstandard care during their hospital admission.

Care complexity in the general hospital: results from a European study.

There is increasing pressure to effectively treat patients with complex care needs from the moment of admission to the general hospital. In this study, the authors developed a measurement strategy for hospital-based care complexity. The authors' four-factor model describes the interrelations between complexity indicators, highlighting differences between length of stay (LOS), objective complexity (such as medications or consultations), complexity ratings by the nurse, and complexity ratings by the doctor. Their findings illustrate limitations in the use of LOS as a sole indicator for care complexity. The authors show how objective and subjective complexity indicators can be used for early and valid detection of patients needing interdisciplinary care.

Risk factors for complex care needs in general medical inpatients: results from a European study.

The authors linked admission risk factors to a series of indicators for complex care delivery to enable detection of patients in need of care coordination at the moment of admission to the general hospital. The authors found 13 risk factors to be predictive of more than one indicator of care complexity. An admission risk screening procedure to detect patients in need of care coordination should focus on these risk factors and should include predictions made by doctors and nurses at admission and information collected from the patient and the medical chart.

COMPRI--an instrument to detect patients with complex care needs: results from a European study.

The authors developed a screening instrument to detect patients in need of complex care coordination at admission to a general hospital. On the basis of a series of risk factors for care complexity, the authors constructed a short, care complexity prediction instrument (COMPRI) and assessed its qualities. The COMPRI is an easily administered screening instrument that detects patients at risk for complex care needs for whom care coordination is indicated. COMPRI's predictive power exceeds all currently available case-mix instruments.

INTERMED--a clinical instrument for biopsychosocial assessment.

Using the INTERMED, a system for classifying case complexity, the authors evaluated patients admitted to a general internal medicine ward on length of stay (LOS), number of medicines prescribed during the hospital stay, and whether they had received specialist medical consults. Using the patients' INTERMED scores, the authors divided the patients into three clusters of patients: standard (n=41), chronic (n=26), and complex (n=18). A comparison of the three clusters indicated that patients who had scored within the complex cluster were at risk of requiring complex care and an increased LOS. The findings suggest that the INTERMED detects complex patients at admission and may, therefore, be used for early integral case management.