Psychiatric Referrals from Medical and Surgical Wards

Abstract

The practice of psychiatry in general hospitals is increasing and some of the problems it raises have been widely discussed. Many administrative questions have received close attention (Bennett et al., 1956; Smith, 1961) and the advantage to psychiatric patients of having readily available medical, surgical and laboratory facilities has been clearly seen (Gillies, 1959). It has been shown, too, that patients with mental illness can be admitted to beds in medical wards and be treated there successfully (Brook and Stafford-Clark, 1961). On the other hand, much less attention has been given to the psychiatric requirements of the general hospital itself, and there is very little information about the use that physicians, surgeons and specialists are likely to make of a psychiatric service for their own in-patients. Studies of psychiatric morbidity among general ward patients (Mittelmann et al., 1945; Zwerling et al., 1955) are of great interest, but they tend to shed an artificial light on the problems of practical needs and probable demands. Shepherd, Davies and Culpan (1960) have provided the most useful report so far, on the incidence of psychiatric referrals by physicians and surgeons and the clinical conditions encountered. This was the result of a one-year work-study specially set up for the purpose of investigating these questions at a general hospital in London. However, there appears to have been no account of findings based on the routine work of a hospital where a psychiatric unit has been well established.

Thirty years of in-patient consultation-liaison psychiatry at Guy's

“…This finding is consistent with both earlier surveys of 20 (Anstee, 1972) and 30 years ago (Fleminger et al 1962) when 'specialist medicine' (which included dermatology, venereology and neurology) produced the greatest number. This suggests it is an appropriate target for the development of a 'special relationship' with closer cooperation between neuroclinician and psychiatrist.…”

“…Organisation of the service Only two consultants ran the service 30 years ago and saw most of the patients themselves with a very much smaller workload of referrals (60 per year v. 148 today) (Fleminger et al 1962). The advantages of a smaller service, allowing it to be consultant-led and facilitating data collection, may be offset by the lack of opportunities to train juniors and to develop closer 'outreach' liaision with particular other services.…”

“…The first general hospital to admit what were then called lunatics was Guy's in 1728 (Mayou, 1989) and one of the earliest and deliberately planned consultation-liaison services was established there by StaffordClark in the 1950s (Fleminger & Mallett. 1962) and re-surveyed in the late 1960s (Anstee, 1972).…”

Reasons against referral to the psychiatrist

“…Davies (1964) estimated that eighteen out of 100 medical out-patients and ten of surgical out-patients needed to see a psychiatrist. Fleminger & Mallett (1962) suggest that surgeons may be more tolerant of psychiatric abnormality, and the shorter stay of surgical patients gives less chance for psychiatric illness to become apparent. They found that two-thirds of surgical referrals had major psychiatric disturbance compared with a quarter of the total sample, supporting their contention that surgeons only refer the serious psychiatric problems.…”

“…Percentage of psychiatric Specialty morbidity (or of Percentage of referrals 'functional disorders') to the psychiatrist General medicine 43-5 (Pemberton, 1951) 14 (Fleminger & Mallett, 1962) 38-51 (Culpan & Davies, 1960 3-8 (Kenyon & Rutter, 1963) 16-2 (Priest, 1962 04-2-8 (Bridges, Koller & Wheeler, 1966) 26 (Maclay, 1965) 4'2 (Crisp, 1968) 14 (Forsyth & Logan, 1968) Neurology 5 (Jacobs & Russell, 1961) 4-6 (Crisp, 1968 General surgery 5-21 0-16 (Fleminger & Mallett, 1962) 0-37 (Kenyon & Rutter, 1963) 2 (Crisp, 1968) …”