| Abstract|| |
Aim: The aim of this study was to evaluate the consultation-liaison psychiatry (CLP) training and services in India.
Methodology: An online survey was conducted involving at least one faculty member from the department of psychiatry working in various institutes providing postgraduate training in psychiatry.
Results: A total of 90 faculty members from different postgraduate institutes across the country participated in the online survey. In three-fourth of the institutes, the CLP services were provided in the form of on-call services with a three-tier system (i.e., CLP team comprising of faculty member, a senior resident, and a junior resident) existing in only about one-third of the institutes. In majority (60%) of the institutes, junior resident was the first-line person responding to the call of other specialists. On an average, CLP teams receive 7.33 calls per day from various clinical departments with a range of 0–20. Among the three most common psychiatric syndromes seen in CLP setting, delirium figured as one of the three most common diagnoses among 79 (87.8%) institutes, and this was followed by substance use disorders (70%), self-harm (60%), and depression (38.9%). Specific CLP posting for junior and senior residents exists only in 28.9% and 12.2% of the institutes, respectively. Joint academic activities with other departments are conducted in 42.2% of the institutes. Regarding research, very few research projects are carried out in the area of CLP. Majority of the participants felt that CLP should be given equal importance or more importance than other subspecialties such as child psychiatry, addiction psychiatry, and geriatric psychiatry in postgraduate training programs. Almost all the participants felt that having good knowledge of CLP helps in managing psychiatric patients in better way. All the participants reported that improving focus on CLP psychiatry will help in reducing stigma attached to mental illnesses and improve the training of postgraduates and the undergraduates.
Conclusions: There is a need to improve the CLP services, training program, and research in various medical institutes to provide good mental healthcare to medically ill patients.
Keywords: Consultation-liaison, practice, psychosomatics, survey
|How to cite this article:|
Grover S, Avasthi A. Consultation-liaison psychiatry services: A survey of medical institutes in India. Indian J Psychiatry 2018;60:300-6
| Introduction|| |
Physical illnesses of any kind are often associated with significant emotional and social consequences for both patients and the caregivers. The psychosocial consequences often are severe enough to manifest as various psychiatric syndromes. The presence of mental disorders, such as depression in physically ill people, like those suffering from myocardial infarction is often associated with poor medication compliance, slower or incomplete recovery, poor participation in the rehabilitation program, and increased mortality. However, mental disorders in physically ill are underrecognized. Accordingly, mental health professionals have a big role to play in providing holistic care to people with various physical illnesses.
The consultation-liaison psychiatry (CLP) is a subspecialty of psychiatry that provides psychiatric treatment to patients attending general hospitals. Therefore, it deals with the interface between physical and psychological health. Lipowski defined CLP as a subspecialty of psychiatry that involves providing clinical service, teaching and carrying out research at the borderland of psychiatry and medicine. CLP is considered to have contributed significantly in moving psychiatry from the bounds of mental asylums to general hospital setting, has helped enormously in reducing the stigma associated with mental disorders among general public and medical professionals too, and has brought psychiatry in parallel to the advances of medicine.
In India, with the establishment of General Hospital Psychiatric Units (GHPUs), CLP as a subspecialty started as early as 1930. However, the GHPU movement took a major leap forward from 1960s onward, and at present, most of the psychiatry facilities are available in GHPU setups. A survey conducted in mid-80s showed that about three-fourth of the postgraduate training centers in India were in GHPUs. At present, as per the Medical Council of India (MCI), 184 and 59 centers are providing MD Psychiatry and Diploma and Psychological Medicine (DPM) training, respectively. Besides, a handful of exceptions, almost all postgraduate psychiatry training in India are in GHPUs. Considering the fact that in the past 50 years, most of the postgraduate training in this country is done in the GHPUs, it was expected that CLP as a subspecialty, should have by this time become the most developed subspecialty. However, in this context, compared to many Western countries, CLP as a subspecialty in India has lagged behind. CLP received accreditation as a subspecialty in psychiatry as “Psychosomatic Medicine” in the United States in 2003. European countries have also not lagged behind, and at present, there are well-established training guidelines with respect to CLP in the United States and Europe., Research in CLP from India is also meager when compared to the developed countries. In fact, very little information is available regarding practice and training in CLP in India. Hence, there is a need for appraisal of CLP services and training in India. Accordingly, this survey aimed to evaluate the CLP training and services in India.
| Methodology|| |
This online survey was conducted using Survey Monkey platform. The list of teaching and training department of psychiatry was obtained from the MCI website for MD and DPM courses. For the Diploma of National Board (DNB), the list of institutes was obtained from the website of the National Board of Examinations. The survey received Ethical Clearance and exemption from the Institute Ethics Committee. For this, a survey link was sent by E-mail to one of the faculty members from each teaching and training department of psychiatry in the country. In case, after four reminders, a particular faculty member from a particular institute did not respond, then the name of that faculty member was substituted by another faculty member from the same institute. The invitation mail clearly stated that the participation in the survey was completely voluntary, and the recipients of the E-mail had an option to “opt-out” in case they did not intend to receive the reminders and participate in the survey. All the responses were checked for the name of the institute and only responses from the institutes which have a postgraduate training program were retained for the analysis.
The survey questionnaire was self-designed and included 36 questions, covering the basic information about the participant, operative service model, training practice, research, acceptance of psychiatric services by other specialists, perception about CLP among the participants, and the final open-ended question enquired about suggestions to improve CLP services and training at their center.
| Results|| |
Out of the 174 institutes contacted, responses were received from 90 (51.7%) institutes. Majority of the responders were working as assistant professor (n = 33; 36.7%), and this was followed by professor (n = 28; 31.1%), associate professor (n = 22; 24.4%), and additional professors (n = 3; 3.3%), and lecturer (n = 4; 4.4%). Among the professors, 19 (21.1%) were also the head of the departments. On an average, the faculty members who responded had spent mean of 7.52 (standard deviation [SD] 6.42; range 0.3–30), and a median of 5 years in the department. Majority of the institutes from which the response was received were providing MD course (n = 64; 71.1%) or both MD and DPM courses (n = 21; 23.3%). Few institutes were providing only DNB course (n = 3), DPM course only (n = 1), and both DPM and DNB courses (n = 1). The mean number of intake of students per year in these institutes was 3.44 (SD = 3.63; median = 3) for the MD courses and 2.52 (SD = 2.42; median = 2) for the DPM courses.
Operative service models
In three-fourth of the institutes, the CLP services were provided in the form of on-call services, in which on receiving a communication from the medical/surgical team a member from the Department of Psychiatry attended the calls. In one-fifth of the institutes, there were no on-call services, and in case, a patient required psychiatric help, the patient was brought to the psychiatry outpatient services. In very few institutes, the psychiatrist was posted in the emergency outpatient services or was part of the medical/surgical outpatient services. In one of the institute, the setup was not attached to medically ill patients. In about two-third or more centers, a faculty member, a senior resident, and a junior resident was part of the CLP team. In few institutes, psychiatric social worker, clinical psychologist, and psychiatric nurse also formed part of the CLP team. However, a three-tier system (i.e., CLP team comprising of faculty member, a senior resident, and a junior resident) existed in only about one-third of the institute. In majority (60%) of the institutes, junior resident was the first line person, who was responsible for attending the patient on receipt of the call. In about one-fifth (21.1%) of the institutes senior resident was the first person and in another one-fifth (18.9%), faculty member was the first-line respondent. The specific mechanism for follow-up was available in only 40% of the institutes. In only about one-sixth (16.7%) of the institutes, there is a specific designated consultant for looking after the administrative issues of CLP services, and in only 4.4% institutes there are faculty members who work exclusively in the area of CLP. In one-third of the institutes (34.44%), the CLP team maintains a separate treatment records of the patients for their use, besides documenting the clinical details in the primary treating team. On an average, CLP teams receive 7.33 calls per day from various clinical departments with a range of 0–20.
When asked to report three most psychiatric diagnoses seen among medically/surgically ill patients at your center, delirium figured as one of the three most common diagnoses among 79 (87.8%) institutes and this was followed by substance use disorders (70%), self-harm (60%), and depression (38.9%) [Table 1].
|Table 1: Service and administrative models for providing consultation-liaison psychiatry services|
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Training in consultation-liaison psychiatry
Regarding CLP training, specific CLP posting is available for the junior residents in about one-fourth (28.9%) of the institutes and for senior residents in only 12.2% of the institutes. Among the institutes where the CLP posting for junior resident is available for 16 institutes it ranged from 15 days to 2 months. In only 10 institutes, the posting was for 3 months or more for the junior residents. The clinical posting for senior residents also varied from 15 days to 6 months with 3–6 months available in only 6 (6.66%) institutes. In about half (47.8%) of the institutes, the CLP work of junior residents was supervised by both senior resident and the faculty. Joint academic rounds involving psychiatry department and other medical-surgical departments were occurring in 42.2% of the institutes, with case discussion being the most common activity. In about three-fifth (57.8%) of the institutes, postgraduate trainees from other departments were also posted in psychiatry for exposure and training in psychiatry. Regarding training of graduate students, at most places, psychiatry training was done at the outpatient level with only one center providing training to graduate students in the CLP setting [Table 2].
Research in consultation-liaison psychiatry
The mean number of research projects carried out by the faculty members from psychiatry as the principal investigators were 1.28 per year with a range of 0–6. Regarding the number of thesis/dissertations, 1.3 thesis per year with a range of 0–5 [Table 3].
Acceptance of Psychiatric Services by other Specialists
Regarding sensitivity of the physicians and surgeons toward the psychological aspects of medically ill patients, about half of the participants rated it as average, and one-third of the participants rated it as good. Regarding acceptance of advice given for psychological aspects of medically ill patients, about half of the participants rated is as good [Table 4].
Perception about consultation-liaison psychiatry among the participants
When the participants were asked to compare the importance to be given to CLP in training, most of the participants suggested that it should be given either equal importance or more importance than other subspecialties such as child psychiatry, addiction psychiatry, and geriatric psychiatry. Very few participants considered that CLP should be given less importance than these subspecialties. Regarding personal interest, 80% of the participants rated it as “somewhat” and only about one-fifth (18.9%) rated it as “very much.” The majority (70%) of the participants felt that having good knowledge of CLP, “definitely” helps in managing psychiatric patients in better way and another one-fifth (22.2%) rated it as “to a large extent.” All the participants reported that improving focus on CLP psychiatry will help in reducing stigma attached with mental illnesses and three-fourth (74.4%) of the participants rated it as “to a large extent,” and another one-fourth rated it as “to some extent.” Almost all participants agreed that improving the focus on CLP at their center can help in improving the training of postgraduates and the undergraduates. When asked about the trainees and the participants own rating of CLP services at their center, majority of the participants rated it as average or good [Table 5].
|Table 5: Perception about consultation-liaison psychiatry among the participants|
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How consultation-liaison psychiatry training can be improved
At the end by using an open-ended question, participants were asked as to how CLP training and services can be improved at your center. Some of the common suggestions which emerged were having dedicated CLP team, maintaining separate records, carrying out more research, training the faculty and students by conducting regular continuing medical education programs with other medical and surgical specialties including psychiatry as a separate subject in undergraduate training, improving the focus of psychiatry faculty on CLP, sensitizing medical/surgical professionals on the importance of psychological well-being of patients, having more academics on CLP, having more joint academic discussions with other specialties, compulsory emergency, medicine and surgical posting for psychiatry trainees, psychiatrists taking lectures for specialists in other departments, developing good relationships with other departments, reviewing the services from time to time, separate consultants for administrative issues of CLP, and having more manpower.
| Discussion|| |
Over the last four decades or so, CLP has emerged as an important subspecialty of psychiatry, which provides holistic care based on the biopsychosocial model, which takes into consideration the inter-relationship between the physiology, psychology, and sociology of human ill health. Despite all this, CLP is not the main focus of training in India. As there is lack of previous data from various parts of the country, it is not possible to compare the findings of the present survey with existent literature.
The present survey suggests that there is marked heterogeneity in the organization of CLP services, training, and research in India. Although the CLP on-call services are available in three-fourth of the institutes, CLP services are provided only at the outpatient level in one-fifth of the institutes, and true liaison model is available in occasional institutes. Only in one institute trainee psychiatrists are posted in the emergency setting. These findings suggest that although over the years consultation model of CLP has evolved in this country, this has not gone beyond to true liaison model. This is in contrast to many developed countries which have well developed CLP services based on the liaison model.
When the composition of CLP teams was evaluated, CLP team with psychiatrists and other professionals such as clinical psychologists, social workers, and nurses are seen in few institutes. From training perspective, three-tier CLP teams are operative only in one-third of the institutes. These findings possibly suggest that lack of manpower in different institutes to organize good CLP services. Studies from some of the western countries also suggest staffing constraints.,
At most of the institutes, there was no specific mechanism available to follow-up the patients after the initial consultation. Majority of the centers lack designated consultant for administrative issues of CLP services, faculty members exclusively working in the area of CLP, and maintenance of separate records for patients seen by the CLP services. Further, at most places, there is no specific CLP clinical posting for the residents, which implies that these services are provided concurrently with other competing services and priorities for the residents. These competing interests can seriously influence the quality of services provided. At few places, the trainee is also not supervised for the services provided. These findings suggest that although the inpatient CLP services are available in many centers in this country; these services are not well staffed and not equipped to run good quality CLP services. Accordingly, there is an urgent need to strengthen the CLP services across the country to provide better care. Regarding academic and research activities, there is heterogeneity across various centers regarding academic activities and research activities. This heterogeneity across the various institutes may not be limited to CLP only but may be exemplification of overall teaching and training programs across the country.
Regarding number of calls received per day, it is apparent that at most centers, there is sufficient number of referrals to have CLP services.
However, at the majority of the places, the physicians and surgeons are sensitive to psychological aspects of medically ill patients and accept the advice given by the CLP team. This finding suggests that, better organization of services are required to further enhance the services and if the services are better organized, there are no barriers to the acceptance of these services.
Regarding the comparison with other subspecialties of psychiatry, majority of the participants, although who themselves were not very much interested in CLP, rated the importance to be given to CLP in the training program to be as much or more than other subspecialties such as child psychiatry, addiction psychiatry, and geriatric psychiatry.
Regarding suggestions, many of the participants agreed that there is a need to have dedicated CLP team, improve focus on CLP, sensitizing medical/surgical professionals on the importance of psychological well-being of patients, developing good relationships with other departments, and auditing the services from time to time. It is important that all the institutes start implementing these suggestions, to improve the organization of CLP services.
| Conclusions|| |
This survey suggests that there is significant variance across the various training centers in this country regarding the organization of CLP services. These findings also support the previous observation of lack of specific philosophy or particular context in which CLP is being practiced in this country. If this issue is not addressed properly, it can have detrimental effect on training of psychiatry and the quality of psychiatrists which are produced in this country.
In India, CLP has never been the main focus of training of postgraduate students at most of the centers. Considering the fact that now more and more psychiatrists are entering into the private practice and joining multispecialty hospitals, after finishing their training, training in CLP assumes importance. For psychiatrists working in multispecialty hospital, a significant proportion of their patients will be from the referrals received from other specialists. Further, a significant proportion of patients with primary psychiatric disorders also have comorbid medical illnesses. Use of various interventions in such a scenario is not the same as seen among those without medical comorbidities. Accordingly, the young psychiatrists who are deficient in the skills of providing CLP services may not be able to gel with the services. Hence, CLP needs to be given due importance in the training programs across the country.
This survey has certain limitations. The survey was answered by one of the faculties from half of the institutes and information is not available about other half of the institutes. It is quite possible than the faculty members from these institutes did not answer the survey because of some semblance of services at their center. In the present survey, more than half of the participants rated that the CLP services at their center as “average” according to their own perception and how the services are rated by the trainees at their own center. The perception about trainees as reported by the participants can be biased by their own opinion. Very few institutes with DNB training participated. Accordingly, the findings may not be a true reflection of the status of CLP services and training in institutes providing DNB training. The survey was limited to the institutes providing postgraduate training, and the findings of the survey cannot be generalized to the institutes having CLP services, but no postgraduate training program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Prof. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]