The psychodynamically oriented Consultation–Liaison Psychiatry Unit, University of Ioannina, Greece

Managing the referral 

Inpatients are assessed within 24 h from the referral (unless there is an emergency situation) after a meeting with the patient's physician, a nurse, and the patient's family member (if available) has been held. Special attention is given to the patient's willingness to accept a psychiatric evaluation and, unless the patient is unable to do so, all patients are interviewed in private in an office on the ward. After assessment, a second meeting with the patient's physician and/or other staff members takes place, a brief psychiatric impression and advice is written in the patient's medical record, and a written psychiatric report is given to the physician.

Details of patients' referral to the C–L Unit are recorded and entered into our electronic database, developed especially for the unit.1 This includes information on the following: demographics; reason and source of the referral; people interviewed; days of hospitalization; brief description of the patient's current state; medical, surgery, and medication history; family history; detailed psychiatric history; developmental and social history; legal problems; life events; current physical examination; main current laboratory findings; present mental state examination; and diagnostic impressions according to DSM-IV criteria (all Axes including GAF).

The database prints an answer sheet of a Psychiatric Consultation Note immediately after the data had been keyed in, which includes the main findings of the psychiatric assessment; our diagnostic impression and suggestions; a brief therapeutic plan; our recommendations regarding the patient's capacity or suicidality; goals, objectives, and risks of the suggested therapy; and possible side effects of the suggested psychopharmacological agents.

A follow-up appointment during the hospitalization or after discharge is programmed either with our service or with the other services of the local Community Mental Health network, if needed. In selected cases, a brief psychodynamic psychotherapy (up to 12 sessions) is offered by an experienced psychotherapist (T.H.).

The therapeutic management of the patient's personality is regarded as an integral part of psychiatric treatment [2], and a brief explanatory formulation of the patient's psychodynamic and personality assessment is also recorded, according to Glenn Gabbard's recommendations [3]. This formulation is mainly based on fundamental elements of the doctor–patient relationship (see Ref. [4]), on the patient's ability to be involved in a psychotherapeutic relationship, and on the examiner's impression concerning possible repetitions of past relationship patterns creating problems in the present.

All cases are discussed at the weekly meeting of all the members of the C–L staff, under the director's supervision. In selected cases, a grand round is scheduled in cooperation with the medical or surgical department in which the patient is hospitalized. Specific C–L groups focusing on oncology, rheumatology, and physical medical rehabilitation have also been developed. These groups consist of one resident, one psychologist, and one or two PhD trainees and aim to offer advice and support to the staff and supportive psychotherapy in severely ill hospitalized patients.

The database 

In addition to the details described above, doctors are requested to routinely record the Health of the Nation Outcomes Scale (HoNOS) score at referral and at discharge to measure the problems patients have when admitted to the hospital and to monitor to what extent these problems have diminished at discharge.

Approximately 15% of referrals are regarded by the C–L consultants to be patients with chronic, physical, and mental health needs who require complex management and detailed discharge planning. These patients are routinely assessed using Mini-Mental State, GHQ-28, SCL-90, and WHOQOL-BREF scales. Although, as a rule, we use generic measures to permit valid comparison among patients with different diseases, in selected cases (e.g., depression in older adults), disorder-oriented measures are also administered (e.g., the Geriatric Depression Scale).

The majority of the C–L doctors so far complied with filling out the database. All C–L doctors, however, admitted that they had difficulty in filling out the electronic database during emergency consultation, and some were reluctant, stating that it was a time-consuming extra load on their routine work. Our electronic database, though, allowed for integration of patient care, educational profiling, and analyses for research, providing a unique bridge between daily patient care activities and ongoing research efforts.

Our initial experience with HoNOS showed that ratings at the referral may serve as a baseline against which subsequent measures can be compared, particularly for patients with complex needs or severe problems. However, although the completion rates of HoNOS at referral increased from 29% the first year to 72% the first 6 months of 2008, more interdisciplinary training is needed to be implemented in our service to improve consistency in use of HoNOS rating scores.

Number of referrals 

As shown in Table 1, the referrals almost doubled 1 year after the establishment of the fully developed C–L Unit but remained relatively stable in the first 6 months of 2008, indicating possibly that there is a tendency to reach a plateau. The most frequent referrals were from the following departments: General Medicine (16%), Orthopedics (14%), Oncology (9%), General Surgery (6%), Neurology (6%), and Rheumatology (6%). Nearly 40% of the referrals were from departments with previous cooperation in research projects. The most frequent reasons for a referral were history of mental illness (16.7%), confusion/agitation (14.6%), depression (10.3%), and unexplained medical symptoms (8.2%). The most frequent psychiatric diagnoses were depression (28.5%), delirium (22.8%), schizophrenia (7.1%), and adjustment disorder (5.7%).

Table 1. Referrals before and after the establishment of the C–L Unit

		Total visits	New referrals	Follow-up visits	Registered in database (%)
	1991–1992	106	106	–	0
	Dec 2005–Dec 2006	658	284	374	0
	Dec 2006–Dec 2007	1149	483	666	43.7
	Jan 2008–June 2008	403	255	148	72.5

Training 

A 27-h course in “Psychosomatics” is offered in the fourth year of our Medical School. Training of the residents in Psychiatry is based on the recently published Guidelines for Training in the C–L Psychiatry and Psychosomatics [5]. Rotation to C–L Unit, for 9 months, occurs during the second part of the residency. Residents are expected to perform at least 150 referrals during this rotation. Clearly designated individual supervision of residents is organized—once per week with each consultant and once every second week for psychodynamic supervision for continual care of patients seen in wards.

Research 

A number of research projects have been developed, focusing mainly on aspects of psychological distress in chronic medical conditions (e.g., inflammatory bowel disease [6], rheumatic diseases [7], [8], [9], diabetes [10], or glaucoma [11]). Studies on the decision-making preferences of cancer patients and risk factors associated with postpartum depression have been recently added to the research, the latter being funded by EU-European Social Fund and the Greek Ministry of Development.

New initiatives 

We are planning to perform more general educational activities, aiming to reduce the stigma of mental illness and change the hospital staff's attitude toward the mentally ill. Extension of the availability of follow-up psychotherapy with cognitive therapy is one of our priorities, following proper staff training. We have also started to develop mutual educational and clinical activities with the recently established Mobile Psychiatric Unit in order to achieve better continuity of care and promote mental health in primary care.

Specific features of this C–L service are the psychodynamic approach, the meetings with the patient's physician and patient's family members, the regular staff meetings, and the database. In these ways, we hope that our C–L service helps to avoid the separation of medical and psychiatric services and to promote a “holistic” approach to medicine.