St George's Hospital Medical School, London, UK
Correspondence: Dr John F. Morgan, Department of Psychiatry, St George's Hospital Medical School, Jenner Wing, Cranmer Terrace, London SW17 ORE, UK. Tel: 020 8725 5565; fax: 020 8725 3350; e-mail: jmorgan{at}sghms.ac.uk
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To repeat the study after 16 years of liaison psychiatry.
Method Anonymous, confidential questionnaires were distributed to doctors at St George's Hospital, London, replicating the original study.
Results Most of the 225 respondents believed that psychological factors could influence physical prognosis and should be routinely assessed, with greater sense of responsibility for overdoses and dying patients. Most respondents found emotional assessment impractical. Although 78% wanted more psychiatric input, referrals were avoided because of stigmatisation. Men were more likely than women to hold pejorative views, but outcomes no longer varied with seniority or speciality.
Conclusions Compared with 1986, hospital doctors appear more aware of the psychological needs of patients.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Statistical analysis
Descriptive statistics were recorded for questions and univariate
comparisons were performed using chi-squared or Fisher's exact tests as
appropriate. Statistical significance was set at the 5% level.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
General attitudes
Hospital doctors' attitudes to psychological factors
(Table 1) show heightened
awareness of the relevance of these factors compared with 1986. In addition,
95% saw the emotional care of patients as being a key element of their work.
In this sample, there was evidence of the enhanced role of nurses in managing
social and emotional difficulties of patients.
|
In addressing responsibility for management of common problems (Table 2), there appeared to be a greater sense of responsibility for the emotional care of dying patients and for overdoses than was found in Mayou & Smith's sample. More than three-quarters held the view that they had primary responsibility for acute confusional states and the emotional care of dying patients, and over half for overdoses, with less sense of responsibility for depression, alcohol misuse or behavioural disturbance.
|
Time constraints and assessment
Doctors' time was more constrained than in the original study and this
affected the capacity to conduct biopsychosocial assessments, despite
awareness of their relevance (Table
3).
|
Treatment
The majority of respondents felt that hospital doctors should be able to
make use of simple psychological methods, with greater use of behavioural
therapies. There was greater use of antidepressants
(Table 4), and selective
serotonin reuptake inhibitors were the most commonly cited drugs of choice,
with amitriptyline also used. Two respondents suggested the use of diazepam as
an antidepressant. In the 1986 study the most commonly used antidepressants
were amitriptyline and mianserin. Similarly, most had treated insomnia,
generally favouring short-acting benzodiazepines, as well as sedating
tricyclic antidepressants and zopiclone.
|
Respondents who had treated acute alcohol withdrawal (48%) in the current study favoured the use of benzodiazepines over clomethiazole, and those who had treated anxiety disorders (40%) tended to use benzodiazepines or beta-blockers. Acute confusional states had been managed by 46% of the sample, by treating the underlying cause and using traditional neuroleptics such as haloperidol when necessary. Although 21% had experience of treating psychoses with neuroleptics, only three respondents cited experience of atypical antipsychotic drugs.
Attitudes to psychiatry and barriers to referral
There appeared to be a greater desire for and interest in liaison
psychiatry (Table 5). Reasons
for not referring patients to psychiatric services were similar to those cited
in Mayou & Smith's study. The most common reason was the belief that
patients dislike referral, followed by fear of stigmatising patients by
psychiatric referral. The perceived ineffectiveness of psychiatric
interventions was a lesser consideration. As in the earlier study, we received
comments requesting greater input from senior psychiatrists. Psychiatrists'
insistence on the exclusion of organic causes of disordered behaviour was also
a source of adverse comment.
|
Pattern of replies
Differences emerged in responses based on gender. Male doctors were far
more likely than female doctors to limit themselves to physical examination,
even when psychological factors appeared to be an important cause
(21=8.56, P=0.003), and to perceive
psychiatrists as having little to offer in a general hospital
(
21=8.01, P=0.018). Men were less likely
to find that the variety of emotional and social care enhanced their work
interest (
21=3.95, P=0.047). None of these
outcomes differed significantly on the basis of seniority or speciality.
In contrast with 1986, there were few significant differences based on speciality (Table 6).
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Limitations of the study
This study has four principal limitations. First, it is difficult to
extrapolate from the results of a questionnaire to clinical practice. The
results of this study may represent the effects of normative social influence
and respondents' wishes to make a good impression, rather than true clinical
procedure. This form of response bias is technically known as social
desirability bias and future studies might address it by use of lie
scales. Second, the study was conducted at a single centre, and the findings
may not apply to other hospitals. Third, because it was not possible to
replicate precisely the questionnaire used by Mayou & Smith, responses to
questions based on the original questionnaire might have been influenced by
factors such as the order of questions. As a result, comparisons between the
two studies are qualitative and not quantitative. Fourth, it is regrettable
that the study was not repeated in the original hospitals.
Differences between 1986 and 2001
Awareness of the relevance of psychological factors to medical and surgical
patients contrasts with the findings of Mayou & Smith. Differences between
the two samples could be explained by three elements. First and most
optimistically they might represent a genuine shift in the culture of
the medical profession. Over the intervening 15 years the undergraduate
curriculum has moved towards a focus on biopsychosocial constructs of disease
and the value of doctorpatient communication. For example, the General
Medical Council (1993) has
stressed the importance of medical students learning how to carry out a mental
state examination. That so many respondents acknowledged the impact of
psychopathology on prognosis may exemplify the fruits of these labours in
terms of knowledge of psychiatry, although elsewhere there is little evidence
that undergraduate education improves attitudes to psychiatry
(Calvert et al, 1999).
In this sample, women were far more likely than men to recognise the relevance
of psychological factors, the value of liaison psychiatry input and the
contribution of emotional care to their job satisfaction. At present, 58% of
applicants and 59% of successful entrants to medical school are women
(Moore, 2002). Thus, some
differences between 1986 and 2001 may simply represent the increasing
proportions of women in the National Health Service (NHS) workforce.
Second, the differences between the two studies might indicate the influence of a liaison psychiatry service on the institution it serves, generating heightened awareness of unmet need among surgeons and physicians (Benjamin et al, 1994; Storer, 2000). However, this is an unlikely explanation. In 1986, Oxford was already leading the way in psychological medicine, with the first full-time consultant liaison psychiatrist in Britain, and so this is unlikely to provide a comprehensive explanation of differences.
Third, differences might be an artefact of institutional differences between St George's Hospital in 2001 and Mayou's sample of Oxford hospital doctors in 1986. This seems possible, but not probable, with no reason to expect major cultural differences between the two teaching hospitals.
In conclusion, the most plausible explanation of differences between the two studies lies in genuine changes in hospital doctors' attitudes to and knowledge of psychological problems.
Attitudinal homogeneity
Whereas the 1986 study found widely differing views regarding psychosocial
care, our study found greater attitudinal homogeneity. In particular, in the
earlier study consultants were less likely than their juniors to see
psychiatric referral as serving a useful purpose, and junior doctors were less
likely to see emotional problems as part of the hospital doctor's job.
Differences between consultants and their juniors did not emerge in the 2001
survey, nor did differences between surgeons and physicians. There appears to
be a shrinking minority of hospital doctors who focus on the physical
complaint to the exclusion of relevant psychosocial factors.
An enhanced sense of responsibility for the management of overdoses may reflect the continued rise in rates of deliberate self-harm since the 1980s to the point where self-harm (most commonly manifest as overdose) is one of the top five reasons for acute medical admission (NHS Centre for Reviews and Dissemination, 1998). In contrast, the relative neglect of depression is consistent with the time constraints of hospital medicine, given that almost all respondents desired more time to communicate effectively with patients and over half felt unable to address emotional factors under the current limitations of the NHS.
Barriers to psychiatric treatment
The fear of stigmatising patients by providing psychiatric input was the
exception to this trend towards better management of patients' psychological
needs, and this is consistent with attitudes in the community reported in this
journal (Byrne, 2001; Crisp, 2001). Pejorative
attitudes to mental disorders among some obstetricians and gynaecologists have
previously been reported (Morgan,
1999), and male gender appears to generate pejorative attitudes in
this study. The perception of the ineffectiveness of psychiatric interventions
and concerns over stigmatisation provide two more barriers to adequate
psychiatric care. However, the greatest barrier to treatment seems to be the
lack of time to communicate and evaluate the psychological needs of
patients.
Psychotherapy and pharmacotherapy
The widespread use of listening, reassuring and discussing anxieties by
hospital doctors was heartening, as the claim of a substantial minority to
practise behavioural methods was unexpected. The study did not
address the detail of these interventions, but at the very least this seemed
to indicate an awareness of cognitivebehavioural therapy and its
efficacy. It also contrasted with the results of the original survey, in which
hospital doctors appeared to rely on pharmacological rather than psychological
treatments. The move towards the prescription of selective serotonin reuptake
inhibitors reflects national prescribing habits, but this was not matched by
use of atypical antipsychotic drugs despite their particular value in the
medically unwell population.
The national context
Given that the doctors who responded to the questionnaire appeared to
appreciate the psychological needs of their patients and yet reported
insufficient time to meet those needs, it was unsurprising that the vast
majority of respondents desired greater psychiatric input. Well-developed
liaison psychiatric services permit health care trusts to achieve essential
performance indicators and offer financial savings in excess of the cost of
liaison psychiatric services, known as the cost-offset effect
(Royal College of Physicians & Royal
College of Psychiatrists, 1995). Properly resourced liaison
psychiatry services are central to the promotion of mental health among
medical and surgical patients, and physicians and surgeons appear to
acknowledge that this facet of hospital care is a key element of a
high-quality health service.
This study implies that hospital doctors have increased their aspirations to provide biopsychosocial care of medical and surgical patients over the past 16 years. Physicians and surgeons have greater awareness of their patients' psychiatric requirements. Most hospital doctors would like more contact with psychiatric services. This provides a powerful argument for the further development of liaison psychiatry services.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Byrne, P. (2001) Psychiatric stigma.
British Journal of Psychiatry,
178,
281-284.
Calvert, S. H., Sharpe, M., Power, M., et al (1999) Does undergraduate education have an effect on Edinburgh medical students' attitudes to psychiatry and psychiatric patients? Journal of Nervous and Mental Disease, 187, 757-761.[CrossRef][Medline]
Crisp, A. H. (2001) The tendency to stigmatise.
British Journal of Psychiatry,
178,
197-199.
General Medical Council (1993) Tomorrow's Doctors. Recommendations on Undergraduate Medical Education. London: GMC.
Lloyd, G. G. (1993) Psychiatry in general medicine. In Companion to Psychiatric Studies (5th edn) (eds R. E. Kendell & A. K. Zealley), p. 790. Edinburgh: Churchill Livingstone.
Lloyd, G. G. (2001) Origins of a Section:
liaison psychiatry in the College. Psychiatric
Bulletin, 25,
313-315.
Mayou, R. & Smith, E. B. O. (1986) Hospital doctors' management of psychological problems. British Journal of Psychiatry, 148, 194-197.[Abstract]
Mezey, A. G. & Kellett, J. M. (1971) Reasons against referral to the psychiatrist. Postgraduate Medical Journal, 47, 315-319.[Medline]
Moore, W. (2002) BMA negotiator calls for more
male medical students. BMJ,
324, 754.
Morgan, J. F. (1999) Eating disorders and gynaecology knowledge and attitudes among clinicians. Acta Scandinavica Obstetrica et Gynecologica, 78, 233-239.
NHS Centre for Reviews and Dissemination (1998) Deliberate self-harm. Effective Health Care, 4, 1-12.
Royal College of Physicians & Royal College of Psychiatrists (1995) The Psychological Care of Medical Patients. Recognition of Need and Service Provision. Council Report CR35. London: Royal College of Psychiatrists.
Shepherd, M., Cooper, B., Brown, A. C., et al (1966) Psychiatric Illness in General Practice. London: Oxford University Press.
Storer, D. (2000) Liaison psychiatry in the accident and emergency department. In Liaison Psychiatry. Planning Services for Specialist Settings (eds R. Peveler, E. Feldman & T. Friedman), pp. 14-26. London: Gaskell.
Received for publication May 23, 2002. Revision received September 26, 2002. Accepted for publication October 10, 2002.