|Year : 2013 | Volume
| Issue : 4 | Page : 359-365
Origin and development of general hospital psychiatry
Daniel Saldanha, Labanya Bhattacharya, Devjit Daw, Bhushan Chaudari
Department of Psychiatry, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||17-Sep-2013|
Padmashree Dr. D.Y. Patil Medical College, Pimpri, Pune - 411 018
Source of Support: None, Conflict of Interest: None
General hospital psychiatry has grown significantly over the years. It has led to the changes in our understanding to provide a comprehensive and holistic approach to the physically and mentally ill. The developments in the West and in India have been traced with an attempt to understand and appreciate the evolving patterns of referral in facilitating the management of the mentally ill in a holistic manner.
Keywords: Consultation liaison psychiatry, general hospital psychiatry unit, psychosomatic medicine
|How to cite this article:|
Saldanha D, Bhattacharya L, Daw D, Chaudari B. Origin and development of general hospital psychiatry. Med J DY Patil Univ 2013;6:359-65
| Introduction|| |
Treatment of the medically ill has been carried out in hospitals since ancient Greco-Roman times while the mentally ill have been cared for in asylums, sanctuaries and the likes. The segregation of the mentally ill from general population, including other patients persisted until modern times when across the Atlantic, the opening of Pennsylvania Hospital in Philadelphia in 1751 provided treatment for persons "Distemper'd in Mind and depriv'd of their rational Faculties". Pioneering American physicians of 19 th century believed in the psychosomatic unity of the human being and many cases of mental illness were treated in general hospitals. Consequently, practice of referrals for psychiatric patients in general hospitals took a turn for the better. The evolution of the referrals of psychiatric patients in United States has been described in four distinct phases : (0 i) The preliminary phase (1900-1930), was stimulated primarily by the opening of the early psychiatric departments in general hospitals. (ii) The pioneering phase (1930-1950), featured special consultation-liaison educational programs in university hospitals. (iii) The developmental phase extended from 1980 and was characterized by the growth of consultation-liaison programs that included research and training programs for medical students and residents. (iv) Consultation-Liaison (C-L) Psychiatry-The phase of consolidation or retrenchment. 
According to Lipowski, the term C-L psychiatry reflects two interrelated roles of the consultants, i.e., 'consultation' refers to an expert opinion regarding the diagnosis and advice on the management of the patient's mental state at the request of another medical consultant and the term 'Liaison' is essentially an effective collaboration between the two consultants. In C-L psychiatry, 'liaison' involves mediation and interpretation, i.e., consultant psychiatrist mediates between the patient and members of the clinical team. 
It also involves the practical application of psychiatric knowledge, ideas, and techniques to situations in which they may be helpful to health care providers in the care and understanding of their patients. 
The General Hospital Psychiatry Units (GHPU's) have to exercise the expertise in the diagnosis and treatment of psychiatric disorders and also manage complex medically ill patients those generally involve three general groups of patients : (0 i) Co morbid psychiatric and general medical illnesses, (ii) somatoform and functional disorders, and (iii) psychiatric disorders that are the direct consequence of a primary medical condition or its treatment. 
In India, as in other parts of the world, the traditional approach to the care of the mentally ill during the last 200 years was of custodial rather than therapeutic. Mental hospitals were constructed in isolated areas with the aim of segregating those who were considered troublesome and dangerous to society. With the advent of social and political changes in public life of the country in the first quarter of the 20 th century, there was a growing awareness of the plight of the disabled members of the society and a concern for the appropriate management of persons afflicted with mental illness. The Indian Association for Mental Hygiene came into being at Shimla on 23 rd August 1928. The first department of psychiatry with outpatient facility in a general hospital in India was opened on 1 st May 1933 at the then Carmichael Medical College (now R.G. Kar Medical College) in Kolkata partly financed by the Calcutta Chapter of the Association. Five years after this event, in 1938, the outpatient facility of Department of Psychiatry of J.J. Hospital, Mumbai was opened.  Subsequently, PG training programs began at Delhi, Chandigarh, Lucknow, Bombay, Madurai and other cities under general hospital psychiatric units.  By 1970, 90 psychiatric clinics were operative in India. At the same time, the Indian armed forces hospitals had 23 general hospital psychiatric units with over 1000 inpatient beds for the mentally ill service personnel spread over-all parts of India.  All India Institute of Medical Sciences started postgraduate training in 1962 and its first batch passed out in 1964.  The growth of general hospital psychiatry and consultation liaison services thus gradually led to deinstitutionalization of mental hospitals in the west as well as in the east.
| Review of Literature|| |
The Beginning of General Hospital Psychiatry
General hospital psychiatry probably had its roots in 1728 in London when Guy's Hospital opened its separate 'lunatic house'. Later in 1736, the French Protestant Hospital in London added places for elderly who suffered mentally. Thereafter several new voluntary hospitals provided separate wards for the mentally ill, but none survived beyond the middle of the 19 th century. Hence a need for voluntary treatment of mental illness arose for admission to the asylum in 19 th century. The first general hospital psychiatry unit was opened in 1887 at the Barnhill Parochial Hospital, Glasgow. In-patient care in general hospitals during the early years developed in four forms : o0 bservation wards for emergency cases, units in teaching hospitals, the management of patient's in general medical wards, and outpatient clinics. The Mental Treatment Act of 1930 and subsequent official encouragement led to opening of psychiatric wards in teaching hospitals and outpatient clinics in several hospitals. A number of hospitals also allowed psychiatrists to admit their patients to general medical wards. 
After World War II, consultation established either as informal referral to individual psychiatrists or by duty doctors. The Mental Health Act 1959 made it essential to involve psychiatrists to transfer cases to a psychiatric hospital. Organized liaison services began in several hospitals subsequently and consultation became an established and popular part of psychiatric practice in general hospitals.
| Referral Patterns in the West and East|| |
The summary of some of the studies carried out in the west and the east are shown in [Table 1]. In a pioneering article in 1929, Henry  discussed general hospital psychiatry in the United States. He spoke of his clinical observations in 300 consecutive consultations about certain 'striking cases': in a young woman with 'homosexual tendencies' who had an apparently unnecessary abdominal operation and of a Russian Hebrew youth who during an illness of 2½ years was admitted to ten different hospitals and was treated by six different private physicians and the errors in diagnosis and treatment commonly committed by physicians and surgeons while dealing with a patient with psychiatric problems. His conclusions mentioned below are worth mentioning:
- Every general hospital should have a psychopathic department with at least one attending psychiatrist.
- Except in emergencies no eccentric or neurotic individual should be submitted to an operation or started on a prolonged course of treatment without psychiatric consultation.
- No medical student should be permitted to graduate without having taken a course in the psychiatric aspect of general hospital practice.
- A period of study in a psychopathic hospital should be a part of all hospital internships.
- All staff conferences in general hospitals should be attended by the psychiatrist so that there might be a mutual exchange of medical experience and frank discussion of those cases in which there are psychiatric problems.
|Table 1: Showing some of the hospital based psychiatric referral patterns in the West and East |
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'These observations have been incorporated in the teaching institutions'. Flanders Dunbar,  one of the early leaders in psychosomatic medicine in the 1930s, supervised the psychiatric liaison services at Columbia University Medical Center. She observed that much of the medical treatment of somatic ailments is purely palliative and symptomatic. The psychic component may be determinative in illness, no matter how "organic" the illness may appear to be. She expressed the hope "that in a not too distant future, psychiatrists would be required in all medical and surgical wards and all general and special clinics". Later, Ralph Bernstein and Kaufman,  Schwab and colleagues looked at the problems in psychosomatic diagnosis in a series of articles published in 1964 and 1965 ,,,, indicated the benefits of psychiatric consultations.
In a large sample of 3,534 Papastamou  attempted to clarify the meaning of referral patterns, in regard to their psychiatric significance and descriptive accuracy. Kligerman and McKegney  who studied psychiatric referrals from1964-1970 at two teaching hospitals 'New Haven Hospital and the West Haven Veterans Administration Hospital opined that in both hospitals, there was a marked decrease in the number of referrals because of well-developed medical services. By applying the Diagnostic and Statistical Manual of Mental Disorders criteria (DSM) Tuason and Rhee  reported psychiatric diagnosis was made in 98% of the referred cases. The authors concluded that high prevalence of psychiatric disorders in the population underlines the importance of providing medical care where psychiatric assistance is available.
A comparative study of referrals from general wards of Guy's Hospital London from 1 st October 1968 to 30 th September 1969 with that of referrals at the same hospital from 1955-1960 published earlier, Anstee  found referrals had increased from 4 to 16 per cent. In another British study, Maguire et al.  found Affective disorders were the major diagnosis (80%), followed by Organic psychoses (13%).
In a significant difference in utilization of psychiatric consultation by various services at two hospitals, the Jacobi and the Van Etten at Bronx New York in 1973 Karasu et al,  reported 40% of the referral was from medicine, 16% surgery, 9% Neurology, 8% Genitourinary, 5% Obstetrics-Gynaecology, 5% Rehabilitation and 5% Plastic surgery. Similar observations were made by Brown and Cooper  at the Victoria Infirmary general hospital in Glasgow from 1973-1979. An interesting study by Tsoi and Kok  carried out psychiatric morbidity between 1979-1981 (2 years) at Singapore General Hospital as per International Classification of Diseases (ICD) 9th revision was 37.4% neurotic disorders, 18.9% organic psychotic conditions, 21.1% functional psychoses and 22.6% other disorders. In another study over 4 years (1978-1981), in a 933 bed University Hospital Leyden, Netherlands, Hengeveld et al,  reported out of 1814 patient referrals 80.3% were from Medicine, 13.7% Surgery, 1.3% Gynaecology and 4.7% others. Suicide attempt was the most frequent reason for referral at 33.6% followed by psychological problems at 24.5%. Lowenstein  reported the average number of psychiatric consultation requests was 150/year for 3 consecutive years at the Clinical Center of the National Institute of Health, Bethesda, Maryland from 1979-1981. Schofield et al,  conducted a survey of liaison psychiatry in Cork Regional Hospital Ireland during 1981-1982 and found referral was 1.6% of all admissions. The most common source of referral 41% was from accidents and emergency.
McKegney et al.  in 1983 examined the use of DSM-III in the 400-bed teaching hospital of University of Vermont covering a period of 18-month. A total of 756 patients were seen in consultation. 38% of all referrals came from internal medicine, 9% neurology and 11% from surgery. The authors highlighted the usefulness of DSM-III. Perez and Silverman  working in an 850-bed teaching general hospital at Ottawa, Canada reported 250 psychiatric consultations in a single year in 1983. 65% were from Medicine, 17% Surgical, 8% Neurological, 4% Gynaecological and 6% by others. Similarly, at a Veterans Administration hospital Louisville teaching hospital, Feldman  too reported 68 percent of the consultations were from internal medicine and 26% surgical. Affective disorders were the most common primary diagnosis at 22%, Organic brain syndromes 19%, Adjustment disorder 11%, Substance abuse 10%, Schizophrenia in 6%, Anxiety disorders 6% and Posttraumatic stress disorder in 4%. The most common reason (28%) given for requesting a consultation was to evaluate a patient's potential to develop depression or attempted suicide!
Sobel et al,  from Beilinson and Hasharon Hospitals in Israel from 1985-1986 and a collaborative study by the European Consultation-Liaison Workgroup  described consultation-liaison service delivery by 56 services from 11 European countries. During the period of 1 year, 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. On an average, deliberate self-harm accounted for 17% of all referrals. The majority of patients came from the Medicine 70% followed by surgery.
Ramchandani et al,  at five urban teaching general hospitals in Philadelphia, New York City, and Providence in 1995 reported several diagnostic categories, e.g. alcohol and drug addiction and organic brain disorders, deliberate self-harm besides other psychiatric disorders being common referrals. It was pertinent to note that the referrals made by the attending physician in 76% of the patients, Nurses, social workers, and family too initiated 20% of them. In a largest multicentre study, Costanzo et al,  reported out of 17 hospitals involving 4182 patients during a period of 12 consecutive months in 1993 and 1994, 93% of the consultations were for inpatients and 6.15% outdoor. 39.9% of the patients were men while 60.1% were women. In 83% of cases, an ICD-10 diagnosis was made by consultants, in 5% diagnosis was deferred, and in 12% no psychiatric diagnosis was made. A diagnosis of neurotic, stress-related, and somatoform syndromes (F40-48) in 33%, Affective syndromes (F30-39) in 19.4%. Organic mental syndromes (F00-09) in 10.7%. Psychoactive substances (F10-19) in 6.3%. Schizophrenia, Schizo-typal, and Delusional disorders (F20-29) in 5.6% and personality disorder in 5.4% was made. Psychological intervention (psychological support) was carried out in 73% of the consultations. 2.1% of the patients were transferred to psychiatric units. The importance of using ICD10 was thus highlighted.
In a retrospective review of 346 consecutive psychiatric referrals, Dilts et al,  reported the accuracy of the initial psychiatric diagnosis of primary medical providers requesting psychiatric consultation in a general medical inpatient setting in a York Hospital, Pennsylvania. The psychiatric consultation rate was 3.7%. Three diagnostic categories-cognitive disorders, substance use disorders and depressive disorders-dominated both the initial and final diagnostic impressions. Using DSM-IV-TR in a retrospective study at The University of California, Davis Medical Center Sacramento, Bourgeois et al,  reported 901 inpatient psychiatric consultations in a calendar year 2001. The most frequent diagnosis groups were mood (40.7%), cognitive (32.0%), and substance use disorders (18.6%). Among 671 consultations in which only one diagnosis was made, the rates of these diagnosis groups were 35.4%, 20.1%, and 10.2%, respectively. The findings were compared with the findings of 19 previous studies published over the past 27 years. Mood, cognitive, and substance use disorders were found to remain major foci of consultation-liaison practice while the rate of cognitive disorder diagnoses had increased. No evidence was found after a change over time in referral rates of DSM IV-TR diagnostic criteria used in the United States vis-à-vis ICD10 used in other countries.
While examining the published research articles involving the practice of consultation-liaison psychiatry in India, a wealth of information was found starting from 1968 some of the studies are shown in [Table 2].
|Table 2: Showing some of the C-L Psychiatric studies and referral patterns in India |
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Out of a total of 108 patients referred for psychiatric consultation from the in-patient population at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital in 1968, Prabhakaran  reported a referral rate from Medicine at 2.2% while that of Surgery was 0.8%. Obstetrics and Gynaecology was the lowest at 0.8%. Major reason for referral was abnormal behaviour (60.2%), no organic cause (11.1%), and unexplained pain (7.4%). Parekh et al,  did a study of all referrals to the psychiatry department over a period of 2 months at King Edward Memorial Hospital, Mumbai. Out of 60 patients referred 90% of them were from Medicine, followed by Surgery 16.66%, Paediatrics 6.66%, Orthopaedics 5% Neurology, Neurosurgery and Gynaecology at 3.33% each and E.N.T. at 1.33%. Unspecified psychoses in 35%, Organic psychosis 41.6%, Schizophrenia 33.3% and rest Hysteria were among the major diagnoses.
Chatterjee and Kutty  in a study of psychiatric referrals in military hospital setting conducted at a Command Hospital from 1972-1975 reported a referral rate of 1.54 per cent for indoor patients while that for outdoor 2.64 per cent. 88% of the referred patients were male. Majority of the outpatient referrals came from the general duty medical officer, while half of the inpatient referrals came from medicine. One fifth came from the surgery, gynaecology 4.33% of inpatients. Abnormal behaviour was the most common reason for referral, functional overlay, management problem, vague complaints, suicidal ideas, etc. Neuroses were the commonest diagnosis at 40% followed by Schizophrenia at 29%.
In a similar referral, pattern study Jindal and Hemrajani  at Safdarjung Hospital, New Delhi reported that over a short period of 2½ months from April to June, 1978 referral rates were 0.15% for indoor patients and 0.06% for outdoor patients. 54.6% of the referrals came from Medicine and 18.2% from Surgery. 50.7% of the patients were diagnosed with Neurosis, while 41.4% had some form of psychosis. In about 5%, no diagnosis was given.
Kelkar et al,  carried out a study of emergency psychiatric referrals at the outpatient department of Nehru Hospital attached to Post graduate institute of medical education and research (PGIMER) Chandigarh between July 26 th and August 31 st , 1981. The referral rate was 5.4%. Most common reason for referral was predominant psychiatric symptoms (43%), no physical illness detected (18%), previously diagnosed psychiatric illness (15%) etc. Major presenting complaints were somatic symptoms, suicidal attempts; hysterical fits, etc. 51% of the cases were diagnosed with neurosis, 13% with functional psychosis, and 8% with acute situational disturbance. The authors lamented about the lack of privacy during the interview in emergency outpatient departments.
In a retrospective analysis of the pattern of inpatient referral at St. John's Medical College Hospital Bangalore, Srinivasan et al,  during a 7-month period from 1984-1985 studied 150 referred inpatients. 82.7% referrals were from Medicine. Management problem being most cited reason at 54.7% and in 42% a diagnostic clarification was sought.
Doongaji et al,  undertook a prospective study to compare the patterns of psychiatric referrals in two general hospitals in Bombay viz. the King Edward Memorial Hospital (64 cases) and the Jaslok (62 cases). Attempted suicide was the commonest primary reason for hospitalization at the K.E.M. while suspected medical or neurological illness was the commonest primary reason for hospitalization at the Jaslok.
Bhogale et al  in a study of psychiatric referrals at Karnataka Lingayat Education Society (K.L.E.S.) hospital at Belgaum, Karnataka from 1.7.1996 to 30.6.1997, reported major source of referral was from medicine and allied, followed by surgery and allied. Reasons for referral were unexplained physical symptoms, frank psychiatric illness, and medico-legal problems. Since then there have been a number of studies highlighting the importance of mind and body and the importance of consultation and liaison with different specialties to treat various mental disorders in a holistic manner. ,,,,,,,,,
| Conclusion|| |
General Hospital Psychiatric units across the country now cater to most of the mentally ill patients in outpatient departments and those requiring inpatient treatments are taken care of in a better environment than what was earlier. With increasing number of GHPU's in a number of Government and Private Medical Colleges in the country and with availability of sophisticated imaging techniques and investigative tools, involvement of various specialities, understanding of the etiology of various mental disorders is better than before.  This is a welcome sign in the days to come.
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[Table 1], [Table 2]