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Psychosomatics 49:29-38, January-February 2008
doi: 10.1176/appi.psy.49.1.29
© 2008 Academy of Psychosomatic Medicine
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New Potential Clinical Indicators of Consultation–Liaison Psychiatry’s Effectiveness in Brazilian General Hospitals

Vanessa de Albuquerque Citero, M.D., Ph.D., Paola Bruno de Araújo Andreoli, Ph.D., Luiz Antonio Nogueira-Martins, M.D., Ph.D., and Sergio Baxter Andreoli, M.D., Ph.D.

Received May 23, 2006; revised August 14, 2006; accepted August 22, 2006. From the Consultation–Liaison Psychiatry Service of the Dept. of Psychiatry at the Universidade Federal de Saõ Paulo (Brazil) and the Consultation–Liaison Psychiatry Service of the Dept. of Psychiatry at Virginia Commonwealth University, Richmond VA; Albert Einstein Hospital (Brazil); the Dept. of Psychiatry, Universidade Federal de Saõ Paulo; the Dept. of Psychiatry, Universidade Federal de Saõ Paulo; and the Universidade Catolica de Santos (Brazil). Send correspondence and reprint requests to Vanessa Citero, M.D., Ph.D., Rua Botucatu 640 3andar, Depto. Psiquiatria/UNIFESP, Saõ Paulo, Brazil 04023-900. e-mail: vcitero{at}uol.com.br
© 2008 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The authors identified patients’ subjective well-being (SWB), relatives’ satisfaction with their information needs, and the medical team’s difficulty in helping patients, as potential indicators of effectiveness of consultation–liaison psychiatry. A random sampling of 74 beds was carried out (1 bed=1 patient + 1 relative + 1 nurse + 1 physician). There were negative correlations between SWB and anxious and depressive symptoms, and positive correlations with nurses’ difficulty in helping patients and patients’ depressive symptoms, nurses’ difficulty in helping patients and their perception about anxious and depressive symptoms; and physicians’ difficulty in helping patients and their perception about anxious and depressive symptoms. Patients’ SWB and difficulty in helping them constituted potential indicators in consultation–liaison psychiatry, whereas relatives’ satisfaction did not.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
There is no first-level scientific evidence,1 with clinical trials using either psychopathological symptom-reduction criteria or decrease in length-of-stay criteria,2,3 that consultation–liaison psychiatry in general hospitals is cost-effective. Faced with that lack of evidence, it became necessary to identify new measurements to assess the effectiveness of consultation–liaison psychiatry.4 The sphere of action of consultation–liaison psychiatry is complex; it includes the patient, his or her family/relatives, and health professionals, as well as relationships established among all of them.5,6 Although its scope is common for all consultation–liaison psychiatry services, there are some difference in terms of practice, according to cultural aspects and hospital characteristics. In Brazil, where the present study was developed, most of the services work in public and teaching hospitals, and the presence of patients’ relatives during hospitalization is relevant. Thus, consultation–liaison psychiatry services focus their work not only on the patient, but also on relatives and the medical team.

With the aim of identifying aspects of assistance that could be affected by interventions carried out by consultation–liaison psychiatry, the studies published in the period ranging between 1993 to 2004 were reviewed, and three concepts were highlighted: 1) subjective well-being of patients (SWB);7,8 2) relatives’ satisfaction with fulfillment of their needs for information;9–11 and 3) health professionals’ difficulty in helping the patient.12,13

The concepts set forth can be selected as measures for an indicator,14 if they are relevant (concepts relate to goals established, have variable quality, constitute a guideline to assess quality), have scientific acceptability (concepts can be assessed by measures that present consistent results—with reliability, validity, adaptability, and risk adjustments); utility (measures have convincing and independent content enabling the user to make a decision, and are subject to statistical tests); and viability (the implementation of such measures is not a burden for those who need to respond to them).

The aim of this study is to ascertain whether patients’ subjective well-being, relatives’ satisfaction with fulfillment of their needs for information, and physicians’ and nurses’ difficulty in helping the patient are potential indicators of clinical effectiveness of consultation–liaison psychiatry services at Brazilian general hospitals, having relevance, scientific acceptability, utility, and viability.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
A cross-sectional study was performed at the hospital at the Universidade Federal de Saõ Paulo, with 724 beds (667 from the national health plan and 57 from private health plans). We created a random sample of 74 beds, based on a draw of all of the 245 beds in the following wards: gastro-surgery, orthopedics, internal medicine, vascular surgery, cardiology, cardiovascular surgery, neurosurgery, and intensive-care units. Each bed represents a set made up of the patient, a family member, a physician, and a nurse.

Patients were included if they were older than age 18, hospitalized for a minimum of 24 hours, and if they had the ability to respond to the questionnaires. Patients who were excluded had their clinical and demographic data recorded for statistical control of losses (the patient was not substituted). The family member included was the one referred by the patient. The nurse who was interviewed belonged to the morning or afternoon shift. All nurses were regular staff in the units where they worked. Regarding physicians, the study approached two types: in the national health plan wards, we have health care offered by medical residents (with supervision of professors), and in the private health plan wards, we have physicians who are professors and postgraduates from universities (junior doctors cannot work in these private wards). We did not carry out any control on requests for psychiatric consultation–liaison requested during the recompiling of data.

On the 74 beds randomly selected, we carried out the study with 67 patients, 61 relatives of 61 patients, 64 interviews from nurses, and 47 interviews from doctors. Although 74 patients responded to the questionnaires, only 67 were included in the well-being assessment (four patients were confused and unable to respond, and three questionnaires were incomplete). In all, 13 patients had no relatives; 10 interviews from nurses were lacking because the patient was released from the hospital before the interview had been carried out; 27 interviews with physicians were missing, 4 because of the refusal of the physician to participate, and 23 because the patient had been released from the hospital before the interview could be carried out. We found no statistically significant differences between interviews included and excluded in terms of patients’ sociodemographic and clinical profiles in the samples of patients, relatives, and nurses. In the physicians’ sample, there were 19 interviews excluded from private health plan wards and only 8 from national health plan wards (p<0.001). Distribution of sociodemographic and professional data from physicians with excluded interviews yielded statistically significant differences (p<0.05), with a greater percentage of them being men over 26 years of age, those with completed specialization training, and more than 2 years since their graduation. We found no statistically significant differences in patients’ sociodemographic and clinical profiles.

Patients completed the clinical and sociodemographic questionnaires, the Hospital Anxiety and Depression Scale (HADS), the Confusional Assessment Method (CAM, answered by the interviewer) and the SUBI (the Subjective Well-Being Domain from the Subjective Well-Being Inventory). The HADS was applied according the Brazilian validation15 that suggests a cutoff of ≥9 for depression symptoms (with a diagnostic sensitivity of 84.6% and a diagnostic specificity of 90.3%) and the same cutoff for anxiety symptoms (with a diagnostic sensitivity of 93.7% and a diagnostic specificity of 72.6%). The HADS was chosen instead of another diagnostic test for depression and anxiety because, to investigate well-being as a possible clinical indicator, it was necessary to differentiate well-being and psychiatric symptoms; moreover it has an easy application. The CAM was also applied according the Brazilian version.16 The delirium diagnosis requires the presence of acute onset/fluctuating course and inattention, and disorganized thinking or altered level of consciousness (with a diagnostic sensitivity of 94.1% and a diagnostic specificity of 96.1%). The SUBI17 was translated and adapted to a Brazilian population in a previous study18 (Table 1), and, at the time of the study period, there were no other well-being scales adapted to the Brazilian population. The well-being measure is obtained by a score (range: 6 to 18 points), that can be divided into three well-being categories: Low (up to the 30th percentile), Moderate (percentiles 30 to 60), and High (>60th percentile).


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TABLE 1. Gender Distribution and Clinical Characteristics of Patients by Subjective Well-Being Levels



The family member completed the sociodemographic questionnaire, an information questionnaire, and the CCFNI (Need for Information domain from the Critical Care Family Needs Inventory),19 validated for the Brazilian population20 (Table 2). The CCFNI was answered regarding the degree of importance of the need, according to the family member, whether considered important or very important; the relative was asked whether this need had been fulfilled. The ratio between the degree of importance and the degree of fulfillment of the need generated a satisfaction index, varying from 0 (Not Satisfied) to 1 (Satisfied), and satisfaction was classified between High and Low, on the basis of the mean value. The information questionnaire referred to the information that the relative had been given about the patient’s situation: if he or she knew the patient’s disease, how long the patient had been ill, who the physician was, and the nurse who was responsible for the patient during hospitalization. The relatives’ responses were checked on the patient’s medical chart by the interviewer, and a score was assigned (0: information not correct; and 1: information correct). Subsequently, the four scores for information were averaged to arrive at the information index (0 to 1, with 0: Not Informed and 1: Well-Informed).


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TABLE 2. Bivariate Correlation (r) of Patients’ Well-Being, Relatives’ Satisfaction, and Difficulty of the Nurse and Physician in Helping the Patient, With Anxiety and Depression Symptoms (of the Patient and as Perceived by the Professionals) and Index-of-Knowledge of the Family Member



Health professionals completed the sociodemographic and professional training questionnaire (whether they had some specialization, and the number of years since graduation), the HADS15 (answered by the professional, based on his or her perception of the patient; this the scale was modified by the authors, and questions were posed in the third person); the CAM (answered by the professional, based on his or her perception of the patient),16 the Karnofsky Performance Status21 (filled in by the nurse regarding the patient), and the Difficulty-in-Helping-the-Patient Questionnaire, adapted for this study on the basis of an instrument developed by Sharpe et al.12 (Table 3). These are open questions on the patient’s disease and the type of help the patient requires, as well as structured questions on the professional’s perception of the psychosocial impact of falling ill for the patient, and a Likert-type question of 5 points on the degree of difficulty in helping the patient. Subsequently, this question was classified between Great and Little difficulty, on the basis of the mean value. The open questions were used merely to sensitize the professional to respond to all other questions.


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TABLE 3. Distribution of Health Professionals’ Degree of Difficulty in Helping the Patient, Based on the Patients’ Clinical and Psychopathological Characteristics



Four psychologists, with previous experience in psychopathological assessment in the general hospital, were trained to apply and use these instruments, and a pilot study was carried out to evaluate logistics of the application. In data recompiling, two interviewers were responsible for each bed selected randomly; one interviewed a patient, the other interviewed the patient’s relative, the nurse, and the physician.

The chi-squared or Student t-tests were applied to assess differences in the concepts of patients’ well-being, relatives’ satisfaction, and the professionals’ difficulty, as distributed by sociodemographic, clinical, and psychopathological characteristics of patients. At the second stage, the three measures were correlated with the variables of psychiatric comorbidities in the patient; satisfaction was also analyzed with respect to its variability with the level of information given to the relative regarding the disease and treatment, and the difficulty-in-helping correlated with the professional’s perception of a psychiatric comorbidity in the patient and with the psychosocial impact of falling ill. Subsequently, measures were correlated among themselves, using Pearson’s bivariable correlation.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Patients were predominantly women (66.2%), with an average age of 52 years (standard deviation [SD]: 17) and an average of 8 years of education (SD: 4); 55.4% were married; 59.5% were unemployed or not employed outside the home; 20.6% were hospitalized for cardiovascular disease, with an average Karnofsky’s rating of 70 (SD: 20) wherein the patient is independent in self-care, but is unable to perform normal activities or work, ill for a median of 24 months; and 55.6% of patients had a previous hospitalization in the last 12 months.

We found that 23.9% of the patients had depression symptoms, 31.3% had anxiety symptoms, and 5.5% had delirium. The mean well-being rating was 14 (SD: 3), with a normal distribution. Low well-being (≤30th percentile; N=13; Table 1) was present in 37.3% of patients, and was predominant (p<0.05) in the female group (44.2%; t[65]=2.4; 95% confidence interval [CI]: 0.3 to 2.8); not married (48.3%; t[65] = –2.2; CI: –2.6 to –0.1); with anxiety symptoms (61.9%; t[65] = –2.8; CI: –3.1 to –0.6); depression symptoms (62.5%; t[65] = –2.8; CI: –3.5 to –0.6); and Karnofsky’s rating of >50 (moderate or lower dependence: 70.7%; {chi}2[4]=10.1). Well-being had an inverse correlation (p<0.001) with anxiety and depression symptoms (Table 2).

The group of family members were 77% women, with an average age of 43 years (SD: 15) and an average of 9 years of education (SD: 4); 57.4% were married; 82% were the patients’ spouses or children; 73.8% were informed on the patients’ diagnosis; 67.2% knew how long the patient had been ill; 50.8% knew the name of the physician; and 23% knew the name of the nurse. The total index of family knowledge varied from 0 to 1, with an average of 0.5 (SD: 0.3), without differences by gender. The need for information was considered very important by over 80% of relatives, and their satisfaction varied from 31.1% to 75.4%. The satisfaction index with information needs varied from 0.5 to 1.0, with an average satisfaction of 0.84 (SD: 0.19) and a normal distribution. Low satisfaction (index <0.84) was found in 39.3% of relatives, and did not vary with any sociodemographic (40.9% of men and 38.4% of women; 48.1% between 43 and 56 years old and 31% under 43 years old or over 56 years old.), clinical (35.3% sick <6 months and 42.3% >6 months; 44% with previous hospitalization and 32% without hospitalization; 46.2% with greater dependence and 35.7% with moderate-or-lower dependence), or psychopathological characteristic of the patients (delirium: 75% of positive patients, 36.8% of negative patients; depressive symptoms: 26.7% of the positive and 40% of the negative; anxiety symptoms: 44.4% of the positive and 32.4% of the negative). The relatives’ satisfaction with fulfillment of their information needs did not correlate with either psychiatric comorbidity in the patient or with the relatives’ level of information (Table 2).

The nurses group was 93.7% women; average age, 27 years (SD: 5); 57.8% had specialized training, especially in clinical specialties, and had graduated a median of 2 years earlier. The physician group was 61.7% male, with an average age of 28 (SD: 5); 87.2% were in their medical residency, mainly in clinical specialties, and had graduated a median of 3 years ago. The physicians’ difficulty in helping the patient showed an average level of 1.32 (SD: 0.91), and the nurses’ difficulty was 0.91 (SD: 0.87); both measures had a normal distribution. Thus, physicians considered 38.3% of patients hard to help, and nurses rated 23.4% as hard to help.

The nurses presented a high difficulty index (>0.91; Table 3) for helping patients with a Karnofsky’s rating of ≤40 (lower dependence: 46.7%; {chi}2[2]=8.6; p<0.05), for helping those with symptoms of depression (60%; {chi}2[1]=8.8; p<0.05), and delirium (20%; {chi}2[1]=10.3; p<0.05), and among nurses who had graduated more than 2 years ago (93.3%; {chi}2[2]4.5; p<0.05). Nurses deemed it difficult to help patients who did not understand the nature of their disease (53.4%; {chi}2[2]=9.8; p<0.05) and treatment (60%; {chi}2[2]=17.7; p<0.05); patients with low treatment compliance (60%; {chi}2[1]=11.3; p<0.05), and those they identified as having symptoms of delirium (33.3%; {chi}2[1]=10.1; p<0.05). Nurses’ difficulty correlated (p<0.05) with the patients’ presenting symptoms of depression and with perceptions of the presence of anxiety and depression symptoms (Table 2).

Physicians had great difficulty (index: >1.32; Table 3) helping patients if they deemed the patient’s disease to be influenced by psychosocial aspects (88.9%; {chi}2[2]=9.5; p<0.05), patients’ low treatment compliance (27.8%; {chi}2[1]=5.9; p<0.05), and the perception of depression symptoms (61.1%; {chi}2[1]=6.0; p<0.05) and anxiety symptoms (72.2%; {chi}2[1]=14.3; p<0.05). The physicians’ difficulty correlated (p<0.05) with their perception of depression and anxiety symptoms in the patient (Table 2).

The study of correlation between the three measures set forth showed the independence of results (p>0.05) among all of the measures (correlation between patients’ well-being and relatives’ satisfaction: r = –0.06; patients’ well-being, and nurses’ difficulty index: r = –0.13; patients’ well-being and physicians’ difficulty index: r=0.05; nurses’ difficulty and relatives’ satisfaction: r=0.08; nurses’ difficulty and physicians’ difficulty: r=0.10; physicians’ difficulty and relatives’ satisfaction: r= –0.22).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
An essential component of the consultation–liaison psychiatrist’s role is to help develop a shared perspective about patient management among a variety of people involved in the patient’s care.22 The psychiatrist has to effectively interpret his or her findings for caregivers, and this is the main step toward guaranteeing a satisfactory consultation–liaison process in the health-professionals’ view, regardless of the patient’s improvement.22 As described by Meyer and Mendelson,23 the satisfactory outcome of psychiatric consultation–liaison is the reduction of strain in the group dynamics in which the patient and the caregivers are involved, the "operational group," in which the psychiatrist is invited to participate, with the aim of reorganizing and decoding the problem. It is the scope of consultation–liaison psychiatry, as described in the last 50 years.5,22–25 To develop indicators that can measure this scope, the three possible indicators were chosen after an extensive review of constructs that could represent the reduction of strain in the operational group.

Patients’ Well-Being
Reported symptoms of anxiety and depression reflect patients’ suffering, whereas well-being represents subjective perceptions of tranquility and happiness. The correlation found between these two questionnaires could be explained by some overlap between anhedonia as assessed by the HADS scale and the well-being scale. Subjective well-being is an aspect of psychological adjustment, determined by coping strategies utilized by the patient.26 In clinical consultation–liaison settings, well-being may be an ultimately more important measure than psychiatric symptoms, since a poor clinical condition may not imply low well-being if the person feels sheltered and cared for, with the possibility of an improved future.7,8,27 This is the health paradox: patients with severe physical diseases do not necessarily express them through a reduction in the feeling of well-being.27 This may explain why some patients who initially experience depressive symptoms feel relief during the first days of stay in the hospital, even without psychiatric intervention. As observed by Kathol and Wenzell,28 spontaneous remission of depressive and anxiety symptoms shortly after admission is common, and one possible explanation is the effects of support and reassurance provided by physicians and nurses during their assessment interviews, examinations, and provision of care. The role of the C–L psychiatrist is to contribute to the reduction of distress, not only with medication when appropriate, but also by helping physicians, nurses, and other providers to better care for the patient.

This means that the concept of well-being is important to assess effectiveness of consultation–liaison psychiatry: reduction of psychiatric suffering in patients, with regard to their illness and hospitalization. It also presents the variable in accordance with the characteristics of the population and describes an area that is lacking more descriptive data: the subjective perception of health of the patient. We can consider that the measure of well-being has utility; it does not include other confounding measures in its reading. Regarding scientific acceptability, we were able to develop an appropriate measurement system, by total scores and categories of well-being levels that will allow for a comparison with other populations. Well-being measures produced consistent results, with their use clearly specified regarding the concept, and simple to adapt to any population of adult patients, with the exception of delirium patients. For them, the most adequate measure perhaps is a reduction of symptoms, as this is the only psychopathological situation that improves during clinical hospitalization.29 Finally, the viability of implementing the well-being measure could be inferred from the ease with which the patients responded to the questions, with full and quick understanding of how to complete the questionnaire. Therefore, we can accept that subjective well-being is a potential clinical indicator of effectiveness of intervention in consultation–liaison psychiatry, operating as a proxy for the patient’s mental health.

Relatives’ Satisfaction
The expanded psychiatric interview23 in consultation–liaison psychiatry refers to the involvement of others persons besides physicians, as in, for example, the process of communication between health professionals and the patients’ family members.25 Considering this aspect, the relatives’ satisfaction with the fulfillment of their information needs was chosen to represent the difficulties they have during the patients’ hospitalization.

All family members considered it important to know who could give them the information they needed and to know who the professionals caring for the patient were, although the fulfillment of these needs was low. Upon being asked straightforwardly, few relatives knew who the physician and the nurse caring for the patient were. The incongruity of these facts leads us to assume that satisfaction attained, over and above the care given, referred to the need for information. A possibility is that satisfaction involves a subjective feeling of sheltering and care; thus, the family member may not know exactly who the physician caring for the patient is, but the fact that the patient is hospitalized and is receiving care could be sufficiently comforting for many relatives. This would explain why satisfaction does not correlate with the presence of anxiety or depression symptoms in the patient or with the level of information for relatives.

In this way, we can consider that the concept of the relatives’ satisfaction with fulfillment of their information needs did not have sufficient importance as a concept that can aid the assessment of effectiveness of consultation–liaison psychiatry, nor did it present a variable that related to the patients’ characteristics. Without a ranking of importance, the concept of satisfaction cannot be considered a possible indicator of effectiveness of consultation–liaison psychiatry for family members.30

Health Professionals’ Difficulty in Helping the Patient
The role of the consultation–liaison psychiatrist should be to support other health professionals in their management of those with physical disorders, and the perceptions of these professionals contribute to predict psychological dimensions of the patient’s physical illness.31 The perception of difficulty in helping the patient was correlated with the perception that the physicians (especially junior doctors) and nurses had of the patients’ psychiatric symptoms. This correlation reflects the importance the medical team attributes to the patients’ psychosocial problems. We can therefore consider that the measure of difficulty in helping the patient is, in fact, a measure of the relationship between the professional and the patient. This aspect is fundamental for the work of the consultation–liaison psychiatrist, as it is his or her role to act upon the relationship established between the professional and the patient, to diagnose the disturbances in communication between them, and consequently to facilitate this interaction, reducing the strain of the situation.22,23,32

The concept of difficulty in helping the patient demonstrated its importance as it relates to one of the objectives of this type of assistance: to improve the professional’s perception of the problem of becoming ill and being hospitalized. It also showed variable quality, and related to an area that is lacking sufficient data: the level of difficulty professionals have in helping patients, especially when psychopathological symptoms are identified. We can consider that the concept of difficulty has utility, as it proves to be an independent measure. Regarding scientific acceptability of the difficulty measure, we were able to apply the appropriate measurement system that allows for comparison with other populations. Measures of difficulty produced consistent results, with clearly specified use of the concept; it proved to be easily adaptable to any population of adult patients, although it is accepted with difficulty by physicians, not because they are more experienced, but because they are not in permanent contact with patients. The viability of use of the instrument should be considered, as a way of guaranteeing that all physician profiles will be able to respond to it. There were no difficulties in understanding and completing the questionnaire and no disagreement with questions the consultation–liaison psychiatrist would ask the professional at the beginning of the assessment. Therefore, the difficulty of the professional in helping the patient is a possible clinical indicator of effectiveness of the intervention in consultation–liaison psychiatry, because it varies with the professional’s perception, operating as a proxy for the quality of the team–patient relationship as it measures the professional’s ability to understand factors affecting the patient.12

Practical Implications
Regarding the development of clinical indicators, further research is needed. After measuring the scientific acceptability of significant measures, their viability should, ideally, be analyzed in a multicenter case–control study. Finally, the effective evaluation of a consultation–liaison service can be developed in a naturalistic study, in which the set of instruments can be included in the first stage of the consultation–liaison process. This set will contain a well-being inventory and the difficulty-to-help questionnaire, plus the regular measures included in a consultation–liaison interview.22,33–35 At the end of the consultation–liaison process, another evaluation can be applied, including the same instruments plus a question about the satisfaction of the professional with the care given by the psychiatrist and the process-indicators developed by Popkins et al.36–38 and Huyse et al.39–41

Another practical implication is the necessity of training the medical team to identify psychiatric symptoms and to provide basic psychosocial support to those in need of it. The consultation–liaison psychiatrist can help the medical staff by teaching interview skills, implementing screening tools to identify symptoms, and developing protocols to improve the psychosocial case management.

Limitations of the Study
We identified the following limitations: 1) The study concentrated on a sample of patients with low-to-moderate dependence and few delirium diagnoses because of the inclusion criteria utilized (the ability to respond to the questionnaires); thus, patients in intensive-care units were excluded; 2) The patient sample was younger than that usually found in a general hospital (the hospital has a geriatric ward that was not included among the beds selected randomly); 3) The Difficulty-in-Helping-the-Patient Questionnaire is a mix of open and directed questions not validated yet, as is the HADS version answered by the medical team (these limitations could bias the results); 4) The physician sample results were obtained specifically with medical residents, so the results must not be generalized; 5) Although the three possible indicators studied were selected by an extensive review and had the intention of summarizing the results of consultation–liaison psychiatry activities, they are a choice among many others, such as changing harmful health behavior in patients, detecting treatable psychiatric and medical conditions, addressing the emotional burden of relatives, etc. This choice was determined by relevant cultural aspects and hospital characteristics.


  CONCLUSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
The results presented on the identification of subjective well-being and health professionals’ "difficulty in helping the patient" as possible indicators, have allowed us to reflect upon the measures set forth as concepts and in relation to the instruments chosen to represent them. Future studies should test these two possible indicators. Once the indicators on effectiveness have been constructed, along with those of the process, the assessment of effectiveness of services per se can be performed as a screening tool in consultation–liaison psychiatry services.


  ACKNOWLEDGMENTS

 
We thank Dr. James L. Levenson (Virginia Commonwealth University) for his insightful comments on the draft paper. This research was sponsored by Fundaçao de Amparo à Pesquisa do Estado de Saõ Paulo (FAPESP; aid to research #02/12918-8) and Coordenaçao de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; grant for a doctorate degree to the first author).


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APPENDIX 1. Subjective Well-Being Domain of the Subjective Well-Being Inventory18




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APPENDIX 2. Need for Information: From the Critical Care Family-Needs Inventory20




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APPENDIX 3. Health Professionals’ Difficulty-in-Helping-the-Patient Questionnaire




  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Andreoli PBA, Citero VA, Mari JJ: A systematic review of cost-effectiveness studies in mental health consultation-liaison interventions at a general hospital. Psychosomatics 2003; 44:499–507[Abstract/Free Full Text]
  2. Hengeveld M, Ancion F, Rooijmans H: Psychiatric consultations with depressed medical inpatients: a randomized, controlled, cost-effectiveness study. Int J Psychiatry Med 1988; 18:33–43[Medline]
  3. Levenson JL, Hamer R, Rossiter LF: A randomized, controlled study of psychiatric consultation guided by screening in general-medical inpatients. Am J Psychiatry 1992; 149:631–637[Abstract/Free Full Text]
  4. Citero VA, Andreoli PBA, Nogueira-Martins LA, et al: Por que é tao difícil avaliar a efetividade da interconsulta psiquiátrica? [Why is it so difficult to evaluate the effectiveness of consultation-liaison psychiatry?]. Revista Brasileira de Psiquiatria 2002; 24:100
  5. Lipowski ZJ. Consultation-liaison psychiatry: an overview. Am J Psychiatry 1974; 131:623–630[Abstract/Free Full Text]
  6. Lyons J, Hammer J, Wise T, et al: Consultation-liaison psychiatry and cost-effectiveness research: a review of methods. Gen Hosp Psychiatry 1985; 7:302–308[CrossRef][Medline]
  7. Wyller T, Holmen J, Laake P, et al: Correlates of subjective well-being in stroke patients. Stroke 1998; 29:363–367[Abstract/Free Full Text]
  8. Lofgren B, Gustafson Y, Nyberg L: Psychological well-being three years after severe stroke. Stroke 1999; 30:567–572[Abstract/Free Full Text]
  9. Astedt-Kurki P, Lehti K, Paunonen M, et al: Family member as a hospital patient: sentiments and functioning of the family. Int J Nurs Pract 1999; 5:155–163[CrossRef][Medline]
  10. Johnson D, Wilson M, Cavanaugh B, et al: Measuring the ability to meet family needs in an intensive care unit. Crit Care Med 1998; 26:266–271[CrossRef][Medline]
  11. Azoulay E, Pochard F, Chevret S, et al: Meeting the needs of intensive care unit patient families: a multicenter study. Am J Respir Crit Care Med 2001; 163:135–139[Abstract/Free Full Text]
  12. Sharpe M, Mayou R, Seagroatt V, et al: Why do doctors find some patients difficult to help? Q J Med 1994; 87:187–193[Medline]
  13. Oliver SM: Living with failing lungs: the doctor-patient relationship. Fam Pract 2001; 18:430–439[Abstract/Free Full Text]
  14. Mcglynn EA: Selecting common measures of quality and system performance. Med Care 2003; 41:I-39-I-47
  15. Botega NJ, Bio MR, Zomignani MA, et al: [Mood disorders among inpatients in ambulatory and validation of the anxiety and depression scale HADS]. Rev Saude Publica 1995; 29:355–363[Medline]
  16. Fabbri R, Moreira M, Garrido R, et al: Validity and reliability of the Portuguese version of the Confusion Assessment Method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr 2001; 59:175–179[Medline]
  17. Sell H, Nagpal R, WHO: Assessment of subjective well-being: The Subjective Well-Being Inventory (SUBI). New Delhi, India, WHO, 1992
  18. Passos P, Solymos G, Miranda C, et al: Subjective well-being survey in the Brazilian general population. Abstracts of the XXII World Congress of Psychiatry. Yokohama, Japan, 2002
  19. Molter NC: Needs of relatives of critically ill patients: a descriptive study. Heart Lung 1979; 8:332–339[Medline]
  20. Castro DS: Estresse e estressores dos familiares de pacientes com traumatismo crânio-encefálico em terapia intensiva. [Stress and stressful factors of patients’ relatives with brain trauma injury in an intensive care unit.] Rio de Janeiro, Brazil, Universidade Federal do Rio de Janeiro, 1999
  21. Karnofsky D, Abelmann W, Craver L, et al: The use of nitrogen mustards in the palliative treatment of cancer. Cancer 1948; 1:634–656[CrossRef]
  22. Ramchandani D, Lamdan RM, O’Dowd MA, et al: What, why, and how of consultation-liaison psychiatry: an analysis of the consultation process in the 1990s at five urban teaching hospitals. Psychosomatics 1997; 38:349–355[Abstract/Free Full Text]
  23. Meyer E, Mendelson M: Psychiatric consultations with patients on medical and surgical wards: patterns and processes. Psychiatry 1961; 24:197–220[Medline]
  24. Diefenbacher A, Strain JJ: Consultation-liaison psychiatry: stability and change over a 10-year period. Gen Hosp Psychiatry 2002; 24:249–256[CrossRef][Medline]
  25. Tuijl JP, van Waarde JA: Competencies of the consultation-liaison psychiatrist: a formulation from the general-hospital section of the Dutch Psychiatric Association. J Psychosom Res 2005; 59:449–450[CrossRef][Medline]
  26. Roesch SC, Weiner B: A meta-analytic review of coping with illness: do causal attributions matter? J Psychosom Res 2001; 50:205–211[CrossRef][Medline]
  27. Albrecht GL, Devlieger PJ: The disability paradox: high quality of life against all odds. Soc Sci Med 1999; 48:977–988[CrossRef][Medline]
  28. Kathol RG, Wenzel RP: Natural history of symptoms of depression and anxiety during inpatient treatment on general-medicine wards. J Gen Intern Med 1992; 7:287–293[Medline]
  29. Fulop G, Strain J, Fahs M, et al: A prospective study of the impact of psychiatric comorbidity on length of hospital stays of elderly medical-surgical inpatients. Psychosomatics 1998; 39:273–280[Abstract/Free Full Text]
  30. Mcglynn EA, Asch SM: Developing a clinical performance measure. Am J Prev Med 1998; 14:14–21[CrossRef][Medline]
  31. Mayou R: Are psychological skills necessary in treating all physical disorders? Aust N Z J Psychiatry. 2005; 39:800-806
  32. Strain JJ: Liaison psychiatry, in Textbook of Consultation-Liaison Psychiatry. Edited by Rundell JR, Wise MG. Washington, DC, American Psychiatric Press, 1996, pp 39-51
  33. Citero VA, Nogueira-Martins LA, Lourenço MT, et al: Clinical and demographic profile of cancer patients in a consultation-liaison psychiatric service. Saõ Paulo Med J 2003; 121:111–116[Medline]
  34. Archinard M, Dumont P, de Tonnac N: Guidelines and evaluation: improving the quality of consultation-liaison psychiatry. Psychosomatics 2005; 46:425–430[Abstract/Free Full Text]
  35. Holmes AC, Judd FK, Lloyd JH, et al: The development of clinical indicators for a consultation-liaison service. Aust N Z J Psychiatry 2000; 34:496–503[CrossRef][Medline]
  36. Popkin M, Mackenzie T, Hall R, et al: Physicians’ concordance with consultants’ recommendations for psychotropic medication. Arch Gen Psychiatry 1979; 36:386–389[Abstract/Free Full Text]
  37. Popkin M, Mackenzie T, Callies AL: Consultees’ concordance with consultants’ recommendations for diagnostic action. J Nerv Ment Dis 1980; 168:9–12[CrossRef][Medline]
  38. Popkin M, Mackenzie T, Hall R, et al: Consultees’ concordance with consultants’ psychotropic drug recommendations: related variables. Arch Gen Psychiatry 1980; 37:1017–1021[Abstract/Free Full Text]
  39. Huyse F, Strain J, Hengeveld M, et al: Interventions in consultation-liaison psychiatry: the development of a schema and a checklist for operationalized interventions. Gen Hosp Psychiatry 1988; 10:88–101[CrossRef][Medline]
  40. Huyse F, Strain J, Hammer JS: Interventions in consultation-liaison psychiatry, 1: patterns of recommendations. Gen Hosp Psychiatry 1990; 12:213–220[CrossRef][Medline]
  41. Huyse F, Strain J, Hammer JS: Interventions in consultation-liaison psychiatry, part 2: concordance. Gen Hosp Psychiatry 1990; 12:221–231[CrossRef][Medline]




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