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Keywords:

  • cancer;
  • psychiatric consultation;
  • psychiatric liaison;
  • truth-telling

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. References

To improve access to psychiatric consultation for cancer patients as well as non-cancer patients with psychiatric disorders, a psychiatric liaison programme to communicate closely with physicians and ward staff regarding anticipated psychiatric morbidity in patients, was introduced in each ward of a general hospital. The rate of psychiatric consultation referrals for cancer patients was significantly higher after the psychiatric liaison programme was established. The programme had a greater impact on the rate of psychiatric consultation in a unit with cancer patients who were informed of their diagnoses. The greater consultation rates in cancer patients after the liaison programme might be, in part, associated with the physicians’ attitude toward the more open disclosure of the cancer diagnosis.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. References

Prevalence studies of cancer patients in the United States of America revealed that psychiatric morbidity was very high. Derogatis et al.1 found that 47% of 215 randomly accessed cancer patients received a DSM-III diagnosis.2 Most of the diagnoses (68%) were adjustment disorders with a depressed and/or anxious mood; however, only approximately 2% are referred for psychiatric consultation.3 It is important to achieve higher psychiatric consultation rates for cancer patients, since adjustment disorders are responsive to brief supportive psychotherapy and psychotropic medications.4, 5 Although most studies have supported the theory that the establishment of a liaison activity could increase the rate of psychiatric consultation referrals for medically ill hospitalized patients,6[7][8]–9 cancer patients with psychiatric disorders tended to receive fewer, not more psychiatric consultations (approximately 0.5–1.9%) than non-cancer patients (0.9–3%).3, 10, 11

There are several important factors that interfere with appropriate referral for cancer patients. These factors include: (i) differences between the perceptions of cancer patients and the perceptions of their physicians regarding the patient’s psychological symptoms; (ii) the psychiatrist’s deficient knowledge of the medical aspects of cancer and its treatment resulting in the physician’s dissatisfaction with psychiatric assessments and recommendations. These first two factors were previously supposed in the United States, where all cancer patients are given their diagnoses;12, 13 and (iii) physicians’ fear of harming their relationship with the cancer patient, since most physicians in Japan do not usually inform cancer patients of their diagnoses. This last factor is the most difficult obstacle in developing a psychiatric liaison with the oncology unit in Japan.14

To improve access to psychiatric consultation for cancer patients as well as non-cancer patients with psychiatric disorders, a psychiatric liaison programme was introduced in each ward of a general hospital in order to communicate closely with physicians and ward staff regarding anticipated psychiatric morbidity in patients. The programme’s effect on the frequency of consultation referrals, psychiatric diagnoses, and the length of time from the initial consultation until death was examined.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. References

Approximately 17% of the patients hospitalized at Kure National Hospital have been diagnosed with cancer. Kure National Hospital is certified as a local cancer centre and is a 608 bed medical and 47 bed psychiatric facility in a suburb of Hiroshima City, serving an area of more than 200 000 people. However, the hospital has no oncology unit. The subjects in the present study consisted of 129 cancer patients for whom psychiatric consultation had been requested between April 1987–March 1993. All were inpatients at Kure National Hospital and had not been informed of the cancer diagnoses or the extent of their illness except for those in the early stages during the study period. In one unit (respiratory medicine) approximately a quarter of the cancer patients were informed of their diagnoses by the unit chief or the attending physician. A psychiatric consultation for both cancer and non-cancer patients can easily be requested by either senior or junior physicians on staff, although not by any other ward staff, by filling out a request card.

In April 1989, a psychiatric liaison programme was established to communicate closely with physicians and ward staff regarding patients with anticipated psychiatric comorbidity. The liaison programme is a weekly walk round programme for both cancer and non-cancer inpatients, by two attending psychiatrists and three post third-year residents in each ward of the hospital. The programme consists of two parts. One is to review initial and subsequent consultations for patients who were previously referred by assessing the patient’s chart. Usually, referred patients are not seen during liaison rounds. The second part consists of a discussion between physicians and nursing staff in each unit regarding patients with anticipated psychiatric disorders.

Psychiatric diagnoses were made according to DSM-IIIR criteria.15 Two time periods were examined: (i) the 2 years prior psychiatric liaison intervention (April 1987–March 1989); and (ii) the first 4 years after the liaison programme was introduced (April 1989–March 1993).

Statistical analysis was performed using Chi-squared test.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. References

There were no differences in the subjects’ age, gender, or Karnofsky performance status16 between patients in the two time periods (Table 1). After the liaison programme was established, a remarkably, but not significantly, increased number of consultations were requested for patients with more advanced diseases. Among patients who had consultations after the programme was established, 45% (49/109) with cancer lived less than 12 weeks after the initial consultation, while 20% (4/20) of patients who had consultations before the programme survived less than 12 weeks (χ2 = 4.35, df = 1, P < 0.10).

Table 1.  . Cancer patients referred for psychiatric consultation Thumbnail image of

After the introduction of the psychiatric liaison programme, the rate of psychiatric consultation referrals for cancer patients was significantly higher (3.1%) than that before the programme (1.2%, Table 2). However, there was no change in rates between the two time periods for non-cancer patients (1.9% vs 2.2%). Although, before the programme, there was a trend toward lower consultation rates for cancer patients (1.2%) than for non-cancer patients (1.9%; χ2 = 3.65, df = 1, P < 0.10), the rate of psychiatric consultation referrals for cancer patients was significantly higher than those for non-cancer patients after the programme (3.1% vs 2.2%).

Table 2.  . Consultation rates of cancer and non-cancer patients before and after introduction of a psychiatric liaison programme Thumbnail image of

We also examined the rates of consultation among cancer patients before and after the introduction of the programme in each medical unit (Table 3). One unit, respiratory medicine, showed a significantly higher rate of psychiatric consultation for cancer patients after the liaison programme was established (1.6% vs 6.1%). Although there was a small but significant increase in referrals from other medical units after the programme, the rate of psychiatric consultation in the respiratory medical unit was significantly higher than that in other medical units (6.1% vs 2.7%).

Table 3.  . Consultation rates of cancer patients before and after the introduction of a liaison programme in a respiratory medical unit Thumbnail image of

There were no differences in the psychiatric diagnoses of the referred cancer patients between the two time periods (Table 4). During the study period, the most common diagnosis (DSM-IIIR) in cancer patients was adjustment disorder and delirium. Similarly, most of the diagnoses in patients in the respiratory medical unit involved adjustment disorder (10/25) or delirium (5/25).

Table 4.  . Psychiatric diagnoses of referred cancer patients before and after the introduction of a psychiatric liaison programme Thumbnail image of

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. References

The results of the study showed that the rate of psychiatric consultation referrals for cancer patients was significantly higher after the introduction of a psychiatric liaison programme in each ward of a general hospital. The liaison programme also had a greater impact on the rate of psychiatric consultation in the respiratory medical unit compared to other medical units. During the study period, only one unit, respiratory medicine, in which about a quarter of the cancer patients were informed of their diagnoses, showed a three-fold higher rate after the programme, while in other units in which cancer patients were not informed of their diagnoses unless they were in the early stages of illness, showed a small increase. The greater consultation rates in cancer patients after the liaison programme was established might be, in part, associated with the respiratory medical physicians’ attitude toward a more open disclosure of cancer diagnoses.

These study results showed no differences in the psychiatric diagnoses in the referred cancer patients between the two time periods. Consistent with the findings of Massie and Holland4 and McCartney et al.5 the most common diagnosis (DSM-IIIR) in the referred cancer patients was adjustment disorder and delirium. The programme therefore may be able to improve access to psychiatric consultation for cancer patients by increasing the physician’s perceptions and interests of psychiatric disorders.12 McCartney et al.5 found that the liaison programme to a gynecological oncology unit influenced the rate of consultations positively and was associated with a higher percentage of consultations for minor psychiatric diagnoses (i.e. adjustment disorder). McCartney et al.5 suggested that the programme had a beneficial effect on an oncologist’s ability to detect more minor psychiatric disorders. The present results demonstrated that the liaison programme failed to increase the percentage of psychiatric referrals for cancer patients with adjustment disorder, but had a greater impact on the rate of psychiatric consultation for cancer patients with other psychiatric disorders. This difference can be explained by variations in the method of the liaison programme. Our programme was undertaken once a week, visits were very brief and covered all wards of the hospital, while McCartney et al’s programme was very strong and related only to one gynecological oncology unit. Although our programme may have been insufficient for non-psychiatric physicians and nursing staff to learn to detect minor psychiatric disorders, it was suggested that the programme was important to improve access to psychiatric consultation for cancer patients with minor and major psychiatric disorders.

It was surprising that the programme had more positive effect on the rate of psychiatric consultation referrals for cancer patients than for non-cancer patients, because the liaison programme was not designed to focus on cancer patients. Prevalence studies revealed that about half of cancer patients received a DSM-III or DSM-IIIR diagnosis.1, 17 Similarly, 30–60% of medically ill hospitalized patients were estimated to have psychiatric morbidities.18[19]–20 There were no differences in the psychiatric co-morbidity between cancer and non-cancer patients. Furthermore, previous reports regarding psychiatric consultation studies showed a trend that cancer patients with psychiatric disorders received fewer, rather more psychiatric consultations (approximately 0.5–1.9%) compared to non-cancer patients (0.9–3%).3, 10, 11 Taken together with the present findings that an increased number of consultations were requested in the respiratory medical unit and for patients with the poor prognosis after the programme was established, it is suggested that psychiatric consultation for cancer patients with advanced disease, as well as for those receiving their diagnoses, may be required more than that for non-cancer patients. The liaison programme may have a greater impact on physician’s recognition of the usefulness of the psychiatric treatment by demonstrating the improvement of the patients’ quality of life even after the failure of the active cancer treatment. However, further studies investigating why referrals for non-cancer patients did not increase after the liaison programme are required.

The present results showed that a psychiatric liaison programme in each ward of the hospital positively influenced the rate of consultation for cancer patients. This effect was enhanced when cancer patients were informed of their diagnoses. It is suggested that a psychiatric liaison programme improves the cancer patient’s access to psychiatric consultations as the physician’s attitude toward more open disclosure of the cancer diagnosis develops in Japan. Recently, most Japanese physicians reported a trend toward informing patients of a cancer diagnosis, therefore, consultation liaison psychiatry in cancer care will be increasingly necessary in Japan.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. References

This work was supported in part by the Grant-in-Aid for Cancer Research (9-36) and the Second term Comprehensive 10 Year Strategy for Cancer Control from the Ministry of Health and Welfare. The authors gratefully acknowledge all staff at Kure National Hospital. They also thank Kumiko Harada, RN and Ms Miho Sakai, at Psycho-Oncology Division, National Cancer Research Institute East, Japan for their research assistance.

References

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. References
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