Why are hospital doctors not referring to Consultation-Liaison Psychiatry? – a systemic review

Systemic factors are defined as the environment factors (external to the hospital doctors or the patients). The systemic factors that influence CLP referrals are summarized in Table 1.

In a naturalistic longitudinal study based in Glasgow, Brown and his colleagues took advantage of the introduction of a new resident CLP team and studied the referral patterns over a period of 7 years [30]. The psychiatric needs of the hospital were previously met by psychiatrists from an associated psychiatric hospital and not a dedicated CLP team. It was found that referral rates increased over the study period, with a disproportionate increase in referrals of inpatients who were not involved in acts of deliberate self-harm. They suggested that the increase in referrals were due to the presence of a dedicated CLP unit. These results were replicated in one other similar study that looked at referral rates after introduction of a CLP unit [31]. Accessibility to a CLP service was also mentioned in several surveys [32, 33] as a factor that may increase CLP referrals.

The presence of a dedicated CLP team may not be adequate. Collaborative screening of inpatients with their treating team can further increase referral rates. In a Swiss study, twice weekly multidisciplinary meetings were held on a medical ward, involving psychiatrist, medical consultant and nurses. It was found that referral rates increased from 4 to 32 % when collaborative screening of patients was done [34]. In addition, active engagement of medical teams by CLP consultant is suggested to increase referrals in a one year single-site German observational study [35], although active engagement was not clearly defined.

Lacking a strategy towards management of psychiatric patients may contribute to low referral rates. It was found that past suicide attempts were not correlated with psychiatric referral in South Korean hospitals [36]. Authors of this study attributed this to a lack of strategies for detailed suicide prevention in Korean emergency departments and possible prejudice towards psychiatric consultation. This was supported by the fact that studies in countries other than South Korea had found suicide attempts to be predictive of referrals [37].

Limited work hours were suggested to be impacting on referrals to CLP. Caplan and his team suggested that there may be increased tendency by referrers to outsource the building of doctor- patient relationships to CLP [38]. The impact of work pressure may decrease referral rates by limiting the referrer’s time or resources to manage a CLP referral. It cannot be concluded at this time if work pressure affects referral as there were no studies looking at correlation of workload of referrer and referrals to CLP.

When close collaborative work with a psychiatrist is not possible, liaison work by mental health nurses may increase referral rates. There were no studies that considered the association of referral rates with the presence of a mental health nurse. One article that described the experience of mental health nurse liaison in a head-and-neck cancer unit, reported some subjective benefits [39]. The referral patterns were not clear in this study, but the authors suggested that referral rates were more dependent on the cancer unit staff on-shift, rather than presence of mental health nurse. Further elaboration of how referral is more associated with some ward staff was not done in this report.

Referrer factors are factors that are associated with the characteristics of the practitioners who may potentially utilise CLP services by referring their hospital patients. These factors are summarised below (Table 2).

Few studies attempted to investigate barriers to CLP referral from the referrer’s perspective. In 1990, Thompson and associates found through a survey of 200 hospital doctors (response rate of 35 %), that physicians agreed upon three main reasons for not referring for psychiatric consultations [32]. These three reasons were stigma, poor communication from psychiatrists and a belief that other mental health professionals may do equally well for the patient's health at reduced cost. It was difficult to assess the quality of this study given the process for survey development and validation (if conducted) was not outlined. No statistical analysis of data was reported.

In 1971, Mezey and Kellett conducted a survey with 106 hospital consultants using a modified survey previously used with general practitioners in 1966 [33]. Patients’ preference not to be referred was identified as the most common barrier to psychiatric referral. Stigma was the second most common reason, followed closely by poor access to services, and inadequate rapport with psychiatrists. Mezey and Kellett also analysed the demographics of the surveyed participants and suggested that older consultants were less likely to recognise psychiatric comorbidities in their patients, while younger consultants were more likely to have inadequate rapport with the psychiatrist. Surgeons and gynaecologists were less likely to refer than their physician counter-parts. Mezey and Kellett were unable to explain this difference between specialties in their survey.

In 1982, through a survey of 400 hospital doctors (including physicians and surgeons) in North Carolina Memorial Hospital, Cohen-Cole and Friedman realised that hospital doctors do not refer most of their patients identified with significant psychological issues [40]. In the same survey, 78 % of hospital doctors felt comfortable handling these psychological issues without psychiatry consultation. In addition, Cohen-Cole and Friedman found that attending physicians in internal medicine (62 %) and family medicine (43 %) tend to estimate more psychological components affecting their patients compared to surgeons (30 %), obstetricians-gynaecologist (19 %) and paediatricians (29 %).

The positive attitude of the hospital doctors towards a CLP service may increase referrals. In a 2015 survey by Hamdieh and team based in Iran, hospital doctors who had positive attitude towards their CLP service were more comfortable in making psychiatric referrals [41]. This result was supported by a one year single-site study of a German CLP service. Following one year of active engagement by the same CLP consultant, it was suggested that referrers were more comfortable with a psychiatric approach with their patients, resulting in more referrals [35].

While there might be differences in recognition of mental illness between specialties, a methodologically sound meta-analysis of 36 prevalence studies suggests that overall recognition of depression by non-psychiatric hospital doctors is lacking [42]. Overall sensitivity was found to be 36.4 % and specificity was 83.7 %. In 1995, in a prospective study of 987 medical and surgical patients in Monash Medical Center, Clarke and colleagues found diagnostic concordance of depression by referring doctor compared to a consultant psychiatrist was at 74 % [43] with a false-positive rate of 41 % and a false-negative rate of 15 %. This finding was replicated in several other studies [44‐48]. Judd et al. found slightly better concordance of depression diagnosis in HIV patients (79 %) with false-positive rate of 20 % and false-negative rate of 23 %. Dilts et al. found low accuracy only in depression diagnosis but not cognitive impairment or substance use disorder. This difference may be due to hospital doctors finding difficulty in identifying clinical depression in physically unwell patients [44]. Canuto and colleagues suggest concordance in diagnosis of clinical depression between psychiatrist and other doctors increases with severity of depression and younger age [49]. Depression is, however not the only mental illness poorly recognised by hospital doctors. Drug and alcohol issues were also frequently missed by hospital doctors [50], although anxiety and psychotic disorders were found to have the lowest diagnostic concordance in a 5 year study [51].

There are differences in estimates of mental illness prevalence among hospital doctors of different specialties. Mezey and Kellet’s survey revealed that surgeons and gynaecologists were less likely to refer than their medical physician counterparts [33]. This was supported by reviews of referrals by surgical, obstetric and gynaecological doctors in several studies [52, 53]. Collating findings of Cohen-Cole and Friedman’s study with Mezey and Kellet’s, lower referral rates from surgeons, obstetricians and gynaecologists may be a result of poorer recognition of psychiatric issues. This view was supported by a study by Balestrieri et al. in medical and surgical inpatients in 2002 [54].

One may argue that lower referral rates from non-physician doctors may be linked to patients being treated adequately, without the need for referral. This was not found to be the case by Fauman in his survey of 11 hospital doctors. Findings suggested a significantly larger proportion of physicians willing to treat psychiatric disorders than their surgical or obstetric-gynaecological peers [55].

The difference in referral rates between specialties could also be accounted for by differences in expectations. In a questionnaire to 77 hospital doctors, De-Nour found that physicians tend to expect liaison service where psychiatrists participate actively in case conferences and routine management of patients [56]. This was in contrast to surgeons who expect a consultation service, where a psychiatrist advises on psychiatric management and diagnosis.

While the focus had been on presence of mental illness in patients, when assessment of competency was involved, many factors could increase referrals. Jourdan and Glickman found that over 25 % of patients referred to their CLP service were for assessment of competency [57]. This same group of patients had no mental illness and three quarters of them were found to be competent. Jourdan and Glickman explained that the fear and anxiety of doctors about medico-legal consequences, and poor understanding of management when patients refuse treatment were possible reasons for increased referrals.

The presence of a psychiatric history increases the likelihood of referral. Fenichel and Murphy examined the decision-making process around making a psychiatric referral in the emergency department [58]. It was found that non-psychiatric staff often based their decision of referral on past psychiatry history if the patient presents with mild to moderate symptoms. In a study by Pritchard in 1972, patients with a psychiatric history are three times more likely to be referred for psychiatric consultation. However, Pritchard suggested that if the patient had previous contact with the psychiatric team in the same hospital, they might not be referred to CLP [37]. This was supported by lowered referral rates for patients with previous psychiatric contact in same hospital but did not reach statistical significance (Table 3).

Referral is more likely to happen if the patient is of younger age. Marcus and team looked at data from 327 American hospitals and found that age was inversely correlated with psychiatric referral rates [59]. Other studies have supported the inverse correlation of age to referrals [37, 60, 61]. The same study from Marcus et al. did not find gender of patients to be useful as predictors to psychiatric referrals [59]. However, patients in urban settings were more likely to be referred. This was attributed to a significantly higher psychiatrist-to-population ratio in urban regions [59].

The psychiatric diagnosis of the patient may predict likelihood of CLP referral. Patients with functional psychotic diagnoses (including schizophrenia and psychotic depression) were more likely to be referred to CLP [37]. Patients with psychosis from organic causes (such as dementia and delirium) were less likely to be referred [37]. In a prospective study of 712 referrals over a five-year period examining timing of referrals, presence of personality disorder was found to predict earlier referral. This was in contrast to presence of depression where a delayed referral was more likely [62]. Although timing of the referral does not inform us of whether a referral has been made, one may expect previous poor recognition of depression from a non-psychiatrist as discussed earlier to have delayed and prevented referrals.

Patient’s race and their socio-economic status may influence psychiatric referrals. In a 1982 review of CLP referrals in a major teaching hospital, Craig found that white patients were more likely to be referred than non-white patients when an active liaison service was present [63]. However, once referred, services rendered to all patients by CLP were of no difference. Low referral rates exist similarly across all races if an active liaison service was not present. Craig suggested that this association may be as a result of higher emotional distress in lower socio-economic groups, which was unfortunately associated with non-white patients presenting to this teaching hospital. Collins and colleagues looked at referral patterns among different ethnic-cultural groups in San Diego Medical Center [64]. They found lower referral rates for Hispanics compared to other groups (Anglos, Blacks and Asians). Different ethnic groups were also more likely to be referred for different conditions. For example, requests for evaluation of depression and suicides were higher in Hispanics, and much reduced in Blacks. The authors were not able to draw conclusions from these results and suggested more research into cultural factors that may influence manifestations of poor mental health and CLP referrals.

The perceived stigma by hospital doctors identified by Mezey and Kellet may not be present from the patient’s perspective. Klein and team interviewed 48 medical inpatients and found that 81 % were either moderately to very agreeable to having a psychiatric consultation [65].