Correspondence Address:
Rajesh Sagar
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India

Full Text

General hospital psychiatry, or psychiatry practiced in general hospitals, holds an important position in the realm of mental health services. General hospital psychiatry units are far more integrated with the medical health-care system and often work in close liaison with other medical and surgical specialists. The cross-talk between mental health specialists and practitioners of medical disciplines results in better conceptualization of the individual's illness, its impact on the psychological functioning and the remedial measures that can result in better outcomes for the patients. This issue of the Journal of Mental Health and Human Behaviour carries forth several articles that originate from cross-talk between psychiatrists and other health specialists.[1],[2],[3] Two of these articles relate to the referral patterns of patients to psychiatric services [1],[2] and one of them deals with suicidal ideations among patients with selected dermatological conditions.[3]

The term general hospital psychiatry implies that psychiatry is practiced in a specific context of general hospitals. This is in addition to other frameworks of the provision of care as well. In fact, before de-institutionalization, much of psychiatry was practiced in the mental health institutions or in private clinics of professionals. However, the need of psychiatrists in the treatment of patients with medical illnesses has been understood for long, and the profile of psychological problems/issues have been somewhat different than those encountered in the mental health institutions. Delirium and depression or adjustment reactions related to medical illness have been recognized as major issues that are encountered in the general hospital.

General hospital psychiatry has a long history, as has been chronicled effectively by Mayou.[4] It apparently began in the 18th century when endowments for care of mentally ill resulted in small areas in general hospitals being designated for care of patients with psychiatric disorders. In the absence of effective treatment options for patients with mental disorders, the patients with severe mental illnesses were largely kept in asylums. Voluntary general hospitals, which were run by the subscriptions of the wealthy people, did admit those considered “insane” based on the recommendation of the subscribers. Herein, patients from affluent families could be admitted with their servants and have a comfortable stay. However, such facilities did not continue for long, and patients with psychiatric problems were either treated in asylums or retreats. General hospitals did encounter patients with delirium and were cared for by the specialists. The general hospitals also encountered patients who had hysteria and hypochondriasis and were managed in the inpatient setting. With the beginning of the 20th century, trauma-related neurosis like “shell shock” or war neurosis,[5] were more frequently encountered in general hospital setting, which the physicians did not seem deserving to send to asylums. This, coupled with the development of psychoanalysis as a treatment of patients with neurotic disorders, provided an alternative option for the remedy of certain psychiatric disorders. Gradual developments in the field of psychopharmacology also provided further treatment options. Thus, the development of treatment options, along with sensitization about the need for training in psychiatry resulted in further expansion of general hospital psychiatry.

In India too, general hospital psychiatry has enjoyed a unique place. The need for the provision of mental health care and training in mental health had been well recognized in India. The first outpatient psychiatry unit in India, which was a precursor for the general hospital psychiatry units, was opened in Carmichael College (currently RG Kar Medical College) by Dr Girindra Sekhar Bose in 1993.[6],[7] This was followed by the opening of an outpatient facility at the J.J. Hospital in Mumbai in 1938 by Masani, and then Prince of Wales Medical College (currently Patna Medical College and Hospital) in 1939 by Dhunjibhoy. Subsequently, postgraduate training programs were started at Delhi, Chandigarh, Lucknow, Bombay, etc., under general hospital psychiatric units. By 1970s, about ninety psychiatric clinics were in operation in India, and gradual expansion of general hospital psychiatry units was seen.

In the present day context, general hospital psychiatry units perform several functions. The functions can be summarized into the context of teaching, service provision, and research. Currently, each of the medical college requires the presence of psychiatric teaching faculty and adequate exposure in psychiatry for accreditation form the medical council of India. While in some places, medical schools are attached to psychiatric institutions, in the majority of other medical schools, the general teaching hospital has a unit dedicated to psychiatry. The psychiatry unit caters to outpatients, inpatients, psychiatric emergencies, and consultations. Hence, a rich variety of clinical material is available for teaching purposes in the general hospital. Teaching of graduate and postgraduate students forms an important focus of such general hospitals psychiatry units. Teaching in the clinics utilizes didactic teaching, case demonstrations, discussion of history, observation of history taking and other skills.

The service provision domain of the general hospital psychiatry units performs various functions. It provides outpatient care to patients with psychiatric illnesses. Over time, psychiatric illnesses are being recognized as important causes of morbidity, and number of treatment options are made available. Outpatient treatment can cater to a considerable proportion of patients with psychiatric disorders. Pharmacological treatment seems to remain the mainstay of treatment, with services generally being available for psychodiagnostics and psychotherapy. Some of the severe cases may need inpatient hospitalization, though general hospital psychiatry units cater primarily to acute cases in the inpatient setting. The inpatient setting provides an opportunity for close observation of cases, some degree of protection from harm to self or others, and enables rapid titration of medications. The presence of psychiatric facilities in the general hospital probably reduced the stigma related to seeking psychiatric care, and thus, makes mental health services more accessible.[8] Comorbid medical conditions of patients with psychiatric illnesses are dealt in general hospital psychiatry unit better. The contact of the patient with the family is maintained. The ability to provide care for psychiatric emergencies is another unique feature of general hospital psychiatry units.

Consultation-liaison is an important aspect of general hospital psychiatry. The presence of psychiatrist in the hospital premises provides an opportunity for referral for behavioral problems encountered among patients in medical and surgical wards. Some of the specialists encounter delirium frequently (especially surgical branches which involve prolonged surgeries). Consultation with psychiatry department offers an opportunity to seek guidance on diagnosis and further management in terms of pharmacological and behavioral measures. In addition, other specialists from the medical and surgical fields often encounter patients who are depressed, suicidal, considered “difficult” or those who indulge in illness related deception. Consultation of psychiatrists is also sought when substance use disorders are a possible concern, especially in situ ations when the patients are not able to provide a history or are suspected to minimize reporting of substance use. The cross talk between psychiatrists and other professionals would rather depend on the sensitization of the physicians and surgeons about the psychiatric illnesses and the facilitators of communication across departments.[9]

Apart from teaching and service delivery, research also forms an important component of the mandate of general hospital psychiatry units. The general hospital setting provides an opportunity for collaboration with other departments in the conduct of research. Thus, research is possible in not only core psychiatric disorders but also other conditions which may be related to psychiatric symptoms, as has been done in one of the articles in this issue.[3] General hospital psychiatry has contributed significantly to the quantum of research in India and is likely to do so in the future.[10] Research endeavors that span across departments can be promoted in such a setting.

The present challenges faced by the general hospital psychiatry in India are many. Inadequate funding has marred the spread of such units across the country. Other limitations like lack of space and physical infrastructure is also a concern. The spread is also constrained due to the lack of trained workforce in terms of psychiatrists, clinical psychologists, psychiatric nurses, and social workers, who provide the services. Anticipated increase in patient load as the awareness regarding mental illnesses in community increases is likely to stress on the existing capacities of the general hospital psychiatry units. There is a need for attention toward psychosocial rehabilitation of patients, special group of patients such as children/adolescents and elderly, and emphasis on preventive and promotional aspects of psychiatry through the general hospital psychiatry units. There is also a need to collaborate smoothly with community services with District Mental Health Programme in a big way in future.

The discussion of the present state of general hospital psychiatry spurs speculation about where it is headed. General hospital psychiatry has established itself as one of the important spoke in the mechanism of the provision of mental health care. It needs to be seen how the wide access to psychiatric treatment through general hospitals can be utilized to provide care to a larger section of the population, especially those who are under-served. It would also be fruitful to assess how the consultation-liaison process can be improved, possibly through quality improvement programs. Although patients with psychiatric issues seem to have reduced duration of hospital stay if consultations are sought early, the initiation of such a consultation lies with the referring medical or surgical department. Practical and implementable models of liaison care need to be endorsed and curated over a period in a given hospital. Several models of care being available, the one to choose would depend on the unique circumstances of the medical facility. Stigma toward psychiatric disorders is a global and real concern.[11],[12] The presence of general hospital psychiatry units can play a major role in reducing this stigma by inducing changes in knowledge and attitude of not only patients but also physicians and surgeons from other specialties. It is hoped that in the future as well, general hospital psychiatry continues to play its purported role in growth and expansion of psychiatry.

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