Psychosomatics 49:487-493, November-December 2008
doi: 10.1176/appi.psy.49.6.487
© 2008 Academy of Psychosomatic Medicine
Toward Defining the Scope of Psychosomatic Medicine Practice: Psychosomatic Medicine in an Outpatient, Tertiary-Care Practice Setting
James R. Rundell, M.D.,
Kierin Amundsen,
Teresa L. Rummans, M.D., and
Gayla Tennen, M.D.
Received December 11, 2006; revised February 26, 2007; accepted March 16, 2007. From the Dept. of Psychiatry, Mayo Clinic, Oronoco, MN. Send correspondence and reprint requests to James R. Rundell, M.D., Dept. of Psychiatry, Mayo Clinic, 990 Riverwood Lane SW, Oronoco, MN 55960. e-mail: rundell.james{at}mayo.edu
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Because psychosomatic medicine (PM) is increasingly practiced in outpatient settings, the scope of practice needs to be delineated from community psychiatry and inpatient psychiatry work. OBJECTIVE: The authors sought to address the question of whether outpatient activities are a definably part the scope of practice of PM. METHOD: Three clinical groups were compared: 200 PM outpatients, 200 consultation–liaison (CL) inpatients, and 200 community-psychiatry (CP) outpatients. RESULTS: The groups differed significantly in 49 of 112 demographic and clinical comparisons (43.8%). Analysis of individual measures validated the concept that PM outpatient practice requires traditional PM/CL expertise with medical-psychiatric differential diagnosis, unexplained physical symptoms, pain, and psychopharmacological management in medically ill and geriatric patients. CONCLUSION: Outpatient PM experiences may also enhance training opportunities, given an expanded case-mix.
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INTRODUCTION
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Psychosomatic medicine (PM) services are and will increasingly be delivered in outpatient settings. How dedicated outpatient PM practices are distinct from community-psychiatry and inpatient consultation work may define aspects of scope-of-practice, reimbursement, training, and models of care-delivery. Mayo Clinic’s Department of Psychiatry and Psychology (Rochester, MN) has long had a Tertiary Psychiatry Division focused on answering inpatient and outpatient consultations from healthcare providers in other specialties and from primary-care services regarding psychiatric issues in medical-surgical patients. This dedicated outpatient PM practice is distinct from clinics serving patients who have mental disorders and who present primarily for psychiatric treatment, even if they also have medical or surgical conditions. The outpatient PM clinic is staffed by psychiatrists who are Mayo Clinic faculty members; all patients are evaluated by physicians. All outpatient PM consultations in this study were conducted by psychiatrists with experience in consultation–liaison (CL) psychiatry, who are board-certified in Psychosomatic Medicine, and who also conduct part of their clinical practices on the inpatient CL psychiatry service.
There have been a number of studies detailing reasons for consultation and psychiatric diagnoses of medical-surgical inpatients who are referred for psychiatric consultation.1–3 The differences between primary community-psychiatry (CP) practice and outpatient tertiary consultative (PM) practice, and between inpatient CL and outpatient PM practices, have not been well studied in terms of identifying required skill-sets and training needs for psychosomatic practice. Identifying specific types of patients, disorders, and treatments most often seen in an outpatient PM practice would more specifically delineate psychosomatic medicine’s overall scope of practice, training priorities, and certification requirements. It would also inform PM fellowship directors, General Psychiatry residency training directors, and medical-student clerkship directors’ decisions about training rotations and curriculum.
We could locate only one study that compares the differences in characteristics among inpatients versus outpatients in the same institution who were referred for psychiatric consultation.4 In that study, two-thirds of the 1,200 patients were inpatients, and one-third were outpatients; outpatients were more likely than inpatients to receive mood disorder, personality disorder, and anxiety disorder diagnoses. They were less likely to receive cognitive disorder and psychotic disorder diagnoses.
The purposes of this study were to 1) characterize and describe differences between patient demographic, clinical, and management categories for (Rochester, MN) Mayo Clinic CL, PM, and CP patients; 2) provide evidence-based refinement of the definition of scope of practice of the new subspecialty of Psychosomatic Medicine; and 3) identify training needs and opportunities presented by the outpatient PM practice.
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METHOD
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Clinical records of consecutive adult patients (age  18) who received outpatient PM consults (primary medical-surgical diagnosis but having a psychiatric question) were reviewed and compared with clinical records of consecutive adult patients receiving inpatient psychiatry consults (hospitalized for medical-surgical problems but having a psychiatric question) and clinical records of initial evaluations of consecutive adult CP (primary diagnosis is psychiatric, and patients live within one surrounding county). On the basis of a power analysis to determine the sample sizes necessary for each of the three groups of study subjects, in order to have sufficient power to detect a significant difference between study categories (clinical diagnostic groups such as mood and anxiety disorders, and general management strategies such as psychopharmacology and psychotherapy), 200 clinical records were drawn from each group.
Three domains of data were collected: demographic, clinical, and management. Demographic data included patients’ age, gender, marital status, and ethnic group. Clinical data included consulting service, reason for consultation, DSM-IV–TR diagnosis, Global Assessment of Functioning (GAF) Scale5 score, total number of medications at time of consultation, and total number of medical or surgical diagnoses. Management data included whether the patient received or was referred for electroconvulsive therapy, psychopharmacotherapy, psychotherapy, addiction treatment, psychological or neuropsychological testing, or follow-up appointments with a psychiatrist. Consultation requests, clinical data, and ratings were collected prospectively at the time of consultation and were not retrospectively inferred, with the exception of 45 GAF Scale scores not recorded at the time, which were retrospectively inferred by two physicians reviewing the record’s data together.
For clinical diagnoses, secondary psychiatric diagnoses were defined as secondary depression, secondary mania, secondary anxiety disorder, and secondary psychotic disorder. DSM–IV defines these categories as mood, anxiety, and psychotic disorders secondary to general-medical conditions or substances. Four general and specific indicators of clinical severity were chosen for analysis: mean number of medical and surgical diagnoses, mean number of medications, percentage of study group deceased within 12 months, and mean GAF Scale5 score.
For categorical data, chi-square analyses were done to compare potential differences in categories among the three comparison groups. When cell sizes were  5, Fisher’s exact test was performed instead. For continuous variables (age, number of follow-up appointments per year), a two-sample t-test was used.
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RESULTS
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Demographic Comparisons
There were only two significant demographic differences among the study groups (Table 1). Outpatient PM patients’ average age was significantly greater than CP outpatients’ mean age (53.2 versus 41.8 years; p<0.001). CL inpatients were more likely to be divorced or separated than were PM outpatients (25.0% versus 15.5%; p=0.004).
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TABLE 1. Demographic Comparisons: Inpatient Consultation–Liaison (CL), Outpatient Psychosomatic Medicine (PM), and Outpatient Community-Psychiatry (CP) Patients (N=200/Group)
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Clinical-Characteristics Comparison: Consultation–Liaison Inpatients Versus Psychosomatic-Medicine Outpatients
We studied 32 categories of clinical characteristics, which included reasons for consultation, clinical diagnoses, and clinical-severity indicators. Of the 32 items, 21 were significantly different between the two study groups (65.6%). Results of this comparison are summarized in Table 2.
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TABLE 2. Clinical Characteristics: Inpatient Consultation–Liaison (CL), Outpatient Psychosomatic Medicine (PM), and Outpatient Community-Psychiatry (CP) Patients (N=200/Group)
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Reasons for Consultation
Compared with PM outpatients, CL inpatients were significantly more likely to have confusion (13.0% versus 0.5%; p=0.001), alcohol-related concerns (5.0% versus 0.0%; p=0.002), drug-related concerns (7.5% versus 1.5%; p=0.009), and psychosis (5.5% versus 1.0%; p=0.024) listed as reasons for consultation. As compared with CL inpatients, PM outpatients were significantly more likely to have depression (71.0% versus 41.0%; p<0.001), anxiety (32.5% versus 15.0%; p<0.001), and unexplained physical symptoms (9.5% versus 3.5%; p=0.019) listed as reasons for consultation; 23 patients had two reasons for consultation, most commonly, anxiety and depression.
Clinical Diagnoses
CL inpatients were significantly more likely than PM outpatients to receive the following clinical diagnoses: delirium (23.5% versus 1.5%; p<0.001), a DSM–IV alcohol use disorder (17.0% versus 5.5%; p=0.001), a DSM–IV drug-use disorder (19.5% versus 7.0%; p<0.001), and a DSM–IV eating disorder (3.0% versus 0.0%; p=0.030). CL inpatients were also more likely than PM outpatients to receive any secondary psychiatric diagnosis (22.5% versus 15.0%; p<0.001). Analysis of individual secondary psychiatric diagnoses did not reveal significant differences, except that CL inpatients were more likely to receive a diagnosis of secondary anxiety disorder (10.5% versus 5.5%; p=0.011). PM outpatients were significantly more likely than CL inpatients to receive the following clinical diagnoses: a DSM–IV primary anxiety disorder (29.0% versus 11.0%; p<0.001), a DSM–IV sleep disorder (5.5% versus 1.5%; p=0.042), DSM–IV pain disorder (10.0% versus 4.0%; p=0.023), and adjustment disorder (15.5% versus 6.0%; p=0.003).
Clinical-Severity Indicators
All four general and specific severity indicators were significant for higher severity among CL inpatients than for PM outpatients: higher mean number of medical and surgical diagnoses (7.5 versus 4.5; p<0.001), higher mean number of medications (11.0 versus 6.5; p<0.001), lower mean GAF score (37.5 versus 54.7; p<0.001), and higher percentage deceased within 12 months (10.5% versus 1.5%; p<0.001).
Clinical-Characteristics Comparison: Psychosomatic Medicine Outpatients Versus Community-Psychiatry Outpatients
We studied 32 categories of clinical characteristics, which included reasons for consultation, clinical diagnoses, and clinical-severity indicators. Of the 32 items, 15 (46.9%) were significantly different between the two study groups. Results of this comparison are summarized in Table 2.
Reasons for Consultation
Compared with CP outpatients, PM outpatients were significantly more likely to have depression (71.0% versus 54.0%; p<0.001), anxiety (32.5% versus 23.0%; p=0.009), and unexplained physical symptoms (9.5% versus 3.0%; p=0.011) listed as reasons for consultation. There were no reasons for consultation significantly more likely in CP outpatients than in PM outpatients.
Clinical Diagnoses
PM outpatients were significantly more likely than CP outpatients to receive the following clinical diagnoses: secondary depression (9.0% versus 0.5%; p=0.004), a primary DSM–IV anxiety disorder (29.0% versus 18.5%; p=0.014), dementia (6.5% versus 2.0%; p=0.035), secondary anxiety disorder (5.5% versus 0.0%; p<0.001), a DSM–IV sleep disorder (5.5% versus 1.5%; p=0.042), DSM–IV pain disorder (10.0% versus 2.0%; p=0.002), and any secondary psychiatric diagnosis (15.0% versus 1.0%; p<0.001). CP outpatients were significantly more likely than PM outpatients to receive clinical diagnoses of a DSM–IV eating disorder (3.5% versus 0.0%; p=0.015) and a DSM–IV relational disorder (e.g., marital problem: 10.0% versus 2.0%; p=0.002).
Clinical-Severity Indicators
PM outpatients had higher indications of clinical severity than CP outpatients on three of the four study indicators: mean number of medical diagnoses (4.5 versus 3.4; p=0.007), mean number of medications (6.5 versus 4.7; p<0.001), and mean GAF score (54.7 versus 62.4; p<0.001). Both groups had low percentages of number of patients deceased within 12 months (1.5% versus 0.0%; p=0.248).
Clinical-Management Comparisons
CL inpatients were more likely than PM outpatients to receive addiction treatment referrals (11.5% versus 1.0%; p=0.001) and outpatient psychiatric follow-up appointments (42.0% versus 29.0%, p=0.003; Table 3). PM outpatients were more likely than CL inpatients to receive psychotherapy referrals (46.0% versus 15.5%; p<0.001). PM outpatients were more likely than CP outpatients to receive psychological or neuropsychological testing referrals (11.5% versus 2.0%; p<0.001). CP outpatients were more likely than PM outpatients to receive psychotherapy referrals (61.0% versus 46.0%; p=0.003) and psychiatric follow-up appointments (72.0% versus 29.0%; p<0.001).
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TABLE 3. Clinical Management: Inpatient Consultation–Liaison (CL), Outpatient Psychosomatic Medicine (PM), and Outpatient Community-Psychiatry (CP) Patients (N=200/Group)
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Psychopharmacological use patterns differed among CL inpatients and PM outpatients: Antidepressants were more likely to be recommended for PM outpatients (58.0% versus 37.5%; p<0.001); antipsychotic medications for CL inpatients (12.5% versus 1.5%; p<0.001); anxiolytic medications for CL inpatients (17.0% versus 7.0%; p=0.003); and mood stabilizers for CL inpatients (7.0% versus 2.0%; p=0.023). There was no statistically significant variation in psychopharmacology-class utilization patterns between PM outpatients and CP outpatients.
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DISCUSSION
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In some areas, psychosomatic medicine (PM) outpatient practice more closely resembles inpatient consultation–liaison (CL) practice than outpatient community-psychiatry (CP) practice. For example, the mean age of patients in the CL and PM groups is almost identical; however, it is much younger in the CP group. Proportions of CL and PM patients with dementia are similar, and significantly higher than in the CP group.
Rates of secondary depression are similar among CL and PM patients, and higher than in CP patients. In other areas, outpatient PM practice is clinically closer to out-patient CP practice than to inpatient CL practice. For example, rates of delirium, alcohol-use disorder, and drug-use disorder among PM and CP patients are similar, and significantly lower than in CL patients. Yet, in other areas, outpatient PM practice appears to be significantly different from both inpatient CL practice and outpatient CP practice; examples include significantly higher requests for consultation for unexplained physical symptoms than either of the other groups, an intermediate level of clinical severity as measured by the GAF scale (although closer to the CP patients), and significantly higher rates of diagnosis of DSM–IV primary anxiety disorder, DSM–IV sleep disorder, and DSM–IV pain disorder than either of the other two study groups. Frequency of diagnosis of secondary psychiatric disorders was intermediate between that of the other two groups.
These findings suggest that skills traditionally important in inpatient CL practice are also important in outpatient PM practice; these skills include expert capabilities in cognitive and noncognitive portions of the mental status examination, medical–psychiatric differential-diagnostic skills, ability to appropriately refer for psychological and neuropsychological testing, ability to address unexplained physical symptoms and pain, knowledge of issues related to aging, psychopharmacological expertise in medically ill and geriatric patients, and a high degree of knowledge about delirium, dementia, and secondary psychiatric disorders.
Outpatient PM practices at some centers have long been felt to make a valuable contribution to psychosomatic medicine training for PM fellows, general-psychiatry residents, residents from other training programs, and medical students.6 These data confirm those beliefs. Among 39 Psychosomatic Medicine fellowship programs with program descriptions on the Academy of Psychosomatic Medicine website,7 20 (51.3%) describe some type of outpatient experience for fellows, 8 (7.7%) describe an optional outpatient experience, and 11 (28.2%) do not describe an outpatient experience. Substantive training in outpatient PM settings, if properly structured, adds important opportunities for medical psychotherapy, continuity clinics, and evaluating patients who may be somewhat less physically ill and more communicative than CL inpatients; this experience provides a richer overall case-mix. Compared with inpatient CL settings in this institution, there are a higher proportion of consultation requests for evaluation of unexplained physical symptoms, depression in medically ill patients, and anxiety in medically ill patients in the outpatient PM practice.
There are a number of limitations to this study. First, psychiatric diagnoses were not made according to a structured psychiatric interview instrument or outline. They are clinical diagnoses derived from consultation reports. Second, the study is limited by relatively small sample sizes among some low-frequency diagnoses of importance to psychosomatic medicine, such as conversion disorder, hypochondriasis, somatization disorder, factitious disorder, and psychological factors affecting medical conditions. Third, the Mayo Clinic is a unique clinical setting, with a high volume of medically complicated patients and a high number of clinicians trained in psychosomatic medicine, most of whom are board-certified in the subspecialty. The structure and form of a dedicated psychosomatic medicine outpatient clinic in other centers may be structured differently from the clinic described in this article. Fourth, the Mayo Clinic is a national referral center; 72% of Psychosomatic Clinic outpatients and 31% of C–L inpatients reside outside the state of Minnesota. Cultural and geographic differences may have an unpredictable impact on clinical presentation. Finally, although the same core clinical faculty group covers the outpatient Psychosomatic Medicine clinic and inpatient C–L Service, different faculty members work in the Community Psychiatry clinic; this makes comparison of clinical data from the varying faculty members more vulnerable to stylistic and documentation differences.
Several different models of outpatient adult psychosomatic medicine practice have been implemented.6,8–15 They include outpatient consultation psychiatry clinics, multidisciplinary consultative clinics, behavioral medicine clinics, psychiatric liaison to primary or specialty care clinics, subspecialty consultation–liaison clinics (e.g., transplantation, psycho-oncology), integration into a general-psychiatry clinic, and Medicine–Psychiatry Clinics (e.g., in combined Med–Psych residencies).
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CONCLUSION
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The data in this study suggest that outpatient activities are a discernable and distinct part of the psychosomatic-medicine scope of practice that calls upon the unique skills and capabilities required of the psychosomatic-medicine subspecialist. Given these distinctions, psychosomatic medicine training may be significantly enhanced by a dedicated Psychosomatic Medicine Outpatient Clinic experience.
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ACKNOWLEDGMENTS
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Data from this article were presented during a workshop at the 2006 Annual Meeting of the Academy of Psychosomatic Medicine, Tucson, AZ, November 17, 2006.
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REFERENCES
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- Clarke DM, Smith GC: Consultation-liaison psychiatry in general-medical units. Aust N Z J Psychiatry 1995; 29:424–432[Medline]
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- First MB: GAF Report for the Global Assessment of Functioning Scale, Windows Version-User’s Manual. Toronto, Ontario, Canada. Multi-Health Systems, Inc, 1996
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- Academy of Psychosomatic Medicine: Consultation-Liaison/Psychosomatic Medicine Fellowship Training Programs in the United States. website: http://www.apm.org/cl-pgms/index.html. Oct 2006
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- Cambridge Health Alliance: Consultation-Liaison Services in the Department of Psychiatry. website http://www.cha.harvard.edu/psychiatry/consult_liaison.shtml 2006
- Columbia University: Child and Adolescent Consultation-Liaison Service in the Department of Psychiatry. website http://wo-pub2.med.cornell.edu/cgi-bin/WebObjects/PublicA.woa/8/wa/viewService/2006
- Dolinar LJ: A historical review of outpatient consultation-liaison psychiatry. Gen Hosp Psychiatry 1993; 15:363–368[Medline]
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- Epstein SA, Gonzales JJ, Stockton M, et al: Functioning and well-being of patients in a consultation-liaison psychiatry clinic. Gen Hosp Psychiatry 1996; 18:3–7[Medline]
- Goldberg RJ, Stoudemire A: The future of consultation-liaison psychiatry and medical-psychiatry units in the era of managed care. Gen Hosp Psychiatry 1995; 17:268–277[CrossRef][Medline]
- Virginia Commonwealth University: Consultation-Liaison Psychiatry in the Department of Psychiatry. website http://www.vcu.edu/psych/education/residency/consultliaison.html 2006
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ABSTRACT
INTRODUCTION
