Challenges in General Hospital Psychiatry

The liberation of psychiatry from the confines of the traditional mental hospital has been hailed as one of the roost significant steps in the progress of psychiatry during the second half of the twentieth century. This has, no doubt, benefitted the patient by providing treatment facilities in his own community, removing the social stigma associated wi th hospitalization, reducing the damaging effects of long-term institutionalization, promoting an easier reintegration into the community on discharge and mobilizing rehabilitation measures in the early phase of the illness itself. It has also enabled the patient's families to be more involved in the treatment and follow-up care. The establishment of psychiatry units in general hospitals have also been beneficial to the psychiatrist by reminding him of psychiatry's roots in medical sciences, improving his ability to communicate with medical colleagues from other specialties and by making the concept of consultation liaison psychiatry meaningful. This move of psychiatry into the general hospital has also posed its own challenges to the psychiatrist, requiring of him/her to be able to identify and treat not only major illnesses, but also the less severe but more prevalent psychiatric disorders in the community. He has also found that he is expected to be able to recognize psychiatric illnesses that may occur concurrently with various physical illnesses and to develop innovative and effective methods of treatment for these illnesses. Many articles in this issue of the Journal highlight these challenges in general hospital psychiatry. The psychological correlates to coronary heart disease are once again brought to our attention in the article by Saldhana et al, who found that these patients showed more obsession and somatic concern than normal controls and their responses in a projective test showed evidence of depression, constriction of range of interests and poor self-image. Arun et al's study of the Irritable bowel syndrome showed that a high percentage of their subjects had psychiatric morbidity of 2 to 4 years' duration. The case reports on delusional parasitosis triggered off by neuritis in leprosy (Shome et al), delusional parasitosis of body orifices (Srinivasan et al), genital self-mutilation (Saldhana), and multiple personality following communal riots (Chaddha & Saurabh) demonstrate the fact that patients with these types of problems are more likely to be encountered in general hospital practice and availability of psychiatric services in these hospitals make psychiatric treatment more acceptable to the patients. It also gives the psychiatrist the unique opportunity to treat these patients in collaboration with other medical colleagues and be an interpreter of the patient's symptoms and behaviour in their psychological and cultural contexts. Some of the characteristics of the patients who attend general hospital psychiatry clinics are described in the paper by Hariharan et al.. They found that among the patients referred to the psychiatry department from the general medical clinics, owing to the presence of somatic symptoms with a lack of organic pathology, the majority were women and those belonging to low income and educational groups. These patients reported more life events and more stressors in the family than controls. These findings have obvious treatment implications. Bhogale and Sudarshan report that among the persons above the age of sixty who attended the psychiatry clinic in a general hospital, 43.3% had a physical problem as well as a psychiatric problem, 33.6% had organic psychoses, 43.7% had functional psychoses and 19.8% had neurotic disorders. These observations stress not only the need to provide psychiatric services in general hospitals, but also the need to provide appropriate facilities for the adequate care of the associated physical problems the elderly psychiatric patients often have. Sato's study on those admitted in a neuro-psychiatry ward, as well as the ICU, emergency ward and renal dialysis unit following attempted suicide, precipitated by interpersonal problems and diagnosed to be having depressive disorder again underline the need for an integrated approach to patient care in all countries, irrespective of cultural and socioeconomic differences. Gopala Sarma's experiences reported in this issue, show that some of the traditional duties of the psychiatrist working in the mental hospital like certification in cri minal and civil cases can be and is being carried out by the general hospital psychiatrist also. The very nature and the variety of problems encountered in psychiatric practice in general hospitals make it imperative that psychiatrists working in these places should be adept not only in the use of psychopharmacological agents and other somatic treatments but also in psychological methods of treatment. In thisconiext, the pioneering effort of Shamsunder and colleagues in providing a formal and systematic training in psychotherapy for psychiatry residents is laudable and worthy of emulation by other training centers, appropriately adapted to suit local needsand theoretical orientation. The positive results obtained in the treatment of hypochondriasis through behavioral methods, as reported by Revar, should encourage us to try these methods in this usually treatment resistent condition. How are we to meet the challenges and special problems encountered in general hospital psychiatry? Are our training programmes geared lo equip our medical graduates and post-graduate trainees in psychiatry to meet the special demands of general hospital practice? Alexander and Kumaraswamy'sobservation thai majority of the senior medical students who received 50 hours of clinical teaching and 20 hours of lectures had an overall favorable impression about psychiatry, is a very encourag-