Review: Comparison of Consultation-Liaison Services in the United States and Japan

The paper reviewed here is  ’A Comparison of Psychiatric Consultation-Liaison Services Between Hospitals in the United States and Japan’ by Kishi and colleagues and freely available here. As the title suggest, the researchers make a comparison of consultation-liaison services in Japan and the Unites States and in the abstract there are a number of conclusions drawn. They begin with an introduction to their study. The researchers briefly describe some of their expectations of a comparison between the services in the two countries in this section.

The researchers describe their method in the next section. The researchers selected hospitals in Minnesota, USA and Kanagawa, Japan for the study. They write that cultural differences between the two countries might be reflected by the patterns of referrals to liaison services. They also state that the period of study was related to a change in the reimbursement fees for consultations although I wasn’t sure of the temporal relationship between the study period and this change. The catchment area of the Minnesota hospital was 3 million and in the Kanagawa hospital was 1 million. The researchers describe the data that was recorded during the study period. The researchers justify their use of an adjusted Length of Stay (LOS) figure which incorporates the timing of the consultation.

In the results section, there was significantly more men in the Minnesota sample (p=0.040), significantly more of the subjects were married in the Kanagawa sample – indeed almost twice as many proportionally (p<0.001) and significantly more employed in the latter sample (p=0.001). Surgical referrals seemed to be proportionally much higher in the Kanagawa sample than the Minnesota sample while the reverse was true for intensive care referrals although chi-squared and p-values weren’t displayed in the table for these figures. Interestingly almost twice as many referrals (proportionally) in the Minnesota sample had a past psychiatric history and this was highly significant (p<0.001). ‘Chemical dependency’ was the most common cause of referral in the Minnesota sample and ‘evaluation’ in the Kanagawa sample and both were significantly different from their counterpart values (i.e. in the other cities). Delirium was the most common diagnosis in the Kanagawa sample and depression in the Minnesota sample and again both proportions were significantly higher than those in the counterpart populations.

In the discussion, the authors suggest that cultural factors might not play a role in the differences in prevalence of depression between East Asian countries and western countries (however an interesting study is reviewed here). They then suggest that in Japanese culture there is a focus on the collective rather than the individual and that this may influence interactions with mental health services. They also comment on referrals from physicians to psychiatrists for ‘psychosocial issues’ which was a frequent finding in referrals. In their discussion the authors note a number of limitations to the study including the lack of controls which would be helpful in better understanding the cultural differences. Additionally they note that the selected hospitals may not be representative of other teaching hospitals in the respective countries.

As this was a comparison of retrospective data and they were interested in characteristics, the absence of primary outcome measures meant that in effect this was an exploratory analysis and adjustments may help to clarify which are the most interesting findings. The findings with regards to referrers and diagnoses would be areas that would be interesting to follow-up using a different paradigm e.g. case-controlled registry-based studies.

 

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Review: Somatic Awareness and Body Distress Symptoms

The paper reviewed here is ‘Somatic Awareness in the Clinical Care of Patients with Body Distress Symptoms’ by Bakal and colleagues and freely available here. The authors describe Body Distress Symptoms thus

‘Symptoms of somatic or body distress (BD), more widely known as medically unexplained symptoms (MUS) or functional somatic syndromes, are characteri(s)ed by patterns of persistent physical complaints for which adequate examination does not reveal specific pathology’

Thus the authors equate Medically Unexplained Symptoms, functional somatic syndromes and symptoms of body distress in their definition. The authors go on to justify their favouring of the term BD and cite evidence suggesting that reattribution therapy which attempts to move the explanation for functional bodily symptoms to a psychological cause does not lead to an improvement in outcome measures. However the article is concerned with BD rather than RT meaning that the efficacy of RT would be explored in more detail in a systematic review which may result in more complex conclusions. The authors then go on to discuss the origins of Bodily Distress Disorder (BDD), discussing the three factor model and then focusing on how core symptoms might relate to the regulation of breathing.

I disagreed with the section on ‘depression and sadness in context’. While it is important to distinguish between ‘normal’ sadness and depression (for which there are many diagnostic criteria) the authors also make some suggestions about prolonged antidepressant use and then finish the section by stating that they do not think that antidepressant treatment is the answer. I would argue on the other hand that appropriate treatments are made only after a carefully considered assessment and that recommendations regarding the optimal treatment strategies should be guided by this individual assessment, the evidence base and the local treatment protocols.

The authors answer some of these points in their section on tacit knowing and somatic awareness. Even here I would argue that they are discussing an area which includes the clinician’s intuition and that where this is carefully honed it should be consistent with related areas such as the clinical evidence base. I would argue that the clinical evidence base is not an area distinct from clinical accumen but is an investigation of clinical data and an attempt to draw meaningful knowledge from this area. The definition of ‘tacit knowledge’ adds an air of mystery by referring to knowledge at the periphery of attention. Within this section, the authors refer to non-verbal material which the physician may use during the clinical process. Such ‘tacit knowledge’ can be systematically converted into explicit knowledge by a close study of such phenomenon and indeed various methods for measuring such factors have long since been developed and employed both in clinical practice and research.

I found the discussion of somatic awareness to be a more interesting contribution if we consider the mind to be both a function of brain as well as being better described by a symbolic system that differs from that used in discussion of the ‘brain paradigm’ (e.g. see here). I was interested however to find out a little more about how the authors intended to align ‘neurobiology’ and ‘consciousness’ as according to the paradigm discussed in the previous sentence this might not be a suitable starting or indeed end point. The authors invoke some of Damasio’s thoughts on the mind-body relationship. My interpretation of what the authors were trying to say was that there is mind-brain-body relationship and that as the body is involved in this relationship it can serve as the focal point for discussions and that this is just as valid as making the mind or the brain the focal points. The justification for this would be that any ‘focal’ point is in itself a simplification of the more complex relationship that occurs between the three and so it doesn’t matter which of the triad serves as this focal point it will still be a simplification and explanations will always return to the complex interactions between mind, body and brain. However by using the body as a focal point for this discussion, the model is apparently made more accessible.

In the final section the authors consider how ’somatic awareness’ might be incorporated into medical practice. Again I disagreed with many of the points in this section. For instance, the withdrawal of medication was difficult to justify as patients may be on a number of medications for different conditions. Although some may not be prescribed as psychotropics they may in some cases have such side-effects and it would be useful to see the management suggestions in such cases where withdrawal is not possible. As above, a blanket statement about medications does not address the complexities of individual needs and even on a theoretical basis there are many counters to this suggestion. Encouraging a focus on introspection and monitoring both symptoms and bodily sensations seems to be a useful approach that could be developed further in a subsequent article again with reference to the evidence base.

In summary, the authors broach psychosomatic issues by consideration of ‘body distress’ although I found a few statements that seemed axiomatic and could be argued to be too simple to address the complexities of individual needs without careful consideration of process, the evidence base and consequences. It is useful however to have discussions in this area.

 

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