Differential aspects of consultation–liaison psychiatry in a Saudi hospital. II: knowledge and attitudes of physicians and patients

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A.M. Alhamad,¹ M.H. Al-Sawaf,² A.A. Osman³ and I.S. Ibrahim⁴

ABSTRACT To assess the attitude and knowledge of physicians and patients towards psychiatry, we asked 115 referring doctors and 188 referred patients to complete questionnaires. We examined the results along with the referral rates to try to identify factors that may affect a consultation–liaison psychiatry service. Generally, knowledge was poor and attitudes towards psychiatry negative in both groups. This negatively influenced the referral rates and reflected the lack of integration of psychiatry and medicine at the training level. This is an indication that psychiatrists need to work in collaboration with hospital doctors to integrate psychiatry into medicine at all levels and emphasizes the priority of education of hospital staff, patients and the community in consultation–liaison psychiatry.

Aspects différentiels de la psychiatrie de liaison dans un hôpital saoudien : II. Connaissances et attitudes des médecins et des patients

RÉSUMÉ Afin d’évaluer les attitudes et les connaissances des médecins et des patients concernant la psychiatrie, nous avons demandé à 115 médecins référents et 188 patients référés de remplir des questionnaires. Nous avons examiné les résultats et les taux d’orientation pour essayer d’identifier les facteurs qui peuvent affecter un service de psychiatrie de liaison. De manière générale, les connaissances étaient faibles et les attitudes vis-à-vis de la psychiatrie étaient négatives dans les deux groupes. Ceci a eu une influence négative sur les taux d’orientation et a reflété le manque d’intégration de la psychiatrie et de la médecine au niveau de la formation. C’est une indication de la nécessité d’une collaboration entre les psychiatres et les médecins hospitaliers pour l’intégration de la psychiatrie dans la médecine à tous les niveaux et de la priorité à accorder à l'éducation du personnel hospitalier, des patients et de la communauté dans le domaine de la psychiatrie de liaison.

¹Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to A.M. Alhamad: This email address is being protected from spambots. You need JavaScript enabled to view it.).
²Department of Psychiatry; 4Department of Biostatistics, King Fahad Hospital, Jeddah, Saudi Arabia.
³Division of Psychiatry, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.
Received: 29/07/03; accepted: 03/03/04
EMHJ, 2006, 12(3-4): 324-330

Introduction

Evaluative research in consultation–liaison psychiatry has gone through several phases of development. It has been clearly shown that factors contributing to a cost-effective service such as consultation setting; liaison activity; and physicians’ psychosocial attitudes towards psychiatry, education and learning needs, vary widely and are difficult to control [1]. This has prompted

consultation–liaison committees and academics to set guidelines for seminars, training, education programmes and ethical aspects of consultation–liaison psychiatry [2].

Another important methodological contribution to enabling generalization from research findings in consultation–liaison psychiatry is to evaluate the interaction of the aforementioned factors simultaneously in the same setting [3].

Previously, we evaluated the interaction of sociodemographic factors of patients, time lag of referral, reason for referral, and clinical diagnoses and the concordance between consultants (psychiatrists) and consultees (non-psychiatric physicians) with the pattern of referral in

consultation–liaison psychiatry [4].

In this paper we present the differential aspects of consultation–liaison psychiatry in the same setting, namely the attitude and knowledge of referring doctors (consultees) towards psychiatry and the consultation needs in this area, along with the attitude and knowledge of patients towards psychiatry and the consultation.

Methods

During the period July–October 1994, we assessed the knowledge and attitude of referring physicians (consultees) and referred patients towards psychiatry and consultation at King Fahad Hospital, a large 930-bed general hospital in Jeddah, Saudi Arabia.

We produced a questionnaire which was sent to all consultees in the hospital. It comprised 10 questions designed to measure knowledge and attitude towards psychiatry, including the need for psychiatric consultation; the reasons for urgent psychiatric consultation and situations they considered important; the need for informed consent of patients to the consultation; their experience of the usefulness of psychiatric consultation in the management of patients; the need for discussing the case with the psychiatrist; the concordance with the psychiatrists’ recommendations; and attitude to psychotropic medication side-effects and prescribing.

Another specially designed questionnaire comprising 9 yes/no questions was given to all patients referred during the study period. The questions covered knowledge and attitude towards the psychiatric consultation, stigma about psychiatry and psychotropic medication.

Results

Attitude and knowledge of doctors

Only 88 (76.5%) of the 115 physicians at the hospital responded to the questionnaire, 58 surgeons (66.0%) and 30 internists (34.1%). Of the respondents, 50.8% had PhD equivalent, 41.3% had MSc and 7.9% had diploma only. The mean period of postgraduate experience for consultants was 9 years and for specialists 5 years (consultees). Fifty consultees (56.8%) needed psychiatric consultations occasionally (only once or twice) during their experience while 16 (18.2%) never needed such consultations. Only 21 doctors (23.9%) (10 internists out of 30 and 11 surgeons out of 58) needed psychiatric consultation more than 3 times during their postgraduate experience, and this was statistically significant (P < 0.01).

Urgent consultation was requested by 40.0% of consultees when the patient had past psychiatric history, 42.4% when the patient refused to communicate, 67.4% when the patient threatened violence, 55.4% when the patient was delusional and 63.1% when the patient was hallucinating. In addition, 61.9% of consultees thought that psychiatric consultation was important for patients with behavioural problems. Seeking the help of a psychiatrist to reach a final diagnosis was thought important by only 38.1% of consultees.

The responses regarding whether to ask for consent and inform the patient about the psychiatric consultation showed that 34.1% of consultees would always do it, 37.5% would do it sometimes and 28.4% would never do it. Psychiatric consultation was found to be almost always helpful in management of patients by 55.7% of consultees, while 44.3% found it only sometimes or not at all helpful. After written consultations, 60.2% of consultees either never or only occasionally discussed the case with the psychiatrist; 75.0% said they would always take the psychiatrist’s recommendations seriously in the management of patients.

In the event of adverse effects of psychotropic medications prescribed by a psychiatrist, 88.6% of consultees said they would inform the psychiatrist and 8.0% said they would discontinue them. Asked about prescribing psychotropic drugs to their patients, 50.0% of consultees said they would never contemplate it while only 6.8% said they would most likely prescribe a psychotropic drug and 43.2% said they would possibly prescribe one. Benzodiazepines were considered the safest psychotropic drugs by 64.9% of consultees, antipsychotics by 13.5% and the tricyclic antidepressants by only 5.4%.

Unexpectedly, the number of years of postgraduate experience did not have any influence on the attitude of consultees or their knowledge about psychiatry, though internists responded more correctly for many items than surgeons. Nephrologists usually responded much more positively than other internists, while orthopaedic surgeons’ responses were much worse than other surgeons. For example, 62.5% of nephrologists said they would seek a psychiatrist’s help when a patient was delusional, compared to 55.0% of other internists. Only 28.6% of orthopaedic surgeons would ask for a psychiatric consultation for a delusional patient in contrast to 58.3% of other surgeons. Inconsistency in regard to psychiatric knowledge was even noticeable within the same specialty: while only 28.6% of orthopaedic surgeons thought a delusional patient needed a psychiatric consultation, 85.7% thought a hallucinating patient needed one.

Attitude and knowledge of patients

Only 4 (2.1%) of 188 patients, refused to fill in the questionnaire (18 extended emergency room patients were not included because of time constraints). Of the 184 who responded, 34.0% considered there was a need for a psychiatric service in hospital, 42.0% said they would seek help from a psychiatrist if needed and only 37.8% thought that their complaint might be psychological.

In response to questions about psychotropic medications, 31.9% thought that psychotropic drugs were treatments rather than sedatives, 58.5% thought they could cause addiction and 67.6% thought they had serious side-effects. In answering questions about stigma, only 26.1% admitted they needed to see a psychiatrist, 79.3% thought it was a social stigma to attend a psychiatric clinic and 98.4% emphasized they had to be informed about referral to psychiatry.

Discussion

Attitude and knowledge of doctors

Even though measuring attitude and knowledge is a complicated process that includes knowledge, attitude and perception, we used a simple questionnaire with simple yes or no answers that served the purpose of this study [5,6].

The response rate of doctors was much lower than that of patients. This may have been because of the doctors’ busy schedule, because patients were keener to please doctors or both. The number of doctors having over 5 years of experience who said there was a need for psychiatric consultation was very low. This may reflect poor psychiatric education in undergraduate medicine for this group and/or a negative attitude towards psychiatry [7]. Seeking urgent psychiatric consultation shows how non-psychiatrist doctors see the role of psychiatrists in the management of their patients and the greatest requirement was for patients displaying disturbed, abnormal behaviour such as violence, hallucinations, delusions and refusal to communicate. This may suggest a notion of calling in a psychiatrist to control a difficult patient rather than to collaborate in establishing clinical diagnosis and management [6,8]. These inferences were clearly confirmed by the fact that only 38.1% of doctors thought that a psychiatrist could help in establishing a final diagnosis, which may also reflect their view of the role of psychiatry in medicine [5].

Gaining the consent of a patient for a consultation, despite being basically an ethical dimension of the doctor–patient relationship [9], may be affected by the perception of the patient to the specialty. For example, referring a patient to oncology may have its own repercussions on the patient, inducing fear and distress [10], but referring a patient for psychiatric assessment may result in social stigmatization [5]. This may explain why 28.4% of doctors would never inform patients or ask their consent for psychiatric referral and 37.5% would only do it sometimes. On the other hand 34.1% of doctors would always obtain consent, perhaps as an expression of their own ethical approach rather than a positive attitude to psychiatry [9].

The finding that the majority of doctors found psychiatric consultation to be helpful in the management of patients may reflect both a positive attitude towards psychiatry on the part of consultees and an efficient liaison service. However, 44.3% found it only sometimes or not at all helpful, which may be a consequence of poor communication with the psychiatrist, the difficult nature of referred patients, the negative attitude of consultees towards psychiatry and the poor service offered [11]. This is analogous to the finding that 60.2% of doctors never discussed their cases with the psychiatrist, emphasizing the importance of the liaison aspect of the service. It may also reflect a poorly written consultation and unhelpful recommendations. But considering that 75.0% of the consultees would always take the psychiatrist’s recommendations seriously, not discussing the cases with the psychiatrist may merely be due to lack of time or overwork.

Informing the psychiatrist about adverse effects of psychotropic medication may be due to lack of knowledge about the medications and an inability to manage the side-effects. This is definitely more appropriate than the attitude of the 8.0% who would discontinue the medication and interrupt the plan of management [12]. Half the consultees said they would never take the initiative to prescribe psychotropic medication. This reflects the necessity of integrating psychiatry into the curriculum at both undergraduate and postgraduate levels. Analysis of the safest psychotropic drugs confirms that knowledge and clinical experience of psychiatry of the consultees are poor [4,12].

It is expected that the more years of postgraduate experience a doctor has, the more positive the attitude towards psychiatry will be and the better their knowledge of psychiatry. On the other hand, recently graduated doctors are more likely to have been taught psychiatry and to have been exposed to clinical psychiatry teachings [7]. It is, therefore, difficult to infer or generalize from any result associating years of experience and attitude and knowledge about psychiatry. Differences in response between internists, surgeons and subspecialties may merely reflect individual preferences and experience in dealing with psychiatric illnesses. This is emphasized by the inconsistency in responses between doctors in the same specialty.

Attitude and knowledge of patients

The response of our patients was similar to reported views of psychiatry overall [13]. Only 34.0% thought that a general hospital needed a psychiatric service, which may indicate that psychiatry is not viewed as a specialty of medicine. On the other hand, a similar proportion said they would seek psychiatric help if they needed to. This can be explained by the general view of the public, but also, by the attitude that psychiatry is a last resort [14]. This may be associated with the finding that only 37.8% of patients believed their complaints were psychological. This lack of insight may be due to the notion of many people of the dichotomy of mind and body, leading to an inability to accept psychological explanation for their bodily symptoms [5,14]. The view of patients about psychotropic medication is no more positive than their view on psychiatric consultation: the majority view these drugs as sedative, addictive, and having serious side-effects. The need for long-term use of the drugs, the non-cure treatment response of many psychiatric disorders and the frightening extrapyramidal side-effects may explain this view [15,16].

The issue of social stigma of psychiatric disorders and treatments is more complicated and there may be a number of reasons for this. First, the patients in our study group were all referred for psychiatry and thus, may have a more negative attitude than the general population [17]. Second, if there is a poor doctor–patient relationship, where no explanation or education of patients takes place, patients will have little knowledge of psychiatry [6]. Third, the psychiatric services may be poorly developed and a comprehensive approach to treatment rarely practised [18,19]. Finally, patients may have had a negative past experience with psychiatry, either personally or through relatives or being influenced by public views [5].

Conclusions

This study confirms the conclusions of our first paper [4], that knowledge of our hospital doctors about psychiatry is poor and negative. It also shows that knowledge and attitude towards psychiatry of referred patients is also poor and negative. This emphasizes that, if psychiatry is an integral branch of medicine and consultation–liaison psychiatry is a necessary service in the general hospital, liaison should be standard practice rather than merely to offer consultation. Joint collaboration of the psychiatrist and physicians in establishing clinical diagnosis and implementing the patient management plan will provide an atmosphere conducive to discussion and exchange of knowledge and experience [20,21]. It is anticipated that this will have a positive effect on the attitude and knowledge of both consultees and patients about psychiatry [22].

Finally, it is apparent that psychiatrists have a responsibility in this area to improve the status of psychiatry in general hospitals and in the community.

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