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Extract

The Reform Law 180, approved in Italy in 1978, had – and still has – great national and international significance for its dramatic consequences on both clinical and health organisational aspects of psychiatry: the law, in short, had the great effect of bringing psychiatry back to medicine, to the community and to the general hospital. This was the starting point of other relevant events, one of which was the establishment of the specialty of consultation-liaison psychiatry in Italy (Cazzullo et al, 1984). Since then, consultation-liaison psychiatry has gradually developed worldwide and in Italy as a super-specialised branch of psychiatry, able to put into practice – to operationalise – the great psychosomatic tradition in its three interrelated strands of clinical, teaching and research activities. The report that follows is strongly influenced by this historical background.

The Reform Law 180, approved in Italy in 1978, had - and still has - great national and international significance for its dramatic consequences on both clinical and health organisational aspects of psychiatry: the law, in short, had the great effect of bringing psychiatry back to medicine, to the community and to the general hospital. This was the starting point of other relevant events, one of which was the establishment of the specialty of consultation–liaison psychiatry in Italy (Cazzullo et al, 1984). Since then, consultation–liaison psychiatry has gradually developed worldwide and in Italy as a super-specialised branch of psychiatry, able to put into practice - to operationalise - the great psychosomatic tradition in its three interrelated strands of clinical, teaching and research activities. The report that follows is strongly influenced by this historical background.

CLINICAL WORK PERFORMED

Founded in 1989, the Consultation–Liaison Psychiatry service of Modena University Hospital is one of the services of that hospital's psychiatric department, which also includes a psychiatric ward (for both voluntary and compulsorily admitted patients), a day hospital, an out-patient clinic and a rehabilitation unit. With its consultation–liaison activities and out-patient clinic, the Modena service now provides about 1200 first consultations a year, corresponding to around 3% of all patients admitted to non-psychiatric hospital departments in the same period - twice the European average of 1.4% (Huyse et al, 2001a ; Table 1). The workforce comprises one full-time and one half-time consultation–liaison psychiatry consultants, four or five psychiatry residents, two consultant psychiatrists who are also PhD students and a clinical psychologist.

Table 1 Modena University Hospital Consultation-Liaison Psychiatry Service: activity data

Year Days of activity Beds n First consultations n Consultations/admissions (%) Out-patient consultations n (%) Concordance of time of request/consultation
1989 232 - 507 1.48 77 -
1990 215 - 467 1.35 86 -
1991 245 - 589 1.6 28 -
1992 243 - 695 1.88 9 -
1993 233 993 756 2.06 47 -
1994 252 1018 878 2.23 74 -
1995 250 1025 771 2.14 123 -
1996 262 911 814 2.25 127 100
1997 247 891 847 2.29 115 100
1998 255 891 949 2.8 98 100
1999 255 892 868 2.34 410 100
2000 251 921 935 2.11 845 100
2001 253 928 1247 2.52 677 100
2002 250 890 1136 3.66 719 100
20031 855

PREVIOUS RESEARCH

In the work previously addressed by the team, three main streams of research are recognisable. The first is that originating from the intense involvement of the team in the three EU-funded multicentre projects and promoted by the European Consultation–Liaison Workgroup (ECLW) since the beginning of the 1990s (Herzog et al, 1995; Huyse et al, 1996, 2000a , b , 2001a ; Lobo et al, 1996; Malt et al, 1996). Further national projects sprang from that experience (Gala et al, 1999; Grassi et al, 2000). This involvement had numerous direct and indirect outcomes, particularly the increasing improvement in clinical and organisational standards: for example, the regular use of structured forms for psychiatric referral and back-referral, and of computerised databases, and better definitions of procedures of intervention, specifically for common or critical clinical situations, such as delirium and self-harm. The obvious next step was the involvement in quality assurance work: from 1994 to 1997, the team took part in a multi-centre quality assurance study (Herzog et al, 1995); meanwhile, work began on the accreditation–certification scheme, culminating in International Organization for Standardization ISO 9000 certification of the whole University of Modena psychiatry department in 2002.

A further emanation of the initial ECLW projects is the development of INTERMED, a screening instrument designed to predict complexity of care, acknowledged as the operationalisation of the Engel biopsychosocial paradigm (de Jonge et al, 2001; Huyse et al, 2001b ).

A second research stream is that dealing with organisational issues in consultation–liaison psychiatry. Two examples are an analysis of what happens to patients referred to a consultation–liaison service following their discharge from hospital (Rigatelli et al, 2001), and a description of the teaching programme promoted by the consultation–liaison psychiatry service in Modena University Hospital (Rigatelli et al, 2000).

The third is less epidemiological and more speculative in nature, involving collaboration with specialists from other medical disciplines. These projects address the ‘boundaries of medicine’ - syndromes of difficult biological definition such as vertigo (Monzani et al, 2001), obstetric and gynaecological or andrological disorders (Pescatori et al, 2000; Rigatelli et al, 2002) and, previously, ulcerative colitis (Rigatelli, 1981).

NEW INITIATIVES

Work is in progress in all of the three areas described above. As a contribution to the operationalisation of psychosomatic constructs, a recent study on interrater reliability of the Diagnostic Criteria for use in Psychosomatic Research, first conceived by Fava et al (1995), is shortly to be published in Psychosomatics (Galeazzi et al, 2004).

The Modena Consultation–Liaison Psychiatry service is one of thirty centres involved in the second national multicentre inquiry into consultation–liaison psychiatry activity in Italy, recently conducted by the Società Italiana di Psichiatria di Consultazione (Italian Society of Consultation Psychiatry; www.sipc.it), which collected data on more than 10 000 patients referred to a consultation–liaison psychiatry service. In another analysis of service management and organisation, the team has conducted a study on levels of satisfaction among the Modena University Hospital ward physicians, surgeons and head nurses about the quality of consultation–liaison activities.

Increasing interest is being focused on consultation–liaison psychiatry in the setting of primary care or general medicine outside the hospital. This is still a pioneer field in Italy. A study is in progress to characterise features of frequent attenders at primary care clinics, and possibly to identify higher rates of psychic distress in these patients compared with normal attenders.

The recent opening of an active transplant unit at Modena University Hospital and the consequent increase in psychiatric referrals, both arising from pre-transplant assessment procedures and after surgery, were the stimulus to initiating research in this area, including psychopathological evaluation, evaluation of psychosocial and familial variables, and investigation of adaptive and compliance abilities.

References

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De Jonge, P., Huyse, F. J., Slaets, J. P. J., et al (2001) Care complexity in the general hospital. Results from a European study. Psychosomatics, 42, 204212.
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