Psychiatric Disorders and the Need for Mental Health Services Among a Sample of Orthopedic Inpatients Pauline
Lorvan
Kuyler
and David
L. Dunner
T
HIS REPORT concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed. It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.‘+ Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19% 86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.:‘.‘.’ Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified. In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.2,4.!‘-‘2 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients. MATERIALS The 42 patients tively
tu the ward service
Orthopedic
I
who were interviewed
Hospital
and November
following The tudinal
interview
Comprehenswe
Center).
orthopedic They
were admitted
who met these criteria
I I were discharged
surgeons
elec-
of the New York between
were not interviewed
before they could be interviewed,
October for the and 7
to be interviewed.
“Schedule
for Afective a psychiatric
and treatment
Psychiatry.
METHODS the ages of 21 and 65 and were admitted
attending
Medical patients
8 did not speak English,
basis for obtaining course
of three
(Columbia-Presbyterian
refused to give permission tured
or to the services
IS. 1973. The 16 other
reasons:
AND
were between
Disorder5 histoq
of disability.
with
and Schizophrenia”
(SADS)‘,’
particular
on symptoms
The criteria
Vol. 17. No. 3 (May/June).
emphasis
for psychiatric
1976
diagnosis
provides
a struc-
and the longi-
were those described
395
KUYLER AND DUNNER
396
et al.‘” As part of the interview,
by Feighner
service, including treatment any other
mental
counselfor.
health
the patient
was asked about previous mental
of mental symptoms by a psychiatrist,
professional,
At the time of the interview
such as a social worker, a determination
by a nonpsychiatric vocational
counsellor,
was made of whether
health
physician, or by or a religious
the person could cur-
mental health service. In addition to those who were receiving mental health were considered to be in need of service if they expressed an interest in available mental health services or if they expressed concern about psychiatric symptoms or social problems which created difficulties for them. rently
service,
benefit
from
patients
RESULTS
Identilving Characteristics
of Subjects
The 42 patients interviewed consisted of 17 men and 25 women. The mean age was 42.6 with a range of 22-64 years. The mean educational level was 12 years, with a range from fourth grade to graduate degree. Twenty-six patients (62%) were married. Twenty were ward patients, and 22 were private patients. The conditions being treated included rheumatoid arthritis, ganglia, bunions, carpal tunnel syndrome, Paget’s disease, benign tumors of the bone and surrounding soft tissue, and late effects of traumatic injury. History of Definable Mental Disorder and of Mental Health Service
Of the 42 subjects interviewed, 19 (45%) had a history of a psychiatric disorder according to the criteria used. The distribution of psychiatric disorders by sex is given in Table 1. A comparison of these data with other studies suggests that our patients had a higher incidence of sociopathy and hysteria (Briquet’s syndrome).‘“-‘7 Although no patient had a primary diagnosis of alcoholism, alcoholism existed as a complicating factor in two of the psychiatrically ill patients, one with schizophrenia and one with sociopathy. There were no significant differences between the psychiatrically ill and the psychiatrically well based on age, sex, marital status, ward or private status, or the type of orthopedic condition. In general, the patients who had a history of a definable mental disorder coincided with the patients who reported having had prior mental health service. However, there were exceptions. One patient with a history of sociopathy had Table 1.
incidence
of Psychiatric
Illness Among Orthopedic
Surgery Patients
Patients
Females
N
Males
ICI
13
Psychiatrically
well
23
Psychiatrically
ill
19
7
12
42
11
25
Total
patients
Psychiatric Antisocial Hysteria
diagnoses personality* (Briquet’s
syndrome)”
4
3
1
5
0
5
Schizophrenia
2
1
1
Anxiety
2
2
0
3
0
3
3 0
1 n
2 l-l
neurosis*
Primary affective
disorder
Secondary affective Alcoholism *Includes
disorder
cases meeting the criterta for deftnite
or probable
illness.
PSYCHIATRIC
DISORDERS
AMONG
ORTHOPEDIC
INPATIENTS
397
never sought professional help. A patient with secondary depression and another with hysteria had never received mental health services. They stated that they were unaware that services were available for their problems. Two people who were psychiatrically well, according to the criteria used, had received mental health service in the past for symptoms which were distressing for them but which were not severe enough and did not last long enough to meet the criteria for a mental disorder. Current
i\:redjbr
Mental
Health
Services
Twenty-three (55%) of the 42 patients interviewed were judged to need mental health services in the hospital, after discharge, or both. The kinds of services thought to be needed included psychiatric evaluation and therapy, milieu therapy. family services, vocational rehabilitation, and socialization. Of the 23 patients, 16 had a psychiatric disorder and I5 had received mental health services in the past, with 13 patients being in both classifications. These two factors were significantly related to the current need for mental health services (Table 2). There was no significant relationship between need for mental health service and any of the following factors: age, sex, education, ward or private status, or type oforthopedic condition. Thirteen patients could have benefited from mental health services both while hospitalized and after discharge. Five additional patients were scored as in need of services only in hospital and five other patients could have profited from services only after discharge. Of the 18 patients needing inpatient services, 9 were thought to need planned milieu variations, such as activities on the ward which would help build self-esteem or help in socializing with other patients. In five of these nine cases, the nursing and social service staff were sensitive to patients’ problems. Nine of the patients benefitted from discussing their orthopedic problem with the interviewer, and only one of them felt that this opportunity had been available on the ward. Of the 18 subjects who needed mental health services outside of the hospital, 8 were already receiving individual psychotherapy, either intensive or supportive, and all but one were satisfied with their therapy. The other ten people reported social problems related to their families, need for vocational rehabilitation, or a Table 2.
Need for Current
Mental
Health Service Among Surgery Patients Mental Health Services Currently
Indicated Total patients
23
Mental Health Services Not Indicated 19
Diagnosed Psychtatrlc
disorder*
Psychiatrically
16;:
well
7
3 16
History of prior psychiatric
treatmentt
15$
3
No history of prior psychiatric
treatment
8
“Chi square with Yates correction
= 10.07,
tChi square with Yates correction
= 8.46, p < 0.01.
l;Thirteen
of these patients coincide.
p < 0.01.
16
KUYLER
398
AND DUNNER
desire to overcome inadequacies in social relationships. Many of these people were unaware of services available for these problems and appreciated suggestions for finding services outside of the hospital. DISCUSSION
The data from this study suggest two major points. First, a large number of patients hospitalized on a nonpsychiatric service had histories of psychiatric disorders. Second, many of these patients could currently benefit from mental health services. The criteria for psychiatric diagnosis which we have used are based on symptom clusters which predict the future course of the disorder and are supported by follow-up studies of diagnosed patients. Using these same criteria, Murphy et al.‘# found that 26% of a group of obstetric patients (mean age 25.8 years) had definable psychiatric disorders. The higher incidence of psychopathology in the present study may be related to our finding an increased incidence of sociopathy, hysteria (Briquet’s syndrome) and secondary depression. Although our sample was older than Murphy’s, both studies had approximately the same incidence of history of mental disorder for each age group. The apparent increased incidence of Briquet’s syndrome and sociopathy may be explained by the observation that these patients complained more about their orthopedic conditions and also seemed to use their orthopedic condition to avoid dealing with reahstic social problems. Although conversion symptoms are a prominent feature of both sociopathy and Briquet’s syndrome, all of the patients we studied had documented surgical conditions and none received treatment for conversion symptoms during their admission. A history of a diagnosable psychiatric disorder and a history of prior treatment are both significantly correlated with need for current treatment and can be used as part of the routine admission evaluation as a basis for direct or indirect psychiatric consultation. However, current psychiatric symptomatology and social problems should not be ignored in the determination of who currently needs mental health services. Three patients who had received past treatment were no longer symptomatic, and eight patients who had never been treated had current social and psychiatric problems. Therefore, the routine admission evaluation should also probe for current symptoms of depression, anxiety, or problems in the family, at work, or with leisure time activities. The use of such a routine evaluation would be consistent with the conclusion of Schwab” that psychiatric consultation is most effective when the primary physician is acquainted with the psychiatric problems of each patient and requests a psychiatric consultation when the problem can no longer be managed within the medical setting. It seemed that many patients were more willing to discuss their problems during a routine interview, such as this research interview, than they might have been if they had been interviewed because they were considered to have a psychiatric problem. As the patients we studied were on a number of different wards, there was no single characteristic ward milieu. However, it was our impression that the ward staffs were sensitive to the mental health needs of many of the patients. Although none of the 42 patients had a forma1 psychiatric consultation during hospitalization, 7 of the patients had extra attention from the nursing or social service staff
PSYCHIATRIC
DISORDERS
AMONG
ORTHOPEDIC
INPATIENTS
399
because their emotional problems had been noted. The treatment of mental problems by the ward staff is consistent with the observation of Lowe et al.” that the majority of psychiatric consultations on a medical ward could be handled by the psychiatrist consultation).
meeting with the ward staff rather than with the patient (indirect In the course of their direct contact with patients, the nursing staff
can help a patient to handle anxiety, to develop self-esteem, and to develop social skills. The social service staff can help a patient plan for the future and can assist in locating appropriate services outside of the hospital. Twenty patients had disabling conditions, such as rheumatoid arthritis, Paget’s disease, or decreased hand function secondary to an injury. Although it would seem that having such physical disabilities might be associated with having altered mental functioning, nine patients were emotionally well adjusted and were not thought to be in need of mental health services. McDaniel]” has noted that the majority of patients with a significant disability do not need mental health service, and this study tends to support this conclusion. However, 11 of these disabled patients experienced problems in socialization and in vocational rehabilitation and seemed to require help with these specific problems. Patients who had a recent injury were often very appreciative of the opportunity to talk about the circumstances surrounding the injury. Keiser, z” in discussing the prevention of traumatic neurosis, has stressed the importance of encouraging patients to talk about the incident which resulted in the injury. The role of the psychiatrist in relation to consultation services on surgical and medical wards has changed from direct treatment of patients to encompass the function of ward personnel in relation to mental health needs of patients. The high incidence of mental illness among surgical and medical patients argues for continual close collaboration between the psychiatrist and the primary physician in the functioning of such wards. ACKNOWLEDGMENT We appreciate the cooperation extended by Dr. Frank E. Stinchfield. Dr. John F. Adams. Jr., Dr. Robert E. Carroll, Dr. Harold M. Dick, and Dr. Sawnee R. Gaston of the Department of Orthopedic Surgery, Presbyterian Hospital and Columbia University College of Physicians and Surgeons. and Dr. John A. Talbott of the Meyer-Manhattan Psychiatric Hospital. We thank Mrs. Mary Romano. Social Worker, and Mrs. Angela Millward and Miss Janet Christie head nurses of the Orthopedic Surgen Wards. The advice of Dr. Donald S. Kornfeld was most helpful in the preparation of the manuscript. We also thank Dr. Ronald R. Fieve for his support of this study. REFERENCES I. Dunbar HF. Wolfe TP. Rioche JM: Psy chiatric aspects of medical problems: Psychic components of disease process (including convalescence) in cardiac, diabetes, and fracture patients. Am J Psychiatry 93:649-679, 1936 2. Lowe DJ. Sabot TJ. Suchinsky RT, et al: Problems in achieving indirect psychiatric consultation on medical and surgical wards. Hosp Community Psychiatry 22:91-94. 197 I 3. Mittelman B, Weider A, Brodman K, et al: Personality and psychosomatic disturbance in patients on medical and surgical wards: A survey
of 450 admissions. Psychosom Med 7:?20 223, 1945 4. Stocking M: Psychopathology in the pediatric hospital: Implications for community health. Am J Public Health 62:55 I 556. 1972 5. Titchener JL. Levine M: Surgery as a Human Experience. New York. Oxford University Press, 1960 6. White AA, Southwick WO. DePonte RJ: Cervical spine fusion: Psychological and social considerations. Arch Surg 106:lSO~l52, 1973 7. Mezey AG, Kellett JM: Reasons against
400
referral to the psychiatrist. Postgrad Med J 47:315~319,1971 8. Noy P, DeNour AK, Moses R: Discrepancy between expectation and service in psychiatric consultation. Arch Gen Psychiatry 14:651-657, 1966 9. Caplan G: Types of mental health consultation. Am J Orthopsychiatry 33:47&481, 1963 10. Nigro S: A psychiatrist’s experience in general practice in a hospital emergency room. JAMA 214:1657-1660, 1970 Il. Schwab JJ, Clemmons RS, Freemon FR, et al: Differential characteristics of medical inpatients referred for psychiatric consultation; A controlled study. Psychosom Med 27:112-l 18, 1965 12. Flach FF: Community hospitals, psychiatry, and illness prevention. Psychiatry Med 3:99-104, 1972 13. Spitzer RL, Endicott J: Schedule for affective disorders and schizophrenia. Prepared with the assistance of other participants in a collaborative project on the psychobiology of
KUYLER AND DUNNER
depressive disorders sponsored by the Clinical Research Branch of the N.I.M.H. 14. Feighner JP, Robins E, Guze S, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972 15. Barchha HA, Stewart MA, Guze SB: The prevalance of alcoholism among general hospital ward patients. Am J Psychiatry 125:681-684, 1968 16. Wheeler EO, White PD, Reed EW, et al: Neurocirculatory asthemia. JAMA 142:878-888, 1950 17. Winokur G, Clayton PJ, Reich T: Manic Depressive Illness. St. Louis, Mosby, 1969 18. Murphy GE: Stress, sickness and psychiatric disorder in a “normal” population; A study of 100 young women. J Nerv Ment Dis 134:228-236,1962 19. McDaniel JW: Physical Disability and Human Behavior. New York, Pergammon, 1969 20. Keiser L: The Traumatic Neuroses. Philadelphia, Lippincott, 1968
Lorvan
Kuyler
and David
L. Dunner
T
HIS REPORT concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed. It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.‘+ Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19% 86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.:‘.‘.’ Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified. In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.2,4.!‘-‘2 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients. MATERIALS The 42 patients tively
tu the ward service
Orthopedic
I
who were interviewed
Hospital
and November
following The tudinal
interview
Comprehenswe
Center).
orthopedic They
were admitted
who met these criteria
I I were discharged
surgeons
elec-
of the New York between
were not interviewed
before they could be interviewed,
October for the and 7
to be interviewed.
“Schedule
for Afective a psychiatric
and treatment
Psychiatry.
METHODS the ages of 21 and 65 and were admitted
attending
Medical patients
8 did not speak English,
basis for obtaining course
of three
(Columbia-Presbyterian
refused to give permission tured
or to the services
IS. 1973. The 16 other
reasons:
AND
were between
Disorder5 histoq
of disability.
with
and Schizophrenia”
(SADS)‘,’
particular
on symptoms
The criteria
Vol. 17. No. 3 (May/June).
emphasis
for psychiatric
1976
diagnosis
provides
a struc-
and the longi-
were those described
395
KUYLER AND DUNNER
396
et al.‘” As part of the interview,
by Feighner
service, including treatment any other
mental
counselfor.
health
the patient
was asked about previous mental
of mental symptoms by a psychiatrist,
professional,
At the time of the interview
such as a social worker, a determination
by a nonpsychiatric vocational
counsellor,
was made of whether
health
physician, or by or a religious
the person could cur-
mental health service. In addition to those who were receiving mental health were considered to be in need of service if they expressed an interest in available mental health services or if they expressed concern about psychiatric symptoms or social problems which created difficulties for them. rently
service,
benefit
from
patients
RESULTS
Identilving Characteristics
of Subjects
The 42 patients interviewed consisted of 17 men and 25 women. The mean age was 42.6 with a range of 22-64 years. The mean educational level was 12 years, with a range from fourth grade to graduate degree. Twenty-six patients (62%) were married. Twenty were ward patients, and 22 were private patients. The conditions being treated included rheumatoid arthritis, ganglia, bunions, carpal tunnel syndrome, Paget’s disease, benign tumors of the bone and surrounding soft tissue, and late effects of traumatic injury. History of Definable Mental Disorder and of Mental Health Service
Of the 42 subjects interviewed, 19 (45%) had a history of a psychiatric disorder according to the criteria used. The distribution of psychiatric disorders by sex is given in Table 1. A comparison of these data with other studies suggests that our patients had a higher incidence of sociopathy and hysteria (Briquet’s syndrome).‘“-‘7 Although no patient had a primary diagnosis of alcoholism, alcoholism existed as a complicating factor in two of the psychiatrically ill patients, one with schizophrenia and one with sociopathy. There were no significant differences between the psychiatrically ill and the psychiatrically well based on age, sex, marital status, ward or private status, or the type of orthopedic condition. In general, the patients who had a history of a definable mental disorder coincided with the patients who reported having had prior mental health service. However, there were exceptions. One patient with a history of sociopathy had Table 1.
incidence
of Psychiatric
Illness Among Orthopedic
Surgery Patients
Patients
Females
N
Males
ICI
13
Psychiatrically
well
23
Psychiatrically
ill
19
7
12
42
11
25
Total
patients
Psychiatric Antisocial Hysteria
diagnoses personality* (Briquet’s
syndrome)”
4
3
1
5
0
5
Schizophrenia
2
1
1
Anxiety
2
2
0
3
0
3
3 0
1 n
2 l-l
neurosis*
Primary affective
disorder
Secondary affective Alcoholism *Includes
disorder
cases meeting the criterta for deftnite
or probable
illness.
PSYCHIATRIC
DISORDERS
AMONG
ORTHOPEDIC
INPATIENTS
397
never sought professional help. A patient with secondary depression and another with hysteria had never received mental health services. They stated that they were unaware that services were available for their problems. Two people who were psychiatrically well, according to the criteria used, had received mental health service in the past for symptoms which were distressing for them but which were not severe enough and did not last long enough to meet the criteria for a mental disorder. Current
i\:redjbr
Mental
Health
Services
Twenty-three (55%) of the 42 patients interviewed were judged to need mental health services in the hospital, after discharge, or both. The kinds of services thought to be needed included psychiatric evaluation and therapy, milieu therapy. family services, vocational rehabilitation, and socialization. Of the 23 patients, 16 had a psychiatric disorder and I5 had received mental health services in the past, with 13 patients being in both classifications. These two factors were significantly related to the current need for mental health services (Table 2). There was no significant relationship between need for mental health service and any of the following factors: age, sex, education, ward or private status, or type oforthopedic condition. Thirteen patients could have benefited from mental health services both while hospitalized and after discharge. Five additional patients were scored as in need of services only in hospital and five other patients could have profited from services only after discharge. Of the 18 patients needing inpatient services, 9 were thought to need planned milieu variations, such as activities on the ward which would help build self-esteem or help in socializing with other patients. In five of these nine cases, the nursing and social service staff were sensitive to patients’ problems. Nine of the patients benefitted from discussing their orthopedic problem with the interviewer, and only one of them felt that this opportunity had been available on the ward. Of the 18 subjects who needed mental health services outside of the hospital, 8 were already receiving individual psychotherapy, either intensive or supportive, and all but one were satisfied with their therapy. The other ten people reported social problems related to their families, need for vocational rehabilitation, or a Table 2.
Need for Current
Mental
Health Service Among Surgery Patients Mental Health Services Currently
Indicated Total patients
23
Mental Health Services Not Indicated 19
Diagnosed Psychtatrlc
disorder*
Psychiatrically
16;:
well
7
3 16
History of prior psychiatric
treatmentt
15$
3
No history of prior psychiatric
treatment
8
“Chi square with Yates correction
= 10.07,
tChi square with Yates correction
= 8.46, p < 0.01.
l;Thirteen
of these patients coincide.
p < 0.01.
16
KUYLER
398
AND DUNNER
desire to overcome inadequacies in social relationships. Many of these people were unaware of services available for these problems and appreciated suggestions for finding services outside of the hospital. DISCUSSION
The data from this study suggest two major points. First, a large number of patients hospitalized on a nonpsychiatric service had histories of psychiatric disorders. Second, many of these patients could currently benefit from mental health services. The criteria for psychiatric diagnosis which we have used are based on symptom clusters which predict the future course of the disorder and are supported by follow-up studies of diagnosed patients. Using these same criteria, Murphy et al.‘# found that 26% of a group of obstetric patients (mean age 25.8 years) had definable psychiatric disorders. The higher incidence of psychopathology in the present study may be related to our finding an increased incidence of sociopathy, hysteria (Briquet’s syndrome) and secondary depression. Although our sample was older than Murphy’s, both studies had approximately the same incidence of history of mental disorder for each age group. The apparent increased incidence of Briquet’s syndrome and sociopathy may be explained by the observation that these patients complained more about their orthopedic conditions and also seemed to use their orthopedic condition to avoid dealing with reahstic social problems. Although conversion symptoms are a prominent feature of both sociopathy and Briquet’s syndrome, all of the patients we studied had documented surgical conditions and none received treatment for conversion symptoms during their admission. A history of a diagnosable psychiatric disorder and a history of prior treatment are both significantly correlated with need for current treatment and can be used as part of the routine admission evaluation as a basis for direct or indirect psychiatric consultation. However, current psychiatric symptomatology and social problems should not be ignored in the determination of who currently needs mental health services. Three patients who had received past treatment were no longer symptomatic, and eight patients who had never been treated had current social and psychiatric problems. Therefore, the routine admission evaluation should also probe for current symptoms of depression, anxiety, or problems in the family, at work, or with leisure time activities. The use of such a routine evaluation would be consistent with the conclusion of Schwab” that psychiatric consultation is most effective when the primary physician is acquainted with the psychiatric problems of each patient and requests a psychiatric consultation when the problem can no longer be managed within the medical setting. It seemed that many patients were more willing to discuss their problems during a routine interview, such as this research interview, than they might have been if they had been interviewed because they were considered to have a psychiatric problem. As the patients we studied were on a number of different wards, there was no single characteristic ward milieu. However, it was our impression that the ward staffs were sensitive to the mental health needs of many of the patients. Although none of the 42 patients had a forma1 psychiatric consultation during hospitalization, 7 of the patients had extra attention from the nursing or social service staff
PSYCHIATRIC
DISORDERS
AMONG
ORTHOPEDIC
INPATIENTS
399
because their emotional problems had been noted. The treatment of mental problems by the ward staff is consistent with the observation of Lowe et al.” that the majority of psychiatric consultations on a medical ward could be handled by the psychiatrist consultation).
meeting with the ward staff rather than with the patient (indirect In the course of their direct contact with patients, the nursing staff
can help a patient to handle anxiety, to develop self-esteem, and to develop social skills. The social service staff can help a patient plan for the future and can assist in locating appropriate services outside of the hospital. Twenty patients had disabling conditions, such as rheumatoid arthritis, Paget’s disease, or decreased hand function secondary to an injury. Although it would seem that having such physical disabilities might be associated with having altered mental functioning, nine patients were emotionally well adjusted and were not thought to be in need of mental health services. McDaniel]” has noted that the majority of patients with a significant disability do not need mental health service, and this study tends to support this conclusion. However, 11 of these disabled patients experienced problems in socialization and in vocational rehabilitation and seemed to require help with these specific problems. Patients who had a recent injury were often very appreciative of the opportunity to talk about the circumstances surrounding the injury. Keiser, z” in discussing the prevention of traumatic neurosis, has stressed the importance of encouraging patients to talk about the incident which resulted in the injury. The role of the psychiatrist in relation to consultation services on surgical and medical wards has changed from direct treatment of patients to encompass the function of ward personnel in relation to mental health needs of patients. The high incidence of mental illness among surgical and medical patients argues for continual close collaboration between the psychiatrist and the primary physician in the functioning of such wards. ACKNOWLEDGMENT We appreciate the cooperation extended by Dr. Frank E. Stinchfield. Dr. John F. Adams. Jr., Dr. Robert E. Carroll, Dr. Harold M. Dick, and Dr. Sawnee R. Gaston of the Department of Orthopedic Surgery, Presbyterian Hospital and Columbia University College of Physicians and Surgeons. and Dr. John A. Talbott of the Meyer-Manhattan Psychiatric Hospital. We thank Mrs. Mary Romano. Social Worker, and Mrs. Angela Millward and Miss Janet Christie head nurses of the Orthopedic Surgen Wards. The advice of Dr. Donald S. Kornfeld was most helpful in the preparation of the manuscript. We also thank Dr. Ronald R. Fieve for his support of this study. REFERENCES I. Dunbar HF. Wolfe TP. Rioche JM: Psy chiatric aspects of medical problems: Psychic components of disease process (including convalescence) in cardiac, diabetes, and fracture patients. Am J Psychiatry 93:649-679, 1936 2. Lowe DJ. Sabot TJ. Suchinsky RT, et al: Problems in achieving indirect psychiatric consultation on medical and surgical wards. Hosp Community Psychiatry 22:91-94. 197 I 3. Mittelman B, Weider A, Brodman K, et al: Personality and psychosomatic disturbance in patients on medical and surgical wards: A survey
of 450 admissions. Psychosom Med 7:?20 223, 1945 4. Stocking M: Psychopathology in the pediatric hospital: Implications for community health. Am J Public Health 62:55 I 556. 1972 5. Titchener JL. Levine M: Surgery as a Human Experience. New York. Oxford University Press, 1960 6. White AA, Southwick WO. DePonte RJ: Cervical spine fusion: Psychological and social considerations. Arch Surg 106:lSO~l52, 1973 7. Mezey AG, Kellett JM: Reasons against
400
referral to the psychiatrist. Postgrad Med J 47:315~319,1971 8. Noy P, DeNour AK, Moses R: Discrepancy between expectation and service in psychiatric consultation. Arch Gen Psychiatry 14:651-657, 1966 9. Caplan G: Types of mental health consultation. Am J Orthopsychiatry 33:47&481, 1963 10. Nigro S: A psychiatrist’s experience in general practice in a hospital emergency room. JAMA 214:1657-1660, 1970 Il. Schwab JJ, Clemmons RS, Freemon FR, et al: Differential characteristics of medical inpatients referred for psychiatric consultation; A controlled study. Psychosom Med 27:112-l 18, 1965 12. Flach FF: Community hospitals, psychiatry, and illness prevention. Psychiatry Med 3:99-104, 1972 13. Spitzer RL, Endicott J: Schedule for affective disorders and schizophrenia. Prepared with the assistance of other participants in a collaborative project on the psychobiology of
KUYLER AND DUNNER
depressive disorders sponsored by the Clinical Research Branch of the N.I.M.H. 14. Feighner JP, Robins E, Guze S, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972 15. Barchha HA, Stewart MA, Guze SB: The prevalance of alcoholism among general hospital ward patients. Am J Psychiatry 125:681-684, 1968 16. Wheeler EO, White PD, Reed EW, et al: Neurocirculatory asthemia. JAMA 142:878-888, 1950 17. Winokur G, Clayton PJ, Reich T: Manic Depressive Illness. St. Louis, Mosby, 1969 18. Murphy GE: Stress, sickness and psychiatric disorder in a “normal” population; A study of 100 young women. J Nerv Ment Dis 134:228-236,1962 19. McDaniel JW: Physical Disability and Human Behavior. New York, Pergammon, 1969 20. Keiser L: The Traumatic Neuroses. Philadelphia, Lippincott, 1968
