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Liaison psychiatry and Indian research

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 Volume 52, Supplement
EDITORIAL
Indian Psychiatry and Indian journal of Psychiatry - A journey
T. S. SATHYANARAYANA RAO, G. SWAMINATH, G. PRASAD RAO S1
REVIEW ARTICLES
History of psychiatry in India
S. HAQUE NIZAMIE, NISHANT GOYAL S7
Indian journal of psychiatry and psychiatric research in India:
Past, Present and Future
AJAI R. SINGH S13
The evolution of Indian psychiatric research: An examination
of the early decades of the Indian journal of Psychiatry
RAJIV RADHAKRISHNAN, CHITTARANJAN ANDRADE S19
Research priorities for Indian psychiatry
VIKRAM PATEL S26
From local to global – Contributions of Indian psychiatry to
international psychiatry
R. SRINIVASA MURTHY S30
Indian psychiatry: Research and international perspectives
ROY ABRAHAM KALLIVAYALIL, RAKESH K. CHADDA,
JUAN E. MEZZICH S38
Partnerships for promoting dissemination of mental
health research globally
HELEN HERRMAN S43
Indian – American contributions to psychiatric research
ANAND K. PANDURANGI S47
Mutual learning and research messages: India, UK, and Europe
GURVINDER KALRA, DINESH BHUGRA S56
Psychiatrists and neuroscientists of Indian origin in
Canada: Glimpses
AMRESH SHRIVASTAVA, D. NATARAJAN S64
Indian psychiatry, research and Asian countries
J. K. TRIVEDI, PAWAN KUMAR GUPTA, RAHUL SAHA S68
Indian psychiatry and research in Pakistan
HAROON RASHID CHAUDHRY S72
Contribution of Indian psychiatry in the development of
psychiatry in Nepal
TAPAS KUMAR AICH S76
Shared challenges in psychiatric research in India and Sri Lanka
HARISCHANDRA GAMBHEERA, SHEHAN WILLIAMS S80
Training and National deficit of psychiatrists in India –
A critical analysis
M. THIRUNAVUKARASU, P. THIRUNAVUKARASU S83
Postgraduate training in psychiatry in India
SHRIDHAR SHARMA S89
Indian Psychiatric epidemiological studies: Learning from the past
SURESH BADA MATH, RAVINDRA SRINIVASARAJU S95
Indian Psychiatry and classification of psychiatric disorders
K. S. JACOB S104
Initiatives in biological research in Indian Psychiatry
AMRESH SHRIVATAVA S110
Molecular biology research in neuropsychiatry:
India’s contribution
T. S. SATHYANARAYANA RAO, B. N. RAMESH, P. VASUDEVARAJU,
K. S. J. RAO S120
Cognitive psychiatry in India
P. K. DALAL, T. SIVAKUMAR S128
Biological investigations in Indian psychiatry
RISHIKESH V. BEHERE, NAREN P. RAO,
GANESAN VENKATASUBRAMANIAN S136
Indian research on acute organic brain syndrome: Delirium
CHARLES PINTO S139
Indian research on aging and dementia
K. S. SHAJI, V. P. JITHU, K. S. JYOTHI S148
Early intervention in psychotic disorders: Challenges and
relevance in the Indian context
MATCHERI S. KESHAVAN, AMRESH SHRIVASTAVA,
BANGALORE N. GANGADHAR S153
An overview of Indian research in Schizophrenia
PARMANAND KULHARA, RUCHITA SHAH, K. R. AARYA S159
An overview of Indian research in bipolar mood disorder
PRASAD G. RAO S173
An overview of Indian research in depression
SANDEEP GROVER, ALAKANANDA DUTT, AJIT AVASTHI S178
Substance use and addiction research in India
PRATIMA MURTHY, N. MANJUNATHA, B. N. SUBODH,
PRABHAT KUMAR CHAND, VIVEK BENEGAL S189
January 2010
An overview of Indian research in obsessive compulsive
disorder
Y. C. JANARDHAN REDDY, NAREN P. RAO, SUMANT KHANNA S200
An overview of Indian research in anxiety disorders
J. K. TRIVEDI, PAWAN KUMAR GUPTA S210
Research in child and adolescent psychiatry in India
PRIYAVADAN CHANDRAKANT SHASTRI, JAY P. SHASTRI,
DIMPLE SHASTRI S219
Learning and other developmental disorders in India
PHILIP JOHN S224
Indian research on women and psychiatry
RAKESH K. CHADDA, MAMTA SOOD S229
Psyche and soma: New insights into the connection
RAHUL KUMAR, VIKRAM K. YERAGANI S233
Understanding and managing somatoform disorders: Making
sense of non-sense
ROY ABRAHAM KALLIVAYALIL, VARGHESE P PUNNOOSE S240
Indian research on comorbidities
ASHISH SRIVASTAVA, SREEJAYAN K., ANUP M. JOSEPH,
P. S. V. N. SHARMA S246
An overview of Indian research in personality disorders
PRATAP SHARAN S250
Indian research on sleep disorders
NILESH SHAH, ABHA BANG, APARNA BHAGAT S255
Sexuality research in India: An update
OM PRAKASH, T. S. SATHYANARAYANA RAO S260
Sexual variation in India: A view from the west
GURVINDER KALRA, SUSHAM GUPTA, DINESH BHUGRA S264
HIV and mental health: An overview of research from India
NISHANTH JAYARAJAN, PRABHA S. CHANDRA S269
Publications on community psychiatry
R. THARA, SUSHMA RAMESHKUMAR, C. GREESHMA MOHAN S274
Psychiatric rehabilitation
H. CHANDRASHEKAR, N. R. PRASHANTH, P. KASTHURI,
S. MADHUSUDHAN S278
Disabilities research in India
H. CHANDRASHEKAR, C. NAVEEN KUMAR, N. R. PRASHANTH,
P. KASTHURI S281
Indian research on disaster and mental health
NILAMADHAB KAR S286
Indian research on suicide
LAKSHMI VIJAYAKUMAR S291
A review of Indian psychiatry research and ethics
A. K. AGARWAL S297
Forensic psychiatry revisited
S. NAMBI S306
Indian culture and psychiatry
SHIV GAUTAM, NIKHIL JAIN S309
Military psychiatry in India
H. R. A. PRABHU S314
Research on antipsychotics in India
AJIT AVASTHI, MUNISH AGGARWAL, SANDEEP GROVER,
MOHD KHALID RASHEED KHAN S317
Research on antidepressants in India
AJIT AVASTHI, SANDEEP GROVER, MUNISH AGGARWAL S341
Research on mood stabilizers in India
AJIT AVASTHI, SANDEEP GROVER, MUNISH AGGARWAL S355
Research on electroconvulsive therapy in India: An overview
BANGALORE N. GANGADHAR, VIVEK H. PHUTANE,
JAGADISHA THIRTHALLI S362
Psychotherapy in India
L. S. S. MANICKAM S366
Indian contribution to behavior therapy
K. KURUVILLA S371
Indian scales and inventories
S. VENKATESAN S378
Liaison psychiatry and Indian research
S. R. PARKAR, N. S. SAWANT S386
Role of non-governmental organizations in mental health
in India
R. THARA, VIKRAM PATEL S389
Women psychiatrists in India: A reflection of their
contributions
MAMTA SOOD, RAKESH K. CHADDA S396
 REVIEW ARTICLE www.indianjpsychiatry.org

Liaison psychiatry and Indian research

S. R. Parkar, N. S. Sawant
Department of Psychiatry, G.S. Medical College and King Edward Memorial Hospital, Parel, Mumbai-400 012, India

ABSTRACT

Liaison in Psychiatry refers to the branch of Psychiatry involving assessment and treatment in the general hospital of
referred patients, like in the casualty, or patients of deliberate self farm. The Indian scene also reveals major reference
from medicine, surgery, surgical super specialty and orthopedics with psychiatric disorders like anxiety, depression and
/ or organic brain syndromes seen in about 40 to 50 % of the medical or surgical patients. Though the Indian published
data is limited, most tertiary hospitals in India carry out liaison work with various departments like Neurology, Organ
transplant, Intensive Care Units and Cosmetic Surgery, so as to give comprehensive health services to patients. Liaison
in Psychiatry has thus brought the emphasis on the teaching of psycho-social aspects of medicine and also increased
research possibilities.

Key words: Liaison psychiatry, GHPU, CLP

INTRODUCTION Though general hospital psychiatry was considered to

Mental health consultation is the need of the hour and
has been emphasized on since time immemorial.[1] In the
beginning, medical professionals reacted unfavorably to
the admission of psychiatric patients in general hospitals.
However with recognition of organicity and superimposed
psychological reaction to medical illness in medical and
surgical departments, psychiatry was appreciated and
eventually integrated.[2] The rapid growth of general
hospital psychiatric units all over the world has provided
impetus to consultation-liaison work carried out by the
psychiatrists. Consultation liaison psychiatry (CLP) was
generally limited to the diagnostic, research and therapeutic
activity in the non psychiatric departments of the general
hospital. It is synonymous to liaison psychiatry (psychiatric
dictionary, Oxford 1970). The mainstay CLP reports are
to recommend the referrer basic logical clinical findings,
appropriate treatment and follow-up programs. In addition,
other objectives are educational, ethical and medico-legal.
Address for correspondence: Dr. Shubhangi R. Parkar,
Department of Psychiatry, Chief: Bombay Drug deaddiction
center, G.S.Medical College and King Edward, Memorial
Hospital, Parel, Mumbai-400,012 India.
E-mail: pshubhangi@gmail.com
DOI: *****
come to light as a result of the lack of sufficient funds to
initiate new lunatic asylums, today it is acknowledged as
a major part of the public health system that takes care
of mental health problems of a large population. Today,
Liaison Psychiatry has acquired the status of a subspecialty
within psychiatry and this has helped shift psychiatry from
mental hospitals to a general hospital setting. This has also
increased referrals from the non-psychiatric departments
and given the psychiatrist an opportunity to directly deal
with the physically ill.[3] In general, there is no specific
philosophy or particular clinical context being identified in
Liaison Psychiatry, at present, in India.
Referral types
Several researchers have found a lower referral rate in the
Indian counterparts as compared to the western figures.
Jindal et al.(1980) found a poor referral rate in their study
as compared to other studies conducted in India.[4] The in-
patient referral rate in their study was 0.15%, as compared
to 1.4%. in the study by Prabhakaran (1968) and 0.66% in the
study by Parekh et al. (1968).[4-6] Chatterjee and Kutty (1977)
reported a referral rate of 2.64% among the out-patients as
compared to 0.06% by Jindal et al.[7,4] Most studies quote
about 60% of referrals from general medicine and 14% from
surgery and surgical super-specialties.[4-6]

There is also a paucity of data concerning psychiatric

How to cite this article: Parkar SR, Sawant NS. Liaison psychiatry
emergency referral in the Indian setting. Most of the
and Indian research. Indian J Psychiatry 2010;52:S386-8.
available studies pertain to the routine inpatient referral.

S386 Indian J Psychiatry 52, Supplement, January 2010

 Parkar and Sawant: Liaison psychiatry
Though psychiatric services are available in almost all
teaching general hospitals in India, little is known as to why
the psychiatrist is called in emergency situations and what
is the magnitude of the problem. Kelkar et al. (1982) found
suicidal attempt (13%), excitement and violence (10%) and
altered sensorium (9%) which constituted 32% of the total
emergency referrals.[8] In the study by Gautam (1978) a vast
majority (88%) of the sample of patients who presented with
somatic symptoms were neurotics.[9]
General hospital psychiatry units
General hospital psychiatry units have provided increased
opportunities for interaction between psychiatrists and
other medical specialists, making consultation-Liaison
Psychiatry more meaningful .The establishment of General
Hospital Psychiatry Units (GHPU) proved an impetus for
Indian studies on psychiatric morbidity in medical-surgical
inpatients.[10] Among the first units of this nature were
those of R. G. Kar Medical College and Hospital, Calcutta
and Grant Medical College and J.J . Group of Hospitals,
Bombay, started in 1933 and 1938 respectively. By 1970,
about 90 psychiatric clinics were operative in India
(Directory of Mental Health Services in India, 1970). The
spectrum of psychiatric case material seen in general
hospital psychiatry units is much wider than seen in mental
hospitals. Unlike mental hospitals, where the clinical
material is predominantly psychosis, in a general hospital
psychiatry unit there is a wide range of clinical problems
including psychoses, neuroses, personality disorders,
drug dependence and organic brain disorders.[11-13] Referral
from inpatient services offers additional area for study in
psychosomatic illness.[14] Malhotra S (1984), in her study, found
that it was not simply the presence of abnormal behavior
that prompted psychiatric consultation, but other reasons
like organic illness insufficient to explain symptoms.[3] The
trends worth noting were, however, a low representation of
personality disorders and drug/alcohol dependence in their
study with a uniformly low representation of psychosomatic
disorder also. The possible explanations for this may be
the focus on classical psychiatric disorders and not the
personality disorders which are prevalent currently, due to
various classification systems like Diagnostic and Statistical
Manual of Mental Disorders (DSM) and International
Classification of Diseases (ICD).
A high prevalence of psychiatric morbidity amongst general
hospital OPD patients was reported in some studies in
India, (36%) Krishnamurthy S et al. (1981)and (10.4%) by
Sriram et al. (1987).[15,16] R.S. Murthy (1998), in his editorial,
stated that the developments in the twentieth century have
dramatically changed concepts of mental healthcare as a
result of new knowledge and has seen a shift from mental
illness to mental health.[17]
Bhogale et al. (2000) found that 47.57% of indoor referrals
and 62.75% of outdoor referrals had unexplained physical
Indian J Psychiatry 52, Supplement, January 2010
symptoms.[18] This group also included those patients
who had co-existing physical illness but symptoms were
disproportionate to the physical condition. Analysis of final
diagnoses in this study discovered that a large majority
of the patients had neurotic, stress related, somatoform
disorders (indoor 36.76% and outdoor 52.29%) followed
by mood disorders (indoor 21.08% and outdoor 18.95%).
The authors suggest that more interaction and dialogue
between psychiatric team and referring physician is a need;
their study highlighted that types of patients referred in
multi specialty hospitals are vastly different and the present
post-graduate training in psychiatry and psychology was
inadequate in this area.[18]
Diverse research studies
There are some diverse studies which have been reported in
the Indian Journal Psychiatry. They are infrequent from those
that follow diagnostic profile. They are worth noting in the
Indian context. In the general hospital, in the psychiatric
clinic, N. N. Wig (1968) reported cases of post vasectomy
syndrome; the common pattern being that of a chronic and
disabling neurasthenic hypochondriac state. [19] However,
till date, these aspects have not been researched in Indian
Psychiatry. There is some research documentation from
army set up in IJP. A survey, by Major R. S. Mathur (1977,) of
638 soldiers hospitalized for physical illnesses or trauma in a
military hospital has revealed psychiatric morbidity in 34.5%
of them, manifesting mainly in states of depression (47.9%)
and anxiety (40.9%).[20] Psycho-neuroses without obvious
depression or anxiety formed 11.4%. The subjects who
showed psychiatric morbidity with their somatic illnesses
had a longer hospitalization period than the others. Positive
correlation of psychiatric morbidity in physical diseases has
been noticed with certain diagnostic categories, literacy
level and certain states of residence; and no correlation has
been seen with age, marital status, and length of service or
rank of the subjects. In some cases of intra-cranial space
occupying lesions, infections and cerebral seizures, who
either presented as psychiatric problem or developed
mental symptom, an attempt was` made to discuss the
pathophysiology of psychiatric symptoms in organic brain
diseases.[21] Dash and Dash (1979) found that despite advice
of termination of pregnancy in certain vulnerable patients
on psychiatric grounds, only 56 per cent of them accepted
medical advice.[22] These patients were better educated,
hailed from urban areas and belonged to higher strata of
society than those who rejected such an advice. Comparison
of diagnoses in the 1967 and 1977 groups showed marked
differences with decrease in the epilepsy and organic
brain syndromes due to the development of a neurology
department.[23]
The proportionate number of schizophrenics in the clinic
population has more than doubled over the 10-year period.
This is possibly because of better awareness. Indian Research
on liaison work is mostly with cardiology, dermatology,
S387
 Parkar and Sawant: Liaison psychiatry
orthopedics, gynecology, medicine, gastroenterology and
ophthalmology. Thus there is a great scope for combined
service and training programs with other specialties like
internal medicine, pediatrics, neurology, obstetrics and
gynecology. In fact, there is hardly any clinical specialty
which is not related to psychiatry or with which psychiatry
cannot combine, to organize a program.
New avenues are coming up daily with the introduction
of new services where psychiatric aspects are of great
importance in a general hospital. Cardiac surgery, epilepsy
surgery, cosmetic surgery, dialysis units, kidney transplants,
intensive care units and family planning services are some
of the examples in this growing field. Chandra has done
extensive work in the area of women’s mental health in
general and specifically the area of the interface between
psychiatry and women’s reproductive and sexual health
with far reaching clinical and social consequences.[24]
Comparatively, a lot of work has been documented in the
area of deliberate self harm and suicide in Indian set-up.
One critical finding by R.K. Chadda and S. Shome (1996) is
that psychiatric consultation services are not sufficiently
utilized by a large number of clinicians.[25] Most of them felt
the need to improve upon undergraduate medical education
in psychiatry in India as well as a desire to have consultation
- liaison psychiatric units in India. In an interesting study
by P. Gopala Sarma (2000), on patients attending general
hospital psychiatry out-patient (OP), the cost of one visit
was Rs. 201. The management’s contribution to the total
expenditure was 68% and patients’ 32%. Salaries accounted
for the maximum - 48%. This was followed by loss of earnings
-17%. Drugs accounted for less than 10%.[26]
Liaison Psychiatry has brought the emphasis on the teaching
of psychosocial aspects of medicine in diverse manners like
bedside interviews, interdepartmental case conferences.
Research possibilities are unlimited. There are many
examples of psycho geriatric clinics and memory clinics in
operation in general hospital psychiatry set-ups in India
and data from these set-ups will be useful in guiding these
special services. Numerous studies on the psychosocial
aspects of physical illness and new medical and surgical
procedures, such as chronic hemodialysis, open heart
surgery, organ transplantation doctor-patient relationship;
stress and coping strategies; psychological antecedents of
illness and many other relevant clinical problems have been
carried out.[3] In all probability, an even more important
need of research in the area of liaison psychiatry is to put
together a “client profile” and develop tailor made services
in the most advantageous way. It is acknowledged that
these services are acceptable to people and there by will
S388
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be able to reduce stigma related to Psychiatry. In future,
however, there is a need to look at cost effective planning
of these services as well as the role of socio-cultural and
biological parameters in liaison psychiatry.
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Source of Support: Nil, Conflict of Interest: None declared
Indian J Psychiatry 52, Supplement, January 2010