|Year : 2015 | Volume
| Issue : 1 | Page : 1-3
Improving the focus on Consultation- Liaison Psychiatry in postgraduate training: Can this be useful in improving the training in geriatric psychiatry too?
Sandeep Grover, Parmanand Kulhara
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||23-Jul-2015|
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Grover S, Kulhara P. Improving the focus on Consultation- Liaison Psychiatry in postgraduate training: Can this be useful in improving the training in geriatric psychiatry too?. J Geriatr Ment Health 2015;2:1-3
|How to cite this URL:|
Grover S, Kulhara P. Improving the focus on Consultation- Liaison Psychiatry in postgraduate training: Can this be useful in improving the training in geriatric psychiatry too?. J Geriatr Ment Health [serial online] 2015 [cited 2020 Apr 2];2:1-3. Available from: http://www.jgmh.org/text.asp?2015/2/1/1/161374
Over the year, Psychiatry as a specialty has expanded, and various subspecialties have been recognized. American Psychiatric Association  broadly recognizes and offers training in subspecialties of child and adolescent psychiatry, geriatric psychiatry, addiction psychiatry, forensic psychiatry, and psychosomatic medicine/consultation liaison (CL) psychiatry. Although, various subspecialties are linked to each other, CL Psychiatry as a subspecialty appears to be closely related to geriatric psychiatry for obvious reasons. Most physical illnesses affect people at the extreme of ages, particularly old age. A large proportion of elderly patients afflicted with various chronic physical illnesses also suffer from mental health problems. Accordingly, the practice of geriatric psychiatry requires a good deal of experience in CL Psychiatry or Psychosomatic Medicine. Keeping this close link in mind, there is the development of geriatric psychiatry CL services all over the world. This growth provides patient and family-centered services for elderly admitted for treatment of medical and surgical illnesses. It also augments community based geriatric services.
In contrast to the West, in India, both CL psychiatry and geriatric psychiatry as sub-specialties are poorly developed.
With the rise in the elderly population in India, both in terms of total number of subjects and proportion of total population, the need for better training in geriatric psychiatry is self-evident. However, with a currently available number of psychiatrists in the country, it is remotely possible to provide adequate mental health care coverage. In view of this, having an adequate number of psychiatrists with specialized training in geriatric psychiatry can only be considered a dream. Before we move further, let's first understand the current psychiatry training and help seeking in India.
| Indian Scenario: Psychiatry Training|| |
In India, at present psychiatry training is mainly available in the form of MD/Diploma in Psychiatric Medicine/Diploma of National Board Exam psychiatry, and these training programs have cursory focus on the various subspecialties including geriatric psychiatry.  In last few years, some of the centers have started subspeciality mental health courses in geriatric psychiatry (KGMU, Lucknow), child and adolescent psychiatry (NIMHANS, Bengaluru; PGIMER, Chandigarh), and addiction psychiatry (PGIMER, Chandigarh). Postdoctorate fellowship programs are available in NIMHANS, for geriatric psychiatry, schizophrenia, obsessive compulsive disorders, and CL psychiatry.
In the present context, most of psychiatry training programs across the country do not focus on either geriatric psychiatry or CL Psychiatry. A survey conducted by the Indian Psychiatric Society, making available data from 60 centers suggested that only about one-fourth to one-third of the centers provided specialized training in CL Psychiatry services and that too mostly in the form of "on call duties."  Psychiatry training at the undergraduate level is also poor. It is often advocated that there is a need to improve the undergraduate psychiatry training as this will improve the sensitivity of the medical graduates toward mental health issues. Further, this will help in improving the mental health service coverage as many of the common mental disorders could be managed by general physicians. , It is also proposed that there is a need to have training programs for practicing general physicians and specialists to improve their basic mental health skills for diagnosing mental disorders and treating these on their own or referring such patients to the mental health professionals for help.  In the last few years, Indian Psychiatric Society has taken up the issue of improving psychiatry training at undergraduate level with the Government of India and Medical Council of India, but still psychiatry has not received the status of separate subject in terms of certification during the MBBS examination.
| Indian Scenario: Seeking Treatment|| |
In India, health care system is not very organized, and the patients can seek treatment for their ailments at free-will contacting general practitioners or specialists on their own. A major proportion of health care services is provided in the private sector in which patients pay from their own pockets. Accordingly, it is understood that patients who seek help for their mental health problems either consult a psychiatrist on their own or go to the general practitioners or other specialists, who may or may not refer these patients to the mental health professionals.  It is suggests that patients who end up in the care of general practitioners often do not receive the desired attention for their mental disorders and in most cases these remain undiagnosed/underdiagnosed and are treated poorly. 
| Psychiatric Morbidity in Elderly: Indian Scenario|| |
Studies evaluating psychiatric morbidity among elderly patients in the community, those living in old age homes and those attending geriatric clinics suggest that depression is the most common psychiatric morbidity in this age group. ,,, Other commonly seen disorders include mild cognitive impairment, mental, and behavioral disorders due to substance use and dementia;  and in many cases patients with psychiatric morbidity have associated physical illnesses with hypertension being the most common. ,
| Psychiatric Morbidity in Elderly: CL Psychiatry Set-Up in India|| |
If we look at the profile of the patients seen in CL psychiatry set-up, elderly form a significant proportion of all the patients' seen in various medical, surgical wards. , Accordingly, it can be said that if the focus on CL psychiatry improves in Indian setting, it will also provide an opportunity to improve the training in geriatric psychiatry. The usual clinical profile of geriatric patients seen in inpatient CL psychiatry set-up reported from India includes those suffering from depression, adjustment disorder and delirium. ,,, Thus, it can be safely concluded that the patient profile seen in CL psychiatry set-up is similar to that of the community dwelling population, at least in terms of most common psychiatric disorders.
| Keeping These Facts in Mind, What can be done in Short Term to Improve the Geriatric Mental Health Services?|| |
CL psychiatry as a subspecialty is understood as an area of clinical psychiatry, which encompasses clinical, teaching and research activities for psychiatrists, and allied mental health professionals in nonpsychiatric divisions of a general hospital.  A CL psychiatrist is expected to provide clinical inputs in terms of mental health care needs of patients with medical illnesses and also teach clinical skills to the mental health professionals and specialists from other branches of medicine. Fortunately in India, most of the postgraduate psychiatry training centers are in general hospital psychiatry units, in which there is a lot of cross-referrals and accordingly setting up of CL psychiatry services would not be difficult.
If one looks at the CL psychiatry service delivery in India, it is mostly in the form of referrals, in which inpatients admitted to various medical-surgical wards are referred to psychiatrists, who either see these patients at the outpatient level or attend them in the inpatient setting. In general, seeing the patients at the bedside can be considered as a better CL psychiatry model, as this provides opportunities for teaching and discussion with colleagues from other specialities. Hence, it can be said that except for the deployment of manpower, development of CL psychiatry services will not require the development of additional infrastructure or financial investment. Actually, in the long term development of CL psychiatry services may possibly turn out to be a cost-effective measure in providing care and training.
Considering all these, rather than waiting for an increase in resources to develop specialized geriatric psychiatry services, there is a need to improvise the CL psychiatry services in general hospital psychiatric units. The CL psychiatry services will help in improving the skills of the budding psychiatrists in dealing with issues of the elderly patients, especially in the context of physical comorbidity, which is a rule rather than an exception in this age group. In addition, this will also help in sentisitizing specialists from other specialists about the mental health care needs of the elderly patients. This will also offer opportunities for research in geriatric psychiatry. Most importantly, CL psychiatry services can also help in dispelling stigma attached with mental illnesses as also mental health professionals.
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