Dr. Sermsak Lolak’s well-written article on bedside psychotherapy (August 2004) stresses the importance of psychiatrists’ psychotherapeutic skills in medical settings. As our roles have shrunk to that of medication management in this era of managed care, this article is timely.
Regularly practicing psychotherapy in consultation and liaison psychiatry, however, is difficult because of several logistical issues:
- Length of stay. The 21-day hospital stay in Dr. Lolak’s example is an exception. On consult service, psychiatrists see up to 40% of patients for three follow-up visits or fewer. 1
- Inability to plan therapy. Often a patient is discharged without the psychiatric consultant’s knowledge or input.
- Reimbursement for follow-up psychotherapeutic visits. Most consultation and liaison psychiatrists generate income through billing; follow-up visits are not routinely reimbursed.
To address these issues, the psychiatrist needs to consider every visit as final and make every session complete in itself.
Although we clinically and intuitively recognize the benefits of ultra-brief psychotherapeutic interventions, clinical trials are needed to show their efficacy. These data would also provide rationale for payers to reimburse follow-up therapeutic visits.
Narsimha R. Pinninti MD, MBBS
Assistant professor of psychiatry
University of Medicine and Dentistry of New Jersey
Cherry Hill, NJ
- Strain JJ, Ginsburg J, Fulop G, Strain JJ. Follow-up of psychiatric comorbidity in the general hospital. Int J Psychiatry Med 1990;20:227–34.
Dr. Lolak responds
Dr. Pinninti raises two commonly recognized major problems in consultation psychiatry:
- Visiting a hospitalized patient in a timely manner is often inconvenient.
- Reimbursement is limited.
These are among the many reasons that the American Board of Psychiatry and Neurology now recognizes psychosomatic medicine as a subspecialty. Hospital-based consultation psychiatrists who can see patients in a timely manner are needed. Often hospitals must subsidize a consultation psychiatrist’s position, but this expense offsets the risks of not seeing these patients.
Evidence for brief psychosocial treatment is another issue. Much of what we do is not supported by randomized controlled trials, but we cannot ignore our patients’ needs until more evidence is gathered. We hope a sufficient cadre of consultation psychiatrists do the research Dr. Pinninti suggests.
Sermsak Lolak, MD
Consultation-liaison psychiatry fellow
Thomas Wise, MD
Professor and vice chairman
Department of psychiatry Georgetown University,