Perspective Comorbidity and Use of Psychiatric Services by General Hospital Patients RICHARD MAYOU. B.M., F.R.C.P., ER.C.PSYCH.
T
he associations between physical symptoms and psychiatric disorder are well established. 1.2 The very substantial implications this has for psychiatric services are receiving increasing attention. with the literature focusing both on the use of non-mental health services by patients with psychiatric disorders~-~ and on the impact of psychiatric comorbidity on the management of medical conditions.'u--16 However. there has been little specific consideration of the issue that is of most interest to consultation-liaison (C-L) psychiatrists: the overall use of psychiatric services by inpatients and outpatients attending general hospital medical and surgical units. There are four closely related reasons why this lack of interest should be remedied: I. Economic analyses have neglected. and planners have underestimated and underfunded. the considerable current use of psychiatric resources by such patients. 2. We need to identify ways in which current psychiatric input can be better coordinated with physical care and be made both more effective and more efficient. 3. There are clinical and economic arguments for improved care of the subgroup of patients who are "distressed high utilizers" of both medical and psychiatric services. 4. More attention should be paid to the formulation of detailed priorities and plans for psychiatric services for general hospital attenders who require. but who are not currently receiving. psychiatric care. METHODS
Received March 7.1991; revised July 23. 1991; accepted July 26. 1991. From the University Depanment ofPsychiatry. Warneford Hospilal. Oxford. England. Address reprint requests 10 Dr. Mayou. University Depanment of Psychiatry. Warneford Hospilal. Oxford. OX3 7JX. Uniled Kingdom. Copyright © 1991 The Academy of Psychosomatic Medicine.
438
It is difficult to obtain a comprehensive picture. The most obvious source of information. C-L service statistics. provides only a partial view. principally of referral to psychiatrists during inpatient admission. Many general hospital attenders receive psychiatric care in other ways. General hospital physicians and surgeons also refer directly to psychiatric services other than C-L units; many other patients see psychiatrists entirely independently of their medical and surgical care. We therefore need to seek information from a wider range of sources in order to examine the extent to which patients use both psychiatric and general hospital PSYCHOSOMATICS
Mayou medical services, both simultaneously and over defined periods of time. We cannot expect definitive answers, but it is helpful to indicate the size of the problem and to define directions for research. This paper, therefore, reviews evidence of the use of psychiatric services by medical patients (i.e., general hospital attenders) from five diverse standpoints: I. 2. 3. 4. 5.
general hospitals as pathways to specialist psychiatric care C-L service statistics prospective studies of specific medical conditions general hospital prevalence studies linked case register studies
Evidence is drawn from both North American and European research. Comprehensive systems of health care (such as those in European countries) offer opportunities for types of epidemiological research that are not possible in the United States." Great caution is necessary in interpreting statistics and research from widely differing systems of health care and especially in international comparisons. In considering the British data presented here, it is important to be aware that I) primary care general practitioners who work in local health centers treat the overwhelming majority of psychiatric problems (90%-95%). All psychiatrists and other general hospital physicians and surgeons are specialists who (apart from some emergency department attenders) see only patients (outpatients, inpatients, home visits) who are secondary referrals from primary care; 2) C-L services are administratively part of catchment area specialist psychiatric services. Most C-L psychiatrists are part-time, spending most of their time providing general adult psychiatry for the community. FINDINGS General Hospitals as Pathways to Psychiatric Care In countries with comprehensive health care systems, most discussions and plans for mental health services concentrate exclusively on care in the community and on liaison with primary care general practitioners. At best, C-L and other general hospital psychiatric services to medical and surgical patients are relegated to footnotes. 17 This is regrettable and inappropriate because there is evidence that the general hospital is a major pathway to specialist psychiatric care; i.e., general hospital physicians and surgeons refer directly to psychiatrists many patients whom they themselves have seen as referrals from primary care or emergency departments. A recent World Health Organization collaborative project provided convincing and remarkably consistent evidence from VOLUME 32· NUMBER 4· FALL 1991
439
Comorbidity and Use of Services
parallel projects in II western and developing countries. IS For example, the United Kingdom participants, Gater and Goldberg '9 reported that during a I-month period, there were 266 new referrals to their Manchester catchment area psychiatric service and that 33% were made by general hospital doctors, compared with 63% from primary care. One-third of the general hospital referrals aged under 65 were made by emergency department doctors in response to deliberate selfharm; most of the remainder were consultation requests from inpatient wards (concerning patients with organic problems, in particular). A small number of patients were seen as psychiatric outpatients (especially those with somatic symptoms), occasionally at home. Thirty percent of the general hospital referrals were aged over 65 and were assessed on wards by specialists in old-age psychiatry (who work independently ofpsychiatrists responsible for younger adults and forC-L). C-L Service Users C-L unit statistics provide important evidence, but they must be examined with care because services vary greatly in their scope. Some C-L units are quite separate from services for accident and emergency departments. Some do not concern themselves with the elderly, and a few have special outpatient clinics for patients who also have physical disorders or somatization complaints. Very few provide comprehensive psychiatric care to all general hospital departments, and a number work in cooperation (or rivalry) with other psychiatric and psychological services to general hospital patients. Large C-L services report referral rates of 5%-10% of all inpatient admissions, but much lower rates are more usual (especially outside North America).1 7.20-25 There is important and consistent evidence that referred patients are greater users of medical resources during admission than those not referred I 1-14 and that C-L interventions can be cost-effective. 11.12 C-L interventions are mainly directed at inpatients and are normally brief. There is little longitudinal information about use of psychiatric services over longer periods of time before and 440
after the general hospital inpatient admission. It is evident that many patients seen in C-L consultations have had previous psychiatric care 23 and that a sizable minority are offered continuing psychiatric care following discharge from the general hospital. 25 Some continue to attend C-L outpatient clinics. Many are referred to (or back to) other psychiatric services for continuing psychiatric hospital or outpatient care. 23- 27 Since there is no published evidence about the longer term use of psychiatric care, we recently have examined figures for two components of our own C-L unit: the services for attempted suicide and for inpatient consultation referrals. During 1990, the Oxford C-L service assessed 843 cases of attempted suicide, 85% of all attempted suicide patients attending the hospital (K.E. Hawton, personal communication). Fortyone percent had had previous specialist psychiatric care; 12% had had inpatient care in the previous year; and 23% had had psychiatric outpatient care. Transfer to psychiatric inpatient care was arranged for 7.6%, and transfer to day care was arranged for 3.0%. Outpatient care at the C-L service was arranged for 27.7% and at other psychiatric clinics for 14.6%. A fifth (21.5%) were referred to other social and voluntary agencies. Almost two-thirds (63%) were given the C-L unit's 'open access' emergency telephone number. We know the rates of readmission for further episodes of attempted suicide (14% in the first year), and we know that many patients continue to be major users of psychiatric and medical care over long periods of time. We also have examined the use of all types of psychiatric care by a cohort of 691 patients who were consecutive (nonoverdose) consultation requests from inpatient wards and who had homes in the Oxford catchment area. At the completion of the consultation, 5% were transferred to psychiatric inpatient care; I % was discharged to psychiatric day care; 23% were offered outpatient follow-up by the C-L unit; and 15% were referred to local social service departments or other agencies for continuing social care. Case register data for the catchment area enabled us to examine the rates of use by the cohort of all specialist psychiatric services over PSYCHOSOMATICS
Mayou a 6-year period (4 years before and 2 years after the consultation referral). Fifty-five percent of subjects had no further psychiatric inpatient or outpatient care during this 6-year period; 19% had one further episode of psychiatric care; 20% had three to eight separate episodes; and 5% had nine or more further episodes. Most of this care was not provided by Col but by other catchment area psychiatric services (general. psychogeriatric. and substance abuse), even if the patient continued to attend the general hospital medical or surgical departments. Prospective Studies of Specific Medical Conditions Prospective studies of representative patient groups with various specific medical conditions consistently report that a sizable minority of patients suffer persistent psychiatric comorbidity. For example, the medical outcomes study2 showed that for eight out of nine chronic conditions studied, psychiatric comorbidity was common and associated with substantial consequences for functioning and well-being. Similarly, Kellner 8 summarized the very large costs of chronic disability due to functional somatic complaints. It is well known that (apart from a number of well-organized psychiatric liaison programs) psychiatric comorbidity associated with acute and with chronic medical conditions is underrecognized. It seems probable that many patients who might benefit from referral to psychiatrists are not referred at any stage of the medical condition. Very few reports describe the nature, duration, and timing of psychiatric care. Indeed, it is usually unclear whether such care is more frequent than would be expected for a matched sample of the general population. The most obvious exception is the increased rate of psychiatric care associated with puerperium. 29 It is clear that much psychiatric disorder continues to go unrecognized and untreated over long periods of time. Further research on psychiatric referral over the whole duration of medical illness would enable conclusions about the most VOLUME 32· NUMBER 4· FALL 1991
effective ways that Col and other psychiatric services could offer care to all those who might benefit. General Hospital Prevalence Studies Two types of research on consecutive general hospital admissions (or discharges) have provided more information about the service consequences ofcomorbidity. Prevalence studies both research assessments of consecutive admissions JO.3I.34 and examination of hospital discharge diagnoses' 2 have shown that psychiatric disorder (organic, emotional, substance abuse) is common among general hospital inpatients and associated with increased costs and use of services. Most studies have taken a cross-sectional view of comorbidity, but several have examined its course during admission. 14 Few have considered comorbidity and its service implications over a period longer than that of the index admission. In our own study31 of 450 consecutive nonoverdose medical admissions to an acute general hospital, we found considerable morbidity but low rates of psychiatric consultation, with referrals by hospital doctors directly to the catchment area psychogeriatric service being as numerous as those to the hospital's own Col unit. Although follow-up showed considerable improvement of psychiatric status during the year after medical admission, there was substantial persistent morbidity, most of which was unrecognized either in the general hospital or in primary care. The majority of new episodes of psychiatric care during the year were prov ided by catchment area general psychiatric services rather than by the Col unit outpatient department consultation service to wards. Linked Case Register Studies Comprehensive case registers for defined populations enable a rather different approach to understanding patterns ofservice use. Two recent studies have used linked data to examine the psychiatric use of physical and mental illness over defined periods of time. Fink32 used the Danish nationwide registers to compare the diag441
Comorbidity and Use of Services
nostic pattern of general hospital medical admissions for a cohort of subjects who either had or had not also been admitted to psychiatric units over an 8-year period. Associations were found for all physical diagnostic categories studied and were especially strong for those with unexplained somatic symptoms. The British National Health Service enables similar research. We recently used linked general hospital and psychiatric service data from the Oxford Health District case register (population 450,(00) to examine the use of psychiatric care by cohorts of inpatients aged 15-64 years and discharged between 1975 and 1985 from our general hospitals.)) We considered 20 different physical discharge diagnoses, diagnoses chosen as examples of a wide range of common medical problems: acute and threatening conditions (e.g., myocardial infarction, stroke, cancer), chronic illnesses (e.g., diabetes, cirrhosis), and nonspecific symptom diagnoses (e.g., chest and abdominal pain). Findings were compared with a control group of admissions (n= 17,333) for nonthreatening medical procedures unlikely to have more than transient psychological consequences (e.g., surgery for inguinal hernia). Observed rates of the use of psychiatric care for the year before and the year after general hospital index admission for each diagnostic group were compared with expected rates that were calculated as if rates in the general population had prevailed in each group. Detailed results have been reported elsewhere, D but the findings are illustrated in Figures 1-3. For control conditions (for example inguinal hernia surgery), rates of psychiatric care in the years before and after admission were similar to those for the general population, but rates for those with chronic illnesses (for example, diabetes) and nonspecific symptom diagnoses in the year before and the year after admission were significantly higher than expected. For acute conditions (for example, myocardial infarction), the rates of care were significantly raised only in the year after admission. By far the highest ratio of observed/expected care was for patients with cirrhosis, being 16 times the expected rate in the year preceding admission for men. Patients who 442
had had any psychiatric care in the 2 years before admission were especially likely (20%-45%) to have further episodes of psychiatric care in the year following general hospital admission. During the 4 years after the index admission, care declined to a level similar to that in the general population for most acute and chronic conditions. In contrast, patients with nonspecific symptomatic conditions, cirrhosis of the liver, and bone fractures continued to have rates of psychiatric care that were significantly higher than those in the general population CONCLUSION Use of evidence from a range of standpoints enlarges the debate about comorbidity. Understanding of current patterns of service use should be a basis (together with what is known of the clinical significance ofcomorbidity) for planning improved care. We can summarize a number of conclusions. FIGURE l. Ratios of observed to "expected" use of psychiatric services by women with selected acute and chronic medical conditions (cancer, n=2,603; myocardial infarction, n=398; diabetes, n=731; inguinal hernia, n=3,178) for the year before (black columns) and the year after (hatched columns) general hospital discharge (°p
T
he associations between physical symptoms and psychiatric disorder are well established. 1.2 The very substantial implications this has for psychiatric services are receiving increasing attention. with the literature focusing both on the use of non-mental health services by patients with psychiatric disorders~-~ and on the impact of psychiatric comorbidity on the management of medical conditions.'u--16 However. there has been little specific consideration of the issue that is of most interest to consultation-liaison (C-L) psychiatrists: the overall use of psychiatric services by inpatients and outpatients attending general hospital medical and surgical units. There are four closely related reasons why this lack of interest should be remedied: I. Economic analyses have neglected. and planners have underestimated and underfunded. the considerable current use of psychiatric resources by such patients. 2. We need to identify ways in which current psychiatric input can be better coordinated with physical care and be made both more effective and more efficient. 3. There are clinical and economic arguments for improved care of the subgroup of patients who are "distressed high utilizers" of both medical and psychiatric services. 4. More attention should be paid to the formulation of detailed priorities and plans for psychiatric services for general hospital attenders who require. but who are not currently receiving. psychiatric care. METHODS
Received March 7.1991; revised July 23. 1991; accepted July 26. 1991. From the University Depanment ofPsychiatry. Warneford Hospilal. Oxford. England. Address reprint requests 10 Dr. Mayou. University Depanment of Psychiatry. Warneford Hospilal. Oxford. OX3 7JX. Uniled Kingdom. Copyright © 1991 The Academy of Psychosomatic Medicine.
438
It is difficult to obtain a comprehensive picture. The most obvious source of information. C-L service statistics. provides only a partial view. principally of referral to psychiatrists during inpatient admission. Many general hospital attenders receive psychiatric care in other ways. General hospital physicians and surgeons also refer directly to psychiatric services other than C-L units; many other patients see psychiatrists entirely independently of their medical and surgical care. We therefore need to seek information from a wider range of sources in order to examine the extent to which patients use both psychiatric and general hospital PSYCHOSOMATICS
Mayou medical services, both simultaneously and over defined periods of time. We cannot expect definitive answers, but it is helpful to indicate the size of the problem and to define directions for research. This paper, therefore, reviews evidence of the use of psychiatric services by medical patients (i.e., general hospital attenders) from five diverse standpoints: I. 2. 3. 4. 5.
general hospitals as pathways to specialist psychiatric care C-L service statistics prospective studies of specific medical conditions general hospital prevalence studies linked case register studies
Evidence is drawn from both North American and European research. Comprehensive systems of health care (such as those in European countries) offer opportunities for types of epidemiological research that are not possible in the United States." Great caution is necessary in interpreting statistics and research from widely differing systems of health care and especially in international comparisons. In considering the British data presented here, it is important to be aware that I) primary care general practitioners who work in local health centers treat the overwhelming majority of psychiatric problems (90%-95%). All psychiatrists and other general hospital physicians and surgeons are specialists who (apart from some emergency department attenders) see only patients (outpatients, inpatients, home visits) who are secondary referrals from primary care; 2) C-L services are administratively part of catchment area specialist psychiatric services. Most C-L psychiatrists are part-time, spending most of their time providing general adult psychiatry for the community. FINDINGS General Hospitals as Pathways to Psychiatric Care In countries with comprehensive health care systems, most discussions and plans for mental health services concentrate exclusively on care in the community and on liaison with primary care general practitioners. At best, C-L and other general hospital psychiatric services to medical and surgical patients are relegated to footnotes. 17 This is regrettable and inappropriate because there is evidence that the general hospital is a major pathway to specialist psychiatric care; i.e., general hospital physicians and surgeons refer directly to psychiatrists many patients whom they themselves have seen as referrals from primary care or emergency departments. A recent World Health Organization collaborative project provided convincing and remarkably consistent evidence from VOLUME 32· NUMBER 4· FALL 1991
439
Comorbidity and Use of Services
parallel projects in II western and developing countries. IS For example, the United Kingdom participants, Gater and Goldberg '9 reported that during a I-month period, there were 266 new referrals to their Manchester catchment area psychiatric service and that 33% were made by general hospital doctors, compared with 63% from primary care. One-third of the general hospital referrals aged under 65 were made by emergency department doctors in response to deliberate selfharm; most of the remainder were consultation requests from inpatient wards (concerning patients with organic problems, in particular). A small number of patients were seen as psychiatric outpatients (especially those with somatic symptoms), occasionally at home. Thirty percent of the general hospital referrals were aged over 65 and were assessed on wards by specialists in old-age psychiatry (who work independently ofpsychiatrists responsible for younger adults and forC-L). C-L Service Users C-L unit statistics provide important evidence, but they must be examined with care because services vary greatly in their scope. Some C-L units are quite separate from services for accident and emergency departments. Some do not concern themselves with the elderly, and a few have special outpatient clinics for patients who also have physical disorders or somatization complaints. Very few provide comprehensive psychiatric care to all general hospital departments, and a number work in cooperation (or rivalry) with other psychiatric and psychological services to general hospital patients. Large C-L services report referral rates of 5%-10% of all inpatient admissions, but much lower rates are more usual (especially outside North America).1 7.20-25 There is important and consistent evidence that referred patients are greater users of medical resources during admission than those not referred I 1-14 and that C-L interventions can be cost-effective. 11.12 C-L interventions are mainly directed at inpatients and are normally brief. There is little longitudinal information about use of psychiatric services over longer periods of time before and 440
after the general hospital inpatient admission. It is evident that many patients seen in C-L consultations have had previous psychiatric care 23 and that a sizable minority are offered continuing psychiatric care following discharge from the general hospital. 25 Some continue to attend C-L outpatient clinics. Many are referred to (or back to) other psychiatric services for continuing psychiatric hospital or outpatient care. 23- 27 Since there is no published evidence about the longer term use of psychiatric care, we recently have examined figures for two components of our own C-L unit: the services for attempted suicide and for inpatient consultation referrals. During 1990, the Oxford C-L service assessed 843 cases of attempted suicide, 85% of all attempted suicide patients attending the hospital (K.E. Hawton, personal communication). Fortyone percent had had previous specialist psychiatric care; 12% had had inpatient care in the previous year; and 23% had had psychiatric outpatient care. Transfer to psychiatric inpatient care was arranged for 7.6%, and transfer to day care was arranged for 3.0%. Outpatient care at the C-L service was arranged for 27.7% and at other psychiatric clinics for 14.6%. A fifth (21.5%) were referred to other social and voluntary agencies. Almost two-thirds (63%) were given the C-L unit's 'open access' emergency telephone number. We know the rates of readmission for further episodes of attempted suicide (14% in the first year), and we know that many patients continue to be major users of psychiatric and medical care over long periods of time. We also have examined the use of all types of psychiatric care by a cohort of 691 patients who were consecutive (nonoverdose) consultation requests from inpatient wards and who had homes in the Oxford catchment area. At the completion of the consultation, 5% were transferred to psychiatric inpatient care; I % was discharged to psychiatric day care; 23% were offered outpatient follow-up by the C-L unit; and 15% were referred to local social service departments or other agencies for continuing social care. Case register data for the catchment area enabled us to examine the rates of use by the cohort of all specialist psychiatric services over PSYCHOSOMATICS
Mayou a 6-year period (4 years before and 2 years after the consultation referral). Fifty-five percent of subjects had no further psychiatric inpatient or outpatient care during this 6-year period; 19% had one further episode of psychiatric care; 20% had three to eight separate episodes; and 5% had nine or more further episodes. Most of this care was not provided by Col but by other catchment area psychiatric services (general. psychogeriatric. and substance abuse), even if the patient continued to attend the general hospital medical or surgical departments. Prospective Studies of Specific Medical Conditions Prospective studies of representative patient groups with various specific medical conditions consistently report that a sizable minority of patients suffer persistent psychiatric comorbidity. For example, the medical outcomes study2 showed that for eight out of nine chronic conditions studied, psychiatric comorbidity was common and associated with substantial consequences for functioning and well-being. Similarly, Kellner 8 summarized the very large costs of chronic disability due to functional somatic complaints. It is well known that (apart from a number of well-organized psychiatric liaison programs) psychiatric comorbidity associated with acute and with chronic medical conditions is underrecognized. It seems probable that many patients who might benefit from referral to psychiatrists are not referred at any stage of the medical condition. Very few reports describe the nature, duration, and timing of psychiatric care. Indeed, it is usually unclear whether such care is more frequent than would be expected for a matched sample of the general population. The most obvious exception is the increased rate of psychiatric care associated with puerperium. 29 It is clear that much psychiatric disorder continues to go unrecognized and untreated over long periods of time. Further research on psychiatric referral over the whole duration of medical illness would enable conclusions about the most VOLUME 32· NUMBER 4· FALL 1991
effective ways that Col and other psychiatric services could offer care to all those who might benefit. General Hospital Prevalence Studies Two types of research on consecutive general hospital admissions (or discharges) have provided more information about the service consequences ofcomorbidity. Prevalence studies both research assessments of consecutive admissions JO.3I.34 and examination of hospital discharge diagnoses' 2 have shown that psychiatric disorder (organic, emotional, substance abuse) is common among general hospital inpatients and associated with increased costs and use of services. Most studies have taken a cross-sectional view of comorbidity, but several have examined its course during admission. 14 Few have considered comorbidity and its service implications over a period longer than that of the index admission. In our own study31 of 450 consecutive nonoverdose medical admissions to an acute general hospital, we found considerable morbidity but low rates of psychiatric consultation, with referrals by hospital doctors directly to the catchment area psychogeriatric service being as numerous as those to the hospital's own Col unit. Although follow-up showed considerable improvement of psychiatric status during the year after medical admission, there was substantial persistent morbidity, most of which was unrecognized either in the general hospital or in primary care. The majority of new episodes of psychiatric care during the year were prov ided by catchment area general psychiatric services rather than by the Col unit outpatient department consultation service to wards. Linked Case Register Studies Comprehensive case registers for defined populations enable a rather different approach to understanding patterns ofservice use. Two recent studies have used linked data to examine the psychiatric use of physical and mental illness over defined periods of time. Fink32 used the Danish nationwide registers to compare the diag441
Comorbidity and Use of Services
nostic pattern of general hospital medical admissions for a cohort of subjects who either had or had not also been admitted to psychiatric units over an 8-year period. Associations were found for all physical diagnostic categories studied and were especially strong for those with unexplained somatic symptoms. The British National Health Service enables similar research. We recently used linked general hospital and psychiatric service data from the Oxford Health District case register (population 450,(00) to examine the use of psychiatric care by cohorts of inpatients aged 15-64 years and discharged between 1975 and 1985 from our general hospitals.)) We considered 20 different physical discharge diagnoses, diagnoses chosen as examples of a wide range of common medical problems: acute and threatening conditions (e.g., myocardial infarction, stroke, cancer), chronic illnesses (e.g., diabetes, cirrhosis), and nonspecific symptom diagnoses (e.g., chest and abdominal pain). Findings were compared with a control group of admissions (n= 17,333) for nonthreatening medical procedures unlikely to have more than transient psychological consequences (e.g., surgery for inguinal hernia). Observed rates of the use of psychiatric care for the year before and the year after general hospital index admission for each diagnostic group were compared with expected rates that were calculated as if rates in the general population had prevailed in each group. Detailed results have been reported elsewhere, D but the findings are illustrated in Figures 1-3. For control conditions (for example inguinal hernia surgery), rates of psychiatric care in the years before and after admission were similar to those for the general population, but rates for those with chronic illnesses (for example, diabetes) and nonspecific symptom diagnoses in the year before and the year after admission were significantly higher than expected. For acute conditions (for example, myocardial infarction), the rates of care were significantly raised only in the year after admission. By far the highest ratio of observed/expected care was for patients with cirrhosis, being 16 times the expected rate in the year preceding admission for men. Patients who 442
had had any psychiatric care in the 2 years before admission were especially likely (20%-45%) to have further episodes of psychiatric care in the year following general hospital admission. During the 4 years after the index admission, care declined to a level similar to that in the general population for most acute and chronic conditions. In contrast, patients with nonspecific symptomatic conditions, cirrhosis of the liver, and bone fractures continued to have rates of psychiatric care that were significantly higher than those in the general population CONCLUSION Use of evidence from a range of standpoints enlarges the debate about comorbidity. Understanding of current patterns of service use should be a basis (together with what is known of the clinical significance ofcomorbidity) for planning improved care. We can summarize a number of conclusions. FIGURE l. Ratios of observed to "expected" use of psychiatric services by women with selected acute and chronic medical conditions (cancer, n=2,603; myocardial infarction, n=398; diabetes, n=731; inguinal hernia, n=3,178) for the year before (black columns) and the year after (hatched columns) general hospital discharge (°p
