Psychiatry, psychosomatic medicine and the general hospital in Germany

In many countries, the integration of psychiatric departments in general hospitals has paved the way for psychiatry as a discipline to be taken increasing notice of by medical-surgical physicians and patients alike. In this commentary, I will discuss aspects of the relationship of psychiatric services and the general hospital in Germany, and comment on peculiarities of the German health care system, regarding the existence of two separate disciplines, 'psychiatry and psychotherapy' and 'psychotherapeutic medicine', within the training of physicians.

While in the USA the foundation of psychiatric departments as integrated parts of general hospitals started as early as in the 1920s, in the Federal Republic of Germany state mental hospitals have given way to general hospital psychiatric departments only since the 1970s. This was the result of a national inquiry into mental health services, initiated by the German Lower House, well-known as 'Psychiatrie- Enquête' (1). Its aim was to end the discriminating segregation and poor treatment of psychiatric patients.

Apart from initiating the discharge of chronically ill patients from institutions into community mental health services, its overall aim was to integrate psychiatry into the whole of medicine. Since then, there was a tremendous increase in psychiatric departments in general hospitals, from a handful in 1970 to 160 in 2003. Together with 150 stand-alone psychiatric hospitals, these services care for the acutely ill psychiatric patients in Germany (2,3).

While the emphasis of the Psychiatrie- Enquête was on de-institutionalization, it also stated that consultationliaison (C-L) psychiatric services could provide better treatment opportunities in general hospitals for somatically ill patients with co-morbid psychiatric disorders. Hence, it called for the establishment of a C-L service in every large hospital for the treatment of suicide attempters and suggested that C-L psychiatry be involved with primary prevention in high-risk groups, such as accident victims, dialysis or transplantation patients.

Since 1990, when the number of psychiatric departments in general hospitals rose to more than 100, psychiatrists increasingly began to extend their research to C-L psychiatric topics. The Lubeck General Hospital Study is an excellent epidemiological study of psychiatric co-morbidity of physically ill patients in internal and surgical departments in general hospitals (4). As of today, the integration of psychiatry via psychiatric departments into the general hospital, or at least close collaboration between stand-alone psychiatric facilities and nearby general hospitals (5), is regarded as standard of care, and psychiatric C-L services are appreciated by medical-surgical doctors.

But, things are not that simple in Germany. It is a very special feature of the German physicians' specialty system that two distinct physician specialties exist for the care of psychologically ill patients: one is called 'psychiatry and psychotherapy' (psychiatry), the other one, in existence since 1992, is called 'physician for psychotherapeutic medicine' (psychosomatics). It is this author's experience that to non-German psychiatrists this development is hardly ever understandable. Do they care, for example, for different groups of patients? Not necessarily, if we look at psychiatric vs. psychosomatic C-L services.

There is a wide overlap in the care of patients with depressive symptoms, with no accepted way of locating patients to one service or the other, if two services exist in one hospital, which is not the usual case, since most of the psychosomatic beds are not in the acute hospital care sector, but in rehabilitation hospitals. Mostly in university hospitals, there may be separate C-L services provided by 'psychiatry and psychotherapy' and 'psychotherapeutic medicine', with a usual ratio of referrals of at least 3 to 1. It is estimated that 95% of existing hospital C-L services are provided by psychiatry, and, due to some overlap, 20% by psychosomatics (6). Plans to increase the number of psychosomatic departments in general hospitals, in addition to psychiatric departments, are controversial.

In the European Consultation Liaison Workgroup study, a cluster analysis on variations in the characteristics of patients referred to 56 C-L services in 11 European countries yielded two types of service provision: one 'psychosomatic' and one 'psychiatric' (7). Genuine psychosomatic service delivery was a German peculiarity, with such services virtually seeing no deliberate self harm patients, only a low percentage of substance abuse patients and a very low percentage of patients with organic mental syndromes. Their main focus was on dealing with unexplained physical complaints, which, on the other hand, was an important function of psychiatric C-L services as well (8). Psychosomatic and psychiatric services differ with regard to the amount of psychotropic drug prescription for similar diagnostic groups, but the few comparative studies did not include measures of severity.

Increasing awareness of psychiatric co-morbidity, especially in elderly general hospital inpatients, has led to increasing interest in medical-psychiatric units in this country. As German psychosomatic wards were mainly located in rehabilitation centres with restricted admission of patients with genuine psychosomatic illnesses, and not in acute care hospitals, such psychosomatic wards should not be mistaken for genuine med-psych units. On the other hand, psychiatric wards focusing on geropsychiatric patients and patients with addictive disorders, resembling med-psych units as known in the USA, can be found in general hospitals and psychiatric state hospitals (2).

It is this author's hope that the pivotal role of the general hospital for the improvement of care for physically and psychiatrically ill patients will also bring along combined psychiatric-psychosomatic treatment approaches in the future, just as it led to the successful re-integration of psychiatry into medicine in the past.