SummaryConsultants practising clinical specialties other than psychiatry in six general hospitals were asked by questionnalre about reasons which might prevent the referral of patients to a psychiatrist. The purpose of the enquiry was to find out the causes of the discrepancy between the prevalence of psychiatric disorder among medical and surgical patients and the low rate of referral.Forty-five per cent of the consultants were influenced by the patient's dislike of referral; there was also evidence of marked dissatisfaction with existing psychiatric services at certain hospitals, felt chiefly by the younger consultants. Part-time consultants gave more reasons for non-referral, but there was no significant difference between medical and surgical specialties despite reported variations in referral practice.It is concluded that general hospital psychiatric units have a role to play in improving the relationship between psychiatrists and other specialties so that referral practice can meet the needs of the patient. IntroductionSeveral surveys have shown a discrepancy between the incidence of psychiatric disorder in patients attending non-psychiatric departments of general

At the beginning of this century the high rate of “insanity” among immigrants was a matter of considerable concern in the U.S.A. and it has been used as one of the main arguments for curtailing immigration. The problem has been reviewed, and examined with modern statistical methods, by Ødegaard (1932) and Malzberg (1940).

Little has been published about psychiatric out-patient work, and even less about the relationship between in-patient and out-patient psychiatric facilities in service requirements for a given population. The reasons for this are partly general to the whole field of medicine —a preoccupation with severe illness and the hospital bed to which it inevitably leads— and partly particular to psychiatry. The growth of out-patient psychiatric work is relatively recent, and its existence outside teaching hospitals is largely a National Health Service development. With in-patients concentrated in large mental hospitals serving an extensive area, the psychiatrist's connection with any individual general hospital was necessarily limited and the out-patients a small and peripheral part of his work.

That there are wide regional differences in the demand for psychiatric beds is common knowledge, and is frequently commented upon. There is no generally accepted interpretation, and it is difficult to draw conclusions from a comparison between different areas when the crucial treatment facilities—in-patient and out-patient services, admission policies, after-care in the community—are far from uniform. It has been argued that much of the variability in admission rates is independent of mental disorder incidence and reflects other forces at work, such as the organization of the services available to the mentally ill.

Attention has been focused on the ecological aspects of mental illness since Faris and Dunham (1939) showed a higher incidence of schizophrenia in the centre of Chicago than in its peripheral parts. Earlier, Ødegaard (1932) had described a disproportionately high rate of psychotic breakdowns in Norwegian immigrants to Minnesota and in those who had returned to their homeland after a period of time in the U.S.A.