What should British consultation-liaison psychiatry be doing?

Commentary and Perspective From time to time, the Journal receives manuscripts that can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.

What Should British Consultation-Liaison Psychiatry Be Doing? Richard Mayou, M.D.

Abstract: Despite increasing clinical interest and research consultation-liaison (C-L) services in the United Kingdom are mainly haphazard and unsatisfactory. Although the clinical problems are similar to those in other Western countries, the answers must reflect the British health care system. The national C-L organization must formulate and promote detailed policies for 1) clinical priorities; 2) staffing and other resources; 3) integration with other specialist psychiatric services for local populations and primary care; and 4) persuading other medical organizations to place greater emphasis on psychological skills, training requirements, and practice. Some of our conclusions are parochial, some are generally applicable; others are applicable only to countries with comprehensive health care.

Introduction Consultation-liaison psychiatry (C-L) is more firmly established in the United States than elsewhere [l--5] and, despite doubts and controversies, is seen by other countries as a model. Some characteristics of aims and methods are universal, but in practice there can be no single approach; services must depend on local circumstances as well as national policies [2,6]. In Britain, we must be cautious about how far we can apply North American ideas. Our National Health Service makes no direct charges to patients; we have fewer psychiatrists and psychologists in relation to our population; primary care is universal and well developed; specialist psychiatry is organized to provide coordinated catchment-area services [2]. Even so, Europeans can learn much from North

From the Universitv Department of Psychiatry, Warneford Hospital, Oxford, United Kingdom. . . Address reurint reauests to: Richard Mavou, B.M., University DepartmLnt of P’sychiatry, Warnefori Hospital, Oxford OX3 7JX, UK. GeneralHospitalPsychiatry 13, 261-266,

1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

American C-L, especially its most impressive feature, the clinical and teaching expertise of experienced senior psychiatrists. In addition, the current radical reorganization of the British National Health Service [7] has sharpened our interest in the continuing North American debates about C-L funding. We are now being required to devolve budgets to clinical units and to create an internal market in which units will negotiate contracts within an internal market. C-L services will therefore be purchased by general hospital departments in the future. Some conclusions about the future of British CL will be generally applicable, but others will not be relevant to countries that do not have comprehensive psychiatric services for catchment areas. International comparisons can stimulate the development of C-L.

The Present State of C-L in the United Kingdom General psychiatrists have for many years accepted a responsibility for general hospital emergency and other referrals, but specific and well-organized C-L services are still uncommon [2,8]. Referral rates are lower than the 0.9% reported in the United States [9] and are probably falling as the turnover of general hospital admissions increases. Development has been hindered both by a general lack of resources and by an overwhelming planning bias toward community care, such that only a minority of local health districts have definite plans to improve C-L services. Neither psychiatrists nor planners have realized the importance of the general hospital as a pathway to specialist care; Gater and 261 ISSN 0163-8343/91/$3.50

R. Mayou

Goldberg have recently reported that it accounted for 33% of all referrals [lo] in a Manchester health district. There are some encouraging signs: the enthusiasm of younger psychiatrists; some good general hospital research; increasing clinical demand for our services from within general hospitals; and probably most important of all, the formation of a national C-L group in 1983. This has had the major advantage of being part of the national professional association, the Royal College of Psychiatrists, which has provided an administrative base, a platform within psychiatry, and the opportunity to in-

Table 1.: Principal Referral

fluence

2. Psychiatric disorder presenting with physical symptoms a. Differential diagnosis b. Psychiatric and psychological treatments c. Advice and organization of medical care

national

policies.

The Clinical Problem C-L planning must derive a clear definition of the clinical priorities and of the resources available [ll]. The clinical problems are similar in all countries, developed and underdeveloped [6]. The presence of psychiatric disorder is described in up to onethird of inpatients and outpatients; many other patients without major psychological symptoms exhibit behavioral or management difficulties that might be alleviated by psychological intervention (for example, functional somatic symptoms, poor compliance, disproportionate disability). Many problems are transient or minor and it is unclear 1) what proportion of patients might benefit from extra psychological or social care; and 2) how many patients need specifically psychiatric assessment

or treatment.

Reasons for Psychiatric

1. Psychiatric consequences of physical disorder a. Organic (delirium and dementia) Differential diagnosis Management of disturbed behavior Long-term care b. Emotional, behavioral, and social Differential diagnosis Assessment of severity of depression Psychiatric and psychological treatments Management of disturbed and maladaptive behavior

3. Physical complications of psychiatric disorder a. Deliberate self-harm Organization of comprehensive service Management of major psychiatric disorder b. Alcohol and drug abuse Organization of comprehensive service Management of problem patients c. Eating disorders Assessment and treatmnt d. Side effects of psychotropic drugs 4. Physical and psychiatric disorders occurring together by chance a. Advice on continuing management of psychiatric disorder b. Management of disturbed and maladaptive behavior

In Britain, as elsewhere, C-L concentrates on the most conspicuous behavioral and diagnostic problems, emergencies, and consultations to inpatients. We neglect other groups who might benefit (Table l), notably outpatients and large categories of patients with treatable disorders, for instance, medically unexplained physical symptoms, psychiatric complications of chronic illness, alcohol abuse, and the problems associated with aging [ll]. Several issues deserve further comment.

who have attempted suicide, preferring to combine initial systematic assessment by nonpsychiatrists (nurses, social workers, emergency-room doctors) with selective psychiatric review [13]. Several approaches have been carefully evaluated [13]. Some innovations, especially in the use of highly trained multidisciplinary teams, could be useful in other C-L settings.

Emergencies

Psychiatric Complications

British C-L is dominated by the assessment of attempted suicide. Because the numbers of patients are very large, few hospitals meet national guidelines [12] that all patients should be psychologically assessed. Most units that do provide organized care have found that it is neither feasible nor necessary for C-L psychiatrists to assess all patients

There are few psychiatric liaison schemes in Britain, but special programs for the seriously and chronically ill organized by nonpsychiatrists are becoming common, offering counseling (for cancer and HIV), education (for diabetes), or rehabilitation (for stroke, cardiac, and orthopedic problems) [14]. Although the aims and enthusiasm of such pro-

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of Physical Illness

British C-L Psychiatry

grams are encouraging, unfortunately many are psychologically naive, and few have links with psychiatric or psychological services. We need to be much more vigorous in ensuring that C-L comes to be seen as an essential part of planning and delivering all care for the chronically ill. Accounts of liaison with oncology [15], pain clinics, obstetric [16], and other units have demonstrated that good psychosocial care can be organized so that it requires only modest specialist psychiatric input.

Medically Unexplained Physical Symptoms It is increasingly evident that medically unexplained symptoms (i.e., somatization, hypochondriacal or functional somatic symptoms) should be a priority for C-L [17,18], but most general hospital doctors (and many psychiatrists) remain unaware of the effectiveness of modern psychiatric and psychological treatments [17,18]. C-L psychiatrists must develop and evaluate cost-effective treatment programs suitable for large numbers of outpatients.

Alcohol and Drug Abuse British general hospital doctors accept a responsibility for detecting alcohol and drug abuse, arranging for detoxification, and giving general advice [19], but in practice, they do very little. Our psychiatric subspecialties for the treatment of alcohol and drug abuse are largely community-based and have had little impact on general hospital care. C-L psychiatrists see many patients with substance abuse problems but lack resources for treatment. We must demand more support and cooperation from specialist services and clarify the ways in which they work with C-L units and other general hospital staff.

Who Should Treat Psychosocial Problems? Many general hospital patients would benefit from more psychosocial help than is presently available, but I believe that only a minority require specialist psychiatric care. Twenty-five years ago, Shepherd and his colleagues [21] discussed the similar dilemma of how to use limited psychiatric resources to maximum effect in primary care and concluded: “The cardinal requirement for improvement of the mental health services in this country is not a large expansion and proliferation of psychiatric agencies but rather a strengthening of the family doctor in the therapeutic role.” C-L should have analagous aims: efficient consultation backed by liaison that aims to strengthen the therapeutic roles of the general hospital and of primary care clinical teams in caring for general hospital patients. Detailed organization depends on the answers to four fundamental questions: 1. How much more can the general hospital doctor and clinical team (nurses, medical social workers, and so forth) do to provide psychosocial care themselves? 2. What is the role of the primary care general practitioner in the continuing psychosocial care of general hospital patients? 3. How should C-L services be coordinated with other parts of catchment-area psychiatric services? 4. What are the detailed specifications for the role and resources of C-L? Once we have defined the aims, they can be achieved by two very different, but complementary, ways: by influencing national policies and by setting the clinical example of well-organized services in every general hospital.

The Elderly

Hospital Doctors

The majority of general hospital inpatients and a high proportion of outpatients are elderly; many suffer from organic mental disorders and require psychological and social care. In almost all British health districts, specialist psychogeriatricians are responsible for all psychiatric services for those over age 65, including general hospital C-L activities [20]. Although such specialist input is welcome, we need to define and improve working relationships with general hospital-based C-L.

Hospital doctors frequently fail to detect psychiatric disorders, and even when problems are recognized they are usually not treated or referred. They readily admit their lack of knowledge and skills [22], and it is clear that the general example of good C-L services is not, by itself, enough to achieve major change. A more effective strategy is to persuade medical and surgical specialty organizations to include psychological skills within their training and examination. National C-L or263

R. Mayou

ganizations, such as the Royal College Group, must make this a major objective.

Liaison

Table 2. Psychiatric Patients

Care for General Hospital

1. General practice primary care

Nurses

2. Catchment-area

In general, nurses accept psychological care for patients and their families as part of their traditional responsibilities, but most know that they are inadequately trained. Better practical training in the recognition and management of the common psyfor general and specialist chiatric syndromes nurses is essential and overdue. Again, the solution lies in political and C-L organizations taking the lead.

3, Consultation-liaison by other psychiatrists a. Psychogeriatricians b. Child psychiatrists c. Drug and alcohol abuse specialists d. Mother and baby services e. Specific liaison attachments by general psychiatrists

Medical Social Workers Most C-L literature has ignored the role of medical social workers, who themselves have done little to examine, describe, or evaluate what they do. As providers of considerable social and psychological care, they need to be able to identify and manage psychiatric disorders; there would be advantages in a close working relationship with liaison units [23]. Psychiatry and medicine must do more to encourage effective social work, and much more to establish a unified approach to psychosocial services and policies in every hospital.

Clinical Psychologists Britain has few clinical psychologists, and we need to train more who will specialize in behavioral medicine, not as rivals, but as partners within C-L services. They could offer individual treatment and supervision of other C-L staff and teach behavioral methods to general hospital staff.

A system in which general practitioners have a central responsibility for the provision of care and for coordinating specialist care has considerable implications for the organization of C-L. Primary care doctors can be expected to follow up patients who have been assessed by C-L services and to identify other patients with medical problems who might benefit from an outpatient C-L referral. In some countries, C-L psychiatrists are developing extensive liaison links with general practitioners. In Brit-

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services

4. Consultation-liaison service a. Provision of clinical services Organization of a service for emergencies, including deliberate self-harm Consultation to wards Specialist outpatient clinics Liaison with specialist medical units Inpatient beds for those with physical and psychiatric disorders b. Coordination of psychiatric and psychological care Coordination of all psychiatric services in the general hospital (general, child, adolescent, psychogeriatric, and substance abuse) Liaison with catchment-area psychiatric services Liaison with medical social work, clinical psychology, and other general hospital services c. Academic Conspicuous participation in general hospital academic life Supervision and teaching for psychiatric trainees Teaching for medical students and others Research

ain,

Primary Care

psychiatric

such

liaison

the community chiatrists.

has become

an integral

responsibilities

of general

part

of

psy-

The Role of the Psychiatrist In Britain, general hospital patients obtain much of their psychiatric care from general psychiatrists not directly involved in C-L (Table 2), with certain advantages. Patients with major or chronic psychiatric disorders are best referred (by general practitioners) to catchment-area psychiatric services, which have the resources to offer continuing

British C-L Psychiatry

care. Other general hospital patients are best managed by subspecialty services, such as those for psychogeriatrics [20], alcohol and drug abuse, and maternal and child problems [16].

The C-L Service In such circumstances we need to ensure that there are C-L services in every health district. British C-L psychiatrists must do much more than provide consultation and liaison; they must also 1) provide liaison with the geographically sectorized adult psychiatric services to the local community; and 2) coordinate all psychiatric consultation services within the general hospital (i.e., services for children, adolescents, the elderly, and substance abuse patients). The minimum C-L service (which still remains the exception) should provide rapid assessment for emergencies, consultation by an experienced psychiatrist or a well-supervised trainee, and easy access to new outpatient psychiatric clinics. Services in all larger general hospitals should have wider aims. Liaison attachments are important in themselves and as a demonstration of the value of psychological management [12] The requirements suggest that Britain must emulate other European countries that have defined detailed staffing requirements [ 11. Although C-L psychiatrists need not be full-time, they must be available enough to carry out administrative, clinical, and teaching responsibilities [24]. They require special expertise, medical skills, and a willingness to respond to the needs of colleagues. We must also specify the staffing and practical facilities. C-L services are most satisfactory when based within a district general hospital psychiatric unit. The essential facilities include interview rooms, space for secretarial support, storage for notes, a small reference library and seminar room, and a well-organized records system. All large hospitals should have a multidisciplinary clinical team with specially trained nurses and a clinical psychologist. Large general hospitals also need special inpatient areas for patients who are both medically and psychiatrically ill. The psychiatric inpatient unit of a district general hospital may be able to offer such care, but most are reluctant to accept physically ill patients. American models are probably inappropriate for our specific needs [25].

Academic Activities Staff must be conspicuous in general hospital clinical and academic activities. Teaching has always been seen as a major responsibility of general hospital psychiatry [8], but only those who have themselves been trained are properly qualified to teach. Every teaching hospital and every psychiatric training scheme must have at least one senior psychiatrist who has the expertise and clinical opportunities to provide clinical and academic training [24]. Research is often seen as an impractical luxury when clinical services are overworked. In reality, it is fundamental to developing and funding worthwhile new services and to demonstrating our value.

Conclusion My recommendations are modest, but for most British health districts, a long way from present reality. They are not impractical, and some districts have already shown that with recognition of the clinical need, modest resources and organizational changes can achieve substantial improvements in services. We do not (at present) require a new subspecialty, but we do need much greater awareness that improving general hospital C-L is as necessary as improving community care. Better C-L services would lead to better care, but clinical experience has shown this is not enough. We have not done enough to demonstrate clinical benefits of C-L as an essential part of psychiatric practice. We must put much more effort into persuading our psychiatric colleagues, medical specialists, nurses, and others that psychological management should be a significant part of their training, examinations, and everyday work. These aims are political; we must ensure that the Royal College of Psychiatrists assumes responsibility and acts with vigor.

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4. Pasnau RO: Consultation-liaison psychiatry: progress, problems and prospects. Psychosomatics 29:415, 1988 5. Strain JJ, Strain JW: Liaison psychiatry. In Howells JG (ed), Modern Perspectives in Clinical Psychiatry. New York, Brunner Mazel, 1988, pp 76-99 6. Sartorius N: Mental health policies and programs for the twenty-first century: a personal view. Integ Psychiatry 5:151-158, 1987 7. Lister J: Return of the British National Health Service. N Engl J Med 322:410-422, 1990 8. Mayou RA: History of general hospital psychiatry. Br J Psychiatry 155:764-776, 1989 9. Wallen J, Pincus HA, Goldman HH, Marcus SE: Psychiatric consultation in short-term general hospitals. Arch Gen Psychiatry 44:163-168, 1987 10. Gater R, Goldberg D: Pathways to psychiatric care in South Manchester. Br J Psychiatry (in press) 11. Von Cavanaugh SA: Future directions in consultation-liaison psychiatry. Psychother Psychosom 48:68-77, 1987 12. Department of Health and Social Security. The management of deliberate self-harm. HN(84)25. London: DHSS, 1984 13. Hawton KE, Catalan JP: Attempted Suicide, 2nd ed. Oxford, Oxford University Press, I987 14. Beardshaw V: Last on the List. Community services for people with physical disabilities. London, Kings Furd, 1989 15. Maguire P: The recognition and treatment of affective disorder in cancer patients. Int Rev Appl Psycho1 33:479-491, 1984

16. Appleby L, Shaw M, Kumar R: The psychiatrist in the obstetric unit: establish a liaison service. Br J Psychiatry 154:510-515, 1989 17. Goldberg DP, Bridges K: Somatic presentations of psychiatric illness in a primary care setting. J Psychosom Res 32:137-144, 1988 18. Kellner RC: Hypochondriasis and somatization. JAMA 258:2718-2722, 1987 19. Royal College of Physicians. A great and growing evil. London, Tavistock, 1987 20. Poynton AM: Psychiatric liaison referrals of elderly inpatients in a teaching hospital. Br J Psychiatry 152:45-47, 1988 21. Shepherd M, Cooper B, Brown AC, Kalton GW: Psychiatric illness in general practice. London, Oxford University Press, 1966 22. Mayou RA, Smith EBO: Hospital doctors’ management of psychological problems. Br J Psychiatry 148:194-197, 1986 23. Hammer JS, Lyons JS, Bellina B, Strain JJ, Plant EA: Toward the integration of the psychosocial in the general hospital: the human services department. Gen Hosp Psychiatry 7:189-194, 1985 24. Royal College of Psychiatrists Group for Liaison Psychiatrists: Guidelines for teaching in Liaison Psychiatry. Bull R Co11 Psychiatry 12389-390, 1988 25. Koran LM: Inpatient care of patients with concomitant medical and psychiatric disorders. In Frances AJ, Hales RE (eds), Annual Review, vol 5. Washington, DC, American Psychiatric Association Press, 1985, pp 627-649