414
Journal of the Royal Society of Medicine Volume 84 July 1991
Liaison psychiatry for the 21st century:
a
review
F Creed FRCP FRCPsych University Department of Psychiatry, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL Keywords: liaison psychiatry; general hospital psychiatry; general medicine
Summary The development of liaison psychiatry services over the last 20 years is briefly reviewed - sophisticated liaison services have been confied to teaching hospitals. Limited manpower and other resources have prevented the development of liaison services in most district general hospitals; further developments are unlikely unless these deficiencies are corrected and psychiatrists take a more active role in developing links with physicians and surgeons. The time is right for such development as physicians are keen to extend our understanding of psychological and social factors in causing non-organic disorders, reduce unnecessary investigations and provide more comprehensive care. Increased collaboration between physicians and psychiatrists will provide a better service for many patients and this should be extended to all district general hospitals. Introduction This paper assesses the future of liaison psychiatry by first considering the changes that have occurred over the last two decades in order to assess whether these trends are likely to continue. Three factors will then be considered; whether psychiatrists have fully adapted to working in the general medical setting, the present changes in medicine relevant to the liaison psychiatrist and, finally, whether physicians are keen for better liaison. The last two decades In the early 1970s Mezey and Kellett' documented the low referral rate of general medical patients to psychiatrists in a district general hospital. The principal reasons quoted by physicians and surgeons for not referring patients were: patients' dislike of referral to a psychiatrist, the disadvantage of being labelled a 'mental case', the lack of readily available facilities, and frank lack of rapport between psychiatrists and their non-psychiatric colleagues. Such rapport would only develop, they suggested, if there was more personal contact between psychiatrists and their non-psychiatric colleagues, if psychiatrists became more adept at assessing relevant physical findings and could express a firm opinion in language that all could understand. To this list may be added the comment of Abrahamson2 that a coherent and successful policy for dealing with deliberate self-harm patients would improve acceptance of psychiatry in the general hospital. Surveys of liaison psychiatry during the 1980s3-6 indicated that in most districts a service for dealing with deliberate self-harm patients has been achieved but little additional liaison work takes place. There continues to be a problem of poor communication between psychiatrists and physicians5, which has
changed little over the last 10 years3. Psychiatrists have complained that physicians refer inappropriately, only requesting help once the medical/surgical team have 'come to the end of their tether' . Physicians who have attempted to develop a closer working relationship with a particular psychiatrist have been thwarted by the operation of a sectorized psychiatric service6. Thus, in spite of psychiatric units being brought into the district general hospitals, the lack of rapport outlined by Mezey and Kellett remains in many districts. In contrast to these rather dismal reports, good liaison services existed in a few centres 20 years ago and exist at rather more today. In 1968, Crisp7 described a well-staffed teaching hospital (with two departments of psychiatry) where the referral rate of general medical patients to psychiatrists reached 10%. Crisp indicated that the availability and inclination of the psychiatrists determined the referral rate. In the most recent reports5 6 there is evidence of sophisticated liaison services in many teaching centres (60 liaison sessions per week were available for liaison psychiatry in Edinburgh), with regular joint meetings and research projects, specialized training posts and spialized inpatient and outpatient facilities for patients with combined physical and psychiatric disorders. However, nearly all the reports of rapidly expanding liaison services come from
Based on paper read to Section of
Psychiatry, 1 May 1990
teaching hospitals6'8-". Prospects of future development The major complaint from psychiatrists trying to run liaison services in district general hospitals has been lack of time; many have been attending liaison referrals 'outside of working hours, when the physicians are unavailable for discussion of the patient'. Such practice precludes the closer contact requested by Mezey and Kellet. Nearly 20 years ago Russell predicted that there would not be enough psychiatrists to run a satisfactory liaison service in the general hospital12; his prediction has apparently come true and there is no definite evidence that this is likely to change in the near future. There is other evidence that liaison services have been given low priority within district psychiatric services; there are widespread complaints of lack of secretarial support, absence of systematic records and inadequate supervision of junior staff56. Only 13% of District Health Authorities have plans to develop their liaison psychiatry (compared to 60% planning to develop Community Mental Health Resource Centres)13 so the prospects of developing liaison psychiatry outside of teaching hospitals seems bleak. There are further stumbling blocks to future development. The pleas for increased resources have sometimes been accompanied by indications that the
0141-0768/91/
070414-04/$02.00/0 © 1991 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 84 July 1991
precise role of liaison psychiatry is uncertain4; a statement which will not impress planners. In addition, there are few centres with the skills and facilities to train psychiatrists for special interest consultant posts6 - a prerequisite for future development. There is also uncertainty as to whether this should be a specialist service or regarded as 'an important and attractive component of the general psychiatrists' work'3. Liaison psychiatry is only likely to develop once adult general psychiatrists follow the example of child psychiatrists who regard 'close contact with paediatricians as an integral part of routine clinical practice'. Many psychogeriatricians have also adopted this attitude to their work with geriatricians6. Patients between the ages of 16 and 65 years deserve this type of service which integrates psychological and physical aspects of medical care. Development of such a service will require a change of attitude by both physicians and psychiatrists in some hospitals, in addition to increased psychiatrists' time.
Psychiatrists in the general hospital It appears that many psychiatrists have moved into district general hospital units without adequately changing their mode of practice in order to become fully integrated with the general medical services. There are no direct data on this problem but the pattern is likely to be similar to that in primary care. Two-thirds of psychiatrists who now work in health centres are operating the shifted outpatient model - ie holding an outpatient clinic without any form of direct liaison with general practitioners'4. One description of such a service concluded that 'a better balance would be obtained if less of a direct clinical service was offered and more time spent in discussion with GPs'15. This situation is paralleled in the general hospital. If psychiatrists could adapt their mode of working and spend more time in discussion with physicians and surgeons in the general hospital the problems of poor communication would be overcome (F Creed et al., submitted for publication). Crisp7 claimed that it was the availability and inclination of the psychiatrist that determined the psychiatric referral rate within the general hospital. This statement appears to be supported by recent reports of an increase in referrals following a more active approach by the psychiatrist8-1". This means that the initial impetus for improving a liaison service probably lies with the psychiatrist. The resulting increase in referrals seems justified if the patients have psychiatric disorders similar in severity to those of patients referred from the general practitioner. The referral of such 'appropriate' patients can only be ensured if there is good communication between physician and psychiatrist at the time of each ward referral and at the physicians' grand ward rounds (F Creed et al., submitted for publication). As well as time and inclination, the liaison psychiatrist must also be equipped with certain skills. General hospital referrals are far more likely to have physical illness than GP referrals, bearing out Mezey and Kellett's insistence that the psychiatrist must be competent to assess physical findings. This may involve difficult diagnostic problems, including combined physical and psychological aetiological factors, or understanding the complex and awkward management problems faced by physicians. Constructive advice is being sought from the psychiatrist
in such referrals so a declaration that formal psychiatric disorder is absent does not help; this does nothing to make the psychiatrist a valued member of the medical team. Instead a full understanding of where the difficulties lie and how they might be resolved is required'6. Special skills are also required to deal adequately with patients whose psychiatric disorder presents to the physician primarily as somatic symptoms somatization. There is little doubt that such patients should be directed towards appropriate psychiatric treatment but the necessary skills are rarely taught'7. Allowance must be made for the fact that these patients are not motivated to seek psychiatric help yet may consume considerable time and expensive resources in the general medical service'7"18. A flexible approach is required and the physician and psychiatrist need to work closely together to enable the psychiatric consultation to be fruitful. Improving the service for such patients is likely to occur only if and when the psychiatrist demonstrates to the physician that he/she has the necessary skills, and when the physician is prepared to discuss with the psychiatrist ways of presenting to the patient the proposed psychiatric referral. If there are inadequate training centres for this type of work6 psychiatrists may be appointed who are illequipped to overcome the initial obstacles that mark the early stages of a liaison service. Patient refusal to see the psychiatrist, a consult report that is not clearly written, or which offers no helpful advice, and failure to discuss with staff ways of handling difficult problems all lead to continuing poor relationships between physician and psychiatrists.
Changes occurring within general medicine There are three changes currently taking place in general medicine which are of relevance to the liaison psychiatrist. Recognition of the high prevalence of non-organic complaints among general medical patients There have been numerous reports of the high prevalence of non-organic disorders (25-45%) presenting to gastroenterology'9'20, and neurology2122 outpatient clinics with evidence that this occurs in many medical specialties23. Many of these patients have psychiatric disorder underlying their somatic
symptoms'7"8'24 Awareness of the high costs of investigations and the need to reduce these costs Costs of CT scans and other investigations in 141 patients with headaches cost £24 140 but revealed no new case of tumour25. Admissions for 'non-specific abdominal pain' (CD code 785.5) have been estimated to cost £16.5 million a year in the UK26. Total costs for non-ulcer dyspepsia in Sweden have been calculated at £394 million27.
The search for 'more appropriate management' The search for more appropriate management is, therefore partly driven by the need to reduce costs and to prevent diagnostic services being overwhelmed. Strategies are therefore being worked out to exclude organic disease at minimal cost, but not necessarily to bring relief to the patient. Simple reduction of the
415
416
Journal of the Royal Society of Medicine Volume 84 July 1991
number of investigations28 may save money but will not provide any symptomatic relief for patients unless the underlying psychiatric disorder is detected and treated. One series of patients presenting with upper abdominal pain29 demonstrated that one of the most fruitful investigations (Hamilton rating scale for depression) was also one of the cheapest. It was only performed, however, after numerous consultant opinions had been sought and numerous radiological and invasive investigations, including laparotomy, had been performed. Such expensive investigations prior to psychiatric referral are not uncommon and the appropiiateness of such investigation needs to be carefully evaluated30. The World Health Organization has indicated that understanding somatization symptoms should be regarded as a major determinant of the effectiveness of general medical care31. This requires that psychiatrists be involved with studies of patients with nonorganic disorders in general medical units. Without psychiatric involvement the studies are predominantly negative in their findings as their titles indicate: 'chest pain ?cause'32 and 'non-specific abdominal pain - an expensive mystery'26. On the other hand collaborative research with psychiatrists has indicated the positive role of stressful life events and psychiatric disorder in numerous non-organic symptoms: chest and abdominal pain, fatigue, headache, back pain'7 '6. Such collaborative studies are now leading to intervention studies, demonstrating that psychological or psychiatric treatment may be successful when 'physical' treatments have failed37-40. The potential role of collaborative research goes further than somatization patients. Another global indicator of Health for All by 2000 used by the WHO is reduction in the number of low birth weight babies. Recent investigations have discounted social and psychological factors as important contributory factors to low birth weight1, but this conclusion was reached on inadequate analysis of life events data. More detailed analyses42 indicated a positive result, which if applied selectively might contribute to the WHO's stated goal by 2000. Accurate measurement of psychosocial factors in epidemiological research is difflcult, but this must not be used as an excuse to dismiss such factors as unimportant - psychiatrists must be involved to ensure that appropriate measurements are made.
Changing attitudes among physicians Attitudes towards psychological factors of general medical complaints are changing. In 1980, when a sociologist and neurologist investigated headaches not due to organic disease their findings were initially rejected by a referee as 'not proper material for a neurology journal'43. In fact the editor decided to publish. The results indicated the role of depression and excessive concerns in explaining the need for specialist consultation and identified sources of dissatisfaction within the consultation35. Such publications reflect clinical practice. A survey of 700 gastroenterologists in the United States indicated that those working in an academic setting used 'personal psychosocial support' more than 75% of their time in their treatment for the irritable bowel syndrome. It is therefore appropriate that increasing space is given in gastroenterology journals to psychological treatments for this condition44. Practically all the physicians in Oxford, surveyed by Mayou and
Smith45, considered management of emotional problems as an important part of their clinical work and would like to do more themselves. They also looked to psychiatrists for more help; 61% requested better educational aids and 68% wanted more contact with the psychiatric service. Many suggested joint meetings. It is time that psychiatrists responded more positively to such requests. The lack of time and facilities should become problems ofthe 20th century and a planned and co-ordinated growth of training and consultant posts for the 21st century is required. If special responsibility posts in district general hospitals can be filled by properly trained liaison psychiatrists, with a remit much wider than organiinng a service for self-harm patients, the problems outlined by Mezey and Kellett can be overcome within a decade. Such development will require a change of attitude of many psychiatrists and the support and co-operation of physicians. Ifposts are filled by young consultants without such training the future of liaison psychiatry looks like the past - separate medical and psychiatric services for patients with combined physical and psychological disorders. References 1 Mezey AG, Kellett JM. Reasons against referral to the psychiatrist. Postgrad Med J 1971;47:315-19 2 Abrahamson D. Psychiatry in a postgraduate teaching hospital. Postgrad Med J 1971;47:583-8 3 Brooks P, Walton HJ. Liaison psychiatry in Scotland. Health Bull 1981;39:218-27 4 Mayou R, Lloyd G. A survey of liaison psychiatry in the United Kingdom and Eire. Bull R Coll Psychiatrists 1985;9:214-17 5 Anderson HM. Liaison psychiatry in Scotland: the present service. Psychiatr Bull 1989;13:606-8 6 Mayou R, Anderson H, Feinmann C, Hodgson G. The present state of consultation and liaison psychiatry. Psychiat Bull 1990;14:321-5 7 Crisp AH. The role of the psychiatrist in the general hospital. Postgrad Med J 1968;44:267-76 8 Sensky T, Greer S, Cundy T, Pettingale K. Referrals to psychiatrists in a general hospital - comparison of two methods of liaison psychiatry: preliminary communication. J R Soc Med 1985;78:463-8 9 Thomas CJ. Referrals to a British liaison psychiatry service. Health Trends 1983;15:61-4 10 Brown A, Cooper AF. The impact of liaison psychiatry service on patterns of referral in a general hospital. Br J Psychiatry 1987;150:83-7 11 House AO, Jones SJ. The effects of establishing a psychiatric consultation-liaison service: Changes in patterns of referral and care. Health Trends 1987; 19:10-12 12 Russell GFM. Will there be enough psychiatrists to run the psychiatric service based on the district general hospital? In: Cawley R, McLachlan G, eds Policy for action. London: Oxford University Press, 1973: 111-16 13 Kingdom D. Mental health services: results of a survey of English district plans. Psychiatr Bull 1989;13:77-8 14 Strathdee G, Williams P. A survey of psychiatrists in primary care: the silent growth of a new service. JR Coll Gen Pract 1984;34:615-18 15 Tyrer P. Psychiatric clinics in general practice: an extension of community care. Br J Psychiatry 1984; 145:9-14 16 Torem M, Saravay S, Steinberg H. Psychiatric liaison: benefits of an active approach. Psychosomatics 1979;
20:598-611 17 Bass CM. Somatization: physical symptoms and psycho-
logical illness. Oxford: Blackwell, 1990:3
Journal of the Royal Society of Medicine Volume 84 July 1991 18 Smith GR, Monson RA, Roy DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med 1986;314:1407-13 19 Harvey RF, Salih SY, Read AE. Organic and functional disorders in 2000 gastroenterology outpatients. Lancet 1983;i:632-4 20 Holmes KM, Salter RH, Cole TP, Girdwood TG. A profile of District Hospital gastroenterology. J R Coll Phys London 1987;21:111-14 21 Hopkins A, Menken M, DeFriese G. A record of patient encounters in neurological practice in the United Kingdom. JNeurol Neurosurg Psychiatry 1989;62:436-8 22 Perkin GD. An analysis of 7836 successive new outpatient referrals. J Neurol Neurosurg Psychiatry 1989;52:447-8 23 Kroenke K, Mangelsdorff D. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med 1989;86:262-6 24 Katon W, Ries RK, Kleinman A. A prospective study; of 100 consecutive somatisation patients. Comp Psych
1984;25:305-14 25 Larsen EB, Omenn GS, Lewis H. Diagnostic evaluation of headache; impact of computerised tomography and cost-effectiveness. JAMA 1980;243:359-62 26 Raheja SK, McDonald PJ, Taylor I. Non-specific abdominal pain - an expensive mystery. J R Soc Med 1990;83:10-11 27 Nyren 0, Adami HO, Gustavsson S, Loof L, Nyberg A. Social and economic effects of non-ulcer dyspepsia. Scand J Gastroenterol 1985;20(suppl 109):41-5 28 Hopkins A, ed. Appropriate investigation and treatment in clinical practice. London: Royal College ofPhysicians, 1989 29 Kingham JGC, Dawson AM. Origin of chronic right upper quadrant pain. Gut 1985;26:783-8 30 Shaw J, Creed F. The cost of somatisation. JPsychosom Res 1991;35:307-12 31 Sartorius N. Mental health policies and programs for the twenty-first century: a personal view. Integr Psych
1987;5:151-8 32 Wilcox RG, Roland JM, Hampton JR. Prognosis of patients with "chest pain ?cause". BMJ 1981282:431-3 33 Creed F, Craig T, Farmer R. Functionsl abdominal pain, psychiatric illness, and life events. Gut 1988;29: 235-42
34 Wessley S, Powell R. Fatigue syndromes: a comparison of chronic 'postviral' fatigue with neuromuscular and affective disorders.. J-4 rol' Nirbosurg Psychiatry 1989;52:940-8 35 Fitzpatrick R, Hopkins A. Referrals to netrologists for headaches not due to structural disease. J Neurol Neurosurg Psychiatry 1981;44:1060-7 36 Crauford DIO, Creed F, Jayson MIV. Life events and psychological disturbance in patients with low-back pain. Spine 1990;15:490-4 37 Feinmann C, Harris M, Cawley R. Psychogenic facial pain: presentation and treatment. BMJ 1984;288: 436-8 38 Klimes I, Mayou RA, Pearce MJ, Coles L, Fagg JR. Psychological treatment for atypical non-cardiac chest pain: a controlled evaluation. Psychol Med 1990; 20:605-11 39 Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991;100: 450-7 40 Pearce S, Beard RW. Chronic pelvic pain in women. In: Bass CM, ed. Somatisation: physical symptons and psychological illness. Oxford: Blackwell, 1990 41 Brooke OG, Anderson HR, Bland JM, Peacock JL, Stewart CM. Effects on birth weight of smoking, alcohol, caffeine, socioeconomic factors and psychosocial stress. BMJ 1989;298:795-801 42 Mutale T, Creed F, Maresh M, Hunt L. Life events and low birth weight - analysis by infants born prematurely and small for gestational age. Br J Obstet Gynaecol 1991;98:166-72 43 Marsden CD. What should neurologists do? J Neurol Neurosurg Psychiatry 1981;44:1059-60 44 Creed FH, Guthrie E. Psychological treatments of the irritable bowel syndrome: a review. Gut 1989;30: 1606-9 45 Mayou R, Smith EBO. Hospital doctor's management of psychological problems. Br J Psychiatry 1986; 148:194-7
(Accepted 20 November 1990)
417
Journal of the Royal Society of Medicine Volume 84 July 1991
Liaison psychiatry for the 21st century:
a
review
F Creed FRCP FRCPsych University Department of Psychiatry, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL Keywords: liaison psychiatry; general hospital psychiatry; general medicine
Summary The development of liaison psychiatry services over the last 20 years is briefly reviewed - sophisticated liaison services have been confied to teaching hospitals. Limited manpower and other resources have prevented the development of liaison services in most district general hospitals; further developments are unlikely unless these deficiencies are corrected and psychiatrists take a more active role in developing links with physicians and surgeons. The time is right for such development as physicians are keen to extend our understanding of psychological and social factors in causing non-organic disorders, reduce unnecessary investigations and provide more comprehensive care. Increased collaboration between physicians and psychiatrists will provide a better service for many patients and this should be extended to all district general hospitals. Introduction This paper assesses the future of liaison psychiatry by first considering the changes that have occurred over the last two decades in order to assess whether these trends are likely to continue. Three factors will then be considered; whether psychiatrists have fully adapted to working in the general medical setting, the present changes in medicine relevant to the liaison psychiatrist and, finally, whether physicians are keen for better liaison. The last two decades In the early 1970s Mezey and Kellett' documented the low referral rate of general medical patients to psychiatrists in a district general hospital. The principal reasons quoted by physicians and surgeons for not referring patients were: patients' dislike of referral to a psychiatrist, the disadvantage of being labelled a 'mental case', the lack of readily available facilities, and frank lack of rapport between psychiatrists and their non-psychiatric colleagues. Such rapport would only develop, they suggested, if there was more personal contact between psychiatrists and their non-psychiatric colleagues, if psychiatrists became more adept at assessing relevant physical findings and could express a firm opinion in language that all could understand. To this list may be added the comment of Abrahamson2 that a coherent and successful policy for dealing with deliberate self-harm patients would improve acceptance of psychiatry in the general hospital. Surveys of liaison psychiatry during the 1980s3-6 indicated that in most districts a service for dealing with deliberate self-harm patients has been achieved but little additional liaison work takes place. There continues to be a problem of poor communication between psychiatrists and physicians5, which has
changed little over the last 10 years3. Psychiatrists have complained that physicians refer inappropriately, only requesting help once the medical/surgical team have 'come to the end of their tether' . Physicians who have attempted to develop a closer working relationship with a particular psychiatrist have been thwarted by the operation of a sectorized psychiatric service6. Thus, in spite of psychiatric units being brought into the district general hospitals, the lack of rapport outlined by Mezey and Kellett remains in many districts. In contrast to these rather dismal reports, good liaison services existed in a few centres 20 years ago and exist at rather more today. In 1968, Crisp7 described a well-staffed teaching hospital (with two departments of psychiatry) where the referral rate of general medical patients to psychiatrists reached 10%. Crisp indicated that the availability and inclination of the psychiatrists determined the referral rate. In the most recent reports5 6 there is evidence of sophisticated liaison services in many teaching centres (60 liaison sessions per week were available for liaison psychiatry in Edinburgh), with regular joint meetings and research projects, specialized training posts and spialized inpatient and outpatient facilities for patients with combined physical and psychiatric disorders. However, nearly all the reports of rapidly expanding liaison services come from
Based on paper read to Section of
Psychiatry, 1 May 1990
teaching hospitals6'8-". Prospects of future development The major complaint from psychiatrists trying to run liaison services in district general hospitals has been lack of time; many have been attending liaison referrals 'outside of working hours, when the physicians are unavailable for discussion of the patient'. Such practice precludes the closer contact requested by Mezey and Kellet. Nearly 20 years ago Russell predicted that there would not be enough psychiatrists to run a satisfactory liaison service in the general hospital12; his prediction has apparently come true and there is no definite evidence that this is likely to change in the near future. There is other evidence that liaison services have been given low priority within district psychiatric services; there are widespread complaints of lack of secretarial support, absence of systematic records and inadequate supervision of junior staff56. Only 13% of District Health Authorities have plans to develop their liaison psychiatry (compared to 60% planning to develop Community Mental Health Resource Centres)13 so the prospects of developing liaison psychiatry outside of teaching hospitals seems bleak. There are further stumbling blocks to future development. The pleas for increased resources have sometimes been accompanied by indications that the
0141-0768/91/
070414-04/$02.00/0 © 1991 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 84 July 1991
precise role of liaison psychiatry is uncertain4; a statement which will not impress planners. In addition, there are few centres with the skills and facilities to train psychiatrists for special interest consultant posts6 - a prerequisite for future development. There is also uncertainty as to whether this should be a specialist service or regarded as 'an important and attractive component of the general psychiatrists' work'3. Liaison psychiatry is only likely to develop once adult general psychiatrists follow the example of child psychiatrists who regard 'close contact with paediatricians as an integral part of routine clinical practice'. Many psychogeriatricians have also adopted this attitude to their work with geriatricians6. Patients between the ages of 16 and 65 years deserve this type of service which integrates psychological and physical aspects of medical care. Development of such a service will require a change of attitude by both physicians and psychiatrists in some hospitals, in addition to increased psychiatrists' time.
Psychiatrists in the general hospital It appears that many psychiatrists have moved into district general hospital units without adequately changing their mode of practice in order to become fully integrated with the general medical services. There are no direct data on this problem but the pattern is likely to be similar to that in primary care. Two-thirds of psychiatrists who now work in health centres are operating the shifted outpatient model - ie holding an outpatient clinic without any form of direct liaison with general practitioners'4. One description of such a service concluded that 'a better balance would be obtained if less of a direct clinical service was offered and more time spent in discussion with GPs'15. This situation is paralleled in the general hospital. If psychiatrists could adapt their mode of working and spend more time in discussion with physicians and surgeons in the general hospital the problems of poor communication would be overcome (F Creed et al., submitted for publication). Crisp7 claimed that it was the availability and inclination of the psychiatrist that determined the psychiatric referral rate within the general hospital. This statement appears to be supported by recent reports of an increase in referrals following a more active approach by the psychiatrist8-1". This means that the initial impetus for improving a liaison service probably lies with the psychiatrist. The resulting increase in referrals seems justified if the patients have psychiatric disorders similar in severity to those of patients referred from the general practitioner. The referral of such 'appropriate' patients can only be ensured if there is good communication between physician and psychiatrist at the time of each ward referral and at the physicians' grand ward rounds (F Creed et al., submitted for publication). As well as time and inclination, the liaison psychiatrist must also be equipped with certain skills. General hospital referrals are far more likely to have physical illness than GP referrals, bearing out Mezey and Kellett's insistence that the psychiatrist must be competent to assess physical findings. This may involve difficult diagnostic problems, including combined physical and psychological aetiological factors, or understanding the complex and awkward management problems faced by physicians. Constructive advice is being sought from the psychiatrist
in such referrals so a declaration that formal psychiatric disorder is absent does not help; this does nothing to make the psychiatrist a valued member of the medical team. Instead a full understanding of where the difficulties lie and how they might be resolved is required'6. Special skills are also required to deal adequately with patients whose psychiatric disorder presents to the physician primarily as somatic symptoms somatization. There is little doubt that such patients should be directed towards appropriate psychiatric treatment but the necessary skills are rarely taught'7. Allowance must be made for the fact that these patients are not motivated to seek psychiatric help yet may consume considerable time and expensive resources in the general medical service'7"18. A flexible approach is required and the physician and psychiatrist need to work closely together to enable the psychiatric consultation to be fruitful. Improving the service for such patients is likely to occur only if and when the psychiatrist demonstrates to the physician that he/she has the necessary skills, and when the physician is prepared to discuss with the psychiatrist ways of presenting to the patient the proposed psychiatric referral. If there are inadequate training centres for this type of work6 psychiatrists may be appointed who are illequipped to overcome the initial obstacles that mark the early stages of a liaison service. Patient refusal to see the psychiatrist, a consult report that is not clearly written, or which offers no helpful advice, and failure to discuss with staff ways of handling difficult problems all lead to continuing poor relationships between physician and psychiatrists.
Changes occurring within general medicine There are three changes currently taking place in general medicine which are of relevance to the liaison psychiatrist. Recognition of the high prevalence of non-organic complaints among general medical patients There have been numerous reports of the high prevalence of non-organic disorders (25-45%) presenting to gastroenterology'9'20, and neurology2122 outpatient clinics with evidence that this occurs in many medical specialties23. Many of these patients have psychiatric disorder underlying their somatic
symptoms'7"8'24 Awareness of the high costs of investigations and the need to reduce these costs Costs of CT scans and other investigations in 141 patients with headaches cost £24 140 but revealed no new case of tumour25. Admissions for 'non-specific abdominal pain' (CD code 785.5) have been estimated to cost £16.5 million a year in the UK26. Total costs for non-ulcer dyspepsia in Sweden have been calculated at £394 million27.
The search for 'more appropriate management' The search for more appropriate management is, therefore partly driven by the need to reduce costs and to prevent diagnostic services being overwhelmed. Strategies are therefore being worked out to exclude organic disease at minimal cost, but not necessarily to bring relief to the patient. Simple reduction of the
415
416
Journal of the Royal Society of Medicine Volume 84 July 1991
number of investigations28 may save money but will not provide any symptomatic relief for patients unless the underlying psychiatric disorder is detected and treated. One series of patients presenting with upper abdominal pain29 demonstrated that one of the most fruitful investigations (Hamilton rating scale for depression) was also one of the cheapest. It was only performed, however, after numerous consultant opinions had been sought and numerous radiological and invasive investigations, including laparotomy, had been performed. Such expensive investigations prior to psychiatric referral are not uncommon and the appropiiateness of such investigation needs to be carefully evaluated30. The World Health Organization has indicated that understanding somatization symptoms should be regarded as a major determinant of the effectiveness of general medical care31. This requires that psychiatrists be involved with studies of patients with nonorganic disorders in general medical units. Without psychiatric involvement the studies are predominantly negative in their findings as their titles indicate: 'chest pain ?cause'32 and 'non-specific abdominal pain - an expensive mystery'26. On the other hand collaborative research with psychiatrists has indicated the positive role of stressful life events and psychiatric disorder in numerous non-organic symptoms: chest and abdominal pain, fatigue, headache, back pain'7 '6. Such collaborative studies are now leading to intervention studies, demonstrating that psychological or psychiatric treatment may be successful when 'physical' treatments have failed37-40. The potential role of collaborative research goes further than somatization patients. Another global indicator of Health for All by 2000 used by the WHO is reduction in the number of low birth weight babies. Recent investigations have discounted social and psychological factors as important contributory factors to low birth weight1, but this conclusion was reached on inadequate analysis of life events data. More detailed analyses42 indicated a positive result, which if applied selectively might contribute to the WHO's stated goal by 2000. Accurate measurement of psychosocial factors in epidemiological research is difflcult, but this must not be used as an excuse to dismiss such factors as unimportant - psychiatrists must be involved to ensure that appropriate measurements are made.
Changing attitudes among physicians Attitudes towards psychological factors of general medical complaints are changing. In 1980, when a sociologist and neurologist investigated headaches not due to organic disease their findings were initially rejected by a referee as 'not proper material for a neurology journal'43. In fact the editor decided to publish. The results indicated the role of depression and excessive concerns in explaining the need for specialist consultation and identified sources of dissatisfaction within the consultation35. Such publications reflect clinical practice. A survey of 700 gastroenterologists in the United States indicated that those working in an academic setting used 'personal psychosocial support' more than 75% of their time in their treatment for the irritable bowel syndrome. It is therefore appropriate that increasing space is given in gastroenterology journals to psychological treatments for this condition44. Practically all the physicians in Oxford, surveyed by Mayou and
Smith45, considered management of emotional problems as an important part of their clinical work and would like to do more themselves. They also looked to psychiatrists for more help; 61% requested better educational aids and 68% wanted more contact with the psychiatric service. Many suggested joint meetings. It is time that psychiatrists responded more positively to such requests. The lack of time and facilities should become problems ofthe 20th century and a planned and co-ordinated growth of training and consultant posts for the 21st century is required. If special responsibility posts in district general hospitals can be filled by properly trained liaison psychiatrists, with a remit much wider than organiinng a service for self-harm patients, the problems outlined by Mezey and Kellett can be overcome within a decade. Such development will require a change of attitude of many psychiatrists and the support and co-operation of physicians. Ifposts are filled by young consultants without such training the future of liaison psychiatry looks like the past - separate medical and psychiatric services for patients with combined physical and psychological disorders. References 1 Mezey AG, Kellett JM. Reasons against referral to the psychiatrist. Postgrad Med J 1971;47:315-19 2 Abrahamson D. Psychiatry in a postgraduate teaching hospital. Postgrad Med J 1971;47:583-8 3 Brooks P, Walton HJ. Liaison psychiatry in Scotland. Health Bull 1981;39:218-27 4 Mayou R, Lloyd G. A survey of liaison psychiatry in the United Kingdom and Eire. Bull R Coll Psychiatrists 1985;9:214-17 5 Anderson HM. Liaison psychiatry in Scotland: the present service. Psychiatr Bull 1989;13:606-8 6 Mayou R, Anderson H, Feinmann C, Hodgson G. The present state of consultation and liaison psychiatry. Psychiat Bull 1990;14:321-5 7 Crisp AH. The role of the psychiatrist in the general hospital. Postgrad Med J 1968;44:267-76 8 Sensky T, Greer S, Cundy T, Pettingale K. Referrals to psychiatrists in a general hospital - comparison of two methods of liaison psychiatry: preliminary communication. J R Soc Med 1985;78:463-8 9 Thomas CJ. Referrals to a British liaison psychiatry service. Health Trends 1983;15:61-4 10 Brown A, Cooper AF. The impact of liaison psychiatry service on patterns of referral in a general hospital. Br J Psychiatry 1987;150:83-7 11 House AO, Jones SJ. The effects of establishing a psychiatric consultation-liaison service: Changes in patterns of referral and care. Health Trends 1987; 19:10-12 12 Russell GFM. Will there be enough psychiatrists to run the psychiatric service based on the district general hospital? In: Cawley R, McLachlan G, eds Policy for action. London: Oxford University Press, 1973: 111-16 13 Kingdom D. Mental health services: results of a survey of English district plans. Psychiatr Bull 1989;13:77-8 14 Strathdee G, Williams P. A survey of psychiatrists in primary care: the silent growth of a new service. JR Coll Gen Pract 1984;34:615-18 15 Tyrer P. Psychiatric clinics in general practice: an extension of community care. Br J Psychiatry 1984; 145:9-14 16 Torem M, Saravay S, Steinberg H. Psychiatric liaison: benefits of an active approach. Psychosomatics 1979;
20:598-611 17 Bass CM. Somatization: physical symptoms and psycho-
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Journal of the Royal Society of Medicine Volume 84 July 1991 18 Smith GR, Monson RA, Roy DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med 1986;314:1407-13 19 Harvey RF, Salih SY, Read AE. Organic and functional disorders in 2000 gastroenterology outpatients. Lancet 1983;i:632-4 20 Holmes KM, Salter RH, Cole TP, Girdwood TG. A profile of District Hospital gastroenterology. J R Coll Phys London 1987;21:111-14 21 Hopkins A, Menken M, DeFriese G. A record of patient encounters in neurological practice in the United Kingdom. JNeurol Neurosurg Psychiatry 1989;62:436-8 22 Perkin GD. An analysis of 7836 successive new outpatient referrals. J Neurol Neurosurg Psychiatry 1989;52:447-8 23 Kroenke K, Mangelsdorff D. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med 1989;86:262-6 24 Katon W, Ries RK, Kleinman A. A prospective study; of 100 consecutive somatisation patients. Comp Psych
1984;25:305-14 25 Larsen EB, Omenn GS, Lewis H. Diagnostic evaluation of headache; impact of computerised tomography and cost-effectiveness. JAMA 1980;243:359-62 26 Raheja SK, McDonald PJ, Taylor I. Non-specific abdominal pain - an expensive mystery. J R Soc Med 1990;83:10-11 27 Nyren 0, Adami HO, Gustavsson S, Loof L, Nyberg A. Social and economic effects of non-ulcer dyspepsia. Scand J Gastroenterol 1985;20(suppl 109):41-5 28 Hopkins A, ed. Appropriate investigation and treatment in clinical practice. London: Royal College ofPhysicians, 1989 29 Kingham JGC, Dawson AM. Origin of chronic right upper quadrant pain. Gut 1985;26:783-8 30 Shaw J, Creed F. The cost of somatisation. JPsychosom Res 1991;35:307-12 31 Sartorius N. Mental health policies and programs for the twenty-first century: a personal view. Integr Psych
1987;5:151-8 32 Wilcox RG, Roland JM, Hampton JR. Prognosis of patients with "chest pain ?cause". BMJ 1981282:431-3 33 Creed F, Craig T, Farmer R. Functionsl abdominal pain, psychiatric illness, and life events. Gut 1988;29: 235-42
34 Wessley S, Powell R. Fatigue syndromes: a comparison of chronic 'postviral' fatigue with neuromuscular and affective disorders.. J-4 rol' Nirbosurg Psychiatry 1989;52:940-8 35 Fitzpatrick R, Hopkins A. Referrals to netrologists for headaches not due to structural disease. J Neurol Neurosurg Psychiatry 1981;44:1060-7 36 Crauford DIO, Creed F, Jayson MIV. Life events and psychological disturbance in patients with low-back pain. Spine 1990;15:490-4 37 Feinmann C, Harris M, Cawley R. Psychogenic facial pain: presentation and treatment. BMJ 1984;288: 436-8 38 Klimes I, Mayou RA, Pearce MJ, Coles L, Fagg JR. Psychological treatment for atypical non-cardiac chest pain: a controlled evaluation. Psychol Med 1990; 20:605-11 39 Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991;100: 450-7 40 Pearce S, Beard RW. Chronic pelvic pain in women. In: Bass CM, ed. Somatisation: physical symptons and psychological illness. Oxford: Blackwell, 1990 41 Brooke OG, Anderson HR, Bland JM, Peacock JL, Stewart CM. Effects on birth weight of smoking, alcohol, caffeine, socioeconomic factors and psychosocial stress. BMJ 1989;298:795-801 42 Mutale T, Creed F, Maresh M, Hunt L. Life events and low birth weight - analysis by infants born prematurely and small for gestational age. Br J Obstet Gynaecol 1991;98:166-72 43 Marsden CD. What should neurologists do? J Neurol Neurosurg Psychiatry 1981;44:1059-60 44 Creed FH, Guthrie E. Psychological treatments of the irritable bowel syndrome: a review. Gut 1989;30: 1606-9 45 Mayou R, Smith EBO. Hospital doctor's management of psychological problems. Br J Psychiatry 1986; 148:194-7
(Accepted 20 November 1990)
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