Recent Development in Consultation Liaison Psychiatry- a View From Oxford

Recent years have seen important developments in the subspecialty known as consultation-liaison psychiatry (C-L psychiatry). These developments include an evolving definition, a widening scope to include out-patient clinics and primary care, and the development of specific and effective treatments. Along with these developments there are challenges facing C-L psychiatry. These challenges include a clarification of the relationship of C-L psychiatry with both medicine and general psychiatry, and a need for the discipline to establish itself in the new climate of evidence-based medical practice.

WHAT IS CONSULTATION LIAISON PSYCHIATRY?

There are many definitions of this area of psychiatry (Mayou & Sharpe, 1991). All have shortcomings. At present there is persisting confusion about the nature of the subspecialty. Definitions of C-L psychiatry can be based on the place of work, the patient groups treated, and the specialist knowledge and skill of the practitioners. Perhaps the most common and traditional definition relates to the place of work. Like the term "hospital doctor", a C-L psychiatrist has been defined as a psychiatrist working in the general hospital ( as opposed to the mental hospital or community). Indeed the term consultation liaison psychiatry evokes the idea of a psychiatrist visiting the general hospital from the psychiatric hospital. In other words, C-L psychiatry defines an activity of general psychiatrists, not a subspecialty.

The recognition that the problems seen in the general hospital are not identical to those encountered by general psychiatrists has led to a definition framed in terms of the clinical patient groups served by the specialty. According to this definition, C-L psychiatry is the branch of psychiatry that deals mainly with deliberate self-harm, medical/psychiatric comor-bidity, and medically unexplained illness.

More recently, the definition of C-L psychiatry is based on increasingly specialized skills and a developing research base, and on the increasing range of applications of the subspecialty. Thus C-L psychiatry is more often defined as the subspecialty of psychiatry that encompasses the necessary knowledge and skills not only to manage psychiatric problems encountered in the general hospital but also to contribute more generally to the psychological care of all medical patients.

This shift in definition has led to doubt about the term C-L psychiatry. There has been difficulty in choosing a more suitable term. The American Academy of Psychosomatic Medicine has suggested the term "medical and surgical psychiatry". Unfortunately this term implies that the rest of psychiatry is not medical --- an implication that many general psychiatrists would dispute. An alternative term, which is favoured by the authors, is "psychological medicine". This term can be ambiguous when it is applied to some traditional psychiatry departments, but it has the advantages of emphasizing a psychological contribution to medical practice, and of being relatively acceptable to non-psychiatric patients. Whatever the definition and the name, clinical and research activity in the area is now vigorous.

INCREASING RANGE OF CLINICAL SETTINGS

IN-PATIENTS

Much of the literature on C-L psychiatry concerns the psychiatric assessment and management of general hospital in-patients. These activities remain central to the work of most C-L psychiatrists, but the latter are working in an increasing range of clinical settings. In common with general trends in medical care, the focus of both clinical and research activity is moving away from hospital in-patients to hospital out-patients and especially to primary care.

OUT-PATIENTS AND PRIMARY CARE

Hospital out-patient and primary care physicians complain about the number of patients who are difficult to help with conventional medical treatment. Doctors working in these settings often express their exasperation by referring to 'frustrating' or even 'heart sink' patients. Whilst most of the literature on this topic is anecdotal, three recent systematic studies have shed new light on the problem. These studies were carried out in Seattle, New York and Oxford. In all three studies physicians were asked to rate consecutive out-patients for the degree of difficulty that they presented in management (specified in terms of the patient being 'frustrating', 'difficult' or 'difficult to help'). The physicians then attempted to elucidate the causes of the difficulty by comparing these patients with other 'non-difficult' patients.

The Seattle study was carried out in a primary care clinic in a Health Maintenance Organization. Lin and colleagues (1991) found that, among patients already identified as being distressed and high utilizers of care, 37% were rated as 'frustrating' by their physicians. Compared with other patients, the frustrating patients were more likely to be anxious and to have unexplained disability and somatic complaints. The doctors considered psycho-social factors to be particularly important in these patients.

The New York study (Hahn et al. 1994) was of medical out-patient office practice. It found that 20% of patients were rated as 'difficult'. The difficult patients were more likely to be emotionally distressed and to have unexplained somatic symptoms. The authors presented evidence suggesting that such patients are more likely to have abnormal personalities.

The third study was conducted by the present authors in National Health Se1vice specialist secondary care clinics (orthopaedic surgery, chest medicine and dermatology) in Oxford, England (Sharpe et al. 1994). In this study we determined the proportion of repeat clinic attenders whom the doctors regarded as 'difficult to help', and we examined the causes of the difficulty by interviewing both doctors and patients. Twenty percent of repeat attenders were rated as 'difficult to help'. As in the two studies mentioned above 'difficult to help' was found to be associated with patient distress, medically unexplained somatic symptoms, and more frequent attendance at the clinic.

From these three studies it is clear that the problem of the difficult or frustrating patient is very common. It is also clear that the difficulty is associated both with emotional distress in the patient, and with somatic symptoms that are medically unexplained. It is notable that these clinical problems are those for which C-L psychiatrists have been developing effective inte1ventions. In summary there is clearly a major need for C-L psychiatry to come to the aid of their colleagues working in medical and surgical out-patient clinics.

WIDENING RANGE OF CLINICAL PROBLEMS

Consultation liaison services have traditionally been provided for general hospital patients with typical psychiatric problems. Such patients include those who have attempted suicide. and those with psychotic disorders or severe depression, and those with clearly behavioural problems such as substance misuse. Essentially these are patients with a 'psychiatric problem' in a medical bed. The main development has been to recognize the potentially greater number of patients and range of problems to which the C-L psychiatrist can contribute. The three main areas of work of the modern

C-L service include not only typical psychiatric problems such as deliberate self-harm, but also a much larger number of patients with emotional disorders and medically unexplained physical symptoms. Research in these areas will be briefly reviewed below:

DELIBERATE SELF-HARM

For the consultation liaison services, a central role has long been to assess and manage patients presenting to the general hospital after deliberate self-harm. Such services have the obvious value of ensuring that all patients admitted following acts of deliberate self harm have their suicide risk and mental state assessed. Perhaps surprisingly, there is still little evidence that C-L se1vices decrease either the risk of further self-harm or completed suicide. These findings have led to a search for better ways to manage this problem. One approach is to focus more intensively on 'at risk' groups such as frequent repeaters (Salkovskis et al. 1990). Another approach may be to focus efforts on preventive measures such as the packaging of paracetamol tablets, a potentially lethal drug that is now the most common substance taken in deliberate overdose in the UK (Hawton et al. 1996). Whatever future services offer, provision for deliberate self-harm patients will be only one part of the modern C-L service.

EMOTIONAL DISORDERS

Emotional disorders in medical patients have long been a focus of C-L psychiatry, but the scale of the problem has only become apparent from systematic research studies. Emotional disorders of significant severity can be detected in a quarter to a half of inpatients, hospital out-patients or primary care patients (Mayou and Sharpe 1995). These emotional disorders are important because they emphasise the suffering of the patient, and because of their effects on medical conditions. Emotional disorders are also of economic importance. Depression in association with myocardial infarction or stroke appears to worsen the prognosis for physical rehabilitation and may increase the risk of death (Frasure Smith et al. 1995; Morris et al. 1993). Depression causes a level of disability similar to that caused by chronic organic disease. When depression and chronic disease are combined, the effect on disability is multiplied (Wells et al. 1989). Finally depression is associated with increased use of medical and surgical services and with increased health care costs (Levenson et al. 1990). Clearly there is a need for C-L psychiatry to contribute to the management of such patients.

MEDICALLY UNEXPLAINED SYMPTOMS

From the study of patients whom physicians and surgeons find difficult to help, it is clear that problems are caused not only by conspicuous emotional disorder but also by medically unexplained somatic symptoms. In primary care as many as 20% of new consultations are for somatic symptoms for which no specific cause can be found (Bridges and Goldberg, 1985). Kroenke and his colleagues (Kroenke and Mangelsdorff , 1989; Kroenke et al. 1990) reported the frequency of 14 such symptoms. The most striking findings were that fewer than one in five patients with such complaints were given an organic diagnosis, and that many patients were dissatisfied at not receiving "helpful" therapy.

In a study of 191 newly referred medical out-patients, a Dutch research group (Van Hemert et al. 1993) diagnosed psychiatric disorder in 38% of patients who presented with "unexplained" physical complaints, as against 15% of those with clear evidence of organic disease. Functional complaints are especially frequent in ce1iain specialist clinics; for example in gastroentrology clinics functional abdominal and bowel symptoms are common; whilst in cardiac clinics functional chest pain and palpitations are common. Contrary to the beliefs of many physicians, follow-up studies suggest that negative physical investigations do not reassure many patients who present to out-patient clinics with worries about physical problems. Patients with multiple somatic complaints are difficult to reassure, and receive extensive general hospital care over long periods of time (Smith et al. 1986). The management of this problem has become a major focus of development in C-L services, and approaches to this problem are summarized in a recent book (Mayou et al. 1995).

INCREASING SPECIALIST KNOWLEDGE & TREATMENT EXPERTISE

USE OF PHARMACOTHERAPY

In medical settings the use of psychotropic drugs requires a considerable knowledge of their effects on disease and interactions with medical and surgical treatments. The introduction of selective serotonic reuptake inhibitor (SSRI) antidepressants has been important for the C-L psychiatrist. These drugs avoid many of the effects on cardiovascular function that have caused concern about tricyclic antidepressants in physically ill people. Because of the relative lack of adverse effects SSRI antidepressants also appear to be better tolerated in patients who have medically unexplained symptoms and who are sensitive to bodily symptoms. There are, however. still only a small number of randomized trials that support the clinical impression that antidepressants are useful in these groups. Recent trials have supported the use of SSRIs for the premenstrual syndrome (Steiner et al. 1996) and for non-cardiac chest pain (Cannon et al. 1994). No film conclusions can be drawn until further trials have been carried out.

USE OF SPECIALIST PSYCHOLOGICAL TREATMENTS

Recent research has shown the efficacy of specialized C-L interventions in both out-patient care and primary care. Specially developed forms of brief psychological interventions have been shown to be particularly appropriate and effective in C-L work.

It has been difficult to demonstrate any effectiveness of psychological interventions for patients admitted to hospital after deliberate self-harm. A small trial has shown that, by comparison with standard management, cognitive behaviour therapy given by a nurse can reduce the repetition of deliberate self-harm in a selected group of frequent repeaters (Salkovskis et al. 1990). This work suggests a basis for a more effective management of deliberate self-harm, and should be repeated in a larger study.

Psychological interventions have a potentially important role in the management of emotional disorders in patients with physical disease. Cognitive behaviour therapy has been shown to be effective in reducing depression and in improving the quality of life of patients with cancer (Moorey and Greer, 1989). There is also some evidence that group therapy may increase life expectancy in women with breast cancer (Spiegel et al. 1989). The accumulating evidence is that psychological intervention for depression may improve the prognosis of patients with physical disease. In this context further evaluation of psychological intervention will be important.

Cognitive behaviour therapy has also been shown to be valuable in the treatment of patients with medically unexplained symptoms. This therapy has been shown to be more effective than simple medical care for patients with a variety of unexplained physical complaints (Speckens et al. 1995). Clinical trials have also shown cognitive behaviour therapy to be beneficial in specific patient groups, - for example patients with non-cardiac chest pain (Klimes et al. 1990), and patients with chronic medically unexplained fatigue or chronic fatigue syndrome (Sharpe et al. 1996).

THE FUTURE

C-L PSYCHIATRY AND ITS RELATION TO MEDICINE AND GENERAL PSYCHIATRY

C-L psychiatry has always presenteded identity problem, - whether it is to be regarded as psychiatry or medicine (or neither). We believe that the future of C-L psychiatry as a subspecialty in its own right depends on the development of specific knowledge and skills, rather than on place of work or on professional designation. In the future it seems likely that psychological medicine will be increasingly recognised as distinct from general psychiatry. It will comprise multidisciplinary teams of psychiatrists, psychologists and nurses. A greater contribution to its funding from medical and surgical budgets seems likely (Royal Colleges of Physicians and Psychiatrists, 1995). The extent of the need for psychiatric intervention in medical populations will lead C-L psychiatrists to spend more time in educational and collaborative work with physicians and surgeons. As integration with medical services increases the name psychological medicine may become more appropriate than C-L psychiatry.

EVIDENCE BASED C-L PSYCHIATRY ?

There is growing support for the belief that a clinician's choice of treatment for a patient should be based on the best available evidence, and that funding should be provided only for treatments of proven efficacy. For the clinician however there may be formidable difficulties in obtaining the relevant evidence, in reviewing the evidence and in implementing the conclusions from the evidence. Recently however, there has been substantial progress toward overcoming these difficulties as a result of the dedicated work of a small but increasing number of enthusiasts. As a result clinicians and health care planners will be more able to make decisions about medical treatments that are 'evidence-based' (Evidence-based medicine working group, 1992).

Evidence-based treatment decisions require that relevant clinical trials have been done, that these trials can be readily located, and that the results of more than one trial can be combined in a sensible fashion. Solutions to these problems have been found in the 'systematic review', which pays as much attention to avoiding bias as would be expected from the investigator conducting the trial on which it is based. Systematic reviewers use explicit, and where possible exhaustive, methods to obtain all the relevant trials. In their evaluation they take steps to minimize bias and, where appropriate, to use the statistical technique of metanalysis and thus to combine the results into a single estimate of relative effectiveness of the treatment in patients with a given condition (Mulrow, 1994).

This approach has been particularly fostered by the Cochrane Collaboration (Chalmers, 1993). This Collaboration offers a highly organized and standardised procedure for producing and maintaining systematic reviews of specific topics. Some medical specialties have already made significant advances in using these methods. For example the Cochrane Collaboration Perinatal and Childbirth Group has completed literature searches and objective reviews of over 500 clinical problems, thus producing a practical and regularly updated guide to treatment in obstetrics. This process of systematic review is being rapidly extended to other areas of clinical practice (Godlee, 1994) and will in time provide important summaries of the available evidence for the effectiveness of treatments.

The general move towards rigorous evaluation challenges C-L psychiatry to demonstrate with hard evidence that it can make an important contribution to medical care. Systematic collaborative reviews should have a strong influence not only on the contribution of individual doctors, but also in shaping the p1iorities of managers, purchasers and governments. If the psychological and social aspects of medical care are given due weight and priority in all areas of medical practice, it is important for C-L psychiatrists to take up this challenge.

CONCLUSION

In recent years there has been a major expansion in the role of C-L psychiatry. The future of this subspecialty lies in the development of skilled multidisciplinaly teams, working in close collaboration with their physician and surgeon colleagues. It is increasingly clear that raising the awareness of physicians and surgeons in the recognition of emotional problems is highly important. This collaborative approach is recommended by the report of a joint working party by professional organizations in the UK (Royal Colleges of Physicians and Psychiatrists, 1995). To meet the challenge of future changes in the health care system it will be necessary to continue further research in the development and evaluation of C-L psychiatry.

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* Michael Sharpe, Tutor in Psychiatry , , Department of Psychiatry, University of Oxford
Dennis Gath, Reader in Psychiatry, Department of Psychiatry, University of Oxford

*Dr. Michael Sharpe, Tutor in Psychiatry, , Department of Psychiatry, University of Oxford, , Warneford Hospital, Oxford, OX3 7JX, U.K.

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