Academic journal article Hong Kong Journal of Psychiatry

Recent Developments in Consultation Liaison Psychiatry-A View from Oxford

Academic journal article Hong Kong Journal of Psychiatry

Recent Developments in Consultation Liaison Psychiatry-A View from Oxford

Article excerpt

INTRODUCTION

Recent yews 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 sub specialty. 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 subspeciality.

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 sub specialty. 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. …

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