Providing a liaison psychiatry service in the absence of a consultant liaison psychiatrist

AIMS AND METHOD

Liaison psychiatry services in Ireland are currently unequallydistributed. In the absence of a specialist liaison psychiatryteam, general adult psychiatrists may provide a consultationservice to their local hospital. Demographic and clinical characteristicspertaining to all psychiatric consultations at the Louth CountyHospital were collected over 12 months to examine one suchlocal service and to highlight the challenges of this mode of service delivery.

RESULTS

A total of 232 consults were audited. The most frequent reasonsfor referral were assessment following deliberate self-harm(38%), affective symptoms (28%) and alcohol or substance misuse(25%). This differs from documented referral patterns to specialistliaison teams. Referring physicians had a low diagnostic ‘hit-rate’with respect to affective disorders. Difficulties in serviceprovision included poor communication by referring teams andtime constraints due to other sectoral commitments.

CLINICAL IMPLICATIONS

Refinements to service delivery may be beneficial in managingthe work-load more effectively. Priority should be placed onfostering communication with non-psychiatric colleagues.

Introduction

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Introduction

The Royal College of Psychiatrists (2003) has emphasised theneed for medical patients to have access to good quality psychiatricand psychological care. Liaison psychiatry services in Irelandoutside of Dublin are currently poorly developed, with certainregions having little or no provision (O’Keane et al, 2005).The report of the Expert Group on Mental Health Policy (Department of Health and Children, 2006)has recommended that the number of specialist liaison teams be expanded nationally to thirteen. Furthermore, Comhairlena nOspidéal’s report (2004) on consultant staffing within Irish mental health services suggested that generalhospitals lacking the service of a full-time designated consultantliaison psychiatrist should have a liaison service providedby the local sectoral (general adult) psychiatry team. Deliveryof a quality service in this manner is quite a challenge, sinceit must be provided in addition to a wide array of other sectoralresponsibilities. There has been little systematic researchto date examining the activity generated within such a localarrangement.

This study was undertaken at the Louth County Hospital, wherea consultation–liaison service is provided on a non-emergencybasis for in-patients. No cover is provided for the accidentand emergency department. The service is delivered by psychiatricregistrars working under the direction of sectoral generaladult consultant psychiatrists. Liaison work is therefore undertakenin addition to delivery of full sectoral duties. Supervisionof registrar assessments is on the basis of a consultant’sor senior registrar’s review of individual cases as required.Psychiatry registrars are supported by two psychiatric liaisonnurses in cases where assessment is sought following episodesof deliberate self-harm.

The aims of this study were to examine the clinical characteristicsof referrals to the service and to broadly compare these withdata from previous studies in the Irish literature which focusedon specialist liaison services, and to highlight specific challengesassociated with this type of service delivery.

Method

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Method

The details of all psychiatric consultations to in-patientsat Louth County Hospital were collected prospectively for a12-month period. In addition to demographic information, thefollowing was recorded: source of referral, presence or absenceof a referral letter, past psychiatric history including previouscontact with psychiatric services, reason for referral, ICD–10 diagnosis as made by assessing psychiatrist, and suggestedmanagement or intervention.

Results

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Results

Reason for referral
A total of 242 consults were seen over the 12-month period,of which 232 were audited. A formal letter of referral wasreceived in 55% of cases. The most common reasons for referralwere for assessment post deliberate self-harm (n=89, 38%),assessment of affective symptoms (n=65, 28%) and alcohol orsubstance misuse (n=56, 25%). Remaining individuals were referredfor various other reasons, including queries in relation to behavioural disturbance, confusion, pharmacotherapy, placementissues and eating disorders.

Demographics
Almost equal numbers of male and female individuals were referredfor assessment (female: n=115; male: n=117). The age/gender distribution of the group is shown in Table 1. Of note, 22%of individuals assessed were over 65 years of age. Older individualswere referred chiefly with affective symptoms or confusion/behaviouraldisturbance.

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Table 1. Age/gender distribution of individuals referred for assessment

Diagnosis
Diagnosis is recorded in Tables 2 and 3. Individuals referredfor assessment post deliberate self-harm have been groupedseparately (Table 2, group A, n=89). Almost a third of thisgroup did not receive a formal psychiatric diagnosis and theepisode of self-harm was seen as a response to acute situationalfactors. The most common diagnosis (22.4%) was that of alcoholuse disorder (harmful alcohol use or alcohol dependence syndrome; binge pattern drinking was not recorded as a diagnosis in thisstudy). Comorbid personality disorder with alcohol use disorderwas observed in a further 7.9% of individuals; 12.4% of individualswere diagnosed as depressed, with a further 11.2% with comorbiddepression and personality disorder.

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Table 2. Individuals presenting with deliberate self-harm (group A, n=89)

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Table 3. Individuals with a diagnosis excluding deliberate self-harm (group B, n=143)

Excluding deliberate self-harm cases, there were 143 furtherindividuals referred (Table 3, group B). Again, the most commondiagnosis was harmful alcohol use or alcohol dependence syndrome(36.4%); 18.9% of group B had a past history of clinical depression, but had euthymia at assessment; 12.7% had acute depression;9.8% did not receive a formal psychiatric diagnosis. Table 4shows interventions implemented by the assessing psychiatrist.

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Table 4. Suggested interventions (n=250)¹

Discussion

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Discussion

Provision of a liaison service by the general adult team atthis study location generated a considerable volume of work.Referral patterns conformed to a degree with those to specialistliaison services in the Irish literature (Freyne et al, 1992; Swanick & Clare, 1994), with the exception of few requestsfor assessment of ‘medically unexplained symptoms’,surprisingly low numbers of individuals referred with ‘confusion’or behavioural disturbance, and higher numbers of alcohol-relateddisorders.

Predictably, assessment following episodes of deliberate self-harmformed the bulk of clinical duties. The Louth County Hospitalpolicy currently requires that all individuals presenting withdeliberate self-harm are admitted for review by a psychiatrist,regardless of severity or degree of intent. However, analysisof accident and emergency records indicated that during thestudy period a substantial number of individuals discharged themselves directly from accident and emergency, having refusedto await admission for psychiatric assessment. This is of concern,since it has been shown that individuals who discharge priorto completion of initial assessment have a considerably increasedrisk of repeated self-harm (Crawford & Wessely, 1998). In 2004, the College issued a consensus statement with respectto the assessment of deliberate self-harm in accident and emergencydepartments and in-patient wards (Royal College of Psychiatrists, 2004).This document included the recommendation that such assessmentsneed not necessarily be undertaken by a psychiatrist, but couldequally be performed by other suitably trained professionals.It is therefore questionable as to whether it is necessaryfor all individuals admitted post deliberate self-harm to theLouth County Hospital to be seen by a psychiatrist, particularlygiven the presence of two experienced psychiatric liaison nurses.Perhaps a more useful strategy would be to have an initial psychosocialassessment completed by the liaison nurses, with subsequent assessment of the subgroup with more complex mental healthproblems by the junior doctor. This would greatly increasethe time available for other aspects of liaison work, withoutcompromising service quality.

The rates of alcohol use disorders among those assessed duringthis study were alarmingly high: 30.3% of the deliberate self-harmgroup (n=27) and 41.4% of others (n=59) were found to havean alcohol use disorder (with or without personality disorder).The adverse physical, psychological and social complicationsof excess acute and chronic alcohol use are well documented(Gilman & Abraham, 2001; Babor et al, 2003; National Crime Council, 2003).Molyneux et al (2006) have demonstrated high-point prevalenceof alcohol use disorders and binge drinking among in-patientsin the Irish general hospital setting. Modalities such as brief intervention have been demonstrated to be clinically effectivein reducing amounts of alcohol consumed in individuals withalcohol disorders (Moyer et al, 2002). At present, there isno alcohol counsellor available within the hospital to offerthis type of input. Full psychiatric assessment may be neithernecessary nor sufficient for many of these individuals. Singlesessions with a designated alcohol counsellor with the requisitetraining in evidence-based brief interventions might be morehelpful, in uncomplicated cases.

Several difficulties arise when a liaison service is providedby a general adult team. Perhaps the greatest challenge isthe conflict created by the need to provide quality assessmentsin the context of significant time constraints, since sectoralduties also demand the attention of those involved. In orderto provide comprehensive assessments, there is frequently theneed for time-consuming gathering of collateral history frommedical staff and family. This is a challenge common to allliaison work. However, it becomes an even more pressing difficultywhen assessments are performed amid a myriad other duties.Formal letters of referral were obtained from the referringmedical team in only 55% of cases in this study, thereby increasingthe need for information gathering by liaison team members.

Ideally, the remit of a liaison team should encompass not merelythe provision of a service for psychiatric emergencies anddeliberate self-harm assessments, but additionally promotionof combined approaches to mental and physical health, preventionof psychiatric morbidity and psychoeducation for non-psychiatricstaff.

Time constraints, lack of a multidisciplinary team and poorlydeveloped shared care approaches restrict the current scopeof service at the Louth County Hospital. Service provisionhas thus become largely consultative in style. This may inturn influence referral patterns. Medical staff may incorrectlyassume that the liaison service is synonymous only with deliberate self-harm assessments, since this is the most visible aspectof service provision. Direct contact between psychiatric andnon-psychiatric staff is invaluable in influencing the typesof individuals that are referred for assessment. At present,the majority of referrals fall predictably into a limited numberof categories – deliberate self-harm, alcohol-related illness and affective-spectrum disorders. Virtually no casesof ‘medically unexplained symptoms’ are seen bythe liaison team at the Louth County Hospital. Although thismay reflect the fact that such individuals are referred initiallyonwards to larger centres for specialist investigations, andthence to liaison services elsewhere, it may also belie a lackof recognition of psychosomatic disorders.

Liaison psychiatry demands a different set of specialised skillsto those required in general adult psychiatry. The liaisonpsychiatrist must be adept at assessing relevant physical findingsin addition to mental state, at engaging individuals with somaticpresentations of psychiatric illness and at managing thosewith psychiatric and physical comorbidity. Such skills may not readily be learned outside of centres which have a well-developedspecialist liaison service under consultant supervision. Nevertheless,a general adult team can do much to aid a positive attitudein the medical setting towards psychiatry, promote a bio-psychosocialapproach to diagnosis, and increase the potential of physiciansto treat common psychiatric disorders. Priority should be placedon fostering communication with non-psychiatric colleagues soas to optimise mutual learning.

Acknowledgments

Thanks to all members of the liaison team at Louth County Hospital.

References

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