Liaison and Consultation Psychiatry

Abstract

This article outlines historical and conceptual aspects, as well as the scope of consultation–liaison psychiatric services in primary and hospital care settings, and in the care of residents with psychiatric disorders in nursing homes. Community studies show that members of the general population who suffer from a physical illness are at increased risk of suffering additionally from a psychiatric disorder. These figures increase in patients seeking help from primary care doctors, and are highest in patients treated in medical–surgical wards of general hospitals. Patients in general hospitals show high rates of comorbid psychiatric disorders, especially organic psychoses, e.g., delirium in dementia, alcohol and other addictions, somatoform and affective disorders including adjustment disorders. Studies show a significant association between psychiatric comorbidity and more complicated illness courses, with longer lengths of stay in hospital and more frequent readmissions, leading to poorer outcomes and increased costs in the treatment of such patients. Inpatients suffering from psychiatric comorbidity have longer lengths of hospital stay than patients with the same severity of the underlying or concomitant physical disease, who are not in addition psychiatrically ill. The high rates of psychiatric comorbidity in physically ill general-hospital inpatients, primary care patients, and nursing home residents are the focus of consultation–liaison psychiatry. Psychiatric care leads to improved management of patients with medical–psychiatric comorbidity, and a reduction of unnecessary costs inflicted on health care systems through underdiagnosis and undertreatment of psychiatric comorbidity. This holds true especially for patients presenting with medically unexplained symptoms not due to organic disease. In order to improve course and outcome of patients with medical–psychiatric comorbidity, psychiatrists have to be involved in their care, as in most of the Western industrialized countries this became possible by the integration of psychiatric departments in general hospitals. General hospitals present an important pathway to specialist psychiatric care for such patients, who will often be seen for the first time by a psychiatrist after having been admitted for a physical disease or for physical symptoms that cannot be explained by an underlying physical disease. Educational and training developments should lead to more elaborate consultation–liaison psychiatric curricula within specialist psychiatric training. Far more, training programs are needed to increase nonpsychiatric physicians' and medical staffs' knowledge of and experience in diagnosis and treatment of psychiatric issues, in order to improve care of patients with somatopsychic disorders in primary and hospital care settings. The development of guidelines for consultation–liaison psychiatric practice and the emergence of joint psychiatric and medical approaches in the care of patients with physical diseases and psychiatric comorbidity, especially within primary care, are expected in years to come.