A historical perspective

While CL psychiatry is a recognized part of psychiatry, the need for its development as a subspecialty is under discussion in several countries (e.g. the United States, the United Kingdom, and Australia).(3) CL psychiatric services have only developed systematically since the 1960s in the United States, and in Europe only during the last 15 to 20 years. Today, the status of CL services in a specific hospital depends on local factors, whichvary throughout the world. (!.)

Although there have been facilities for the treatment of the mentally ill in most general hospitals in all parts of the world, the major stimulus for the development of CL psychiatry came from the United States during the 1960s. (!,.3,4) The first series of patients seen in psychiatric consultation was described in the 1930s in the United States.(4) In the 1950s Querido, in The Netherlands, reported a follow-up study of patients admitted to medical and surgical wards and argued for integrated services.(5) In the United States, services in a few university centres were supported by government grants, so that CL psychiatry became a recognizable type of service delivery. In 1967 and 1968 Lipowski compiled the literature into three key articles, and in 1977 Engel published a bio-psychosocial model as an alternative to the biomedical model/67 The Massachusetts General Hospital Handbook of General Hospital Psychiatry(88) was another important step in the systematic development of CL psychiatry. Others argued for the need to develop more integrated services on wards with highly vulnerable populations using the liaison model. (9) Because of language barriers, the German psychosomatic model developed independently to become, perhaps, the most successfully implemented liaison model. (1) These psychosomatic CL services focus on the assessment and treatment of patients with unexplained physical complaints and coping problems often seen on neurological and internal medicine wards. In the United Kingdom two other developments took place. First, there was more emphasis on outpatient services with a specific focus on patients with unexplained physical symptoms. Second, the related research on treatment focused on the effectiveness of cognitive behavioural therapy. In the United Kingdom, in contrast with other European countries, psychiatric services for the elderly in general hospital wards are usually provided by psychogeriatric consultants. Health-care reform in the United States during the early 1990s, changed the focus of CL psychiatry towards outpatient CL psychiatric services for patients with unrecognized depressive and anxiety disorders as well as the somatoform disorders. There is growing interest (mostly by Japan) in CL psychiatric services for patient populations receiving highly technological and complex therapy such as oncological treatments or transplantation. (1

During the 1990s, in parallel with the above-mentioned developments, professional organizations for CL psychiatry began to emerge in most countries. (1) They started to address issues such as subspecialization as well as guidelines for clinical practice, training, and research. fy.0.,!1 Nowadays, there is increasing international contact between representatives of these organizations, and in 1998 the International Organization for Consultation-Liaison Psychiatry was established (website:

Owing to the changing functions of hospitals, the changing epidemiology (increasing age of patients and the chronicity of their illnesses), and the greater recognition of the effect of psychiatric morbidity on the use of health-care facilities, the role of a psychiatrist as a consultant is likely to develop steadily. This development will require new skills, organizational structures, and financial mechanisms to be put in place. (2) The report of a joint working group of the United Kingdom Royal College of Physicians and the Royal College of Psychiatrists, has described the psychological needs of the medically and surgically ill (12) and suggested a framework for more integrated care. In the near future, in addition to direct consultation, consultants are likely to act indirectly in developing mental health services for the general hospital setting, including those for the cognitively impaired elderly, those patients with delirium impairment, and substance abusers. The indirect function includes the development of guidelines and training for house-officers and general nurses in the basic psychiatric skills required to meet the mental health needs of their patients. Some of this training can be carried out by psychiatric nurses. Similar models of integrated psychiatric care have been tested in primary care settings for the treatment of anxiety and depressive disorders, and, for instance, in patients with cancer (see ChapieL^.Z). It is likely that the liaison function will merge with these more structured preventive functions, defined by the needs of a target population, thus providing ward staff with more effective tools to detect and manage psychiatric morbidity or vulnerability.

One such tool is the Complexity Prediction Instrument (COMPRI),(2) a screening instrument to be applied at admission to detect patients at risk for highly complex care and long hospital stay. Another recently developed tool is the INTERMED ( Table 1),(1 14 and 15 which is a method for analysing integrated multidisciplinary care needs through the assessment of a series of bio-psychosocial risk factors. It can be used as an instrument to control for case mix in clinical studies, and also as a structured clinical interview in the clinical setting for the initiation of integrated care in more complex patients. Depending on the type of population treated and the extent of comorbidities, ward managers should decide which levels of physical and psychological complexity they have to handle. The acuity levels are shown in TableZ^6

th ■■'■■ rf Hi MW^Wl P *


Table 2 Medical psychiatric units: patient characteristics, procedures available, and type of intervention required for each level and type of acuity

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