CHAPTER 14 Peter Byrne1,2 and Iyas Assalman3 1 Homerton University Hospital, London 2 Royal College of Psychiatrists, UK 3 Newham Centre for Mental Health, London and East London Foundation NHS Trust Modern general hospitals cannot function effectively without on-site psychiatric assessment and treatment. This goes beyond the management of delirium (Chapter 19) and the safe evaluation of self-harm (Chapter 20) – respectively, the commonest complication of general hospital admission and the top cause of general hospital presentations among young people. With an ageing population, most admissions comprise people over 65, two thirds of whom will have mental health problems, with about half the population over 70 showing objective evidence of cognitive impairment [1]: Chapter 10. A major component of our work in East London has been the evaluation of drug/alcohol misuse and dependence: we will not revisit the early intervention evidence set out in Chapter 17. On-site mental health personnel also address the high prevalence of common mental disorders in medical and surgical inpatients. Holistic care must include psychological evaluation and appropriate support for inpatients, whose resilience is overwhelmed by physical morbidity: adjustment disorders may develop into depression and/or personality traits may become exaggerated such that they interfere with the business of recovery. Psychiatrists who work in general hospitals treat every type of psychiatric disorder: presentation to and/or frequent use of the emergency department along with hospital admission provide excellent opportunities for early intervention to improve mental and physical well-being. Although functional psychosis has a relatively low incidence in acute care inpatients, people with established schizophrenia and bipolar disorders frequently deteriorate around general hospital admission, where physical ill health is a precipitant (life event) for relapse. As a consequence of the premature morbidity and mortality of people with any mental illness [2], in general hospital psychiatry at least 11% of their referrals comprise people with severe mental illness (SMI). In this chapter, we will set out the evidence for timely interventions in three groups: (i) people with SMI who develop (predictable) physical ill health, including cancer, (ii) patients who are admitted with stroke (cerebrovascular accident) and develop depression and (iii) patients across primary care and specialist services with medically unexplained symptoms (MUS). A brief note on terminology first. Many US and European centres use the term consultation liaison psychiatry, abbreviated to liaison psychiatry in the United Kingdom. Some US colleagues prefer the term general hospital psychiatry, and this includes emergency psychiatry (e.g. assessing self-harm or risk of harm to others), coincident physical and mental ill health and the range of presentations of people with somatoform disorders. The latter conditions, currently the subject of much debate in both ICD-11 and DSM-V reclassifications, led to many European specialists’ description of their work as psychosomatics. The heterogeneity of the patients seen by liaison psychiatrists makes it at once an interesting speciality with a high turnover, but also a challenging area to evaluate, and therefore relatively less well-funded than other branches of psychiatry. If during the 1990s, had we rebranded the speciality ‘early intervention psychiatry in general hospitals’, this may not have been the case. At time of writing, the United Kingdom has seen a resurgence of interest in liaison psychiatric teams due to the work of Professor George Tadros and others in Birmingham. He and his team demonstrated the health and economic benefits of resourcing a single team to achieve early intervention across all age groups, the Rapid Assessment and Discharge (RAID) Team [3]. Their ethos is rapid, early assessment by senior clinicians through a single point of referral of everything (not ‘nearly everything’), with a low threshold to accept cases for assessment: no arguments that the alcohol is ‘causing’ the depression and only an abstinent patient can be assessed, or that dementia/delirium is ‘not psychiatric’. This is clearly the way forward, given that doctors, our primary referrers, will have left medical school with lots of experiences of treatment-resistant schizophrenia but without the skills to accurately differentiate depression from unhappiness or dysthymia from ‘whatever’. All scientific studies that examine excess mortality and premature death (by natural and unnatural causes) confirm the same grim findings of the meta-analysis of Harris and Barraclough [2]. Hippisley-Cox et al. [4] record substantially higher rates of illness in populations of SMI of the common physical diseases of coronary heart disease, cerebrovascular accident, chronic obstructive pulmonary disease and diabetes. More striking are the age-adjusted death rates at 5 years from diagnosis, when compared to the general population with the same four diseases respectively, 22% vs. 8% (general population), 28% vs. 12%, 28% vs. 15% and 22% vs. 15%. Overall, the 5-year survival for people with SMI is less than half the expected survival for coronary, cerebrovascular and obstructive lung diseases, and broadly we expect one in five of ‘psychiatric patients’ to die within 5 years of diagnosis of any of the 4 diseases. We know of several confounders here – factors that will lead to higher rates of both mental illness and to physical morbidities/mortalities: It is worth noting that every one of these factors is modifiable by early intervention programmes. Lawrence and Kisely [5] have identified inequalities of the access and delivery to physical health care as possible causes for higher morbidities and mortality of people with SMI, in particular: While we await integrated public mental health programmes to address the upstream causes of poor health, mental and physical, such as low birth weight and poverty, these latter four categories are a useful focus for all liaison psychiatrists. On-site liaison psychiatry allows near full integration of the liaison team into the general hospital team. We assess and manage patients alongside our medical, nursing and surgical colleagues. Physicians may be nervous around people with the negative symptoms of schizophrenia, and our role is to prompt timely, appropriate physical investigation and management. Diagnostic overshadowing, first described in the learning disability literature 30 years ago, describes how physicians (including psychiatrists) are likely to ascribe physical symptoms to an underlying mental disorder, and thereby less likely to investigate and treat symptoms of physical illness [6]. Recently, a medical registrar asked our team if psychosis could cause a high temperature. The patient was delirious (see Chapter 19) and once the medical cause was identified and treated, septicaemia from a lung infection, he recovered fully. Diagnostic overshadowing preferences assumptions over the methodical search for facts, and is closely related to the therapeutic nihilism some medical and surgical colleagues hold about people with SMI. This leads to less treatment, in some cases denial of life-saving treatments such as organ transplantation [7]. One of us encountered a 45-year-old man with schizophrenia who denied a renal transplant on the basis that his future adherence would be unreliable. Evidence was produced that he had missed one monthly depot antipsychotic injection in 11 years with psychiatric services, and he got his transplant. Embedded in general hospitals and clinics, liaison psychiatrists are ideally placed to persuade, engage and train their hospital colleagues to reverse the adverse effects of stigma and discrimination (see Chapter 26).
Early Intervention in the General Hospital
The physical health of people with severe mental illness
Related posts:
Perinatal Preventive Interventions in Psychiatry: A Clinical Perspective
How Early Intervention Can Turn Things Upside Down and Turn a Patient Into a Psychiatrist
Transiting Out of Child and Adolescent Mental Health Services – Influences on Continuities and Discontinuities in Mental Health Care
Early Intervention for Borderline Personality Disorder
Early Intervention for Self-Harm and Suicidality
Early Intervention in Older Adults – A Focus on Alzheimer’s Dementia
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