Liaison psychiatry
Very few disorders can be considered to wholly affect the body but not the mind, and vice versa. The majority of psychiatric disorders have some impact upon the patient’s physical wellbeing. For example, depression can result in weight loss, constipation and tiredness, in addition to having an impact on the individual’s ability to cope with any existing physical illness. Pain from arthritis is often worse during a depressive episode. Similarly, physical disorders will often affect the emotional state of the patient. Feelings of anxiety, depressed mood, anger and frustration are common accompaniments to physical illness. They will impact upon the recovery process (Fig. 1), and mental illness may be precipitated.
High rates of mental illness have been found in general hospitals, even when those patients being treated for overdose and other forms of deliberate self harm are excluded from the figures. Up to 60% of medical inpatients have a mental disorder, and up to half of all medical outpatients. A quarter of male medical inpatients have problems associated with alcohol abuse. The reasons for these high rates are illustrated in Figure 2.
Liaison psychiatry
Liaison psychiatry is a sub-specialty of psychiatry in which a service is offered to patients of a general hospital. A liaison psychiatry team in a general hospital would usually include a psychiatrist, a psychologist, psychiatric nurses and social workers, and sometimes other mental health professionals. They provide input to patients in the hospital in two ways:
consultation, in which patients are assessed by members of the liaison psychiatrist at the request of the physician or surgeon caring for them
liaison, in which members of the liaison psychiatry team have a broader role and become integrated into the work of their general hospital colleagues. They may attend ward rounds or take part in assessment or follow-up of patients attending outpatient clinics. This approach is time-consuming but improves joint working between general hospital and mental health staff. It also reduces the stigma of a psychiatric referral, which can be a problem with the consultation model, particularly for patients with conditions such as somatisation disorder, in which psychological explanations for symptoms are actively resisted.The consultation model of service is the most widely practised, and at the most basic level psychiatrists may provide consultations for patients admitted following deliberate self harm and psychiatric emergencies only. The integrated liaison model of service, where it exists, is usually focused on specific areas where psychiatric morbidity is highest and has most impact on the management of the physical illness. This may include pain clinics, oncology wards, paediatric and geriatric departments.
Psychological causes of physical illness
There is good evidence that stress plays an important role in the aetiology of many physical disorders. For example, studies have demonstrated an increase in stressful life events in the weeks prior to myocardial infarction, acute abdominal pain and acute subarachnoid haemorrhage.
Mental illness is also associated with increased morbidity and mortality from a wide range of physical disorders. This continues to be true even when disorders directly associated with the mental illness are not included in the figures, such as deliberate self harm and the effects of alcohol abuse. This is likely to be due to a combination of factors, including the effects of stress, increased tendency to smoke and take illicit drugs, harmful effects of prescribed drugs and failure to seek medical help.
Mental illness may present with physical symptoms, thereby obscuring the primary diagnosis, and in some cases resulting in unnecessary and potentially harmful investigations and treatment. For example:
Depressive disorder may present with biological symptoms including sleep disturbance, loss of energy and lethargy, sexual dysfunction, loss of appetite and weight loss and loss of concentration with apparent memory loss resulting in a misdiagnosis of dementia (known as pseudodementia).Related posts:
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