From consultation-liaison psychiatry to psychosocial advocacy: maintaining psychiatry's scope

Abstract

Objective: To review the status of consultation-liaison (C-L) psychiatry and the forces shaping it, and to propose strategies for dealing with the crisis in which it finds itself.

Method: A Medline search of C-L psychiatry and related terms, together with hand-searching of C-L psychiatry and psychosomatic journals and bibliographies of found articles, was used for the literature base. The experience of membership of the committees of national and international C-L psychiatry organisations and their interaction with health care administrators was used as the basis for the discussion of strategies.

Results: It is argued that patients with physical/psychiatric comorbidity and somatisation have been marginalised by application of narrow definitions of what constitutes 'serious mental disorder' in the public sector. Evidence is presented to support the argument that physical/psychiatric comorbidity is the most common form of psychiatric presentation in the community, that such comorbidity has serious consequences in terms of morbidity, mortality and health-care costs, and that even subthreshold psychiatric symptoms have serious implications when physical comorbidity exists.

Conclusion: It is concluded that a number of strategies, including pre-admission screening, integrated discharge planning, liaison, as well as shared care with general practitioners, advanced training in C-L psychiatry and more research to establish practice guidelines, are required if psychiatry is to remain a broad-based discipline rather than retreat to being a specialty for psychosis. Consultation-liaison psychiatrists must become the advocates for the psychosocial system.