Fifteen Eighty Four

Most people are familiar with the idea that there is an interaction between physical and mental health. Living with severe chronic illness or disability can have very marked psychological impact, and experience from the recent pandemic has shown how acute severe illness and its personal and social consequences can affect mental health. Other obvious examples include delirium caused by (say) acute infection, the physical disorders caused by persistent drug or alcohol misuse due to addiction, and the bodily damage that can be caused through intentional self-harm.

The idea that emotional or psychological problems can cause illness – typically what are called medically unexplained syndromes and (especially in neurology) functional disorders such as paralysis with no neurological cause – is rather less prominent in public consciousness, and the psychological or social origins of these disorders are sometimes actively disputed. Even more unfamiliar to most people would be the range of other mental disorders that can occur in medical settings – for example acute psychosis due to brain disease or medication effects; dissociative states; life-threatening non-adherence with self-care.

In fact such problems as these are not only common but can be severe enough that many general hospitals in developed countries now provide on-site mental health services (psychiatry, clinical psychology and psychiatric nursing for example) to assist with their management. Liaison psychiatry is the name for that branch of psychiatry that involves the specialty care of patients in whom this interaction between mental health and physical health is proving problematic. It can also be known as consultation-liaison (or C-L) psychiatry, psychological medicine, or less commonly psychosomatic medicine. Although not always so, liaison psychiatry services are typically based in general hospitals and especially those with an emergency department.

The case for liaison psychiatry services was first articulated in the middle of the last century in the USA, and since then services have developed incrementally. In the UK, every acute general hospital now has some liaison psychiatry input, ranging from acute services linked to the emergency department, a service to general wards offering consultation and shared care, and specialist outpatient clinics. Most such services are multidisciplinary. Specialist training in liaison psychiatry is accredited by professional bodies such as the UK’s Royal College of Psychiatrists, which now includes a Faculty of liaison psychiatry. Academic liaison psychiatry is found in several medical schools, its practitioners researching and teaching about clinical conditions and their management at individual and service level.

That the book Seminars in Liaison Psychiatry is now published in its 3^rd edition is a marker of the maturity of liaison psychiatry as a subspecialty in mental health care. The aim of this multi-author volume is to provide an up-to-date view of the specialty from the perspective of an international panel of contributors using their extensive clinical experience and knowledge of the relevant research.

The diversity of the clinical practice of liaison psychiatry is reflected in Seminars. The opening chapters cover common clinical problems, and in these we made the editorial decision to organise chapters around psychological presentations rather than physical disease states. There are therefore chapters on depression, psychosis and so on rather than psychiatry and heart disease, cancer, diabetes and so on. The definition of liaison psychiatry is an organisational one – the liaison is between two apparently distinct forms of clinical practice – and there are inevitably chapters on working in settings such as the emergency department, in paediatrics or primary care. A summary chapter on issues relevant to liaison psychiatry in later life is absent – there is a forthcoming Seminars volume dedicated to later life CL Psychiatry, going to press in the next few months.

In any clinical practice there is a great deal of activity that does not involve direct patient management. Examples include making the case for, planning, and developing new elements of service, setting standards including those related to legal imperatives, and measuring outcomes. These and other aspects of providing a comprehensive and well-run service are also reviewed.

There are organizational challenges in the field. In the UK, clinical health psychology services are typically provided separately from liaison psychiatry with the interface not always logically delineated. Collaborative links with neuropsychiatry colleagues in the general hospital setting are not always developed. Only a minority of liaison services provide specialist outpatient clinics. There are substantial pressures that arise, especially in the emergency department, from under-provision of community-based acute mental health care. Old age services work against an enduring inadequacy of social care for the elderly. Child and adolescent liaison psychiatry remains relatively less well developed than other age-related parts of the services. Nonetheless liaison psychiatry appears in good health, and we look forward to continuing consolidation and even growth in this interesting and important branch of medicine.

Title: Seminars in Consultation-Liaison Psychiatry, 3rd Edition

Editors: Rachel Thomasson, Elspeth Guthrie, Allan House