Editorials

Psychological care of medical patients

People with appreciable physical illness have at least twice the rate of psychiatric disorder found in the general population, with a concomitant increase in clinically important disorders that just fail to meet standard diagnostic criteria. The main problems are mood disorder,^{1 2 3} cognitive impairment,^{4 5} substance misuse,^{6 7} and abnormal illness behaviour or somatisation.^{8 9} These disorders are clinically and personally important: they impair quality of life; reduce the ability to adhere to, or benefit from, treatment for medical conditions; and are associated with a poor outcome of treatment for physical illness. Episodes of medical care are more complex and costly in those whose physical disorder is accompanied by psychiatric comorbidity.¹⁰

Effective treatments exist for psychiatric disorder in physically ill people, which are remarkably cheap for the benefits they provide. In fact, the costs of providing psychiatric treatment in a medical setting may be more than met by the savings that result from reductions in inappropriate medical investigation and treatment--the so called cost offset effect.¹¹

Unfortunately, few hospitals arrange formal services to meet the psychological needs of their patients. Instead they rely on a mixture of informal provision in some areas and neglect in others. This approach may be unsustainable in future. Existing working relationships between psychiatrists and general hospital doctors are under strain as the health service reforms have placed most mental health services in different trusts from general hospitals. The emphasis on community care in psychiatry means that psychiatrists spend less of their working week in hospitals, so the opportunities for informal contact with colleagues are diminished. Until recent years many people with chronic mental illness and coexisting physical illness could be treated in psychiatric hospitals. Now, pressure on beds in both psychiatry and general medicine makes the already difficult task of caring for patients with coexisting mental and physical illness harder. At the same time, the growth of consumerism in medicine and heightened public awareness of the psychological aspects of physical illness add to the demand for relevant services.

Daunting agenda

In response to the perceived gap between the needs for, and availability of, psychiatric services in general hospitals the Royal College of Psychiatrists and the Royal College of Physicians have jointly published a report on the psychological care of medical patients.¹² This is not a bland appeal to the principles of holistic care but a bench manual for those who plan and deliver services. The working group has tackled many practical aspects of the psychological care of medical patients, and the agenda it sets the profession is daunting.

Physicians, surgeons, and general nurses need the skills to identify psychological problems in their patients, to offer appropriate psychological care, and to know when and how to refer for psychiatric help. When a referral is made it needs to be picked up by a psychiatric service that understands the complexity of physical and psychiatric comorbidity and can deliver appropriate treatments that are accessible and acceptable to the referring agent, the other staff working in the general hospital, and the patient.

Fortunately, the working group's report includes sections on defining and recognising psychological problems and outlines the main approaches to treatment. There are sections on different models of liaison psychiatry services and how to arrange for their purchase (liaison psychiatry is the subspecialty of psychiatry concerned with clinical service, teaching, and research in non-psychiatric health care settings).¹³

Training for specialists and non-specialists has a separate section, although there is unfortunately nothing on the relevance of liaison psychiatry to undergraduate education. The refocusing of undergraduate medical education by the General Medical Council¹⁴ has highlighted the need for training in those aspects of psychiatric practice required most urgently by newly qualified house staff, and most of these are recognisably within the remit of the working group's report.

There is a welcome guide for purchasers, many of whom will not think about these issues unless carefully briefed to do so. The advice is forthright: acute services in general hospitals should be purchased only where an adequate liaison service is included, and the cost of the liaison psychiatry service should be included within the costs of each medical service. Quality of service and expediency are among the reasons for arranging integrated physical and psychiatric care. There is also a financial argument. One study from the United States showed that an orthopaedic liaison psychiatry service paid for itself by reducing lengths of stay by an average of two days, saving more than $250000 of the inpatient costs of treating 452 patients.¹⁵

For those who want the planning of services to be evidence based, the authors have included an extensive bibliography to support their conclusions and recommendations. This important report deserves to be widely read and acted on by those who commission care for physically ill patients and those who provide it.

Consultant and senior lecturer Department of Liaison Psychiatry, Leeds General Infirmary, Leeds LS1 3EX

Professor Digestive Diseases Research Centre, Medical College of St Bartholomew's Hospital, London EC1M 6BQ

Senior lecturer Department of Psychiatry, Royal South Hants Hospital, Southampton SO14 0YG

Allan House, Michael Farthing, Robert Peveler 

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8. Bass C, ed. Somatization: physical symptoms and psychological illness. London: Blackwell, 1990.
9. Creed F, Mayou R, Hopkins A, eds. Medical symptoms not explained by organic disease. London: Royal College of Psychiatrists and Royal College of Physicians of London, 1992.
10. Saravay S, Lavin M. Psychiatric comorbidity and length of stay in the general hospital: a critical review of outcome studies. Psychosomatics 1994;35:233-52. [Abstract/Free Full Text]
11. House A. Psychiatric disorders, inappropriate health service utilization and the role of consultation-liaison psychiatry. J Psychosom Res (in press).
12. Royal Colleges of Physicians and Psychiatrists. Joint working party report: the psychological care of medical patients: recognition of need and service provision. London: RCGP, 1995.
13. Benjamin S, House A, Jenkins P. Liaison psychiatry--defining needs and planning services. London: Gaskell Press, 1993.
14. General Medical Council. Tomorrow's doctors. Recommendations on undergraduate medical training. London: GMC, 1993.
15. Strain J, Lyons JS, Hammer J, Fahs M, Lebovits A, Paddison P, et al. Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. Am J Psychiatry 1991;148:1044-9. [Abstract/Free Full Text]