Doubts about being of value: an important aspect of countertransference in consultation-liaison psychiatry

Doubts about being of value to medically ill patients and their referring physicians is not an uncommon emotional reaction of consultation-liaison psychiatrists to the medical environment. Both realistic perceptions of negative attitudes of non-psychiatric physicians as well as unrealistic doubts about their potential usefulness, which may be projected upon and attributed to their non-psychiatric colleagues, can contribute to this unsettling response. This reaction may interfere with effective collaboration between consultation-liaison psychiatrists and their non-psychiatric colleagues and needs to be understood and mastered.     

The family in consultation-liaison psychiatry

This article calls attention to an underemphasized aspect of consultation-liaison psychiatry: the importance of the family in the management of illnes response. Recent trends in family dynamics have focused primarily on family therapy and less on the critical role family members play in the “coloration”, course, and outcome of acute episodes of illness. Case vignettes illustrate examples of intervention by liaison team members in the care of hospitalized medical-surgical patients. The authors suggest that a typology of family response to illness and hospitalization would offer a useful framework for diagnosis, evaluation, and management of the psychosocial aspects of illness. A coordinated approach by liaison team members is important to ensure comprehensive treatment.     

The future of consultation-liaison psychiatry

OBJECTIVE: To review the status of consultation-liaison psychiatry and the factors shaping it, and suggest strategies for its future development. METHOD: In addition to searches of the main computerized psychiatric databases and review of relevant Commonwealth of Australia publications, the author drew on discussions with national and international colleagues in his role as convenor of the International Organization for Consultation-Liaison Psychiatry. RESULTS: Physical/psychiatric comorbidity and somatization, the conditions in which consultation-liaison psychiatry specializes, are the commonest forms of psychiatric presentation in the community. They are as disabling as psychotic disorders, and comorbid depression in particular is a predictor of increased morbidity and mortality. Acknowledging this, the Second Australian National Mental Health Plan called for consultation-liaison psychiatry to be allowed to participate fully in the mental health care system. It stated that failure to define the term 'severe mental health problems and mental disorders' in the First Plan had led to some public mental health systems erroneously equating severity with diagnosis rather than level of need and disability. The call has been largely unheeded. The implication for patient care is both direct and indirect; the context created for psychiatry training by such a restricted focus is helping to perpetuate the neglect of such patients. This is a worldwide problem. CONCLUSIONS: Proactive involvement with consumers is required if the problem is to be redressed. At a service level, development of a seamless web of pre-admission/admission/post-discharge functions is required if patients with physical/psychiatric comorbidity and somatoform disorders are to receive effective care, and consultation-liaison psychiatry services are to be able to demonstrate efficacy. Focus on comorbidity in the Australian Third National Mental Health Plan may force resolution of the current problems.     

会诊联络精神医学的研究进展

随着社会发展，各方面的压力使患有精神心理疾病的人数不断增加，由于对精神医学知 识的认识不足，大部分患者就诊于综合科室，可能存在相当数量的漏诊。会诊联络精神医学逐渐发展、 完善起来，探索出适合我国国情的会诊模式具有重要的临床意义。因为会诊联络精神医学的服务对象 是综合科室中有精神心理问题的患者，所以对会诊医师的专业水平和技能要求较高。关于会诊联络精 神医学服务模式、对会诊医师的培养及有效性的研究，值得临床医师进行进一步探讨。     

Psychotherapy in consultation-liaison psychiatry

Psychotherapy in the Consultation-Liaison (C-L) setting is shaped by the realities of the patient's situation, since all patients referred are dealing with physical illness. The patient's state of physical and mental health will determine both the type of therapeutic work possible and the focus of such work. Tailoring the therapeutic intervention to the patient's specific needs and flexibility in altering and adapting therapeutic strategies over time in line with the patient's changing needs are essential. Although periods of treatment may range from single session to long term, supportive, insight oriented, group, family, cognitive and behavioral techniques have all been used successfully in a C-L setting, with measurable impact on well-being. Psychotherapeutic work in C-L is unique in that the focus of the therapist extends beyond the patient and family to include all caregivers, including other health care professionals, in line with the biopsychosocial model.     

会诊-联络精神医学述评

会诊-联络精神医学（CLP）是精神病学的分支学科，现对CLP发展史做一简评，寻找国内 外差距，从临床及医学教育的角度提出CLP国内未来发展方向及建议。     

Products of consultation-liaison psychiatry

The products of consultation and liaison activities differ considerably and require distinct marketing strategies. Whereas consultation results directly in improved patient care, the products of psychiatric liaison typically consist of less easily measured changes in nonpsychiatric physicians' attitudes and skills. The difficulty of demonstrating the benefits of liaison psychiatry as presently conceived suggest that its future course lies in the active collaboration of liaison psychiatrists in specialized treatment programs.     

Concordance with recommendations in a consultation-liaison psychiatry service

We studied the concordance of physicians with the recommendations of psychiatric consultants in a sample of 270 consultations in a 400-bed general hospital. Of the patients about whom a consultation was sought, 37% had a past psychiatric history, and 67% were on psychotropic drugs. Twelve percent had Organic Mental Disorder, 35% Affective Disorder, and for 24% no DSM-III diagnosis could be made. The psychiatrist made psychotropic drug recommendations in 62%, and the physicians' concordance with this recommendation was 86%. The physician's discharge summary included a diagnosis which concorded with the psychiatrist's diagnosis in 53% of files. The psychiatrist recommended further investigations in only 5.2% of files.     

Recent research developments in consultation-liaison psychiatry

With the major changes in health care and general hospital practice in the last decade, practice and research in consultation and liaison psychiatry have also changed dramatically. The authors present a selected review of recent advances and implications for five important topics in consultation-liaison research: diagnosis, disease mechanisms, biologic treatments, health services, and psychosocial treatments for medical disorders.     

Clinical applications of DSM-III in consultation-liaison psychiatry

The authors examine the clinical application of DSM-III from the perspective of the consultation-liaison psychiatrist. They discuss contributions of DSM-III that have refined psychiatric diagnosis in medical-surgical settings, including the multiaxial system, a broader approach to the organic mental disorders, introduction of the category of psychological factors affecting physical condition, and an improved classification of disorders that present with physical symptoms. However, some areas of continuing ambiguity remain, such as how much discretion a clinician has to discount somatic symptoms related to physical illness in the diagnosis of depression, the implications of exempting bereavement from diagnostic status, and uncertainty about what constitutes evidence of an etiological relationship.     

Application of systems principles in consultation-liaison psychiatry

The application of systems principles in a hospital setting, its value as a diagnostic tool in assessing problem behavior and its use in planning intervention are described. Examples from different treatment settings are used to demonstrate the applications.