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CONSULTATION-LIAISON PSYCHIATRY: AN AUSTRALIAN EXPERIENCE. BY DR HENRY AGHANWA, MBBS, FWACP, FRANZCP 1 Consultant Psychiatrist Toowoomba Base Hospital Toowoomba, Queensland Australia Senior Lecturer (Psychiatry) Rural Division, School of Medicine University of Queensland Toowoomba Queensland Australia 2 DEFINITIONS Consultation-Liaison Psychiatry is defined as consultation to and collaboration with the non-psychiatric specialist in the management of a patient with a primary physical condition complicated by psychiatric comorbidity in the general hospital setting or any other health facility 3 Consultation Psychiatry • The provision of assessment and intervention to a patient with primary medical condition who has developed a psychiatric complication. • It is reactive 4 Liaison Psychiatry • The is the conduction of an exploration with the intent of carrying out a mediatory role between a patient with primary physical condition and the treating team. • It is proactive • It helps to improve the interpersonal relationship between the treatment team and the patient • It prevents the development of a full-fledged psychopathology or prevents the deterioration of the primary physical condition. 5 Synonyms • • • • • Consultation-Liaison Psychiatry Psychosomatic Medicine General Hospital Psychiatry Medical/surgical Psychiatry De facto Psychiatry 6 The areas of activities • Mainly inpatient settings • Some outpatient settings The settings include the medical, surgical, and obstetric units, ICU, coronary care unit, burnt unit, renal unit, oncology unit, palliative unit. Paediatric unit- for the child & adolescent psychiatrist. 7 Settings cont’d • The outpatient units include general and medical speciality clinics (renal unit and ANC) 8 Areas of interest within CLP • • • • • Psychooncology Psychonephrology Psychosomatic Obstetrics and Gynaecology CLP of Cardiology and Gastroenterology General CLP 9 Theoretical Basis • CLP was originally based on psychosomatic medicine which was the body of theoretical information put together by psychoanalysis. • CLP has been described as the clinical pendant of psychosomatic medicine • Biopsychosocial is emphasized • Adolf Meyer’s psychobiological approach was the starting point of CLP in the USA where its practice began 10 Scope of the CLP service Psychiatric assessment and intervention in the non-psychiatric speciality context Assessment of capacity/competence to accept or refuse treatment of a general medical condition Education of non-psychiatric team on mental health 11 Scope cont’d Collaboration with non-psychiatric specialists in research at the interface between physical and psychological medicine Provision of support to the non-psychiatric specialists in the management of psychiatric condition in the general medical context. 12 Conditions commonly encountered • Anxiety related conditions such as generalized anxiety disorder • Affective Disorders such as depressive episode • Psychotic disorders (e.g. acute and transient psychotic disorder) • Cognitive disorders (e.g. Delirium, Dementia) • Addiction disorders • Somatoform disorders (somatization disorder) 13 Conditions commonly encountered cont’d • Adjustment Disorders • Personality Disorders 14 INTERVENTIONS IN CLP • Pharmacotherapy • Review of patient’s existing medications • Provision of advice on laboratory and radiological investigations • Psychotherapeutic interventions CBT, IPT, Brief dynamic psychotherapy, supportive psychotherapy • Liaising with other members of the multidisciplinary team. 15 Models of CLP • Consultative model • Joint endaevour model • Outpost model In practice services are often adapted to local situations or developed to serve the peculiar needs of a situation. No two services are identical 16 Staff Composition • • • • • A psychiatrist A nurse Psychologist Social Worker Psychiatry registrar 17 Challenges • The use of psychopharmalogical agents in the presence of compromised physical status • The possibility of an interaction between medications for physical and those of mental illness. • The tendency of some non-psychiatric specialists to reject the mentally ill patient due to stigma • Determining when to evoke the guardianship administration or the mental health act 19 • Determining when to transfer the mentally disruptive patient from the non-psychiatric unit to the psychiatric facility • Working with two clients—the referring specialist, and the referred patient. 20 Emerging Issues • The reluctance of the health insurance to fund mental treatment for a physically unwell person. • The confusion between CL as a sub-speciality and as a process. • The ongoing debate on who funds the CLP? the general hospital or the psychiatric service? 21 Training in CLP • In a 5-year postgraduate program in psychiatry leading to the award of the Fellowship, a 6 month rotation in CLP is mandatory. However, any interested registrar can spend an additional period of 6 months as a part of his advanced training. Doing this will enable the registrar to obtain a certificate in advanced training in addition to the fellowship. 22 References J A. Bourgeois, D M. Hilty, M E. Servis and R E. Hales. Consultation-Liaison Psychiatry Advantages for Healthcare Systems Dis Manage Health Outcomes 2005; 13 (2): 93106 REVIEW ARTICLE 1173-8790 23 Aghanwa HS, Morakinyo O, Aina OF. Consultation-liaison psychiatry in a general research? J Psychosom Res 1995; 39: 247-50 hospital setting in West Africa. East Afr Med J 1996; 73: 133-6 24 Aghanwa HS. Consultation-liaison Psychiatry in the main general hospital in Fiji-Islands. Pacific Health Dialog (Asia- Pacific) 2002; 9(1): 21-28. 25