506
Journal of the Royal Society of Medicine Volume 83 August 1990
Styles of liaison psychiatry: discussion
paper
A White MRCPsych MD Department of Psychological Medicine, County Hospital, North Road, Durham DH1 4ST Keywords: psychiatry; medicine; audit
Liaison psychiatry is the term used confusingly both for the whole field of psychiatric services to general hospitals and for one of the two styles within it; the other is the more traditional consultation style. At times, particularly in North America, the two styles of liaison psychiatry have polarized until they come to rival each other'. Such rivalry may reflect the stressful nature of a common task that has potential to induce tension between those who work within it. This is a familiar problem in psychiatry, best countered by ensuring well organized, cohesive and mutually supportive clinical practice. Nevertheless, for practical reasons either a consultation or a liaison style is usually adopted. There have been few previous comparisons of these styles2-4. This paper describes their common theoretical aims, examines the extent to which they are fulfilled by each style and the advantages and disadvantages of each. A liaison psychiatrist here refers to the doctor who provides the service in the general hospital, irrespective of the style used.
Theoretical aims of liaison psychiatry Psychiatry in general hospitals has always proved contentious. Early attempts to proselytize about the influence of non-organic factors on the course of the classic psychosomatic illnesses were unrealistic and brought disrepute5-7. Subsequently psychiatry has mellowed in its aims and concentrated on the identification of medical patients who have a psychiatric disorder which warrants treatment. The way this is done may create or solve many problems but will have certain fundamental features. A liaison service must be accessible, without geographic or administrative barriers7'8. The liaison psychiatrist must adopt a broad clinical approach variously termed biopsychosocial, unitary or holistic9"10. Indeed, the responsibility for teaching comprehensive patient assessment has been said to lie with liaison psychiatry; the important point is the avoidance of hard mind-body distinctions"A68'1'. Treatment may need to be flexible and eclectic, requiring a sound knowledge of medicine and pharmacology in addition to the range of psychotherapeutic skills of general psychiatry. However, if used without discretion psychodynamic principles can become simplistic cliches or woolly jargon that is aversive to physicians7"12. Several studies have addressed the resistance of physicians to psychiatric referral'2-'6. The reasons elicited warrant repetition as many of the desirable features of a liaison service follow logically (Table 1). Much antipathy arises from a lack of understanding of the fundamental differences between the concepts and models used by each specialty. This places
Table 1. Reasons cited in surveys ofwhy medical patients are not referred to psychiatrists
Psychiatric service dissatisfies physician Psychiatric language useless to physician Physician unaware of need for psychiatric intervention Physician unaware of possibility of psychiatric intervention Physician unaware of benefit of psychiatric intervention Physician believes psychiatric disorder incurable Physician fears patient's emotions Physician feels he does not know patient well enough Denial of significance of psychological issues Poor working relationships between physician & psychiatrist Physician believes patient is disadvantaged by being labelled as a psychiatric case Patient refuses psychiatric referral Physician believes patient too physically ill Physician believes every doctor should be able to treat psychiatric illness Physician unable or unwilling to spare time for psychological issues
conflicting demands upon the liaison psychiatrist. He must keep pace with advances in medicine, accustom physicians to his presence, respond to their interests, gain rapport and counter negative views. Yet at the same time he must ensure provision for the special needs of mental illness which may fit uneasily with general medical care7"2"7 Meeting these demands may leave liaison psychiatrists isolated from their peer group. They may be drawn to this work by compassion arising from personal experiences, motives which are not wrong in themselves, but may be dangerous ifthe psychiatrist is left vulnerable to the frequent suffering and mortality that the work entails7"8. The frequent social problems and the need to work across disciplines means that a liaison unit will benefit from staff with diverse backgrounds. Junior doctors, nurse counsellors, social workers and psychologists can provide clinical input and education in an economical and acceptable way that cannot be achieved in the time available to a consultant liaison psychiatrist1'6'7"9'0. There are also dangers for the rest of psychiatry. Firstly, psychiatry has been drifting away from medicine in conceptual thinking. If liaison psychiatrists have a monopoly their colleagues in general psychiatry may actually avoid contact with medicine, impoverishing both specialties as a result7"17"18. Secondly, if liaison psychiatry succeeds in an alliance with medicine, it may become separated from the rest of psychiatry and forfeit the accompanying benefits'8. Thirdly, problems arise with funding. In the UK resources are allocated according to estimates of population and morbidity. Treating previously
0141-0768/90/
080506-03/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 August 1990 507 latent psychiatric disorder in the physically ill could short change the service to the general population. The continuing controversy over the optimal style of liaison practice probably reflects the unresolvable nature of these problems.
The two styles of liaison psychiatry The cornerstone of the consultation style is a psychiatrist available to respond to the requests of a general hospital8. The ideal consultation style would employ its own designated psychiatrists full time, but more commonly general psychiatrists are 'on duty' to the general hospital in addition to other commitments. This gives all psychiatrists some experience of the physically ill and they have the use of their own psychiatric beds to transfer patients who need further inpatient care. The disadvantage is that a 'hit and run' service results, with a different psychiatrist responding to each request for consultation. Continuity of care is lacking and no corpus of liaison skill accumulates in the psychiatric staff, who remain unfamiliar, unavailable and inaccessible to the general hospital7'8. The single visit and entry in the case notes limits the potential for teaching of psychological skills to medical ward staff. The only further intervention is transfer to a distant psychiatric hospital, where provision ofmedical care becomes the problem. A major difficulty arises from the way the consultation style relies upon, yet at the same time de-skills, the general medical staff who detect and refer patients with psychiatric disorder. The result is that nobody has responsibility for the routine psychological care of medical patients. Latent psychiatric disorder may remain undetected, referrals remain undiscerning and the service operates at the crude level of identifying patients who are uncooperative, noncompliant, disruptive or acting oddly2l'22. This has analogies with primary care, where Goldberg and Huxley have described the need to educate general practitioners so that they can act as effective gatekeepers in the pathway to psychiatric care23. Similarly, Sensky likens physicians to gatekeepers for the physically ill24. The liaison style provides a more pervasive psychiatric service, influencing many aspects ofmanagement through increased contact with patients or staff or both. The ideal liaison style would deploy a staff member to each medical unit, but this is a luxury seldom achieved outside North America. A common compromise uses a multidisciplinary team working from a single office and consulting rooms in the District General Hospital (DGH)25. These full-time staff become familiar around the general hospital and in particular casualty, removing the enigmatic remoteness that so often surrounds psychiatry and lowering the threshold for formal referral and informal advice. The disadvantage is that the liaison staff may become isolated from their general psychiatry colleagues, who in turn are deprived ofthe benefits of contact with medicine. Neither the liaison nor the consultation style provides for the special needs of mental illness, as in each case the patients are cared for entirely by general nurses in a medical ward. However, the liaison style does permit general nurses to develop skills of psychological care under guidance from consistent members of liaison staff. In this way general medical and nursing staff have been shown
to become more insightful and discerning in their referrals once a liaison service is established20. The liaison style does to some degree permit care to be tailored to patients' individual needs. The largest single diagnostic category is deliberate self harm (DSH), who are ideally admitted to a designated short stay ward, concentrating the experience of general nurses in their care and liaison staff in their assessment. Subsequent management may be a period of outpatient treatment followed where appropriate by open access through a telephone 'hotline' to the same specialist staff25. Similarly, referrals from medical wards can also receive assessment and followup by the same liaison staff. The consultation style has no special provision for DSH patients, who may be scattered through different medical wards where their psychological needs have to rival the range of demands on busy nurses who have no recourse to psychiatric advice. At times beds have to be borrowed in units where the staff may lack the skill or motivation to attend to the psychological needs of a temporary 'guest' patient perceived as a nuisance that will go away sooner if ignored. The management difficulties presented by DSH necessitated the 1984 DHSS guidelines, recommending that each DGH should have a Multidisciplinary Standing Committee on the Management of Self Harm. Sadly, few Districts have heeded this recommendation, but those that have now benefit from innovative care and research that helps to overcome the difficulties of the consultation style26. A DGH psychiatry unit clearly brings the possibility of the right balance of care, but true joint medical and psychiatric care remains an elusive ideal that is seldom attained.
Conclusion On most accounts the liaison style appears more effective, more fully achieving the aim of psychological care for the physically ill. However, like the green vote in politics, the very justification of liaison psychiatry is threatened by the irony that it will no longer need be required when its goals are realized. At present we are far from this position; the standard of psychological care in most general hospitals does not justify the absence of a liaison service; but before we, argue for ubiquitous liaison psychiatrists we must consider the hitherto unmentioned parameter of resources. There can be no doubt that a liaison unit is extravagant. Proponents of the consultation style could well claim that general hospital staff could be more efficiently equipped with the necessary psychological skills for less outlay. The 'reluctant registrar' called upon by the consultation style to assess and dispose of cases between other cmitments may be irresistibly economical. This extreme position is represented by a 1981 Editorial, 'Psychiatry and psychiatrists are set to stay in the doldrums ... in future all hospital doctors should understand and apply the principles and practice of psychological medicine'27. Project 2000 brings the nursing profession considerably closer to achieving this than the medical profession. So, can the greater effectiveness of a liaison service be justified? House and Jones cite as justification the increased referral of major mental illness after introduction of a liaison service, but this has to be offset against a corresponding increase in referrals of the 'worried well'28. Individuals with these minor
508
Journal of the Royal Society of Medicine Volume 83 August 1990
psychological or psychosocial disorders are often skilled at recruiting help yet most remit spontaneously219Z. They must not be allowed to divert resources from the more handicapped patient who may suffer in silence. Liaison psychiatry has an important role in directing as well as providing psychological care; we must audit both the efficiency and the effectiveness of our work6. However, the present situation in the UK is dangerous, as resource indicators are developingfaster than indicators of clinical quality and outcome. Present stringencies are requiring demonstration of physical benefit from psychological care. A relationship between physical and mental health has long been recognized, but the direction -of the effect is less easy to establish30. Psychological interventions in cancer lead this field but replication in other settings is proving more difficult. Clinical practice must not be dominated entirely by loyalties to financial considerations. Psychological care is integral to good medicine and this should be ample justification, something that present political proposals for the NHS fail to realize. Acknowledgments: I am grateful to Dr Erica Jones and Professor H G Morgan for their helpful advice. References 1 Lipowski ZJ. Consultation-liaison psychiatry: the first half century. Gen Hosp Psychiatry 1986;8:305-15 2 Crisp AH. The role of the pychiatrist in the general hospital. Postgrad Med J 1968;44:267-76 3 Torem M, Saraway SM, Steinberg H. Psychiatric liaison: benefits of an "active" approach. Psychosomatics 1979,20:598-611 4 Sensky T, Cundy T, Greer S, Pettingale K. Referrals to psychiatrists in a general hospital - comparison of two methods of liaison psychiatry. J R Soc Med 1985; 78:463-8 5 Editorial. Referred to the psychiatrist. Lancet 1937;
ii:1496-7 6 Lloyd GG. Whence and whither liaison psychiatry. Psychol Med 1980;10:11-14 7 Thomas C. Establishing liaison psychiatric services: a personal view. Int J Soc Psychiatry 1985;31:149-55 8 Lipowski ZJ. Review of consultation psychiatry
and psychosomatic medicine. I. General principles. Psychosom Med 1967;29:153-71 9 Meyer A. Psychobiology: a science of man. Springfield: CC Thomas, 1957 10 Engel GL. The biopsychosocial approach and medical education. N Engi J Med 1982;306:802-5 11 McKegney FP, Weiner S. A consultation-liaison psychiatry clinical clerkship. Psychosom Med 1976; 38:45-54
12 Mason AS. Psychiatry and general medicine. Medicine (2nd series), 1975;11:510-12 13 Mezey AG, Kellett JM. Reasons against referral to the psychiatrist. Postgrad Med J 1971;47:315-19 14 Pritchard M Who sees a psychiatrist? A study offactors related to psychiatric referral in the general hospital. Postgrad Med J 1972;48:645-51 15 Steinberg H, Torem M, Saraway SM. An analysis of physicians resistance to psychiatric consultation. Arch Gen Psychiatry 1980;37:1007-12 16 Mayou R, Smith EBO. Hospital doctors' management of psychological problems. Br J Psychiatry 1986; 148:194-7 17 Hackett TP. The psychiatrist: In the mainstram or on the banks ofmedicine? Am JPsychiatry 1977;134.432-4 18 McKegney FP. Cultation4iaison teac g of pycosomatic medicine: opportuif es and obstacles. J Nerv Ment Dis 1972;154:198-205 19 Shepherd M, Davies B, Culpan RH. Psychiatric illness in the general hospital. Acta Psychiat Scand 1960; 38:518-25 20 Davis DS, Nelson JKN. Referrals to psychiatric liaison nurses: changes in characteristics over a limited period. Gen Hosp Psychiatry 1980;2:41-5 21 Maguire GP, Julier DL, Hawton KE, Bancroft JHJ. Psychiatric morbidity and referrals on two general medical wards. Br Med J 1974;1:268-70 22 Ries RK, Kleinman A, Bokan JA, Schukit MA. Psychiatric consultation-liaison service. Patients, requests, functions. Gen Hosp Psychiatry 1980;3:204-12 23 Goldberg D, Huxley P. Mental illness in the community. The pathway to psychiaric care. London: Tavisock, 1980 24 Sensky T. The general hospital psychiatrist: too many task and too few roles? Br JPsyvhiaty 1986;148:151-8 25 Hawton K, Gath DH, Smith EBO. Management of attempted suicide in Oxford. Br Med J 1979;2:1040-2 26 Brisol & Weston Health Authority Staing Connittee on the management of self harm. Code of Practice. Bristol Royal Infirmary. Bristol & Weston Health Authority, 1989 27 Editorial. Psychiatry in the general hospital. Br Med J 1981;282:1256-7 28 House AO, Jones SJ. The effects of establishing a psychiatric consultation-liaison service: Changes in patterns of referral and care. Health Trends 1987; 19:10-12 29 Schwab JJ, Clemmons RS, Freemon FR, Scott ML. Differential ateristics of medical inatients referred for psychiatric consultation. Psychosom Med 1965; 27:112-18 30 Mayou R, Hawton K. Psychiatric disorder in the general hospital. Br J Psychiatry 1986;149:172-90
(Accepted 24 January 1990)
Journal of the Royal Society of Medicine Volume 83 August 1990
Styles of liaison psychiatry: discussion
paper
A White MRCPsych MD Department of Psychological Medicine, County Hospital, North Road, Durham DH1 4ST Keywords: psychiatry; medicine; audit
Liaison psychiatry is the term used confusingly both for the whole field of psychiatric services to general hospitals and for one of the two styles within it; the other is the more traditional consultation style. At times, particularly in North America, the two styles of liaison psychiatry have polarized until they come to rival each other'. Such rivalry may reflect the stressful nature of a common task that has potential to induce tension between those who work within it. This is a familiar problem in psychiatry, best countered by ensuring well organized, cohesive and mutually supportive clinical practice. Nevertheless, for practical reasons either a consultation or a liaison style is usually adopted. There have been few previous comparisons of these styles2-4. This paper describes their common theoretical aims, examines the extent to which they are fulfilled by each style and the advantages and disadvantages of each. A liaison psychiatrist here refers to the doctor who provides the service in the general hospital, irrespective of the style used.
Theoretical aims of liaison psychiatry Psychiatry in general hospitals has always proved contentious. Early attempts to proselytize about the influence of non-organic factors on the course of the classic psychosomatic illnesses were unrealistic and brought disrepute5-7. Subsequently psychiatry has mellowed in its aims and concentrated on the identification of medical patients who have a psychiatric disorder which warrants treatment. The way this is done may create or solve many problems but will have certain fundamental features. A liaison service must be accessible, without geographic or administrative barriers7'8. The liaison psychiatrist must adopt a broad clinical approach variously termed biopsychosocial, unitary or holistic9"10. Indeed, the responsibility for teaching comprehensive patient assessment has been said to lie with liaison psychiatry; the important point is the avoidance of hard mind-body distinctions"A68'1'. Treatment may need to be flexible and eclectic, requiring a sound knowledge of medicine and pharmacology in addition to the range of psychotherapeutic skills of general psychiatry. However, if used without discretion psychodynamic principles can become simplistic cliches or woolly jargon that is aversive to physicians7"12. Several studies have addressed the resistance of physicians to psychiatric referral'2-'6. The reasons elicited warrant repetition as many of the desirable features of a liaison service follow logically (Table 1). Much antipathy arises from a lack of understanding of the fundamental differences between the concepts and models used by each specialty. This places
Table 1. Reasons cited in surveys ofwhy medical patients are not referred to psychiatrists
Psychiatric service dissatisfies physician Psychiatric language useless to physician Physician unaware of need for psychiatric intervention Physician unaware of possibility of psychiatric intervention Physician unaware of benefit of psychiatric intervention Physician believes psychiatric disorder incurable Physician fears patient's emotions Physician feels he does not know patient well enough Denial of significance of psychological issues Poor working relationships between physician & psychiatrist Physician believes patient is disadvantaged by being labelled as a psychiatric case Patient refuses psychiatric referral Physician believes patient too physically ill Physician believes every doctor should be able to treat psychiatric illness Physician unable or unwilling to spare time for psychological issues
conflicting demands upon the liaison psychiatrist. He must keep pace with advances in medicine, accustom physicians to his presence, respond to their interests, gain rapport and counter negative views. Yet at the same time he must ensure provision for the special needs of mental illness which may fit uneasily with general medical care7"2"7 Meeting these demands may leave liaison psychiatrists isolated from their peer group. They may be drawn to this work by compassion arising from personal experiences, motives which are not wrong in themselves, but may be dangerous ifthe psychiatrist is left vulnerable to the frequent suffering and mortality that the work entails7"8. The frequent social problems and the need to work across disciplines means that a liaison unit will benefit from staff with diverse backgrounds. Junior doctors, nurse counsellors, social workers and psychologists can provide clinical input and education in an economical and acceptable way that cannot be achieved in the time available to a consultant liaison psychiatrist1'6'7"9'0. There are also dangers for the rest of psychiatry. Firstly, psychiatry has been drifting away from medicine in conceptual thinking. If liaison psychiatrists have a monopoly their colleagues in general psychiatry may actually avoid contact with medicine, impoverishing both specialties as a result7"17"18. Secondly, if liaison psychiatry succeeds in an alliance with medicine, it may become separated from the rest of psychiatry and forfeit the accompanying benefits'8. Thirdly, problems arise with funding. In the UK resources are allocated according to estimates of population and morbidity. Treating previously
0141-0768/90/
080506-03/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 August 1990 507 latent psychiatric disorder in the physically ill could short change the service to the general population. The continuing controversy over the optimal style of liaison practice probably reflects the unresolvable nature of these problems.
The two styles of liaison psychiatry The cornerstone of the consultation style is a psychiatrist available to respond to the requests of a general hospital8. The ideal consultation style would employ its own designated psychiatrists full time, but more commonly general psychiatrists are 'on duty' to the general hospital in addition to other commitments. This gives all psychiatrists some experience of the physically ill and they have the use of their own psychiatric beds to transfer patients who need further inpatient care. The disadvantage is that a 'hit and run' service results, with a different psychiatrist responding to each request for consultation. Continuity of care is lacking and no corpus of liaison skill accumulates in the psychiatric staff, who remain unfamiliar, unavailable and inaccessible to the general hospital7'8. The single visit and entry in the case notes limits the potential for teaching of psychological skills to medical ward staff. The only further intervention is transfer to a distant psychiatric hospital, where provision ofmedical care becomes the problem. A major difficulty arises from the way the consultation style relies upon, yet at the same time de-skills, the general medical staff who detect and refer patients with psychiatric disorder. The result is that nobody has responsibility for the routine psychological care of medical patients. Latent psychiatric disorder may remain undetected, referrals remain undiscerning and the service operates at the crude level of identifying patients who are uncooperative, noncompliant, disruptive or acting oddly2l'22. This has analogies with primary care, where Goldberg and Huxley have described the need to educate general practitioners so that they can act as effective gatekeepers in the pathway to psychiatric care23. Similarly, Sensky likens physicians to gatekeepers for the physically ill24. The liaison style provides a more pervasive psychiatric service, influencing many aspects ofmanagement through increased contact with patients or staff or both. The ideal liaison style would deploy a staff member to each medical unit, but this is a luxury seldom achieved outside North America. A common compromise uses a multidisciplinary team working from a single office and consulting rooms in the District General Hospital (DGH)25. These full-time staff become familiar around the general hospital and in particular casualty, removing the enigmatic remoteness that so often surrounds psychiatry and lowering the threshold for formal referral and informal advice. The disadvantage is that the liaison staff may become isolated from their general psychiatry colleagues, who in turn are deprived ofthe benefits of contact with medicine. Neither the liaison nor the consultation style provides for the special needs of mental illness, as in each case the patients are cared for entirely by general nurses in a medical ward. However, the liaison style does permit general nurses to develop skills of psychological care under guidance from consistent members of liaison staff. In this way general medical and nursing staff have been shown
to become more insightful and discerning in their referrals once a liaison service is established20. The liaison style does to some degree permit care to be tailored to patients' individual needs. The largest single diagnostic category is deliberate self harm (DSH), who are ideally admitted to a designated short stay ward, concentrating the experience of general nurses in their care and liaison staff in their assessment. Subsequent management may be a period of outpatient treatment followed where appropriate by open access through a telephone 'hotline' to the same specialist staff25. Similarly, referrals from medical wards can also receive assessment and followup by the same liaison staff. The consultation style has no special provision for DSH patients, who may be scattered through different medical wards where their psychological needs have to rival the range of demands on busy nurses who have no recourse to psychiatric advice. At times beds have to be borrowed in units where the staff may lack the skill or motivation to attend to the psychological needs of a temporary 'guest' patient perceived as a nuisance that will go away sooner if ignored. The management difficulties presented by DSH necessitated the 1984 DHSS guidelines, recommending that each DGH should have a Multidisciplinary Standing Committee on the Management of Self Harm. Sadly, few Districts have heeded this recommendation, but those that have now benefit from innovative care and research that helps to overcome the difficulties of the consultation style26. A DGH psychiatry unit clearly brings the possibility of the right balance of care, but true joint medical and psychiatric care remains an elusive ideal that is seldom attained.
Conclusion On most accounts the liaison style appears more effective, more fully achieving the aim of psychological care for the physically ill. However, like the green vote in politics, the very justification of liaison psychiatry is threatened by the irony that it will no longer need be required when its goals are realized. At present we are far from this position; the standard of psychological care in most general hospitals does not justify the absence of a liaison service; but before we, argue for ubiquitous liaison psychiatrists we must consider the hitherto unmentioned parameter of resources. There can be no doubt that a liaison unit is extravagant. Proponents of the consultation style could well claim that general hospital staff could be more efficiently equipped with the necessary psychological skills for less outlay. The 'reluctant registrar' called upon by the consultation style to assess and dispose of cases between other cmitments may be irresistibly economical. This extreme position is represented by a 1981 Editorial, 'Psychiatry and psychiatrists are set to stay in the doldrums ... in future all hospital doctors should understand and apply the principles and practice of psychological medicine'27. Project 2000 brings the nursing profession considerably closer to achieving this than the medical profession. So, can the greater effectiveness of a liaison service be justified? House and Jones cite as justification the increased referral of major mental illness after introduction of a liaison service, but this has to be offset against a corresponding increase in referrals of the 'worried well'28. Individuals with these minor
508
Journal of the Royal Society of Medicine Volume 83 August 1990
psychological or psychosocial disorders are often skilled at recruiting help yet most remit spontaneously219Z. They must not be allowed to divert resources from the more handicapped patient who may suffer in silence. Liaison psychiatry has an important role in directing as well as providing psychological care; we must audit both the efficiency and the effectiveness of our work6. However, the present situation in the UK is dangerous, as resource indicators are developingfaster than indicators of clinical quality and outcome. Present stringencies are requiring demonstration of physical benefit from psychological care. A relationship between physical and mental health has long been recognized, but the direction -of the effect is less easy to establish30. Psychological interventions in cancer lead this field but replication in other settings is proving more difficult. Clinical practice must not be dominated entirely by loyalties to financial considerations. Psychological care is integral to good medicine and this should be ample justification, something that present political proposals for the NHS fail to realize. Acknowledgments: I am grateful to Dr Erica Jones and Professor H G Morgan for their helpful advice. References 1 Lipowski ZJ. Consultation-liaison psychiatry: the first half century. Gen Hosp Psychiatry 1986;8:305-15 2 Crisp AH. The role of the pychiatrist in the general hospital. Postgrad Med J 1968;44:267-76 3 Torem M, Saraway SM, Steinberg H. Psychiatric liaison: benefits of an "active" approach. Psychosomatics 1979,20:598-611 4 Sensky T, Cundy T, Greer S, Pettingale K. Referrals to psychiatrists in a general hospital - comparison of two methods of liaison psychiatry. J R Soc Med 1985; 78:463-8 5 Editorial. Referred to the psychiatrist. Lancet 1937;
ii:1496-7 6 Lloyd GG. Whence and whither liaison psychiatry. Psychol Med 1980;10:11-14 7 Thomas C. Establishing liaison psychiatric services: a personal view. Int J Soc Psychiatry 1985;31:149-55 8 Lipowski ZJ. Review of consultation psychiatry
and psychosomatic medicine. I. General principles. Psychosom Med 1967;29:153-71 9 Meyer A. Psychobiology: a science of man. Springfield: CC Thomas, 1957 10 Engel GL. The biopsychosocial approach and medical education. N Engi J Med 1982;306:802-5 11 McKegney FP, Weiner S. A consultation-liaison psychiatry clinical clerkship. Psychosom Med 1976; 38:45-54
12 Mason AS. Psychiatry and general medicine. Medicine (2nd series), 1975;11:510-12 13 Mezey AG, Kellett JM. Reasons against referral to the psychiatrist. Postgrad Med J 1971;47:315-19 14 Pritchard M Who sees a psychiatrist? A study offactors related to psychiatric referral in the general hospital. Postgrad Med J 1972;48:645-51 15 Steinberg H, Torem M, Saraway SM. An analysis of physicians resistance to psychiatric consultation. Arch Gen Psychiatry 1980;37:1007-12 16 Mayou R, Smith EBO. Hospital doctors' management of psychological problems. Br J Psychiatry 1986; 148:194-7 17 Hackett TP. The psychiatrist: In the mainstram or on the banks ofmedicine? Am JPsychiatry 1977;134.432-4 18 McKegney FP. Cultation4iaison teac g of pycosomatic medicine: opportuif es and obstacles. J Nerv Ment Dis 1972;154:198-205 19 Shepherd M, Davies B, Culpan RH. Psychiatric illness in the general hospital. Acta Psychiat Scand 1960; 38:518-25 20 Davis DS, Nelson JKN. Referrals to psychiatric liaison nurses: changes in characteristics over a limited period. Gen Hosp Psychiatry 1980;2:41-5 21 Maguire GP, Julier DL, Hawton KE, Bancroft JHJ. Psychiatric morbidity and referrals on two general medical wards. Br Med J 1974;1:268-70 22 Ries RK, Kleinman A, Bokan JA, Schukit MA. Psychiatric consultation-liaison service. Patients, requests, functions. Gen Hosp Psychiatry 1980;3:204-12 23 Goldberg D, Huxley P. Mental illness in the community. The pathway to psychiaric care. London: Tavisock, 1980 24 Sensky T. The general hospital psychiatrist: too many task and too few roles? Br JPsyvhiaty 1986;148:151-8 25 Hawton K, Gath DH, Smith EBO. Management of attempted suicide in Oxford. Br Med J 1979;2:1040-2 26 Brisol & Weston Health Authority Staing Connittee on the management of self harm. Code of Practice. Bristol Royal Infirmary. Bristol & Weston Health Authority, 1989 27 Editorial. Psychiatry in the general hospital. Br Med J 1981;282:1256-7 28 House AO, Jones SJ. The effects of establishing a psychiatric consultation-liaison service: Changes in patterns of referral and care. Health Trends 1987; 19:10-12 29 Schwab JJ, Clemmons RS, Freemon FR, Scott ML. Differential ateristics of medical inatients referred for psychiatric consultation. Psychosom Med 1965; 27:112-18 30 Mayou R, Hawton K. Psychiatric disorder in the general hospital. Br J Psychiatry 1986;149:172-90
(Accepted 24 January 1990)
