Discussions about services for people with co-existent physical
and mental health problems usually start with a brief account of how common that
state of affairs is, and how important it is.
Fair enough, but there’s another step in the discussion: how do you
decide who is best placed to respond to the needs of the people affected? Of course clinicians who specialise in
physical health should know something about mental health and vice versa: my
question is what to do when help is needed from specialists in this so-called
co-morbidity? And more specifically, what’s the role of liaison psychiatry?
To begin at the beginning…
Below is a schematic representation of a clinical service,
pictured as a simple care pathway. It acknowledges that at each stage some
people will not be referred on or will refuse referral, some accept referral
and do not attend, and some attend but drop out early. Also at each stage there
are some who complete treatment at each level but do not improve. These groups
are represented on the right.
The pathway also acknowledges, in line with standard thinking
care, that some people present with such severe and complex needs that they
should be referred directly to a special service.
In the UK, brief psychological therapies are usually delivered in
primary care through a service known universally by the acronym IPAT (pr. eye apt)
and in secondary care by a range of services, most typically clinical health
psychology, or psychiatric nurse therapists working in liaison mental health
The numbers who move along the branches of this pathway into the
complex/severe end are huge. To take one
example – figures
from NHS Digital indicate that only about a third of those referred to IAPT
for a talking therapy complete the course of treatment and of these only just
over a half have “moved to recovery” by the end of treatment. We know from
other research that relapse rates after brief therapies are high – up to 50%
over the next 1-2 years.
So…the pathway above is right to indicate the need for a
specialist service for complex and severe cases. What are the features of such cases?
The answer is – no two cases are the same.
Here’s a list of some of the features of complex and severe problems.
1. Diagnostic complexity (physical health)
Multiple or persistent severe symptoms that don’t fit standard
diagnostic categories (including don’t fit standard MUS categories like
or encompass multiple diagnostic categories
Multiple drug treatments including opioid or equivalent analgesia
Multiple physical diagnoses, including some validated (so both
significant LTC and MUS)
Erroneous physical diagnosis assigned in past or by 3rd
Disability out of proportion to physical disease severity
non-adherence or misuse of therapeutic regime, including induced illness, with
serious physical consequences
2. Diagnostic complexity (mental health)
Illness conviction, especially non-affective – can sometimes have
a delusional quality, sometimes shared by close others
Suicidal and related thinking, self-harm history or current risk
3. Organisational complexity (healthcare)
Frequent unscheduled attendance – GP surgery; ED; other healthcare
Recurrent unscheduled acute admission
Recurrent unwarranted physical investigation
out from or failure to respond to first line treatment, with persistent
4. Organisational complexity (social care)
Receipt of benefits dependent upon non-recovery
Various forms of assisted living for functional disabilities
5. Social complexity
Wider social dysfunction – tension or conflict with others,
impoverished illness-centred social network – having an impact on health or healthcare
that acts as a barrier to effective brief psychological therapies
Children or others as enmeshed carers
Involvement in long-running and contested litigation or complaints related to health or
The origin of liaison psychiatry and the fuel for
its growth in the UK (until recent years) was the demand for expertise in the
management of such cases.
However, not only does a comprehensive service need
a component to deal with chronicity/complexity/severity, it also needs to be
able to offer integrated care – across primary and secondary care and between
the various components of mental health care. So…what are the characteristics
of integrated care? Here’s another list.
All this points to a (to my mind) relatively
obvious conclusion. Liaison
psychiatry services have an important role in the care of people with mental
and physical co-morbidity and, at least in secondary care, it would be best if
services were arranged so that IAPT, clinical health psychology and liaison
psychiatry were brought together in a genuinely-integrated multidisciplinary
service. There are barriers to that development – professional resistance is
one, and in my experience mainly from clinical psychology; in recent times
liaison psychiatry services have been swamped by the acute/urgent component of
liaison work, not least because of NHS England policy; manpower shortages and
funding limitations consequent on government policy – all play a part. It would
be great to see this practical and basically cost-free improvement to care
adopted as a national strategic priority by all the key interested parties.