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Psychological medicine and the future of psychiatry

  • Michael Sharpe
Summary

Psychological medicine (liaison psychiatry) aims to integrate psychiatry into other areas of medicine. It is currently enjoying considerable expansion. The degree to which it can take advantage of this opportunity will be important not only for its own future, but also for the survival of psychiatry as a medical discipline.

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Corresponding author
Michael Sharpe, MA, MD, FRCP, FRCPsych, Professor of Psychological Medicine, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK. Email: michael.sharpe@psych.ox.ac.uk
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Declaration of interest

M.S has worked with various National Health Service bodies to develop clinical services, research and teaching in psychological medicine.

Footnotes
References
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1 Lloyd, GG, Mayou, RA. Liaison psychiatry or psychological medicine? Br J Psychiatry 2003; 183: 57.
2 Parsonage, M, Fossey, M, Tutty, C. Liaison Psychiatry in the Modern NHS. Centre for Mental Health, 2012.
3 Royal College of Psychiatrists. Who Cares Wins: Improving the Outcome for Older People Admitted to the General Hospital. Royal College of Psychiatrists, 2005.
4 Francis, R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. TSO (The Stationery Office), 2013.
5 Parsonage, M, Fossey, M. Economic Evaluation of a Liaison Psychiatry Service. Centre for Mental Health, 2011.
6 Bermingham, SL, Cohen, A, Hague, J, Parsonage, M. The cost of somatisation among the working-age population in England for the year 2008–2009. Ment Health Fam Med 2010; 7: 7184.
7 Katon, WJ, Lin, EH, Von Korff, M, Ciechanowski, P, EJ, Ludman, Young, B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010; 363: 2611–20.
8 Strong, V, Waters, R, Hibberd, C, Murray, G, Wall, L, Walker, J, et al. Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. Lancet 2008; 372: 40–8.
9 Mental Health Network. Healthy Mind, Healthy Body: How Liaison Psychiatry Services can Transform Quality and Productivity in Acute Settings (Briefing, Issue 179). NHS Confederation, 2009.
10 Naylor, C, Parsonage, M, McDaid, D, Knapp, M, Fossey, M, Galea, A. Long-Term Conditions and Mental Health. King's Fund, 2012.
11 Department of Health. No Health Without Mental Health: Implementation Framework. HM Government, 2012.
12 Academy of Medical Royal Colleges. No Health Without Mental health: The Alert Summary Report. Academy of Medical Royal Colleges, 2009.
13 Joint Commissioning Panel for Mental Health. Guidance for Commissioners of Liaison Mental Health Services to Acute Hospitals. JCPMH, 2013.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Psychological medicine and the future of psychiatry

  • Michael Sharpe
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eLetters

Does reframing of needs domains of people with schizophrenia improve resource allocation?

Da Li, Psychiatrist
26 November 2014

Schizophrenia is a severe mental disorder. Being an illness, it is ofno surprise that healthcare resources are consumed to provide the sufferers with medical services such as medication and hospitalization. These service needs are under the health-related domain. This domain receives more attention and hence its needs are more adequately satisfied than those (such as housing, employment) under non-health related ones (1).

Nonetheless, unlike physical illnesses, the goal of mental illness interventions is not just reduction of signs and symptoms but also promotion of social functioning (2). In other words, people with schizophrenia need both psychopharmacological and psychosocial interventions. While the needs domains under psychosocial interventions are regarded as "non-health related", they are indeed well recognized elements crucial for recovery from the illness (3). Unfortunately, non-health related domains receive very scarce (if not none at all) allocationof healthcare resources (4). As a result, the development and implementation of psychosocial interventions for people with schizophreniais hindered and so are the outcomes. So, how to tackle this issue? Reframing the needs domains may be a way out. Instead of framing those needs as "non-health related", they should be categorized under rehabilitation as they are essentially the rehabilitation needs (5). Certain proportion of healthcare resources is generally reserved for rehabilitation (no matter of physical or mental illnesses) in many countries (6). Resources for interventions tailored to satisfy the rehabilitation needs can therefore be well (or at least better) justified and hence allocated.

In short, reframing psychosocial needs as rehabilitation needs is a crucial means to fight for healthcare resources.

References

1.Fleury M, Grenier G, Bamvita J, Tremblay J: Adequacy of help received among individuals with severe mental disorders. Administration and Policy in Mental Health and Mental Health Services Research 2014, 41(3): 302-316.

2.Middleboe T, Mackeprang T, Hansson L, Werdelin G, Karlsson H, Bjarnason O, Bengtsson-Tops A, Dybbro J, Nilsson LL, Sandlund M, S?rgaard KW: The Nordic Study on schizophrenic patients living in the community. Subjective needs and perceived help. European Psychiatry 2001, 16(4), 207-214.

3.Tsang HW, Chen EY: Perceptions on remission and recovery in schizophrenia. Psychopathology 2007, 40, 469.

4.Cedereke M, Ojehagen A: Formal and informal help during the year after a suicide attempt: a one year follow-up. International Journal of Social Psychiatry 2007, 53(5), 419-429.

5.Li D, Tsui MCM, Yuan G., Zhang G., Tsang HWH: Measuring perceived rehabilitation needs of people with schizophrenia in Wuxi China. Administration and Policy for Mental Health and Mental Health Services Research 2013, doi: 10.1007/s10488-013-0510-8.

6.Putoto G., Pegoraro R (2011): Resource allocation in health care. InTech. http://www.intechopen.com/books/bioethics-in-the-21st-century/resource-allocation-in-health-care.

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Conflict of interest: None declared

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Liaison Services for Older Adults in the integrated model of psychological medicine provision

Elizabeta B. Mukaetova-Ladinska, Senior Lecturer in Old Age Psychiatry
11 March 2014

Professor Sharpe's editorial summarizes elegantly the latest developments in psychological medicine1. The economical evaluation of the Liaison services that started with the evaluation of the Birmingham Raid Model, has naturally progressed with the recent National Institute for Health Research Health Services and Delivery Research Programme on commissioning research grants for 'Organisation, quality and cost- effectiveness of psychiatric liaison services in acute setting'. This callwas also accompanied by another one on 'Assessing alternatives to face-to-face contact with patients'. The outcomes of these two calls will undoubtedly bring a new wave of changes to our current Liaison Services that are already undergoing remodelling. The editorial argues that 'small'liaison subspecialties should 'join forces under a single banner' to provide 'flexible and shared service provision'. The Liaison Services for Older Adults (LSOA) are among those that are numbered in the list of smallsubspecialties. Our analysis of the LSOA services within our locality2 andwider3 confirms that the LSOAs appear to be the fastest growing liaison discipline. In Newcastle alone we witness a steady 10% yearly increase of older people referred to our service, with the overall numbers being very close to those of our Deliberate Self Harm (DSH) team (37% LSOA vs. 39% DSH)3. Those of us who already work in the newly integrated Liaison services are under increasing pressure to become more generalist, shadow our DSH colleagues to 'broaden' our clinical experiences whilst at the same time the suitability of referrals to our 'small' subspecialty is frequently scrutinised. And yet, the majority of hospital beds are occupied by physically compromised and cognitive impaired older people, who are either known to the Old Age Psychiatry services, or are referred to the LSOA as a result of the Dementia CQUIN. For many of them, our subspecialty would facilitate the diagnosis and initiate the treatment fortheir cognitive impairment, challenging behaviour and/or depression, our expertise will aid the decision about their long-term needs and placement,and enable maintain that essential continuity of care that is currently failing them 4, 5. In addition, the LSOA medical expertise is not confinedto our old age psychiatric knowledge, but many of us are also dual trained(e.g. family medicine, neurology etc.) and/or hold diplomas in geriatric medicine. The threat of 'small' subspecialties being assimilated by the generalist type of Liaison services is a reality. However, the question remains - is this the best way forward? Mental Health Trusts have already benefited from a number of diversification of services6. The rapidly changing demographics in the UK population, with older population doublingby 2050 from 10 to 19 millions7 and the expected 80% increase in people with moderate or severe dementia in the following 15 years8, argues for urgent diversification of the health services to meet the older people's health requirements, including their mental health. In this respect, it would be counterproductive to rely on liaison services catering for a single commodity. The steady growth of LSOA demand provides a further support that this is the area for diversification of not only the psychology medicine portfolio, but also the mental health services in general.

References:1. Sharpe M: Psychological medicine and the future of psychiatry, Br J Psychiatry 2014 204:91-92. 2. Mukaetova-Ladinska EB, Cosker G, Coppock M, Henderson M, All-Ashgar Y, Hill A, Scully A, Robinson D, Sells K, Brotherton S, Lowthian C: Liaison old age psychiatry service in a medical setting: Description of the Newcastle clinical service. Nurs Res Pract. 2011; 2011: 587457. doi: 10.1155/2011/587457 3. Mukaetova-Ladinska EB. Liaison Psychiatry Services Provision: the Newcastle Model. BA (Hons) Thesis. Teesside University 2013. 4. Cornwell J, Sonola L, Levenson R, Poteliakhoff E. Continuity of care for older hospital patients: a call foraction. http://www.kingsfund.org.uk/publications/continuity-care-older-hospital- patients. 2012 (accessed 17.02.2-14). 5 Cornwell J. The care of frail older people with complex needs: time for a revolution. The Sir Roger Bannister Health Summit. Leeds Castle. http://www.kingsfund.org.uk/publications/care-frail-older-people-complex- needs-time-revolution. 2012 (accessed on 17.02.2014). 6. Lintern S. Mentalhealth trusts look to diversify. http://www.hsj.co.uk/mental-health/mental-health-trusts-look-to- diversify/5059668.article#.UwDZeYUVaVo 7. Cracknell R. The ageing population. Key isues for the New Parlament 2010. House of Commons Library Research. Pp 44-45 2010. 8. Select Committee on Public Service and Demographic Change: Ready for Ageing? Report of Session2012-2013. House of Lords: 14 March 2013

Address for correspondence: Elizabeta B. Mukaetova-Ladinska, BA(Hons)MD MMedSci PhD MRCPsych MCMI MInstLM,Institute for Ageing and Health Newcastle University Campus for Ageing andVitality Newcastle upon Tyne NE4 5PL UK Tel: +44 191 246 8777 Fax: +44 191246 8613 E-mail: Elizabeta.Mukaetova-Ladinska@ncl.ac.uk

Dr Ann Scully, MRCGP, MRCPsych Centre for Health of the Elderly Gibside Offices Campus for Ageing and Vitality Newcastle upon Tyne NE4 6 BE

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Conflict of interest: None declared

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Rediscovering the Soul of Medicine

Matthew Rowett, Consultant Liaison Psychiatrist
07 March 2014

Dear Editor,

We have read with interest the editorial by Michael Sharpe entitled 'Psychological Medicine and the Future of Psychiatry'.1 Recognition of Liaison Psychiatry as valuable to patients, general hospitals and commissioners has been a long time coming.

We agree that the crisis of identity in psychiatry may have indeed resulted from the many decades of isolation from the rest of medicine. As such, there may be a temptation to redefine psychiatry based on the path of least resistance which is one left by the 'compassion' vacuum highlighted by the Francis inquiries.2 Psychiatry does indeed 'retain strengths in humane social and psychological care'1 although it has much to learn from the involvement of service users in the design of care3, 4 and often struggles with the interface between physical and mental healthcare itself.

There is indeed a need to 'enhance the patient's experience of medical care' and for medicine to move away from purely 'disease-focussed medical care'.1 However we differ on the opinion that Liaison Psychiatry or Psychological Medicine 'aims to put these skills back into medical care'.1 We may be at risk of medicalising the distress that is prevalent in healthcare settings.5 Healthcare professionals have a duty to improve the experience of people they care for and to respond to their distress ina humane and compassionate manner. 6,7 From our experience of delivering training and support in general hospital settings, there are many barriersto Liaison Psychiatry being able to achieve this kind of change, not leastthe sheer scale of the task. This may actually be a strength of the current trend of psychiatric superspecialisation occurring in general hospital settings- more psychiatrists advocating and modelling change.

In the article, an excellent point is made that the current approaches to commissioning Liaison Psychiatry may be less than ideal.1 Itis unlikely that teaching from another specialty, let alone another organisation, will address these issues to a satisfactory extent or in a timely manner. We could avoid the temptation of calling for more training.Instead perhaps each specialty and organisation could take seriously the responsibility of creating a right culture and putting patients first.

Indeed it may be that lessons can be learned from psychiatry, but we have many lessons to learn ourselves. The key to medicine rediscovering its humanity may be more likely to lie in re-engaging with its patients and carers than looking to another medical specialty.

References:

1.Sharpe M. Psychological Medicine and the Future of Medicine. British Journal of Psychological Medicine 2014; 204: 91-92.

2.The Mid Staffordshire NHS Foundation Trust Public Enquiry. Report of The Mid Staffordshire NHS Foundation Trust Public Enquiry Volume 3. London: The Stationery Office; 2013.

3.Nettle M. Time to Change Campaign through the Eyes of a Service User. Invited Commentary on...Evaluation of England's Time to Change Campaign. British Journal of Psychiatry 2013; 203: s102-s103.

4.Russo J, Rose D. "But What if Nobody's Going to Sit Down and have a Real Conversation with You?" Service User/Survivor Perspectives on HumanRights". Journal of Public Mental Health 2013; 12 (4):184 - 192.

5.Dowrick C, Frances A. Medicalising Unhapppiness: New Classification of Depression Risks More Patients Being Put on Drug Treatment from Which They Will Not Benefit. British Medical Journal 2013; 347: F7140.

6.General Medical Council. Good Medical Practice. Manchester: General Medical Council; 2013.

7.Balducci L. Communication as the Heart and the Art of Person-Centered Medicine: Making a Case for Qualitative Research. Journal of Medicine and The Person 2014: doi 10.1007/s12682-014-0164-7. (accessed 04 March 2014).

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Conflict of interest: None declared

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Future of Psychiatry!

Dr Mukesh Kripalani, Consultant Psychiatrist
04 March 2014

I read with great interest Michael Sharpe's editorial outlining the case for Psychological medicine and the future of Psychiatry (1).Given my interest in Liaison Psychiatry, I could feel the passion in his piece which he has extended to include the proposed future of psychiatry as a discipline. However, even though he has mentioned patient safety in passing, I would like to urge a wider debate on the fact repeatedly highlighted by several publications of the National Confidential Enquiry in to Suicide and Homicide by People with Mental illness. In its last publication, it again highlighted that 72% of those who went on to commit suicide (between 2001 and 2011), where not open to mental health services in the last year before their death (http://www.bbmh.manchester.ac.uk/cmhr/centreforsuicideprevention/nci/reports/NCIAnnualReport2013V2.pdf).

Given the massive variation in funding of mental health services across the country and some viewing it as a Cinderella service, I feel mental health providers and advocates have failed to grasp the nettle in terms ofattempting to reach out to that group of individuals, who "successfully" commit suicide. We are aware that a majority of those individuals could bediagnosed with F43.0 (Reaction to severe Stress and Adjustment disorder) of the ICD-10 (http://www.who.int/classifications/icd/en/GRNBOOK.pdf). Yet we fail to invest in services and concentrate efforts on a narrow remit to severe mental illness. With the amended Mental Health Act 2007 in England and Wales (http://www.legislation.gov.uk/ukpga/2007/12/contents), we have successfully replaced the erstwhile 4 categories in to a single category of mental disorder. Along with it, we have replaced "treatability" and "care" tests with appropriate treatment test. Yet we do not seem to adequately invest and respond to the above mentioned category, costing potentially a lot more to the community than accepted under the Mental illness umbrella.I raise this issue again with the hope of extending our roles not only to the "Holy Grail" of reducing costs and improving outcomes, as the editorial focuses, but also to the wider losses our community and society suffer but are unable to react to the same. On another note, the editorial mentions the RAID model (Rapid Assessment Interface and Discharge). This along with the latest iteration (Feb 2014) of the NICE guidance on Schizophrenia (http://guidance.nice.org.uk/CG178),which refocuses attention to combined physical and mental health care and the mandate around parity to physical and mental health care just debated in the English Parliament (http://www.england.nhs.uk/2013/11/12/mandate-response/ ), gives us hope for the future. Psychiatrists are unique in addressing the boundary disputes between specialties and offer value for money even in this economy.

References1.Sharpe M, Psychological medicine and the future of psychiatry Br J Psychiatry 2014; 204: 91-92.

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Conflict of interest: None declared

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