Depression is common in people with long-term physical conditions and those seen in medical settings. The actual prevalence varies according to the setting, type and severity of disease, the individual’s perception of their condition and premorbid risk factors (e.g. childhood adversity). Depression has a bi-directional causal relationship with physical disease, so each can be a risk factor for the other. Depression and anxiety symptoms co-occur more often than as separate conditions and are often undetected or diagnosed by primary and secondary healthcare staff. People who experience depression and physical illness understand depression as part of their whole life experience and not just as being simply related to their physical health. Depression, and to a lesser extent anxiety, in the context of physical disease are associated with a range of poor outcomes, including poorer physical health outcomes and quality of life; increased hospitalisations, investigations and healthcare costs; and higher mortality.

This chapter will focus on the evaluation of liaison services, including the evidence regarding what liaison services actually do (activity), the types of clinical problems they manage and how they effect change and service outcomes. Liaison services in different settings, including the acute hospital, emergency department (ED) and primary care, will be discussed. Individual psychological or pharmacological treatments for specific conditions are covered elsewhere in this book. Interventions for self-harm are discussed in Chapter 5 and psychological treatments for persistent physical symptoms and co-morbid depression and physical disease are discussed in Chapter 15. The challenges and complexities involved in the assessment of liaison services are explained in Chapter 20.

Psychological therapies are used widely in liaison mental health settings to treat individuals with a variety of different mental health problems. The three most common clinical problem areas, however, are persistent physical symptoms (PPS), depression/anxiety associated with physical disease and self-harm. There is a relatively strong evidence base for treatments which target PPS, albeit with certain caveats, whereas the evidence for co-morbid depression/anxiety is quite weak. Psychological treatments for self-harm are discussed in Chapter 5. The most common psychological intervention is cognitive behavioural therapy (CBT), for which there is a large evidence base. There is, however, no clear evidence that CBT is superior to most other bona fide therapies which are currently delivered in a National Health Service (NHS) setting.

Physical illness is stressful; however, given time and support, most people manage to adjust and cope with serious physical illness without the need for psychological intervention. Psychological reaction to physical illness refers to a set of cognitive, emotional and behavioural responses which are triggered by the development of physical symptoms or a diagnosis of a physical condition by a healthcare professional. Experiencing and living with illness is a dynamic process and it takes time to assimilate new information, manage feelings and make appropriate adjustments to family and social circumstances. Chronic physical illness usually involves having to make a sequential series of psychological adjustments as the disease progresses.

The term medically unexplained symptoms refers to physical symptoms for which there is either no or insufficient evidence of any underlying conventional disease/disorder process. There is a wide spectrum of severity ranging from essentially normal experience (e.g. an occasional headache) to symptoms which result in severe and long-standing disability. Where symptoms group together in clusters suggestive of a link to a particular bodily system, they have been termed functional somatic syndromes. The term somatoform disorders refers to a specific set of formal psychiatric diagnoses involving conditions which predominantly present with physical symptoms or a worry about physical disease. Only people at the more severe end of the medically unexplained symptoms spectrum meet criteria for one of the somatoform disorders and there is considerable dissatisfaction with the current psychiatric classification system for these conditions, which is discussed later in this chapter.

Functional somatic syndromes

By the time most people with medically unexplained symptoms are referred to a liaison psychiatrist, they are likely to have picked up a label of one or more of the functional somatic syndromes (e.g. irritable bowel syndrome, functional dyspepsia, fibromyalgia). Many different functional syndromes have been described over the past 30 years according to different symptom clusters (Table 6.1). There is considerable overlap in symptoms between different functional conditions and somatoform disorders, yet most of these syndromes are studied as if they are discrete conditions within particular medical specialties, with a focus on the specific set of somatic symptoms, which are specialty specific.

There is still uncertainty as to the degree of overlap of these conditions and the relative common factors they may share. In one study, Fink et al (2007) studied 978 patients admitted to hospital from primary care and a medical and neurological department who scored highly on somatic screening measures. They found that patients complained of a median of five functional somatic symptoms (women six and men four). Principal component analysis identified three symptom groups explaining 37% of the variance: cardiopulmonary, musculoskeletal and gastrointestinal. Further analysis showed that the symptom groups were not discrete and patients were likely to report symptoms from different groups, suggesting that the groups were different manifestations of a common latent phenomenon: bodily distress.

Competencies for all psychiatrists

As specified for all doctors, plus the following.

• Full biopsychosocial assessment of patients, across the age range, with physical health problems, physical symptoms and mental health symptoms or psychological distress, including:

1. • somatisation/medically unexplained symptoms

2. • adjustment disorder

3. • the interrelationship of depression and anxiety on chronic medical conditions, for example diabetes, asthma, chronic obstructive pulmonary disease.

• Mental state examination in difficult circumstances:

1. • intensive care units

2. • breaking bad news

3. • variable conscious level

4. • lack of privacy.

• Assessment of self-harm across the age range, including children

• To advise competently on the treatment of patients with chronic mental health problems while in the general hospital

• Knowledge of medical and surgical treatments and conditions that have an impact on mental state

• Anxiety, depression and psychotic states in in-patients in medical and surgical settings

• Assessment of general medical and surgical admissions

• Demonstrate knowledge of management of alcohol and substance misuse problems in medical and surgical settings

• Diagnose psychiatric symptoms in the presence of confounding severe physical illness and biological symptoms (e.g. cancer, renal disease, severe trauma)

• Implementation of appropriate management plans, including the use of basic psychological, social and environmental interventions as well as psychotropic use from the British National Formulary

• Use risk assessment to advise management plan

• Review notes and drug cards, including investigations and results

• Awareness of medical, surgical and nursing assessment and management plan in the general hospital and its interaction with mental state

• Assessment of patient in A&E

• Identification of medically unexplained symptoms

• Identification, investigation and advice on the immediate management of delirium

• Basic management of patients with eating disorders in medical and surgical settings

• Criteria for referral and signposting to other mental health services including liaison

• Management of behavioural disturbance in medical and surgical settings including:

1. • assessment

2. • environmental measures

3. • use of appropriate drug treatments

4. • management of delirium tremens

5. • management of other drug withdrawal states.