Liaison psychiatry in detection and management of mental illness

General psychiatry liaison services have seldom been studied, apparently because of inadequate record keeping which has made it impossible for either psychiatrists or managers to assess the numbers of people seen or the resources used (Mayou et al 1990). Hall (1994) looked at reasons for and disposal of referrals to general psychiatry liaison services. To our knowledge, there are few short-term follow-up studies of such referrals. Mayou et al (1994) followed up, over a 14-year period, a four-year cohort of consecutive inpatient referrals to a consultation-liaison service of a British general hospital, and revealed that a third made considerable use of a wide range of specialist psychiatric services.

General psychiatry liaison services have seldom been studied, apparently because of inadequate record keeping which has made it impossible for either psychiatrists or managers to assess the numbers of people seen or the resources used (Mayou et al 1990).Hall (1994) looked at reasons for and disposal of referrals to general psychiatry liaison services.To our knowledge, there are few short-term follow-up studies of such referrals.
Mayou et al (1994) followed up, over a 14-year period, a four-year cohort of consecutive inpatient referrals to a consultation-liaison service of a British general hospital, and revealed that a third made considerable use of a wide range of specialist psychiatric services.

Aims
First we surveyed the sources of all referrals, over a six-month period, to the Dundee general psychiatry liaison services.The DSH patients were of particular interest as they constituted the vast majority of the referrals.
Second, we monitored the management of the referrals.Specific note was taken of character istics of patients followed up by the general psychiatry service and the Area Alcohol Service (AAS).
Lastly, we carried out a six-month follow-up on Dundee based patients and all patients referred to the AAS.

The study
All referrals made between 1 January 1993 and 30 June 1993 were studied.The Dundee general psychiatry liaison service routinely assesses referrals seven days per week.From Mondays to Fridays, all ward referrals are made by telephone to the senior medical secretary.The liaison consultant delegates appropriate referrals to junior medical staff and sees the remainder personally.Outwith normal working hours, the duty senior registrar sees all ward referrals.Direct referrals from the Accident & Emergency department are seen by junior medical staff.Such referrals were rare and were not included in this survey.
Patients under 16 years and those still at school are assessed separately by the child and adolescent psychiatry service.Patients over 65 years are assessed by the psychiatry of old age service.A questionnaire devised by the authors was completed by the assessing psychiatrist after each referred.As well as general demographic data, information was sought on referral source, DSH or other liaison, method of DSH used and alcohol intake.The type of disposal and use of the Mental Health (Scotland) Act 1984 was noted.Six-month follow-up of patients was limited to those from the Dundee catchment area.By utilising the local psychiatric case notes, we detected most of those people currently in contact with the psychiatric services.However, a number of people may have been lost to follow-up by moving address.Similarly, patients referred to the AAS were followed up six months after their initial appointment date, to monitor if they were in current contact with the Service.

Findings
Two hundred and ninety-nine people were seen (143 males and 156 females); 239 (80%) lived in the Dundee catchment area (population 180 000).The rest were from neighbouring catchment areas.The mean age of the patients was 34.8 years (age range 16-65).Among the DSH cases, 237 (94%) had taken an overdose, seven (3%) had self-injured and four (2%) had done both.Two referrals had used other forms of DSH and in one case the DSH method was unknown.In the overdose/overdose and selfinjury group (n=241), analgesics were the drugs most frequently used (n=95; 39%).Others were antidepressants (n=33; 14%) or benzodiazepines (n=25; 10%).In 82 cases a mixture of drugs was utilised and in six cases unknown drugs were involved.Alcohol was involved in 141 (56%) of all DSH attempts.
All referrals were sub-grouped by age bands and gender (Table 1).These sub-groups reveal greater numbers of males than females in the 26-35 and 56-65 age bands for total liaison referrals, DSH and overdose sub-groups.The reverse is true for other age bands.
The management of the patients was also examined (Table 2).Within the in-patient group, 23 were considered suicidal.Three males and two females were detained under the Mental Health (Scotland) Act 1984 to enable treatment to be carried out.
A further 22 DSH patients were referred to the Tayside Alcohol Problems Service (TAPS).Three individuals were referred twice, so there were 25 referrals (17 males and 5 females).Prior to being offered an out-patient appointment, patients were asked to complete a questionnaire regarding alcohol-related issues.
Twenty-one (95%) returned the questionnaires and were offered an appointment at a TAPS out-patient clinic.Dr Peter Rice, Consultant Psychiatrist with TAPS, has Indicated that the response rates to the questionnaires is about 70% so this group had a higher response rate than average.Subsequently, 16 (76%) of these people attended the TAPS clinic.
A six-month follow-up of Dundee-based pa tients (n=239) was carried out by examining the Dundee psychiatric case notes (Table 3).
At six-month follow-up of patients given a first appointment by TAPS, 5 (23%) were still in contact with the service.The remainder had been discharged or had defaulted.

Referrals
As in other UK studies, the majority of referrals to the Dundee general psychiatry liaison service were parasuicides.It is not routine policy in Dundee to refer all adult DSH cases to the general psychiatry liaison service.Personal communica tion indicates that the referral rate is approxi mately 80%.Informal communication with other hospital specialists indicates general satisfaction with the psychiatry liaison service.
The excess of female referrals repeats findings of previous studies in the UK.However, the excess of male DSH cases in the 26-35 age groups may reflect the increasing suicide rates in young men (Crombie, 1990).As in previous Scottish studies, associated alcohol consump tion is present in a high percentage of cases of DSH.
A sixth of all referrals were admitted directly to a psychiatric ward.The majority were admitted on a voluntary basis but 10% refused treatment and had to be detained under the Mental Health (Scotland) Act 1984.This emphasises the importance of immediate bed availability for crisis intervention.

Follow-up
A quarter of liaison referrals remained in contact with the service.Females were more likely than males to be in treatment.TAPS also continued to have contact with a quarter of patients who had been given an appointment with the service.More males than females remained in contact.

Conclusions
This survey was concerned with referrals from other clinical specialities.The high percentage of referrals for DSH confirms the findings of another Scottish survey (Hall, 1994).There were only 48 referrals which were non-DSH.If the referrals from the general medical wards were excluded, there were few referrals (n=27) from other sources.However, if the liaison service were to expand referrals might increase, particularly if more active links were established with other specialities.
Other follow-up studies of DSH (O'Brien, 1987) have also illustrated a high non-attendance rate at out-patient clinics.The low numbers of patients receiving day hospital follow-up was because this study was carried out shortly before the opening of a new resource centre in Dundee.Since then, the number of patients receiving day hospital follow-up has increased.This seems to be an appropriate use of resources, particularly if it improves follow-up of patients by assertive outreach.It may also reduce the number of patients requiring in-patient treatment.For audit purposes, the impact of increasing the commun ity resources could be monitored by repetition of this study.

Management
After the initial assessment, the patient's man agement was transferred to the General Service.Although the Dundee general psychiatry service does not operate a local sectorised system, if possible, patients were transferred to available beds in the Ninewells Psychiatric Unit.
Females were more likely to be offered follow-up by the general psychiatry service.In contrast, males were more likely than females to be referred to AAS.This finding has been reported elsewhere (Hall, 1994).

Table 1 .
Liaison survey grouped for age and deliberate self-harm

Table 2 .
Liaison survey management by Dundee psychiatric service (n=160) only4910974215411285563 CRN, community psychiatric nurse Liaison psychiatry in detection and management of mental illness

Table 3 .
Liaison survey at six-month follow-up of Dundee based patients (n=239)