PLAN has a Liaison Psychiatry referrer’s survey – but we think you need to be part of PLAN to use this.

A consultant from Kingston wished to share our experience of MUS in primary care and polyclinics. There was little initial response but nonetheless a useful discussion ensued.  We for example learnt that the Healthcare for London MUS care pathway was not given the go ahead for commissioning because it needed further piloting - due to concerns about the evidence base and also feasibility issues. There is ‘a pilot happening in City and Hackney and there is also a pelvic pain joint clinic at GST. The aim is eventually that some joint work could happen in polyclinics’.

The use of computerised CBT for patients with physical illness was discussed. A useful reference cited was ‘Hind D et al. The acceptability of CCBT for the treatment of depression in people with chronic physical disease, Psychology and Health 2009, 1-14’.

St Georges use ‘Beating the Blues’ – around £2000 per package – but the experience was that it doesn’t save much on clinician time – a NZ consultant agreed with this, though acknowledged that ‘it does open up a lot of possibilities for people who are hard to engage if there is txt and email support plus video as part of the CBT package’

Happy New Year to all and we hope the 2010s is the decade when Liaison Psychiatry truly flourishes!

November 2009

The psychological consequences of facial trauma were discussed. An East London service sees a variety of problems e.g. PTSD and pain – where the pain can serve as a trigger, perpetuating the problem. Others get a BDD type picture. There are a handful of psychologists working with orthognathic patients.

Changing Faces (good website), a UK Charity for facial disfigurement, is the best established group but isn't always locally-represented. They have psychologists and counsellors and useful information leaflets. There is substantial and overlapping literature on facial burns. More good advice, from Leeds naturally, for those (like me!) in a hospital without specialist services and looking for local resources rather than literature - speech and language therapists often see these cases and may know who takes referrals.

How do we address looking after hospital staff that self harm? A Canadian response suggested the following: that this would be handled on a case to case basis with some sensitivity to the individual and awareness of confidentiality issues. Professional organisations have their own resources – e.g. we have the excellent Mednet in the KSS deanery. Generally staff would be transferred to another hospital than their own if admission is necessary. Criteria for admission and treatment considerations wouldn't differ dramatically. If there are concerns about professional competence (e.g. drug abuse) then this should be addressed with the patient as to whether the licensing body needs to be involved.

August 2009

There were further discussions about ED risk assessments by A&E staff – St Helier and Southampton both use a lengthy assessment (see JISC archive for detail). Where patients score green (low risk), debate about whether they go home or should there be next day liaison follow up clinic? Also in Southampton they have an agreement with A&E that after 2am, patients can stay on CDU to be seen by Liaison Psychiatry the next day.

The diagnosis of Korsakoff’s Syndrome in the GH was a subject of debate. Scotland and Southampton don't routinely MRI if the history and clinical presentation are in keeping, but often do CT to rule out subdural. Addenbrookes and OT functional assessments are performed before referring to Social Services in Scotland.

In Southampton if it is alcohol dementia then referral is to OPMH and health often fund. But if pure memory impairment (eg Korsakoffs) or not progressive problem then social care will fund care. These patients are a challenge to place. Leicester: 2 fabulous presentations around diagnosis – please see archive.

The European Delirium Association is holding its annual meeting in Leeds on 8-9 October. 

Concerns in one hospital were raised about a proposed ward policy for dependent drinkers: ‘a policy of sending dependent drinkers home with instructions to drink immediately after any medical problems are excluded’. Many Liaison psychiatrists expressed concerns at this idea.

The College Report on Psychiatry in A&E states:

• Alcohol detoxification requires appropriate supervision.
• It should not be initiated in those patients discharged from A&E unless such support has been arranged.
• If resources for immediate detoxification are not available, then motivated patients should be advised to continue drinking and to gradually cut down their intake in order to avoid potentially dangerous withdrawal symptoms.
• In the meanwhile, appropriate follow-up should be arranged.

Further discussion took place about patients on wards that were starting to withdraw and there was a strong body of opinion that detoxes should be completed. However symptom triggered detoxes (Lingford-Hughes AR, Welch S & Nutt DJ (2004) Evidence based guidelines for the pharmacological management of substance misuse, addiction and co-morbidity: recommendations from the British Assocaition of Psychopharmacology. Journal of Psychopharmacology 18(3) 203-335) are successfully used as described below in Ireland:

• Brief as opposed to prolonged medical admissions can usually be identified early on.
• Admitting such patients to the CDU in our ED allows the patients to have symptom-triggered detox (CIWA =/- Diazepam 20mg every 90 minutes). None of these patients are sent home on benzodiazepines as detox generally takes less than one day.

CDU is a more controlled environment than the medical and surgical wards (such wards preclude the use of a symptom-triggered method of detox) and thus the fixed dose tapering standard-regimen of chlordiazepoxide is used in these general wards. This generally shouldn’t take longer than 5 days but such a delay can be problematic wrt completion of detox. Not a reason to tell the person to go home and start drinking again! We need to be convincing colleagues of the futility of such an approach. Reminding them of the likely alcohol-related reason for admission in the first place. Reminding them of Rumpf et al’s Archives paper some years ago on alcohol dependent patients in the general hospital being more ‘ready for action’ by comparison with those in the community.

July 2009 

A lot of discussion took place about risk assessment tools within the general hospital. I liked the Australian view – that good psychosocial clinical assessment trumped any known tool. However, the point was raised about the first contact being A&E staff, where mental health competence is more doubtful – and perhaps a risk assessment tool here would be of value. For ED staff 3 risk tools were cited from Southampton, St Helier and Bristol – they are all excellent and I recommend you look at the JISC archive for details. Southampton have also developed a tool for mental health assessment by Liaison staff.

There was a discussion about ways of monitoring and ensuring safety and protection from self harm in inpatient units. A useful tool from the Australian Newcastle (though actual origin unknown) was shared.

Rio hasn't hit Worthing, but reading your numerous opinions on its usefulness and usability I frankly hope it never does. And using it takes longer than to see a new patient? Our man in Guys suggests we lobby against it – go Al!

Other not very useful electronic activities include a mapping of Liaison Services in the UK which is not very accurate.

We thank a breath of fresh clinical air with an unusual case presentation of episodic psychosis always preceded by a mild pyrexia. It seems there may be a neurotransmitter 'something' going on, with an uncle with 'Stiff man syndrome' and the patient having neuroleptic hypersensitivity; but other clinical phenomena are puzzling here. Steroid treatment was a suggestion from across the pond.

June 2009

Nationally, there are high levels of postoperative delirium reported for pseudomyoma surgery – question raised about possible prophylactic medication to prevent this. Some useful references:

• Oxford Journals 
• Oxford Journals 

This was from Sydney:

Haloperidol

• Kalisvaart (2005): DBPCT (N=430, mean age 79, 13.5% became delirious) of haloperidol 1.5mg/d (started one or two days pre op) in hip surgery patients judged to be at high risk for post-operative delirium and continued for up to 3 days postoperatively. Low-dose haloperidol prophylactic treatment did appear to have positive effect on the severity and duration of delirium (5.4 versus 11.8 days) and length of hospital stay (17.1 ± 11.1 versus 22.6 ± 16.7).
• Kaneko (1999) N=78 RCT (non-blinded) haloperidol 5mg/d IV for 5 days pre gastro surgery & found decreased incidence.
• Lonergan (2007) reviewed efficacy and adverse effects of haloperidol cf risperidone, olanzapine and quetiapine for treatment of delirium. No evidence that haloperidol in low (<3mg) dose has different efficacy compared to olanzapine or risperidone or that it has more adverse effects.

Olanzapine

• Larsen: DBRCT (N=400) of perioperative olanzapine (5mg preop & 5mg postop on day of surgery) verses placebo to prevent post-operative delirium in hip & knee replacement surgery over 65yrs. Incidence of delirium of 41% in PBO & 15% in the olanzapine arm (p>0.001).

Clinical governance in Liaison psychiatry – where do we sit?

In Leeds, this is mainly within the mental health trust, but some policies and procedures sit within the acute trust. Islington similarly straddle both trusts – some aspects are OK e.g. self harm guideline, but this can be tricky where there are differences e.g. rapid tranquilisation policy.

Swine flu

Else asked what could be the impact to liaison psychiatry services. From Scotland: 1. staff sickness, 2. FFP3 masks – is there any experience? 3. neuropsychiatric effects of relenza and tamiflu? – reported suicidality in adolescents cited.

There were requests for expertise on: 1. setting up an old age liaison service when there is extra funding and 2. Providing psychological support for renal patients – advice given on where to find information and who to visit.

May 2009

A much quieter month for JISCmail.

We had an update on our patient with conversion blindness who remains without sight. Midazolam neither helped diagnostically nor therapeutically and the plan was for a specialist neurology ophthalmologist and a hypotherapist psychologist.

An interesting American case was presented of a gentleman with lymphoma who was about to receive haemodialysis and who despite not being depressed suffered with complete lack of libido. A helpful response from Guys was to do an endocrine screen – in particular to look for low testosterone and high FSH; and that dialysis does not tend to help libido. Testosterone replacement may be the solution.

Else started up a discussion around the psychological implications of a ‘swine flu’ pandemic and the gradual unfolding nature of such a situation. She recommended a good read about the medieval plague and wondered whether there would be mass panic, noting that this is not what has happened in Mexico – where people have tended to remove themselves from society. The Leeds response pointed out that encephalitis lethargica overlapped with the Great War flu pandemic and complicated interpretation of the psychological aftermath in that situation.

The role of politicians in such a situation was cited – and false reassurance from them tended to incite panic more than realistic reporting of a serious situation. The latter was more likely to bring people together in a useful way.