Consultation Liaison (C-L) Psychiatry is defined as the branch of psychiatry that offers psychiatric services to medical or surgical inpatients whilst at the same time providing teaching and research in collaboration with the other specialties¹. C-L Psychiatry is practiced in the general hospital by the psychiatric departments that operate in them. C-L Psychiatry is also practiced in primary care units.

C-L is composed of two notions: "Liaison", which relates to the daily (regular) contact between members of the psychiatric team and the team of treating physicians. This aims to promote and develop the communication between the teams in order to ensure that the patient is viewed in a holistic (bio psycho-social) way. The consulting psychiatrist takes part in medical or surgical staff meetings and teaches (sensitizes) his colleagues on issues of the holistic approach, communication with the patient, and early detection of psychiatric disorder. The psychiatrist is also asked to search for the causes that lead to poor cooperation between patient and doctor or patient and staff in general. He/she can often play a mediating role between patient, medical staff and relatives.

On the other hand, in "Consultation", the psychiatrist offers his opinion regarding the diagnosis and treatment of a psychiatric disorder or a behavioral disturbance the patient is exhibiting, at the request of the treating physician or surgeon.

Consultation liaison psychiatry has developed over the last 50 years as a natural development of the existence of psychiatric units in the general hospital. This is shown by the fact that in USA, in 1932, there were psychiatric clinics in 2% of the general hospitals but in 1978 the psychiatric clinics in general hospitals exceeded 33%. The opening of psychiatric departments in the general hospital is a landmark in the evolution of psychiatry and has led to major changes on the way psychiatric patients have been managed and dealt in general. The return of psychiatry from the asylums to the general hospital is signaling its acceptance as an equally important medical specialty that has a lot to offer the patients. The recognition that psychiatric problems trouble a substantial proportion of the general population and not a marginalized minority as well as the realization by the medical establishment that psychiatry has to offer tried and effective treatments have all contributed to this change. It is now obvious that the "holistic" or "bio-psycho-social" approach can be applied not only for the psychiatric disorders but for the somatic ones as well².

Additionally, C-L Psychiatry has made a significant contribution in the reduction of stigma that follows mental illness and psychiatry not only amongst members of the public but within the medical establishments as well. The fact that psychiatrists work in a general hospital makes it easier for patients with a psychiatric disorder to receive appropriate care for their physical problems.

It is interesting to note that the development of C-L Psychiatry in Greece started in the periphery of the country and not in the capital (Athens) or the second largest city (Thessaloniki). The first psychiatric clinic in a general hospital operated for the first time in Alexandroupolis in 1978 and the next that followed was the University Psychiatric Clinic in loannina. Since 1986 psychiatric clinics have been established in the National Health System (ESY) general hospitals as well as the University general hospitals.

Regarding the organization models for psychiatric clinics in the general hospital, the following three have been described: First is the consultation model (classical) in which the patient is the focus of attention. Second is the liaison (partnership) model, in which the psychiatrist is a member of the medical team and the team needs are the focus of his attention. The third model focuses more in the general therapeutic milieu. It aims to promote the best possible cooperation between the various health services in the hospital and the community. These operating models are not the only ones that have been tried. In special hospital like cancer or transplant specialist centers, C-L takes care not only for the patients mental health needs but takes steps to psychologically support the hospital staff (medical and non-medical) and prevent burnout. In these settings staff and relatives support groups are set up.

All the models described above have been tried to some extent in Greece. The most widespread approach in state hospitals is patient centered. The psychiatrist is called in order to assess a patient who has raised concern amongst the physicians with his/hers behaviour, or who has an established psychiatric history, or that upon admission and during the history taking it emerges that they are receiving psychiatric medication. This approach is believed to increase the psychiatrist's autonomy from the medical team that cares for the patient. It should not be forgotten that this approach has "practical" benefits as psychiatric clinics are understaffed and psychiatrists have often many other pressing clinical commitments.

C-L Psychiatric services include: (a) Diagnosis and treatment of psychiatric disorders in physically ill patients as well as the treatment of psychiatric disorders with predominant somatic symptoms, (b) Prevention (on all levels), (c) Improvement of the patient's suffering from a physical illness quality of life, (d) Raising awareness and training the medical and nursing staff in detecting psychiatric disorders, (e) Improvement of communication between patients and hospital staff, minimizing burnout, (f) Research.

The development of C-L Psychiatry is connected with the psychosomatic view of man and from this respect is directly related to the clinical research. Everybody agrees that psychiatry in the general hospital is one of the two pillars supporting psychiatric reform in Greece. Thus, C-L Psychiatry has a dominant position within the services offered in the general hospital³.

In the dawn of the 21st century the primary aim should be the promotion of research and the improvement of training through a fertile and creative cooperation between specialties.

Lefteris Lykouras, Athanasios Douzenis

Reference

1. Lloyd GG, Guthrie Ε (eds) A handbook of liaison psychiatry. Cambridge University Press. Cambridge. 2007
2. Levenson JL (ed) Essentials of psychosomatic medicine. American Psychiatric Publ, Washington, DC, 2007
3. Steptoe A (ed) Depression and physical illness. Cambridge University Press, Cambridge, 2007

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