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ObjectiveCollusion is a largely unconscious, dynamic bond, which may occur between patients and clinicians, between patients and family members, or between different health professionals. It is widely prevalent in the palliative care setting and provokes intense emotions, unreflective behavior, and negative impact on care. However, research on collusion is limited due to a lack of conceptual clarity and robust instruments to investigate this complex phenomenon. We have therefore developed the Collusion Classification Grid (CCG), which we aimed to evaluate with regard to its potential utility to analyze instances of collusion, be it for the purpose of supervision in the clinical setting or research.MethodSituations of difficult interactions with patients with advanced disease (N = 10), presented by clinicians in supervision with a liaison psychiatrist were retrospectively analyzed by means of the CCG.Result1) All items constituting the grid were mobilized at least once; 2) one new item had to be added; and 3) the CCG identified different types of collusion.Significance of resultsThis case series of collusions assessed with the CCG is a first step before the investigation of larger samples with the CCG. Such studies could search and identify setting-dependent and recurrent types of collusions, and patterns emerging between the items of the CCG. A better grasp of collusion could ultimately lead to a better understanding of the impact of collusion on the patient encounter and clinical decision-making.

Background When a patient is found to be lacking capacity to make a medical decision, the medical team is advised to turn to the patient's most appropriate surrogate decision maker (hereafter, surrogate) to make a choice on behalf of the patient. The assumption made by the medical team is that the surrogate will have the capacity to make appropriate medical decisions on behalf of the patient. At times though, the capacity of the surrogate himself may be called into question, leading to uncertainty in terms of how best to proceed in the care of the patient. Consultation-liaison psychiatrists are commonly consulted to assess a patient's capacity to make a particular medical decision, but their role assisting in cases of incapacitated surrogates is less clear. Objective In this article, we summarize the existing literature and current state laws regarding incapacitated surrogates and propose guidelines for the role the consultation-liaison psychiatrist can take when the surrogate may be incapacitated.

SUMMARYOwing to the continuing shortage of organs, the demand for transplantation outstrips supply. Liaison psychiatrists, as part of a multidisciplinary team, have a key role in the assessment of transplant candidates and participate in the decision-making process regarding ‘listing’ the patient for transplantation. Psychiatric and psychosocial factors affect prognosis post-transplantation and there are absolute and relative contraindications to transplantation. The skills of the liaison psychiatrist are employed throughout the patient's illness journey, in the pre-, peri- and post-transplantation periods.LEARNING OBJECTIVES•Learn the salient factors in a pre-transplantation psychosocial assessment•Know the contraindications to transplantation•Appreciate the factors associated with a poor outcome post-transplantationDECLARATION OF INTERESTNone.

Paediatric psycho-oncology is an evolving speciality and is increasingly being recognised as an essential component in children’s cancer care. Modern paediatric oncology services aspire to integrate physical care with psycho-social care and build capacity within clinical teams to address the emotional needs of parents and children side by side with other aspects of medical care. This article discusses the unique challenges of paediatric psycho-oncology and common situations where psychological assessment and management of children and young people with cancer become especially important. The authors propose a tiered structure of training. Providing empathic evidence-based psycho-social care is ‘everyone’s business’ in paediatric oncology and not merely that of mental health professionals. However, there are times when a more specialist intervention by a paediatric liaison psychiatrist and/or a clinical psychologist is needed for optimum outcome. Learning interviewing techniques suitable for children and adolescents should be a core part of the training in paediatric psycho-oncology. Professionals should be encouraged to reflect on their own emotional wellbeing, which in turn will provide a stable foundation of emotionally matured care to children, young people and their families.

Objective To compare the diagnostic, management, and treatment recommendations made by consultation-liaison psychiatrists (CLP) and neurologists (CLN) for suspected delirium and to investigate factors that may have influenced the choice for a particular consultation service. Method In this retrospective case analysis, we screened the files of 1882 (CLP: 1112, CLN: 770) inpatients seen by CLP and CLN at the Charité – University Medicine, Berlin, Germany, in 2013. This revealed a total of 148 (CLP: 99, CLN: 49) delirium patients. Information found on the consultation form and in the patients’ files was used for data collection and subsequently analyzed. Results Intensive care and surgical units preferably called CLP, while internists consulted more CLN and patients suffering from neurological or psychiatric preconditions were more often seen by the respective specialist. Despite no significant difference between psychomotor activity levels among the groups, CLP recommended significantly more pharmacological interventions ( p = 0.000) and CLN ordered significantly more diagnostic procedures ( p = 0.000). Conclusion Our results show considerable differences between CLP and CLN treatment recommendations, which may indicate a conflicting approach to delirium work-up, not accountable to unequal patient characteristics. These preliminary results are not conclusive and should be followed up by high evidence level research.

Introduction Chimeric antigen receptor (CAR) T-cell therapy is a promising novel T-cell immunotherapy in cancer treatment that has shown clinical efficacy in treating refractory CD19+ B-cell malignancies. However, its use is associated with severe immune-mediated toxicities, including cytokine release syndrome (CRS) and CAR T-cell-related encephalopathy syndrome (CRES). CRS is a systemic inflammatory immune response resulting in symptoms ranging from constitutional to profound organ dysfunction; CRES is a neurotoxicity that can occur concurrently or separately from CRS. Objective This case report and discussion provide an overview of CRES and CRS and highlight special considerations for consultation-liaison (CL) psychiatrists. Method We describe a case of a woman treated with CAR T-cell therapy who developed CRES and CRS, including neuropsychiatric manifestations. We reviewed the literature using “Pubmed” search terms of “CAR T-cell therapy” and “CRS” or “CRES”. Discussion We provide an overview of CRS and CRES. We also highlight special considerations for the CL psychiatrist including completing a delirium workup, weighing risks/benefits of psychotropic agents to treat neuropsychiatric manifestations of CRES, and recognizing the potential for long-term behavioral health symptoms related to CRES, CRS, or their treatments. Conclusion CAR T-cell immunotherapy is becoming more prevalent. It is imperative that CL psychiatrists become familiar with this immunotherapy's toxicities including pathophysiology, neuropsychiatric manifestations, and evaluation and management to ensure optimal patient care. Finally, since immune activation, inflammation, and cytokine activation - as occurs with CRES - are known to affect cognitive and/or emotional functioning, CL psychiatrists must remain vigilant for these potential long-term psychiatric complications.

The Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings.A cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).A total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients.The S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.

Background When a patient is found to be lacking capacity to make a medical decision, the medical team is advised to turn to the patient's most appropriate surrogate decision maker (hereafter, surrogate) to make a choice on behalf of the patient. The assumption made by the medical team is that the surrogate will have the capacity to make appropriate medical decisions on behalf of the patient. At times though, the capacity of the surrogate himself may be called into question, leading to uncertainty in terms of how best to proceed in the care of the patient. Consultation-liaison psychiatrists are commonly consulted to assess a patient's capacity to make a particular medical decision, but their role assisting in cases of incapacitated surrogates is less clear. Objective In this article, we summarize the existing literature and current state laws regarding incapacitated surrogates and propose guidelines for the role the consultation-liaison psychiatrist can take when the surrogate may be incapacitated.

Assessing medical decision-making capacity is a clinical skill required of all medical professionals, but it is particularly essential for consultation- liaison psychiatrists. Medical decision-making capacity, often confused with competency, is evaluated by assessing 4 standards, which include whether a patient (1) can understand his or her medical situation, (2) can manipulate the information, (3) can evidence a choice about the proposed treatment, and (4) can appreciate the situation and its consequences. Multiple myths and pitfalls may be encountered during capacity evaluations; many of these can be avoided by proper education and training. We discuss the case of a 71-year-old man who presented to the emergency department by ambulance and was refusing non-emergent neurosurgery after a self-inflicted gunshot wound to the head. He was evaluated for medical decision-making capacity, specifically on whether he had the capacity to refuse neurosurgery and accept intravenous antibiotic treatment. In discussing this case, which illustrates the elements, challenges, and ethical dilemmas of the capacity evaluation, we review several mental illnesses that may prevent individuals from having medical decision-making capacity. Myths and pitfalls of capacity evaluations and possible methods for avoiding them are proposed. Specifically, we emphasize the importance of communication between the primary team and the consultationliaison psychiatry service and describe possible solutions to common communication problems that may arise between services. It is hoped that this case presentation and review will help educate psychiatry residents and other physicians so that they are well prepared to perform a medical decision-making capacity evaluation.

Aims and methodThis article presents a 12-month case series to determine the fraction of ward referrals of adults of working age who needed a liaison psychiatrist in a busy tertiary referral teaching hospital.ResultsThe service received 344 referrals resulting in 1259 face-to-face contacts. Depression accounted for the most face-to-face contacts. We deemed the involvement of a liaison psychiatrist necessary in 241 (70.1%) referrals, with medication management as the most common reason.Clinical implicationsA substantial amount of liaison ward work involves the treatment and management of severe and complex mental health problems. Our analysis suggests that in the majority of cases the input of a liaison psychiatrist is required.

Background: Sleep disorders are common in medical out-patients. They are seldom addressed despite being known to worsen overall health of patients. Detailed evaluation to differentiate these into primary sleep disorders, psychiatric and medical co-morbidity or both can be done by a liaison Psychiatrist. Managing these is necessary for providing good quality recovery for the patient. Method: Cross-sectional survey of 148 randomly selected medical out-patients in a tertiary care hospital was carried out to assess various sleep disorders. Pittsburgh sleep quality index was used for assessment. They were assessed by qualified psychiatrist to establish Psychiatric diagnosis by clinical interview as per ICD-10 classification. Co-occurrence of these with chronic medical problems as diagnosed by clinician was documented. Results: Sleep disorders were common in medical out-patients (48.64%). Commonest among them was difficulty initiating sleep and reduced duration. A significant number screened to have sleep disorders, also had psychiatric co-morbidities (63.8%), Depressive disorders being the commonest (52.1%). Chronic medical illnesses were present in 50 (33.8%) of the all patients assessed for having sleep disorders. Co-occurrence of medical and psychiatric co-morbidities was not statistically significant. Conclusion: Considering high prevalence, patients should be routinely assessed for various sleep problems by Physician and referred to Psychiatrist for management as many of them also have psychiatric co-morbidities. Physician and Psychiatrist liaison is important in managing complex medical and psychiatric co-morbidities associated with sleep disorders.

Aims and MethodLiaison psychiatry services in Ireland are currently unequally distributed. In the absence of a specialist liaison psychiatry team, general adult psychiatrists may provide a consultation service to their local hospital. Demographic and clinical characteristics pertaining to all psychiatric consultations at the Louth County Hospital were collected over 12 months to examine one such local service and to highlight the challenges of this mode of service delivery.ResultsA total of 232 consults were audited. the most frequent reasons for referral were assessment following deliberate self-harm (38%), affective symptoms (28%) and alcohol or substance misuse (25%). This differs from documented referral patterns to specialist liaison teams. Referring physicians had a low diagnostic ‘hit-rate’ with respect to affective disorders. Difficulties in service provision included poor communication by referring teams and time constraints due to other sectoral commitments.Clinical ImplicationsRefinements to service delivery may be beneficial in managing the workload more effectively. Priority should be placed on fostering communication with non-psychiatric colleagues.

Pathological laughing and crying (PLC) has been known by a number of different names, but the most widely used terms are “pseudobulbar affect,” “emotional lability,” “emotional incontinence,” and “pathological laughing and crying.” The cardinal feature of PLC is a pathologically lowered threshold for the exhibition of behavioral responses that include laughter, crying, or both. An affected individual exhibits episodes of laughter and / or crying without an apparent motivating stimulus or in response to stimuli that would not have elicited such an emotional response before the onset of their underlying neurologic disorder. Symptoms of PLC can be severe, and episodes can be persistent and unremitting. PLC is a clinical condition that occurs in patients with various neurological disorders. The majority of evidence relates to stroke patients. The review summarizes the available data about pharmacological and behavioral treatment efficiency for this condition. Furthermore the management of these patients adds a rich avenue to the future understanding of emotional behavior.

Background: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a relatively newly identified autoimmune neuropsychiatric disorder that predominantly affects children and young adults. Although psychiatric symptoms are highly prevalent and frequently severe, it has mainly been reported in neurological, but not psychiatric, literature. Understanding this form of encephalitis, its quick diagnosis and which treatment to provide are of utmost importance for consultation-liaison (C-L) psychiatrists. The aim of this paper was to describe a case of anti-NMDAR encephalitis with severe psychiatric manifestations, who showed impressive recovery but required intensive involvement of the C-L psychiatry team. We emphasise the behavioural aspects, psychiatric symptoms and challenges faced by the CL consultant across the different phases of the treatment. Methods: We report the different treatment phases for a young woman with anti-NMDAR encephalitis who developed severe neuropsychiatric symptoms, with a focus on the role and challenges faced by the C-L psychiatrist. The literature is reviewed for each of these challenges. Results: This case illustrated that even extremely severely affected patients may show impressive recovery, but require long lasting psychiatric care. C-L psychiatrists are faced with numerous challenges where only little literature is available. Conclusion: C-L psychiatrists play a pivotal role throughout the multidisciplinary care of patients with anti-NMDAR encephalitis and should be informed about this entity.

Child and adolescent psychiatry has a long tradition in Jena, Germany, and goes back to the psychiatrists Theodor Ziehen and Wilhelm Strohmayer. It seems that Rudolf Lemke (1906-1957) eminently promoted the development of child and adolescent psychiatry after World War II. A versatile scientist, Lemke had many publications in psychiatric and neurologic fields. His significance to the development of the specialty of child and adolescent psychiatry is reflected not only by his publications but also by his work as a clinician and liaison psychiatrist in the Johannes Trueper School in Jena. He founded an independent psychiatric unit for the treatment of children which allowed treatment separated from adults.

(1) To evaluate consultant orthodontist opinion on referral of orthognathic patients to a liaison psychiatrist or psychologist and (2) To investigate the value of training orthodontic specialists in recognition of patients with psychological profiles that might affect orthognathic outcome.Questionnaire-based study.A structured questionnaire was distributed to all consultant orthodontists in the UK.Approximately 40% of consultants thought that up to 10% of their orthognathic patients would benefit from psychological assessment by appropriately trained personnel. Twenty per cent of consultants were not certain what proportion of their patients would benefit from referral and over half the respondents said they do not refer any orthognathic patients for assessment. The most common reasons for referral were past/current psychiatric history (36%), unrealistic expectations (32%), 'gut instinct' (14%), no significant clinical problem (13%). Reasons not to refer were: nobody to refer to (30.5%), fear of patient reacting badly (15.8%), not sure who to refer to (14.7%), response from mental health team not useful (12.4%), waiting list too long (9.6%). The majority of clinicians felt they would benefit from training in this field (84.7%), as over 80% reported no teaching or training in psychological assessment/management.Although we have no evidence to prove that interdisciplinary care is better for patients, clinical experience and reports from clinicians working in large centres, tells us there are probable advantages. The development of a training programme for both orthodontists and mental health teams would seem to be beneficial for both clinicians and patients.

Aims and MethodTo identify psychiatric conditions that may require psychiatric treatment in individuals referred from a diabetes centre to a liaison psychiatry diabetes clinic and to examine the referral pattern and reasons for referral. the study was a prospective case-note survey over a 12-month period.ResultsThe most common reason for referral was low mood (37.5%) and the most common psychiatric diagnosis was adjustment disorder (28.6%). Most individuals were referred by diabetes specialist nurses (53.1%). the majority (85.7%) were seen by a clinical psychologist after an initial assessment by a psychiatrist.Clinical ImplicationsCommon mental disorders occur frequently in individuals referred to a liaison diabetes clinic, hence the importance of early diagnosis. the involvement of psychiatrists in specialist diabetes clinics is very limited and better involvement is desirable.

Aims and MethodTo determine the nature of current liaison psychiatry services in Wales, a structured telephone interview was conducted with representatives of all 11 National Health Service trusts.ResultsThree trusts (27%) had no dedicated liaison psychiatry service and only one of the eight (13%) with a service had a full-time consultant liaison psychiatrist. Only two services (25%) had a full-time junior doctor and three (37%) were not multidisciplinary, comprising nursing staff alone. No team had a clinical psychologist and only two (25%) provided a psychological treatment service.Clinical ImplicationsLiaison psychiatry services across Wales are fragmented, under-resourced and unlikely to meet patients' needs. They fall well short of the recommendations of the Royal Colleges of Physicians and Psychiatrists.

In this article, an experienced consultation liaison psychiatrist presents several cases in detail that illustrate the wide range and complex natures of psychiatric patients seen on the medical and surgery floors. The cases presented appear as they would to the psychiatrist consulting within the hospital and represent a challenging test of the clinician's diagnostic skills, an experience encountered daily by the consultation liaison psychiatrist.

Neuropsychiatric problems are common among liver transplant recipients, and immunosuppressant neurotoxicity is an important etiologic factor in the posttransplant period. Four typical cases of immunosuppressant neurotoxicity are presented from the clinical experience of the University of California, Los Angeles-Dumont Liver Transplant program. All patients presented with acute behavioral symptoms and received urgent psychiatric consultation; each proved to be suffering from a variant of immunosuppressive-related neurotoxicity. Correlative neuroimaging studies and descriptions of clinical course are included. Psychiatrists are urged to become familiar with the signs, symptoms, differential diagnosis, neuroimaging findings, and management of immunosuppressive neurotoxicity and secondary psychiatric disorders in solid organ recipients.

Alcohol related problems amongst patients referred to a liaison psychiatric service have been examined in terms of primary diagnosis but the prevalence has not been estimated using screening instruments. The aim of this study was to establish the prevalence of alcohol related problems using the CAGE and brief MAST screening questionnaires together with data on self reported weekly alcohol consumption and ICD10 diagnosis. On a sample of 100 consecutively referred patients with a response rale of over ninety percent we found 34.0% to be positive for “alcoholism” on the CAGE, 25.5% on the MAST and 13.8% to have a diagnosis of alcohol dependence syndrome. The mean self reported weekly alcohol consumption was 28.4 units per week. Excessive alcohol consumption and misuse were much more prevalent in male referrals. We conclude that it would be advantageous for liaison services to work closely with alcohol services.

Patients with dysfunction of the temporomandibular joint (TMJ) commonly present to oral and maxillofacial departments and are increasingly being managed by a subspecialist group of surgeons. We review the outcomes of patients attending a specialist TMJ multidisciplinary team (MDT) clinic. All patients are simultaneously reviewed by a consultant oral and maxillofacial surgeon, consultant in oral medicine, specialist physiotherapist, and maxillofacial prosthetist, and they can also see a consultant liaison psychiatrist. They are referred from primary, secondary, and tertiary care when medical and surgical treatment in the routine TMJ clinic has failed, and are triaged by the attending maxillofacial surgeon. On discharge they are returned to the care of the referring practitioner. We review the outcomes of patients attending this clinic over a 2-year period and show improvements in pain scores and maximal incisal opening, as well as quality of life outcome measures. All units in the UK with an interest in the management of diseases of the TMJ should consider establishing this type of clinic and should use available resources and expertise to maximise outcomes.

Pain is one of the most ubiquitous problems of today’s world, its impact being far-reaching. Current conceptualizations of pain medicine adopt a bio-psycho-social perspective. In this model, pain is best described as an interactive, psycho-physiological behavioral pattern that cannot be divided into independent psycho-social and physical components. Neurophysiologic substrates of the pain experience can be broken down into the pain transmission elements emanating from peripheral, spinal, and supra-spinal processes. There are many complex mechanisms involved in pain processing within the central nervous system, being influenced by genetics, interaction of neurotransmitters and their receptors, and pain- augmenting and pain-inhibiting neural circuits. The patient’s emotional experiences, beliefs and expectations may determine the outcome of treatment, and are fully emphasized in the focus of treatment interventions. There are several common psychiatric disorders accompanying and complicating the experience of pain that warrant clinical attention and that can be the focus of psychiatric treatment. These include depression, anxiety, sleep disorders, somatoform disorders, substance-related disorders and personality disorders. Complex and disabling pain conditions often require comprehensive pain treatment programs, involving interdisciplinary and multimodal treatment approaches. There are many roles that the psychiatrist can perform in the assessment and treatment of the patients with pain, individually tailored to meet the specific needs of the patient. Rational poly-pharmacy is of a high importance in the treatment of patients with chronic pain, with antidepressants and anticonvulsants contributing as the important adjuvant analgesic agents.

All referrals to a psychiatrist from a palliative care unit, during a one year period, were reviewed. The reasons for referral of patients from the unit, the psychiatric diagnosis on assessment, the intervention by the psychiatrist and the results of the intervention are discussed. Depressive illness was the commonest diagnosis in the 26 patients referred (50%). Sudden immobility due to a hemiplegia or paraplegia was noted to be a risk factor for the development of depression (17%). Family factors played a role in the presentation of 14 patients. In the majority of cases intervention by the psychiatrist was in the form of a diagnostic consultation, which led to guidelines for further management by the palliative care team. In four of the cases, intervention by the psychiatrist was more prolonged (greater than three interviews). Forty per cent of the patients referred showed an improvement in their mental state. The conclusion of the paper is that psychiatric assessment can be useful to the palliative care team, in the assessment and management of psychological disorder in patients with a terminal illness.

agnosis was probable pneumonitis related to venlafaxine, with an improvement of mosaic pattern in lung images when treatment was withdrawn. Three months after discharge the patient was examined without pathologic findings. The patient was evaluated during admission by a liaison psychiatrist because she had been treated for 1 year for depression with a predominance of somatic symptoms. Before discharge, the patient improved noticeably, with a total remission of physical symptoms and mood state.

Liver disease is a common cause of morbidity and mortality in the United States and elsewhere. Arising from infectious, hereditary, or toxin-induced sources, the detection of liver disease often requires a high index of suspicion. Clinical presentations are highly variable and are often accompanied by neuropsychiatric symptoms. This fact, along with an increased incidence of liver disease among patients with primary psychiatric disorders and the presence of varied drug use, complicates the tasks of providing care to patients with liver disease. To assist the consultation–liaison psychiatrist, the authors present the first of a two-part series focused on psychiatric issues in liver disease.

In this article we review the field of HIV liaison psychiatry and illustrate the manner in which psychiatric care can contribute to the health and quality of life of this group of patients. To illustrate our discussion we review experience and findings in relation to affective illness, cognitive impairments, and personality disorder in HIV infection. We also highlight some of the areas where psychiatric care of people with HIV infection is unique from other types of psychiatric liaison work.

Surgery, an everyday occurrence for us, is a unique and dramatic event in a patient’s life. Although an operation almost always feels like a hazardous enterprise, the patient is usually reluctant to share his anxieties with his doctor, fearing that his nervousness could be interpreted as a lack of confidence in the surgeon’s skill. We should remember that the term minor surgery is a technical surgical term. To most patients, surgery is only minor if done to someone else. As a liaison psychiatrist and member of a surgical department for 40 years, I have had the opportunity to speak with thousands of patients before and after operations, listening to their concerns about their experiences. I will-outline some common problems that I believe should be recognized by my surgical colleagues. Most of the references in this paper are rather old. But psychologic reactions of patients have not changed pari passu along with the tremendous advances in surgical techniques and procedures. Recent articles have rarely dealt with these emotional issues.

​FormerFormer consultant liaison psychiatrist Guy's and St Thomas' NHS Trust, London (b 1936; q Cambridge/St Thomas' Hospital, London, 1962; MD, FRCP, FRCPsych), died after a fall on 14 June 2006. Figure 1 After postgraduate clinical work at the Maudsley Hospital, John Young returned to St Thomas' as a consultant in psychological medicine in 1972. He won numerous academic awards, balancing a heavy clinical workload with teaching and a well published academic career. He ruthlessly defended psychiatric services at the hospital and was renowned internationally as a clinician. John's other passion after his family was fishing. Having converted a tank aerial into his first fishing rod as a boy, he was relentless in his pursuit of fish, his reputation as an angler coming to rival that as a doctor. He leaves a wife, three children, and four grandchildren.

Medical care in general hospitals is a collective activity and liaison psychiatrists may become part of this process. Cornerstones of successful management are co-operation with colleagues and ‘teamwork’, although these elusive goals are not always achieved. A shared uniform is one possible solution to improve this teamwork, the white coat being the livery of the hospital doctor. Furthermore, patients may appreciate a uniform. One survey of 200 North American general hospital in-patients showed the white coat to be surprisingly popular (Dunn et al, 1987); 65% of those replying wanted to see their doctor in a white coat. But the white coat is often unpopular with doctors and perhaps a more relevant question is whether it makes any difference to patient behaviour.

The author, a consultation/liaison psychiatrist, reviews five important questions about liaison work which are pressing, but remain unanswered. With some trepidation, he seeks to temper the enthusiasm of his colleagues who, by prematurely promising more than can ever be delivered in the name of “holistic” and “biopsychosocial” medicine, may lead our discipline astray.

A liaison psychiatrist participated in the postoperative care of a group of elderly patients who underwent surgery for fractured femurs. Clinical outcomes for this group were compared with a control group of patients who were not treated by a liaison psychiatrist. Length of stay for the treatment group was 12 days shorter than for the control group, and twice as many patients in the treatment group returned home rather than being discharged to a nursing home or other health-related institution; therefore, a substantial reduction in the cost of their medical care was effected. The authors suggest that psychiatric liaison services should be viewed as a potential cost containment mechanism for general medical care. Language: en

Psychiatrists have, for years, offered consultation to their nonpsychiatrist colleagues in many settings and have worked with them in a variety of ways. The development of new programs in primary medical care offers new challenges and opportunities to the liaison psychiatrist. This paper describes the experience of a full-time psychiatrist in a hospital-based primary health care setting. Special problems are encountered in developing working relationships with patients, physicians, nurses, social workers, administrators, and other members of the health care team. Effective resolution of these problems makes it possible to offer comprehensive mental health services as an integral part of primary health care. This psychiatrist's role differs from other consultation-liaison functions by virtue of full-time economic, patient care, academic, geographic and administrative assimilation into the primary health care setting itself. It is suggested that this role is an effective way to bring supportive and educational psychiatric services to patients and providers of all levels of sophistication and need.

Intensive care units (ICU) of hospitals are characteristically stressful environments with high turnover of personnel. Support groups to help nurses deal with the stresses of the ICU environment have been widely recommended as a means to raise morale and increase communication, but are infrequently reported. Data on these groups are fragmentary. A review of the literature and correspondence with the authors of published papers demonstrated that most nurse support groups are open-ended groups with open membership, usually meeting for an hour a week, occasionally attended by nursing supervisors and unit physicians, and usually conducted by a liaison psychiatrist or a psychiatric consultant. Such groups are reported as positive experiences by nurses and group leaders. The small amount of available objective evidence of the impact of support groups is positive; further research is required to arrive at a more definitive evaluation.

A liaison psychiatrist invited to help a burn unit staff explore problems affecting morale and patient care employed a four-step procedure: (1) assess the work environment systematically; (2) give the staff feedback from this assessment; (3) help the staff plan and institute changes; and (4) reassess. To assess the work environment, the staff completed the Work Environment Scale (WES), a 90-item, true/false questionnaire that measures ten dimensions of the actual and preferred work environment. At the second of 12 bi-weekly meetings, the psychiatrist presented the unit's WES profile and began helping the staff explore and resolve problems. Reassessment six months later revealed statistically significant changes on several pertinent WES scales and reduced discrepancies between actual and preferred work environments on nine of the ten scales. The findings indicate that systemmatic assessment and feedback procedures may help liaison programs improve the quality of hospital work environments and thereby enhance staff performance and morale.

This article reminds the practitioner that alcohol abuse and dependence is the most common of psychiatric disorders, impacts on the general hospital at a variety of levels, repels our referrant-colleagues, and is difficult to diagnose but is eminently treatable. Because both clinicians and their patients are subject to alcohol abuse and dependence, the consultation-liaison psychiatrist is in an ideal position to impact therapeutically on alcoholism at all levels of presentation. Alcoholism is a natural object of a consultation-liaison psychiatrist’s time, interest, and energy.

Editor's Note: We are aware of the controversial nature of this communication and invite responses from psychiatrists in practice as well in academic settings.

The author reviews the scope, underlying assumptions, and organization of consultation-liaison psychiatry. During the 40 years since their inception, liaison services in general hospitals have played a mediating role between psychiatry and medicine. The liaison psychiatrist is one of the few health professionals with a broad enough perspective to achieve a measure of integration of diverse data relevant to comprehensive evaluation and management of patients. Liaison psychiatrists are increasingly involved in teaching and research in addition to clinical activities. The author predicts that the education, functions, and professional attitudes of the liaison psychiatrist represent a viable model that psychiatry as a whole will increasingly adopt.

This paper focuses on the differences between liaison and consultation psychiatry, emphasizing the social role. To carry out systematic liaison intervention, a psychiatrist must become a fully accepted high-status member of the ward culture. Examples of how a liaison psychiatrist can effect change in his/her social role are provided.