East Asian Arch Psychiatry 2019;29:39-40 | https://doi.org/10.12809/eaapv29n2_editorial

Editorial

Consultation-Liaison Psychiatry in Hong Kong: a 2019 Update

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Consultation-liaison (CL) psychiatry (variously known as psychological medicine, liaison psychiatry, and psychosomatic medicine) is a subspecialty of psychiatry concerning management of psychiatric illnesses in general hospital settings.1 The discipline was first developed in the United States in the 19th and early 20th centuries under the influence of the then-prevalent psychosomatic theories of illnesses, and then flourished in the 1950s to 1970s. This was spurred by the combined influences of federal funding and various academic and clinical incentives to develop training and services for psychological and psychiatric management of individuals in general medical settings.2,3

CL psychiatry has been brought to bear in improving diagnosis and treatment outcomes in patients with physical- mental comorbidities,4,5 medically unexplained syndromes,6 and psychiatric emergencies.7 Liaison psychiatric service in general hospitals has contributed to cost savings and efficiency by reducing medical and psychiatric admissions and length of stay.8 CL psychiatry has been tasked with bringing back the more humane and psychosocial care to modern clinical medicine,1 but the expertise in both physical and psychological aspects of clinical medicine also make CL psychiatry a salient component in the training of a competent psychiatrist.

In Hong Kong, inpatient psychiatric consultations have been provided to general hospitals since 1974,9 but it was not until 1991 when the first CL team was established in Princes of Wales Hospital,10 followed by Kwai Chung Hospital 3 years later,11 and subsequently all acute public hospitals in Hong Kong. In the ensuing decades, there has been strong demand for CL services to expand to serve the growing population, but also to map onto the modern terrain of specialization in clinical medicine such as perinatal psychiatry,12 psycho-oncology services, palliative medicine, and renal transplant assessment services.10 Although the introduction of CL nurses in the 2010s has enhanced emergency psychiatric service coverage, it was not an answer to the demand from modern general hospitals for psychiatrists with highly specialized knowledge and skills required to navigate modern psychological medicine.

It was in these contexts that the Clinical Division of Consultation Liaison Psychiatry of the Hong Kong College of Psychiatrists was established in 2014. It aims to promote and advance the scientific understanding and multidisciplinary integration in clinical practice of biological, psychological, behavioural, and social factors in human health and disease. Its establishment paralleled the interest in developing research agenda in psychological medicine and the need to ensure access to equitable mental health service to patients with mental and physical health needs in general hospital settings.

The Division establishes the curriculum for CL specialist training. It regularly holds educational seminar series ‘Medicine for Psychiatrists’ and invites reputable physicians to update practicing psychiatrists on topics of high clinical relevance. In the series 3 years ago, Dr YC Chan, consultant of Hong Kong Poison Information Centre, spoke on clinical toxicology—a summary of which is included in this issue of East Asian Archives of Psychiatry.13 Other topics included rheumatology, pain medicine, and metabolic syndrome.

CL psychiatry provides opportunity for collaborative research and service development with other medical disciplines. Functional gastrointestinal disorders are highly comorbid with anxiety and depressive disorders,14,15 and are effectively treated with antidepressants and psychological treatment.6 Specialist gastroenterology clinics are usually ill-equipped to cater for psychosocial needs. Such patients rarely present to psychiatric service, which is also ill- equipped to cater for medical needs. The Functional Gastrointestinal Disorders Clinic at the Department of Medicine at Prince of Wales Hospital and The Chinese University of Hong Kong enables collaborative care and research between psychiatrists and physicians on these common but often neglected conditions. This theme issue of East Asian Archives of Psychiatry includes two papers from this effort. Wong et al16 review the neurocognitive characteristics of patients with irritable bowel syndrome and the salience of executive dysfunction and emotional arousal-related cognitive aberrations in the pathological mechanisms in this brain-gut disorder. Mak et al17 report that, in a community sample, gastro-oesophageal reflex disease was strongly associated with general anxiety disorder and major depression in a dose-response manner, and the role of mental comorbidities in driving healthcare utilisation behaviour.

This theme issue also includes a summary of a conference on legal issues in compulsory mental health treatment.18 In 2017, the Hong Kong College of Psychiatrists co-organised the conference with the Centre for Medical Ethics and Law. It raised issues about delivering mental healthcare against patients’ will.

In the editorial of the last theme issue on CL psychiatry in 1997, Prof Michael Sharpe remarked on the salience of “developing skilled multidisciplinary teams working in collaboration with physicians and surgeons” as the key to the discipline’s development, guided by research to evaluate its performance.19 In Hong Kong, systematic studies evaluating outcomes of existent CL service programmes are limited. Sustained service/research collaborations between psychiatry and other disciplines in medicine are encouraging, but these remain few and far between. Innovative service paradigms involving new collaborative models and funding mechanisms in various areas in CL psychiatry, guided by rigorous evaluation and support from the Hospital Authority, are required to meet the challenges ahead. In its capacity as the torchlight for development of CL psychiatry in Hong Kong, the Division invites colleagues to share our vision for a promising and exciting prospect. Get on board and stay for good.

Acknowledgement

The authors wish to express their heartfelt gratitude to Dr Chi-Ming Leung for his intellectual, moral, and practical guidance, without which CL psychiatry would not have existed in Hong Kong.

Dr Arthur Dun-Ping Mak, MBChB, FRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, The Chinese University of Hong Kong. Email: arthurdpmak@cuhk.edu.hk

Dr Evelyn Kit-Yi Wong, MBChB, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, North District Hospital, Hong Kong. Email: kyw117@hku.hk

References

  1. Sharpe M. Psychological medicine and the future of psychiatry. Br J Psychiatry 2014;204:91-2. Crossref
  2. Aitken P, Lloyd G, Mayou R, Bass C, Sharpe M. A history of liaison psychiatry in the UK. BJPsych Bull 2016;40:199-203. Crossref
  3. Schwab JJ. Consultation-liaison psychiatry: a historical overview. Psychosomatics 1989;30:245-54. Crossref
  4. Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363:2611-20. Crossref
  5. Sharpe M, Walker J, Holm Hansen C, Martin P, Symeonides S, Gourley C, et al. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial. Lancet 2014;384:1099-108. Crossref
  6. Creed F, Fernandes L, Guthrie E, Palmer S, Ratcliffe J, Read N, et al. The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology 2003;124:303-17. Crossref
  7. Kates N, Eaman S, Santone J, Didemus C, Steiner M, Craven M. An integrated regional emergency psychiatry service. Gen Hosp Psychiatry 1996;18:251-6. Crossref
  8. Parsonage M, Fossey M. Economic evaluation of a liaison psychiatry service. London: Centre for Mental Health; 2011.
  9. Tang OWN. General hospital psychiatry in Hong Kong. Hong Kong J Psychiatry 1997;7:3-8.
  10. Leung CM, Lee S. Consultation-liaison psychiatry at the Prince of Wales Hospital: a new look. Hong Kong J Psychiatry 1991;1:57-60.
  11. 1 Ku KH, Nguyen GHD, Ng YK. Consultation-liaison psychiatry in Kwai Chung Hospital. Hong Kong J Psychiatry 1997;7:3-8.
  12. Lee TD, Yip AS, Chan SS, Tsui MH, Wong WS, Chung TK. Postdelivery screening for postpartum depression. Psychosom Med 2003;65:357-61. Crossref
  13. Chan YC. Clinical toxicology and overdose of psychiatric medications. East Asian Arch Psychiatry 2019;29:57-62. Crossref
  14. Mak AD, Wu JC, Chan Y, Chan FK, Sung JJ, Lee S. Dyspepsia is strongly associated with major depression and generalised anxiety disorder - a community study. Aliment Pharmacol Ther 2012;36:800-10. Crossref
  15. Lee S, Wu J, Ma YL, Tsang A, Guo WJ, Sung J. Irritable bowel syndrome is strongly associated with generalized anxiety disorder: a community study. Aliment Pharmacol Ther 2009;30:643-51. Crossref
  16. Wong KMF, Yuen SSY, Mak ADP. Neurocognitive characteristics of individuals with irritable bowel syndrome. East Asian Arch Psychiatry 2019;29:48-56. Crossref
  17. Mak ADP, Wu JCY, Chan Y, Tse YK, Lee S. Association between gastroesophageal reflux disease, generalised anxiety disorder, major depressive episodes, and healthcare utilisation: a community-based study. East Asian Arch Psychiatry 2019;29:41-7. Crossref
  18. Cheung D. Compulsory mental health treatment in Hong Kong: which way forward? East Asian Arch Psychiatry. 2019;29:63-5. Crossref
  19. Sharpe M, Gath D. Recent development in consultation liaison psychiatry: a view from Oxford. Hong Kong J Psychiatry 1997;7:9-13.
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