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The European Association of Consultation-Liaison Psychiatry and Psychosomatics

A Welcome New Addition to the Global Practice of C-L Psychiatry

Dr. Wise is Editor-in-chief, Psychosomatics. Dr. Lobo is President of the European Association for Consultation-Liaison Psychiatry and Psychosomatics.

On June 16, 2000, the European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) was formally established. The three articles by de Jonge, Huyse, et al.^1–3 in this issue of Psychosmatics demonstrate both the vigor and the focus of our European colleagues. Consultation-liaison (C-L) psychiatry is often spoken of as an American export to Europe.⁴ However, C-L psychiatry has shared roots in Great Britian, and medical historians have found early efforts to treat psychiatric patients in some general European hospitals as early as the 15th century.^5,6 Nevertheless, it is widely acknowledged in Europe that contemporary C-L psychiatry is basically an American phenomenon.

That "psychosomatics" is part of the EACLPP title reifies that discipline, which is very active in Germany and Austria.^7,8 Psychosomatic medicine, practiced by internists and psychologists, is a specialty that differs from C-L psychiatry in that it addresses traditional psychosomatic disorders such as peptic ulcer disease and asthma, not the psychiatric disorders such as depression, delirium, and adjustment disorders in the wide variety of physical illnesses found in general hospital settings. Thus, C-L psychiatry, clearly a subspecialty of psychiatry, is a more recent continental phenomenon. Some of the leaders in European C-L originally traveled to North America for C-L training and then returned home to establish C-L psychiatry services. Such endeavors have been particularly fruitful, as demonstrated by both individual and collaborative studies from European centers. These pioneers had the courage, energy, and vision to introduce C-L into psychiatry departments that previously had minimal interaction with other medical specialties.

Although the number of C-L psychiatrists in European countries is still limited, their numbers are growing rapidly. National C-L associations now exist in most countries. Training programs have been developed, and C-L rotations are mandatory in several national psychiatry residency programs.

The establishment of the EACLPP is the outcome of the growing awareness of the importance and implications of treating psychiatric morbidity in medical patients, but this organization is also the outcome of multisite research efforts by the European C-L Workgroup (ECLW).^9,10

The EACLPP strongly endorses empirical studies, and the ability to collaborate across borders is a model to be emulated. Such multicenter initiatives offer larger sample sizes and more generalizable results. The initial, transnational ECLW study described European C-L clinical practice with reliable psychometric instruments. Theses collaborative investigations have documented a low referral rate (1.4% in the ECLW study of 13 countries, 56 hospitals, and 15,000 patients). These studies also attempted to verify simple hypotheses regarding structural and procedural differences across European countries with respect to the quantity, intensity, and quality of C-L interventions, as correlated with structural factors (e.g., staffing and training of clinicians).¹¹ Subsequent studies document the usefullness of a simple screening procedure to detect medical patients requiring complex care at the time of their admission to the hospital.¹² Furthermore, Herzog et al.¹³ demonstrated the feasibility of transnational quality assurance studies aimed at improving C-L practice on the basis of empirical research.

C-L psychiatrists abroad face many of the same problems as C-L psychiatrists in the United States, including insufficient funding, underdiagnosis and undertreatment of patients with comorbid psychiatric symptoms, and problems with the proper recognition of C-L psychiatry within academic departments of psychiatry. Because of insufficient staffing, the ECLW has concentrated its research efforts in developing effective screening and early referral for patients requiring the most complex care, as the INTERMED project described in the following articles demonstrates.

Differences do exist between American and European C-L psychiatry. In fact, different countries within Europe have considerable differences in their health care systems and academic structures. We believe, however, that the similarities in the practice of C-L psychiatry across different nations are more important than the differences. The common denominator to all of C-L psychiatry is to effectively provide medical care to patients with psychiatric comorbidity, particularly to patients who require the most complex care. This emphasis on patients who require complex and coordinated care is central to the application for C-L subspecialty status being spearheaded by the Academy of Psychosomatic Medicine (APM). The clinical guidelines developed by the APM are well known and influential in Europe.¹⁴ European C-L guidelines are also in the process of development.

Although the emphasis on empirical data is clear on both sides of the Atlantic, there is another crucial similarity between American and European C-L psychiatry. This similarity focusses on the interest and determination to integrate humanistic medicine into medical settings to allow a human-based biopsychosocial approach. Obviously this spirit is implicit in the concept of C-L psychiatry; however, it is the role of C-L psychiatrists and their academic and medical institutions to make such a merger explicit by example and education.

We would be remiss not to mention the significant C-L efforts in Australia, New Zealand, and Japan, where clinical services and research abound.^15–18 Finally South American C-L psychiatrists are emerging in a region long dominated by psychoanalysts and hospital psychiatrists. These efforts are examples of the global development of C-L psychiatry as a vigorous subspecialty and the mandate to consider psychosocial aspects within general medical care. Organizations such as the APM, and now the EACLPP, offer collegeal support, a forum for new knowledge, and a locus for education. With such sentiments, we warmly welcome the EACLPP into our professional associations and congratulate its members for their achievments.

REFERENCES

1. de Jonge P, Huyse FJ, Slaets JPJ, et al: Care complexity in the general hospital: results from a European study. Psychosomatics 2001; 42:204–212[Abstract/Free Full Text]
2. de Jonge P, Huyse FJ, Herzog T, et al: Risk factors for complex care needs in general medical inpatients: results from a European study. Psychosomatics 2001; 42:213–221[Abstract/Free Full Text]
3. Huyse FJ, de Jonge P, Slaets JPJ, et al: COMPRI—an instrument to detect patients with complex care needs: results from a European study. Psychosomatics 2001; 42:222–228[Abstract/Free Full Text]
4. Wise TN: A tale of two societies. Psychosom Med 1995; 57:303–309[Abstract/Free Full Text]
5. Mayou R: Liaison psychiatry. Br J Psychiatry 1990; 157:156–158[Free Full Text]
6. Mayou R: The history of general hospital psychiatry. Br J Psychiatry 1989; 155:764–776[Abstract/Free Full Text]
7. Freyberger HJ, Nordmeyer J, Kunsebeck H, et al: Clinical and educational activities of a psychosomatic division. Adv Psychosom Med 1983; 11:166–176[Medline]
8. Schuppel R, Gatter J, Hrabal V: Teaching psychosomatic medicine: predictors of students' attitudes toward a compulsory course. J Psychosom Res 1997; 42:481–484[CrossRef][Medline]
9. Alaja R, Tienari P, Seppa K, et al: Patterns of comorbidity in relation to functioning (GAF) among general hospital psychiatric referrals. European Consultation-Liaison Workgroup. Acta Psychiatr Scand 1999; 99:135–140[Medline]
10. Mayou R, Huyse F: Consultation-liaison psychiatry in western Europe. The European Consultation-Liaison Workgroup. Gen Hosp Psychiatry 1991; 13:188–208[CrossRef][Medline]
11. Huyse FJ, DeJonge P, Slaets JPJ, et al: COMPRI: an instrument to detect patients with complex care needs. J Psychosom Res 2000; 48:303–305[CrossRef]
12. Huyse FJ, Herzog T, Lobo A, et al: European consultation-liaison services and their user populations: the European Consultation-Liaison Workgroup Collaborative Study. Psychosomatics 2000; 41:330–338[Abstract/Free Full Text]
13. Herzog T, Stein B, Huyse F, et al: The outcome of BIOMED1: European quality management project: implications for the future of European C-L Psychiatric and Psychosomatics. J Psychosom Res 2000; 48:305–308[CrossRef]
14. Stoudemire A, Bronheim H, Wise TN: Why guidelines for consultation-liaison psychiatry? (editorial). Psychosomatics 1998; 39:S3–S7
15. Carr VJ, Lewin TJ, Reid AL, et al: An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice. Aust N Z J Psychiatry 1997; 31:714–25; discussion 726–7[Medline]
16. Horikawa N, Yamazaki T, Sagawa M, et al: The disclosure of information to cancer patients and its relationship to their mental state in a consultation-liaison psychiatry setting in Japan. Gen Hosp Psychiatry 1999; 21:368–373[CrossRef][Medline]
17. Hosaka T, Aoki T, Ichikawa Y: Emotional states of patients with hematological malignancies: preliminary study. Jpn J Clin Oncol 1994; 24:186–190[Abstract/Free Full Text]
18. Smith GC: From consultation-liaison psychiatry to psychosocial advocacy: maintaining psychiatry's scope. Aust N Z J Psychiatry 1998; 32:753–761[Medline]

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