Consultation liaison psychiatry in Norway

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The history of Norwegian CL psychiatry dates back to 1951 when a psychiatrist was appointed to perform psychiatric consultations at the National Hospital. Over the next 20 years, two more psychiatrists were appointed at the same hospital. A separate department was established in 1972 and is now known as the Department of Psychosomatic Medicine, which is under the leadership of Professor Ulrik F. Malt. The department has been steadily growing, mainly after the head of the department also became professor at the University of Oslo in 1985. In the beginning, the department had only psychiatrists, now, there are 9 medical doctors and 6 psychologists, as well as nurses, physiotherapists, and secretaries, for a total of 24 staff members. The department is the leading CL unit in Norway, with regard to magnitude and broadness of clinical and scientific activities. In addition to meeting hospital requirements, it employs several general practitioners and specialists. It is the only Norwegian CL unit with an outpatient clinic. In addition to general CL services to patients with various medical disorders, special services are given within the field of complex psychosomatic or affective disorders, clinical psychopharmacology, neuropsychiatry, and gender identity disorder.

At Ulleval University Hospital, which is the Norwegian hospital with the most number of beds, a part-time psychiatrist was affiliated to one of the medical departments in the late 1950s, mainly working with patients with lung disease and, later, with those with cardiac problems. In the late 1970s, a full-time CL psychiatrist was appointed. The psychiatric department had no formal CL unit, and the psychiatrists on duty, often young residents, provided the service. The author has been working as a consultant psychiatrist at the Department of Acute Medicine since 1981, working mainly with patients admitted for self-poisoning and with those who have emergency medicine concerns together with a social worker. The psychiatrist is also a professor at the University of Oslo. There is also a CL team at the Department of Psychiatry, consisting of a senior psychiatrist, a psychiatric nurse, and a psychiatric resident. Furthermore, there is a senior psychiatrist working with consultancy and research, who is also an associate professor at the University of Oslo. The Department of Child and Adolescent Psychiatry has one CL psychiatrist for patients under the age of 18 years.

There are six other hospitals with CL teams in Norway, but many have only one psychiatrist. CL psychiatrists working in isolation poses a problem.

In 1992, The Norwegian Psychiatric Association appointed a subcommittee for CL Psychiatry and Psychosomatic Medicine, with three adult psychiatrists and one child and adolescent psychiatrist. The committee strives to gain more interest in the field, promote knowledge and competence in a biopsychosocial understanding of illness, as well as the function of CL psychiatry, and stimulate research in this field. The committee has since organized two meetings each year for CL psychiatrists, mainly with presentations of research in the field, as well as discussions of common problems that CL psychiatrists face. The committee has also tried to add more time for teaching CL psychiatry in the compulsory educational program for psychiatric residents. This has not been as successful as expected so far.

During 2005, a postal survey was conducted in the Nordic countries to assess the extent and perceived quality of CL psychiatry. Questionnaires were developed for psychiatric and somatic departments. Data analysis comparing findings from the different countries is in progress. Some preliminary results have been presented [1]. Some data from Norway will be presented in this article.

There were 39 psychiatric units that returned the questionnaire, 36 of them providing CL services. Most departments (60%) were served by a psychiatric resident, 20% by a CL team member, and 20% by a senior psychiatrist during daytime. This means that most consultants are not specialists in psychiatry. About 40% of the consultations were made by a senior psychiatrist, 20% by a psychiatric resident, 15% by a psychologist, 15% by a psychiatric nurse, and 10% by a social worker. Although the residents are supposed to be supervised, only 60% regularly receive supervision, which is not sufficient to ensure specialist quality of the consultation services. Eighty-three percent of the psychiatric residents gave consultations as a regular part of their psychiatric training, whereas this was optional for another 10%.

The number of beds at the hospitals that were served varied from 20 to 850 beds, with an average of 240.

The number of consultations performed each week varied considerably, with an average of 8 consultations (range, 1–50). The average duration of a consultation was 90 min, including report writing.

Most services are given to medical (60%), surgical (15%), and neurological (10%) departments. All services are based on the agreement that the service is free from payment, in accordance with medical or surgical services to patients at the psychiatric departments, which are also free.

Patients most commonly assessed were those who attempted to commit suicide (50%), those with somatic symptoms that are difficult to diagnose (15%), and those with psychiatric symptoms associated with a known somatic disease (25%).

The respondents expressed considerable need for further education in CL psychiatry [3.6 on a 5-point scale (5 being the best)]. One third of the psychiatric departments were involved in research projects relevant to CL psychiatry, half of which have only one project. The psychiatric departments regarded the extent of these services as too low, although the services had been extended somewhat during the last 3 years. Seventy-nine percent found that there was a need to extend the CL services, and 82% were interested for a CL network to develop a forum for service development discussions. Satisfaction regarding the services was moderate/rather high.

There were 127 somatic departments that completed the questionnaires, coming mainly from medical (34%), surgical (31%), and gynecological (22%) departments. The somatic departments also considered the extent of the CL services as too low, although it had increased during the last 3 years. Satisfaction regarding the services was moderate/rather high. In addition to the CL services, there are some departments with regular appointments for psychologists.

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Conclusion 

The CL services in Norway have expanded somewhat during the last 25 years and are still slowly growing. The Department of Psychosomatic Medicine at the National Hospital is by far the biggest unit. There are rather few CL teams in Norway. Suicide attempt is the most common reason for referral. Psychiatric residents, who often get no supervision, make a significant proportion of the consultations. The extent of CL services is considered too low among both somatic and psychiatric departments. The service that is provided is regarded as satisfactory by psychiatric and somatic doctors. The following are suggestions that might improve the services: (a) supporting consultants working alone, (b) establishing more CL teams, (c) teaching and educating psychiatric residents, and (d) engaging in research projects, preferably in cooperation with colleagues in the medical disciplines.

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Reference 

1. Ekeberg O, Birket-Smith M, Dammen T, Hiltunen P, Wahlstrom L. Consultation–liaison psychiatry in the Nordic countries. 8th Annual scientific meeting of the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP). Istanbul, Turkey, 2124 Sept 2005. J Psychosom Res. 2005;59:27
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