Controversies in consultation–liaison psychiatry

“Controversies in Consultation–Liaison Psychiatry” was the title of the Ninth Annual Meeting of the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP), which was held in Lausanne last June. It attracted 176 visitors from 23 countries. Were there controversies? Some years ago, the theme of this conference would not have been appropriate. However, the recognition of liaison psychiatry, as symbolized by the recently recognized subspecialization status of consultation–liaison (CL) psychiatry in the United States, might mark a point for reflection on the achievements of the field and on future directions.

As examples, the following issues were included on the agenda of the plenary sessions of the meeting: (a) Treatment of adjustment disorder in the medically ill: psychopharmacology or psychotherapy?; (b) What is left of the early German psychosomatic model, what is the perspective of George Engel's heritage, and what is the link with current models of CL psychiatry?; (c) In the session “same case, different views,” an example was given as to how analyses and propositions concerning the same case differ among different cultures (Switzerland, United States, Turkey, and The Netherlands) and among different professionals (psychiatrists and nurses). Probably, the most important observations and conclusions of these presentations and of related debates brought forth the reconciliation between more theory-driven (read: psychoanalytic) models and more empirically driven models. The sessions also allowed a broader understanding of the meaning of the German psychosomatic model of CL psychiatry. Before the introduction of the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III), the psychodynamic model of thinking was the dominant theoretical model in US CL psychiatry. However, in contrast to the German languaged countries, the United States, and other Western countries, the liasion model, including the psychosomatic/psych-med wards, were nowhere so systematically developed as in the German psychosomatic model. With a recent focus on empirical research and with a broadened psychotherapeutic concept, the psychosomatic model becomes an example for integrated medicine, which, until now, has failed to develop in the western world. As such, the second “P” of the acronym EACLPP became a more integrated part of the EACLPP annual meetings than ever before. While the consultation model was needed to develop our knowledge and skills, the future belongs to integrated models, such as early integrated interventions for the main population referred to general hospital psychiatrists—the complex medically ill [1], [2].

During the meeting, a round-table discussion on issues such as “Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-V): are there relevant changes for CL psychiatry” and “Subspecialization of CL psychiatry: can we really expect benefits?” was organized. Here, the controversies concerning the current classification of somatoform disorders in the DSM, as well as the consequences of the fragmentation of psychiatry (as reflected by the continuous increase in the number of diagnoses without an appropriate balance of available treatment options), were addressed (Fig. 1) [3]. Since the complex medically ill often suffer not only from multiple somatic diagnoses but also from multiple psychiatric diagnoses, current psychiatric diagnostic thinking is of limited interest and benefit for the complex medically ill. Complexity models, such as the biopsychosocial model—which focuses more on interactions such as compliance, the quality of the patient–doctor relationship, or interdependence between psychological stressors and physical disorders, rather than on separate disease identities—enrich the quality of service delivery to these patient groups [4], [5].

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Fig. 1. DSM and the number of diagnoses. Modified from Kroenke and Rosmalen. Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders. Med Clin North Am 2006;90:603–26 [3], with permission from Elsevier.

Moreover, several workshops on topics such as “implementation of guidelines,” “communication skills training for physicians and nurses” or “CL nursing,” and “meet-the-expert sessions” allowed an atmosphere of reflection and exchange, contrasting with the more common and at-times-rigid presentations of “evidence” during congresses. The feeling of the program committee, that interaction and exchange on controversies would therefore be stimulating alternatives, was confirmed by the participants. For the EACLPP, which is primarily a professional association for liaison psychiatrists who also conduct research and provide pregraduate and postgraduate teaching, this last meeting provided an update on the relevance of some clinical work, on the interest and interpretation of scientific evidence, and on the development of new teaching methods, as well as on future strategies to foster progress in the field.

By tackling controversial issues, the Lausanne meeting attempted to overcome unnecessary and unproductive splits in the field of CL psychiatry. After years of separation and after a slow and careful approach between different currents of CL psychiatry, the Lausanne meeting will hopefully be remembered as a demarcation point for a more integrated development of the field, embracing different clinical, theoretical, and “cultural” approaches [6]. This hope is also illustrated by the joint decision of the board of the EACLPP and of President Steve Saravay of the Academy of Psychosomatic Medicine (APM) to have a combined meeting of the APM, the EACLPP, and the Spanish Society for Consultation Liaison Psychiatry in Barcelona in 2009. Consistent with the theme of integration at the recent EACLPP meeting, the annual meeting of the Academy of Psychosomatic Medicine in Tucson this November, entitled “Defining the Scope of Psychosomatic Medicine,” will address the challenge of integrating psychosomatic medicine and CL psychiatry (http://www.apm.org).

This trend of having meetings focusing on interactions and reflections on the values and relevance of our work, combined with the presentation of high-quality research, will continue in future meetings (such as in Milan in 2007 and in Zaragoza 2008) and will culminate in the abovementioned joint meeting in Barcelona, where different CL psychiatry and psychosomatic cultures will meet. Since the field of CL psychiatry is presently growing to an international level, it is time to have more intensive contacts with colleagues from around the world, with whom we share the same difficulties of working and liaising within a fragmented health care system.