Response to “The guideline ‘consultation psychiatry’ of the Netherlands Psychiatric Association”

Congratulations to the working group of the Dutch Psychiatric Society for their review of the literature and the development of the “Guideline for consultation psychiatry.” Describing the process of consultation is not an easy task, especially in light of the scant literature. In reviewing the literature recently in order to develop education material for our psychiatrists-in-training during their consultation–liaison (CL) rotation, we found that clear guidance on how to consult and liaise in the CL sense is sadly lacking, so these guidelines go part way to redressing this.

The strength of the guideline is that it provides concrete guidance to psychiatrists and psychiatrists-in-training regarding the process of psychiatric consultation as requested by general practitioners in the community or physicians in general hospitals or nursing homes. The guideline contains clear and practical advice that can be used by a consultant to respond to the referral of a patient for psychiatric evaluation and a framework for providing recommendations to the treating physician. In our experience, psychiatric registrars are on a steep learning curve when they undertake their CL rotation. They need to familiarize themselves with both the clinical psychiatry of general hospital patients and the processes of consulting to a treating team within the clinical setting. This guideline can be utilized as a teaching aid as well as enhancing consistency of approach across a team.

One omission from the guideline is that, ideally, a referred patient should be told about the referral by the referring physician, not only to keep the patient informed in relation to his or her care but to seek agreement for the consultation to occur. This respects patient autonomy and contributes to the development of a productive, collaborative relationship with the patient. Obviously, there are some situations where this is not applicable, for example, when risk issues warrant intervention from psychiatry without agreement from the patient and within the framework of local mental health legislation.

There are a couple of aspects of the guidelines worth commenting on in terms of their applicability at an international level. There is no reference within the article to the concept of the psychiatrist working within a multidisciplinary team, but the actual guideline acknowledges this likelihood. The focus in the guideline is on 1:1 medical-to-medical consultation, limiting its applicability to contexts where multidisciplinary psychiatric teams are preferred or when the consultation is to another kind of clinician within a hospital setting, commonly a senior nurse. The Australian health system, especially the mental health system, operates on the basis of multidisciplinary teams in both inpatient and community settings, and this is increasingly the case in CL teams. The article states that the practice of consultation “should be performed by doctors.” While this may be preferable in answering referral questions that are medical in nature such as diagnosis and treatment options, it may be difficult to achieve in settings with a shortage of psychiatrists. Caplan [1] developed his model of consultation bearing in mind the lack of mental health expertise available within community settings to meet the mental health needs of the population. Having mental health clinicians providing the front line assessment, with access to psychiatrist supervision and case review, can work well in these circumstances.

In the general hospital setting, our experience is that a multidisciplinary response to a referral provides a more comprehensive consultation to what are often multidisciplinary questions. We have found that the medical CL consultation does not necessarily meet the needs of nurses and allied health staff and that the addition of the nursing role to the CL team improves the satisfaction of the referring team with the consultation. Given that nurses provide the most continuous form of care to patients in the general hospital setting, we believe that the psychiatric nursing role is essential to an effective CL team.

In summary, the guideline is very useful as an adjunct to psychiatry training, particularly during the CL rotation. It may also be applicable to 1:1 consultations but it has significant limitations in its applicability to the environment of multidisciplinary teams. While the aim of the guidelines is to describe the consultation process, not collaborative or liaison activities, the need for work in the latter is apparent, especially given the link between liaison/collaboration and improved patient outcomes.