Response to “The guideline ‘consultation psychiatry’ of the Netherlands Psychiatric Association”
Article Outline
The primary purpose of clinical practice guidelines (CPGs) should be to improve quality and consistency of care and health outcomes, taking into account cost-effectiveness [1]. Physicians also understandably hope that CPGs will support reimbursement for their services and defend their turf from other specialists or professionals. Payors, whether governmental or private, hope that CPGs will reduce costs. Both hopes led to the development of the Dutch guidelines [2], which are clearly articulated, concise, referenced, and sensible.
However, there are a number of factors that challenge the utility of a CPG for psychiatric consultation, including limitations in the evidence base, the complexity of cases, and the scope of consultation–liaison (CL) psychiatry [3]. The evidence base is inevitably limited by a number of factors, including the clinical and ethical impossibility of conducting a randomized clinical trial of naturally occurring consultations [4]. The complexity and scope of our cases cannot be captured by a concise general guideline for consultation, which by its nature is limited to those elements common to all psychiatric consultations. Some common reasons for consultation include capacity for medical decisions, delirium, unexplained physical symptoms, and following suicide attempts; essential aspects of each type of consultation lie outside the common denominator. Psychiatric consultants may encounter any psychiatric disorder combined with any medical disorder [5]. An earlier US CPG for psychiatric consultation listed 20 required skills and 43 consult request foci [6]. The CPG of the UK Royal College of Psychiatrists is 134 pages long and still is limited in specific information [7].
To the best of my knowledge, no other specialty (except for geriatric medicine) has developed an evidence-based CPG for undifferentiated consults, i.e., not specific to any particular diagnosis or treatment. No one seems to be suggesting that neurologists should prove the worth of a neurological consultation or that surgical consultations should be judged by whether they reduce the number of patients referred for surgery. Why should there be a different standard for psychiatry?
Leentjens et al. [2] conclude that psychiatric consultations should be performed by psychiatrists and not by other disciplines. I share their belief, but this is not an evidence-based conclusion. Like many of their sensible recommendations, it is derived from the consensus of experts. It would carry more weight if the work group had included representation from psychology, social work, and nursing.
In the final analysis though, the goals of quality, consistency, and effectiveness of general psychiatric consultation are inarguable, and the Dutch guideline can contribute toward their attainment. However, I think that CPGs more narrowly focused on particular C-L tasks and specific conditions can be better rooted in a more defined evidence base and are ultimately more useful, e.g., for delirium [8] or psychosocial evaluation of living unrelated organ donors [9], and whenever possible should be composed by multidisciplinary work groups [10].
References
- Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318:527–530
- The guideline ‘consultation psychiatry’ of the Netherlands Psychiatric Association. J Psychosom Res. 2009;66:531–535
- . Are practice guidelines helpful for C-L psychiatry and psychosomatic medicine?. In: XI Annual Scientific Meeting of the European Association for Consultation-Liaison Psychiatry and Psychosomatics, Zaragoza, Spain, June 25. 2008;
- . The lesson of Icarus. J Psychosom Res. 1998;45:433–436
- A fallacy of subspecialization in psychiatry. Consultation–liaison is a supraspecialty. Psychosomatics. 1991;32:343–345
- The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. The Academy of Psychosomatic Medicine. Psychosomatics. 1998;39:S8–S30
- Royal Colleges of Physicians and Psychiatrists. Joint working party report: the psychological care of medical patients: recognition of need and service provision. London: RCGP, 1995. 2nd ed., 2003.
- . A survey of delirium guidelines in Europe. J Psychosom Res. 2006;61:123–128
- Guidelines for the psychosocial evaluation of living unrelated kidney donors in the United States. Am J Transplant. 2007;7:1047–1054
- Chronic heart failure and depression: the limitations of specialization-specific multidisciplinary guidelines. Ned Tijdschr Geneeskd. 2004;148:2312–2314
PII: S0022-3999(09)00087-7
doi:10.1016/j.jpsychores.2009.02.008
© 2009 Elsevier Inc. All rights reserved.
Refers to article:
- The guideline “consultation psychiatry” of the Netherlands Psychiatric Association , 17 April 2009
