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The urge of
psychiatrists to acquire a specific set of knowledge to assess and treat the
medically ill has opened the need for developing a subspecialty that systematizes
years of this theoretical and practical area within mental health. Liaison
Psychiatry and Psychosomatic Medicine becomes a relevant part of current
medical practice and a key feature of a resolute health system. Several
experiences from psychiatrists in general hospitals, in addition to the
contribution from biomedical and social sciences, have brought international
recognition to this specialized field of mental health. The history of liaison
psychiatry in Chile shares a similar background with other experiences around
the world and can be traced back to 1953. Even though the progress in this
field is dissimilar across the region, we emphasize the fact that the local
efforts are reflected in two major milestones: the publishing of the first Latin
American textbook of Liaison Psychiatry and Psychosomatic Medicine and the
development of a subspecialist two year training program in Liaison Psychiatry
and Psychosomatic Medicine; the first in Chile and Latin America, which started
teaching its first resident in 2016 and it will have its third titled
subspecialist by the end of this year.
Keywords: Liaison psychiatry, Consultation-liaison, Psychosomatic medicine
INTRODUCTION
Current medicine moves towards an approach
that considers human being in its integrity, evolving from an overpassed model
of biomedical causality to one that takes account of psychological and social
variables as fundamental in the health-disease process.
Even though the biopsychosocial framework
has shown an exponential growth in the past few decades, with its general
acceptance in the contemporary medical practice, it is remarkable how the fluid
relationship between mental and body phenomena, psique and soma, can be traced
back to the history of medicine in its entirety, from ancient Egypt, early
medical references in China and the systematization of diseases as propose by
Hippocrates, just to name a few examples.
In our recent history, this just passed
century [1], the evolution of psychiatric and psychological care of the
medically ill has grown exponentially. The magnitude of scientific advances in
medicine, in addition to the ethical considerations brought by the end of the
Second World War, became a fertile field to start taking account of the mental
health requirements in the general hospital. This brings the development of
initiatives that incorporate the psychiatrist in the day-to-day work of the
classically somatic medicine.
Even though there is a long tradition of
psychiatrists teaming with colleagues from other medical specialties, there is
no unanimous agreement on how to call this specific field of work. It’s
believed that Johan Heinroth coined the expression psychosomatic in 1818 and
that Felix Deutsch was the first to use the concept psychosomatic medicine in
the 1920s [2]. Liaison psychiatry was used in the Psychiatry Service of
Colorado General Hospital in the US [3]. Since then, there have been many names
and different traditions on why use one specific designation over the other,
revised elsewhere by the authors [4]. As a product of the local experience, the authors rather
name this subspecialty
as
The urge of psychiatrists to acquire a
specific set of knowledge to assess and treat the medically ill has opened the
need for developing a subspecialty that systematizes years of this theoretical
and practical area within mental health. Liaison Psychiatry and Psychosomatic
Medicine gets relevant in current medical practice and becomes imperative in
how a resolute health system should be conceived. The creation of the Group of
Interest in Liaison Psychiatry of the Royal College of Psychiatrists in the 80s
[5] and the recognition of Psychosomatic Medicine as a medical subspecialty by
the American board of Medical Specialties in the US in 2003 [6], are pristine
reflections on how the work of psychiatrist with medically complex patients in
fields such as oncology, HIV, neurology and transplant medicine gets its proper
recognition [7,8].
Several experiences from psychiatrists in
general hospitals, in addition to the contribution from biomedical and social
sciences, support the specific work ethos of the LPPM specialist [9]. There is
a demanding atmosphere surrounding the somatic patient, so the proceeding of the
psychiatrist can no longer be limited to answer medical and surgical consults;
the LPPM specialist is an active part of the team and not a visitor from a
distant psychiatric ward.
LIAISON
PSYCHIATRY IN CHILE: HISTORY AND PERSPECTIVES
The history of liaison psychiatry in Chile
shares a similar background with other experiences around the world; psychiatry
units in general hospitals starts answering to colleagues from the rest of the
hospital until the help from a mental health professional becomes part of the
regular interactions in surgical or medical wards. Such is the case of Hospital
José Joaquín Aguirre, in Santiago, Chile; the first general hospital in Chile
with a Psychiatry Service, with its respective liaison unit or the Psychiatry
Service of Hospital de Temuco, led by Dr. Martín Cordero from 1969 to 1973; a
service with an active participation of patients and community members [10].
The pioneering public health system model designed in the 60s encouraged many
psychiatrists and mental health professionals to integrate their work to the
general health care until 1973, when Augusto Pinochet dictatorship
disarticulated the organization of Chilean health care and progressively
replaced it with one centered in health as a consumer good.
Since the return of democracy, several
factors have come together to help the evolution of LPPM in Chile, like the
recommendation from the Health Ministry in 2003 for including a Liaison
Psychiatry module in the general psychiatry residence [11]. Unfortunately, this
is just a recommendation, and the teaching in this subject is still very
divergent and varies widely from one university to the other. Despite what can
be considered as lack of uniformity, the local effort of psychiatrists working
in LPPM is reflected in the conformation of a Group of Interest in Liaison
Psychiatry, part of the Chilean Society of Neurology, Psychiatry and
Neurosurgery (SONEPSYN), with monthly reunions that gather liaison teams from
different regions of Chile. From an academic point of view, we have to
emphasize the importance of publishing the first Latin American textbook of
Liaison Psychiatry and Psychosomatic Medicine in 2016, a book that summarizes
years of clinical experience and updated evidence based practice in this field.
The conjunction of this fertile clinical environment and psychiatrists with
widely diverse academic backgrounds and training experiences in different parts
of the world, like England, Spain and Germany, just to name a few, sets the
ground for one of our local most proud achievement: the development of a
subspecialist two year training program in Liaison Psychiatry and Psychosomatic
Medicine [12], the first in Chile and Latin America, which started teaching its
first resident in 2016 and it will have its third titled subspecialist by the
end of this year.
The relevant work of this subspecialty is
manifested by such reasons as the high psychiatric morbidity rate in general
hospital admissions, which goes from 27.7% to 38.7% [13]. A major concern and
one of the main reasons on why a LPPM assessment is needed is in the case of
what we call a “complex patient”, not only from a medical-somatic point of view
but also from the behavior that he or she may present and the effect or
response from the medical team. In this group of patients, the psychiatric
comorbidity is overrepresented, with an estimation of 2-5 times more prolonged
stays in the general hospital [14]. It is well documented that neuropsychiatric
diagnoses such as delirium, raise the morbidity and mortality and that the cost
for the general hospital administration can double when compared with patients
that are not delirious during their in-patient stay [15,16]. A hospital
management that considers an adequate implementation of a liaison psychiatry
program has proven to be cost-effective and impacts in lowering the length of
stay; a fundamental justification for investing in LPPM as a resource [17,18].
In our country, we can consider two main
frames that highlight the effort of validating the work of conjoining mental
health with the general health system. The first one is the incorporation of
psychiatric diagnoses in a law that guaranties access and treatment of highly
prevalent disorders (Law of Explicit Health Guarantees) where primary care and
general practitioners have a main role in diagnosing and treating major
depression, bipolar affective disorder and schizophrenia, and at the same time
incorporates psychiatric care in other diseases such as HIV, transplant
medicine, metabolic surgery, among others. The second one is the recently
published Mental Health Management Model (Management Model: The Mental Health
Thematic Network in the General Health Network, 2018) were is explicitly stated
that mental health care is a part of the general health network and even
stipulates that highly complex hospitals should have a Liaison Psychiatry,
Health Psychology and Psychosomatic Medicine Unit. Despite all of this, the
implementation of such recommendations lacks of equity, mainly because of the
disparity of incomes through different regions of Chile and one of the main
liabilities towards mental health patients in our country; the lack of a Mental
Health Law.
In conclusion, the history of Liaison
Psychiatry and Psychosomatic Medicine advances at a staggering speed from the
last century to the first decades of the new millennia. The robust core
knowledge in this field is wide and its teaching results beneficial to health
teams, and to our main goal: the wellbeing of our patients. This is why it is
imperative to develop and standardize programs in training new clinicians and
future leaders in this fascinating subspecialty.
1. Leigh H (2015) Nature and evolution of
consultation-liaison psychiatry and psychosomatic medicine. In: Leigh H,
Streltzer J, editors. Handbook of Consultation-Liaison Psychiatry. 2nd
Edn. Heidelberg: Springer.
2. Lipsitt DR (2003) Psychiatry and the general
hospital in an age of uncertainty. World Psychiatry 2: 87-92.
3. Steinberg H (2007) The birth of the word
“psychosomatic” in medical literature by Johann Christian August Heinroth.
Fortschr Neurol Psychiatr 75: 413-417.
4. González M, Carreño M (2017) Psychiatry of
Link and Link Medicine, New Scope. Rev méd Clín Las Condes 28: 944-948.
5. Billings E (1936) Teaching psychiatry in the
medical school general hospital. JAMA 107: 635-639.
6. Çamsarı UM, Babaliogu M (2016) Brief history
of consultation-liaison psychiatry, its current status and training in modern
psychiatry: A perspective from the United States. Turk Psikiyatri Derg 27:
290-294.
7. Aitken P, Lloyd G, Mayou R, Bass C, Sharpe M
(2016) A history of liaison psychiatry in the UK. B J Psych Bull 40: 199-203.
8. Gitlin DF, Levenson JL, Lyketsos CG (2004)
Psychosomatic medicine: A new psychiatric subspecialty. Acad Psychiatry 28:
4-11.
9. González M, Calderón J, Olguín P, Flores JL,
Ramírez S (2006) In the general hospital: A doctors'perception survey. Eur J
Psychiatr 20: 224-230.
10. Torres R, Sepúlveda R, Monografía (2001)
Experiencias de Psiquiatría Comunitaria en Chile. Curso de educación continua
Gestión en psiquiatría y salud mental, Universidad de Santiago.
11. Ministry of Health (2002) Referential
academic program for the training of specialists in psychiatry, Chile, p: 23.
12. González M, Calderón J (2015) Programa de
especialidad médica en psiquiatría de enlace y medicina psicosomática.
Dirección de Posgrado, Pontificia Universidad Católica de Chile.
13. Silverstone PH (1996) Prevalence of
psychiatric disorders in medical inpatients. J Nerv Ment Dis 184: 43-51.
14. Wise MG, Rundell JR, Publishing AP (2002) The
American Psychiatric Publishing Textbook of Consultation-Liaison Psychiatry:
Psychiatry in the Medically Ill. American Psychiatric Pub.
15. Hansen MS, Fink P, Frydenberg M, Oxhoj M,
Sondergaard L, et al. (2001) Mental disorders among internal medical
inpatients: Prevalence, detection and treatment status. J Psychosom Res 50:
199-204.
16. González M, Martinez G, Calderon J,
Villarroel L, Yuri F, et al. (2009) Impact of delirium on short-term mortality
in elderly inpatients: A prospective cohort study. Psychosomatics 50: 234-238.
17. Huyse FJ, Herzog T, Lobo A, Malt UF, Opmeer
BC, et al. (2001) Consultation-Liaison psychiatric service delivery: Results
from a European study. Gen Hosp Psychiatr 23: 124-132.
18. Wood R, Wand APF (2014) The effectiveness of
consultation-liaison psychiatry in the general hospital setting: A systematic
review. J Psychosom Res 76: 175-192.
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