Abstract
What is the place of the psyche in health care? Does the mind really matter? Thiswas the focus of a recent meeting held to mark the retirement of Professor Graeme Smith from the Chair of Psychological Medicine at Monash University – a meeting culminating in a debate on the topic, ‘Is consultation–liaison psychiatry worth paying for?’ This vexed question uniquely challenges both evidence and attitude. Problems in both domains have until now mitigated against a resolution of the question in a way that would provide optimum care for patients with comorbid physical and psychiatric disorder, or provide the support necessary for the health-care professionals involved. Although consultation–liaison psychiatry now has subspecialty status in many countries including Australia, New Zealand, UK, US and Germany, lobbyists from the professional bodies supporting the discipline have faced resistance from health-care funders. However, they are now able to draw on the rapidly increasing evidence that psychiatric disorders such as depression are major risk factors for the development of coronary heart disease, stroke and diabetes, and for increased morbidity and mortality once these disorders are established [1]. They can also point to increasing evidence of the effectiveness of intervention in such cases. However, the greatest resistance is to the notion that this is an interface activity, one that requires special expertise and evaluation in other than reductionist ways.
This issue of the Journal contains papers that address various aspects of the question. Strain gives an overview of the ways in which our current medical and psychiatric taxonomies fail with respect to what is the commonest form of psychiatric presentation in the community; physical and psychiatric comorbidity and somatization. Fink et al., follow with a creative attempt at developing a new descriptive classification of somatization and illness worry, arguably the most difficult area for clinicians to diagnose and treat. Diefenbacher describes the way that the question is addressed organizationally in Germany, where there has been an attempt at resolution through creation of an interdisciplinary interface profession of Psychosomatics. De Jonge et al., describe a joint European initiative providing a validated instrument for screening for complexity of care needs. This is an example of the type of tool that physicians and consultation–liaison psychiatrists working at the interface will need in the operationalization of their collaborative liaison activity. Mayou and Creed et al., describe some of the cost-effective psychological interventions available for treatment of two of our enigmatic disorders, non-cardiac chest pain and irritable bowel syndrome. Finally, Kathol, who has worked with managed care providers in the US, provides a model that describes how, by making mental health and substance abuse treatment an integral part of general medical care through reorganization at the level of funding, administration and clinical care, a higher percentage of those now untreated for their psychiatric disorders, both within and outside of the medical setting, can have their mental health and substance abuse problems addressed in coordination with their physical disorders while, at the same time, expanding the number of patients that can be treated within the same budget.
Together these articles summarize a large body of scientific literature and clinical experience, and present a great challenge to health-care professionals and administrators – a challenge to construct a health-care system, including diagnosis and treatment, that better handles the problems of people currently falling through the cracks of medical and psychiatric care.