Social determinants of health, 2nd edn

Abstract

General psychiatry is increasingly being practised in the community with fewer psychiatrists being available or wishing to work in general hospitals. Indeed, an attitude is developing whereby admission of patients to a psychiatric hospital is being discouraged and perhaps tantamount to therapeutic failure. New Ways of Working, a 2005 government initiative, actively encouraged the use of staff from medical and non-medical backgrounds to make the initial assessment on new patients referred to a mental health resource centre. 1 The general expertise in dealing with the medically and psychiatrically unwell is diminishing. Against such a background liaison psychiatry, the interface between psychiatry and medicine/surgery, has developed: The need for a special expertise in the management of complex problems involving psychological and physical issues is now undeniable. Successful care depends on specialist expertise which goes well beyond the skills of the more general psychiatric specialties. It has been estimated that one full-time psychiatrist (and team) is required for a district general hospital with 600 beds. 2 Delivery of services to general hospitals is highly variable but few if any services in the UK are adequately staffed. The handbook devotes chapters to the general concepts of the specialty, legal and ethical issues and the development of an effective service. There is a simple but clear explanation of the Mental Capacity Act 2007 (assessment of capacity in patients will usually fall to the responsible medical officer) and then various scenarios are discussed, for example best interest in an incapacitated dying man and the use of the Mental Health Act following an overdose. 'Bread and butter topics' , for example self harm, alcohol and drug misuse, and delirium, are, of course, covered and there is an emphasis on the need to ask the right questions. In the chapter on functional somatic syndromes, attention is drawn to the similarity of symptoms. In other words, diseases such as fibromyalgia and chronic fatigue syndromes overlap and there are more similarities than differences: In a sample of women with chronic fatigue syndrome… only 38% had 'pure' chronic fatigue syndrome, whilst 43% met criteria for chronic fibromyalgia, 35% for multiple chemical sensitivity and 16% for all three syndromes. Neurology, gastrointestinal disorders, liver disease, oncology, head and neck cancer, renal disease, cosmetic procedures, perinatal and gynaecological disorders, intensive therapy unit, burns, genito-urinary complaints, accident and emergency (A&E), palliative care, psychocutaneous disorders, sexual disorders in medical patients and diabetes are all covered in subsequent chapters as are pharmacological and psychological treatments and planning for disasters. Such planning is now sadly a necessary part of hospital administration and although psychiatrists should probably keep well away from the A&E department in the immediate aftermath of a disaster their input is essential for the long-term well-being of staff and patients. The handbook highlights the range of the subject and some well-chosen cases exemplify the relationship and the complexity between disease and psychiatric disorders: I can't catch my breath, doctor-a 45-year-old woman with severe chronic obstructive airways disease-admitted 18 times in 18 months. Psychiatric assessment demonstrated the additional symptoms of anxiety whose management dramatically reduced frequency of admission. It's just too strange to be true-a 30-year-old female admitted with pulmonary embolism but in whom all investigations proved normal. Psychiatric investigation revealed 139 admissions to hospitals within a period of four years. The diagnosis and management of factitious disorders are discussed. Two chapters are devoted to primary care and convincing material is presented to show 'the strong association between frequent attendance and psychiatric disorder'. The handbook is not intended to be a complete textbook and will whet but not satiate the appetite for the subject. It 'will be essential reading for liaison psychiatrists, liaison nurses, other members of the mental health team and service managers'. It enthusiastically conveys the excitement and breadth of this developing subspecialty. ALFRED WHITE Consultant Psychiatrist Queen Elizabeth Psychiatric Hospital, Birmingham References 1 Department of Health. New ways of working for psychiatrists: enhancing effective, person-centred services through new ways of working in multidisciplinary and multi-agency contexts. London: DH, 2005. 2 Royal College of Physicians, Royal College of Psychiatrists. The psychological care of medical patients. A practical guide, 2nd edn. London: RCP, RCPsych, 2003.