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Online Essay Club: Essay No. 10 of 10

20 posts in this topic

This is the last in a series of essay questions. If you've any ideas for further questions, please start a new topic 'Essay x' where x is the essay number.

Q: 'In every hospital outpatient clinic there should be easy access to an assessment by a psychiatrist.' Discuss this statement, focusing on the potential contribution of psychiatry to other clinical departments of a general hospital.

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Introduction

1. Reiterate statement which is to be discussed: creating new service for hospital outpatients

2. Mention that there is some overlap with the role of GP

3. Mention that this will be an extension of current liaison service

4. Mention that this would occur in background of psychiatry being underresourced

5. Argument will be against this idea

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Arguments for constructing this service

Advantages for psychiatry

1. Liaison psychiatry already established discipline - this would just be an extension

2. Use of psychiatric liaison nurses would allow more flexible allocation of resources

3. Pathology is there regardless of who finds it. This system means more (referrring) doctors would be identifying pathology = more resources for psychiatrists

Introduction

Advantages for hospital specialists

1. Generic

a. Compliance may be reduced for untx psychiatric illness

b. Attendance at OP may be less consistent for untx psychiatric illness

c. Interactions with medication may be issue (especially in elderly population)

d. Early referral/assessment is time saving - may allow speedy delivery of medical/surgical tx which otherwise delayed

e. Psychopathology may otherwise be ignored

f. Dissociation/Somatisation secondary to PD/Depression may present as medical/surgical problems

g. The process will give hospital specialists a better grounding in psychiatry which may benefit their other patients also and lead to improved interaction with psychiatric services

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Specific

1. Medicine

a. Geriatrics

- increased morbidity - psychiatric illness more likely - detection therefore more likely

- polypharmacy - interactions important; psychiatric sequelae of polypharmacy - close cooperation between specialties needed

- Old carers at home may be debilitated - untx psychiatric illness + medical illness may mean care at home not possible - tx of former may therefore free up resources

b. Neurology

- Epilepsy and antidepressants tricky area - seizure threshold - needs close cooperation

- Marked increase in incidence of psychiatric illness in neurologic population

- Neuropsychiatric manifestations of TLE may need psychiatric input; also interictal psychosis equally likely in all forms of epilepsy

- Dissociative disorders may need psychiatric input

c. Oncology

- Non-compliance secondary to untx depression may have serious consequences (also true of cardiology especially)

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2. Surgery

- Plastic surgery - dysmorphophobia 2 to depression - tx may prevent surgery

- General surgery - somatisation - identification may preclude need for exploratory laparotomy provided adequate exclusion of organic pathology - controversial

3. Obs and Gynae - problems more likely in community

4. Paediatrics - identification of psychiatric illnesses may suggest problems in home environment which need investigation

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2. Surgery

- Plastic surgery - dysmorphophobia 2 to depression - tx may prevent surgery

- General surgery - somatisation - identification may preclude need for exploratory laparotomy provided adequate exclusion of organic pathology - controversial

3. Obs and Gynae - problems more likely in community

4. Paediatrics - identification of psychiatric illnesses may suggest problems in home environment which need investigation

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Against

Disadvantages for Psychiatry

1. Increased workload with psychiatry currently being underresourced

2. Ad hoc clinics for this service would be a waste of resources as the load is variable e.g. some clinics may be empty

3. Consequently the service demands would be very unpredictable and there would also be marked discontinuity of care if dealt with by specific liaison service

4. Hospital specialists may be more likely to make inappropriate referrals especially when this service is first set up

a. May be insufficient history

b. Problem may already be dealt with by psychiatric services/GP

c. May be bias in patients referred e.g. those with psychiatric hx or personality disorders or patients being 'difficult'

5. Would need a pilot study to investigate cost/benefit + feasibility

6. Psychiatrists do not have access to a similar service in their outpatients which would be equally important i.e easy access to medics/OG/surgeons/paediatricians

7. Hospital specialists referring back to GP may be more appropriate - more time to plan e.g. slotting patients into psychiatric clinics when notes will be available

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Disadvantages for specialities

Generic

1. Hospital specialists - very busy clinics - not enough time to assess patients problems in detail let alone make referrals to other specialists

2. Hospital specialists may not be confident in ability to refer patients to psychiatrists

3. May not be aware of management pt already receiving in psychiatric services e.g. pt may not disclose information

Obs and Gynae

1. Problems such as postnatal depression and puerperal psychosis more likely to be picked up by community nurses

Conclusions

Extension of current liaison service

Oversteps role of GP

Psychiatry unable to resource current services therefore expanding service provision presently does not seem wise

No evidence to support benefits of this service

Although psychiatry will be beneficial to all other specialties - it would probably not be so useful in this context

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sorry about that - couldn't send it as one post so had to divide it up and send it in packets - ended up sending one of the bits twice - bit of a mess.

I've probably missed loads of points about benefits of psychiatry to other specialities so i'd be grateful if people could contribute theirs

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ive just noticed that this has become a very hot topic as a result ::)

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8)Intro:Psychosocial disability and psy disorders are prevalent in the popln and more often encountered in medical outpatient settings than in psy settings.one month and point prevalence studies show that 16 percent of community cohorts exhibited psy morbidity. lifetime prevalence in chronically ill reaches 42%

:'( hence med facility excellent place for screening.

Main arguements would be those put forth for a clp service rather than saying this would be in addition to a clp service 8)

???these would include screening, teaching, pedagogic functions, ambassador role,participation in ethical committes and the scholarly tasks mentioned by Justin.

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Thx there were some good points there :lol:

I suppose one important lesson I learnt from that point is that the introduction is probably the best place to include statistics, definitions and references to the literature (at least now it shouldn't be too difficult to write an intro)

I think at the end of the day I would still stand by my viewpoint but it has raised some interesting questions.

For instance different types of clinics may make different demands on the psychiatric services e.g. those which typically have more chronically ill patients will make more demands (42%.....).. but what about antenatal clinics/cardiology clinics etc - might get fundamentally different pathology.

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I think the screening process is not going to be done by the psychiatric service but by the hospital specialists themselves - implicit assumption in development of this service - making their roles more like GP's.

I haven't had any input into service decision making so i'm quite intrigued by the mention of ethical committees - how does that work?

I'd be grateful for any specific ways in which the service might benefit paediatrics, o & g and surgery because I wasn't able to think of many

thx

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::)the question merely states an psy examination should be obtained easily, does not say by whom, when or where ;so what does easy acscess mean?

there are mentally ill people in all clinics and paed act as proxy psychiatrists as there are not enough child psy about, they look after the LD popln very well until 16.

8)psy pts use general medical services quite a lot. ::)

depressed pts in the medical setting use three times more health resources,encounter twice the costs, make visits to the emergency 7 times more the non depressed.

specific pts for obs and gyn includes the whole icd 10.pain clinics, intensive care ,transplant pts assesment are laso points to add.

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i think most of the issues have been covered between the two of you

well done

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Easy access to Psychiatrists in out-patients

1. Naturaly I object in principle.

2. It would be nice and holistic, as long as the practical problems were taken care of etc. (see above).

3. But.. 'too many cooks spoil the broth', 'the ship has just one captain' etc.; should psychiatrists really be stepping in on their medical coleagues? getting embroiled in a matter that realy needs to be 'medically cleared' first?. Would this not cause confusion?

4. Should 'normal' doctors find it so easy to disengage from their more 'abnormal' patients?.

5. If there is an acute psychiatric problem there are already services available to deal with this.

not realy an essay, most of the points have already been made.

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As with all aspects of psychiatry 'boundaries' are important here. If something is too easily available, it will be overused.

Certain groups of psychiatric patients (and referring doctors/paramedics) by the nature of their disorders frequently overstep these boundaries. :(

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Intro

Psychological and psychiatric disorders are the fourth commonest cause of ill health according to the world healh organisation, after heart problems and other physical disorders. At any one time, the prevalence of depressive symptoms is 20% in the community.

Thse disorders are often comorbid with physical problems, for example elderly people are more at risk of attempted suicide if they are isolated and disabled by physical illness. co morbid physical illness increases the risk of psychiatric disoreder in all populations.

Approximately 40 - 50 % of A and E attendences are related to alcohol abuse and 30 percent of medical in patients have harmful levels of drinking. Alcohol is associated with various psychiatric disorders including depression and anxiety.

It is well known that psychiatric disorder is underdetected and under treated by primary care physicians, and this holds true of other hospital specialists also - hence surgeons feel their treatment has been successful if the operation was a success and don't often screen their patients for depression. as psychological disorders over lap with so many other specialties it would make sense to have a psychiatric liason service available in general hospitals. This would be useful eg

liver clinic - the hepatologist can liase with an alcohol specialist or general adulyt psychiatrist and the community alciohol team, providig a holistc package of care,a iming at harm minimisation, psycho eduation and relapse prevention. The psychiatrist can spend more time with the patient elucidatig the psycho social aspects of the disorder whilst the liver specialist concentrates more on the physical organ itself.

old age wards - often have people who are depressed. Neuropsychiatry/neurology - people with organic brain syndromes or epilpsy/stroke have a higher incidence of psychiatric morbidity.

Epilepsy and pseudo seizures

plastic surgery- people with delusioanal disorders/hypochondriacal disorders

pain clinic - often people with intractable pain have psychiatric disorders

oncology - issues of death, bereavement, loss adjustment reactions

there are two models of care - consultation model of care and liason model eg joint clinics - improves attendance as psychi patients can be erratic at attending due to the nature of their ilness, maximises multidisciplinary team working.

conclusion

this is an important area of psychiatry which would also help improve the working relations between the disciplines and allow both psychiatrists and other medics to expand their experience.

from the patients point of view - a better care package.

issue - as always - resouces, lack of expertise.

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