Liaison psychiatry

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 23Liaison psychiatry

23. Liaison psychiatry

23.1. Introduction

People with mental ill health have significantly worse physical health status than people without mental health problems, and individuals with more serious mental illnesses die on average 10-17 years early. When people with mental ill health develop a physical health problem, they use less planned admissions, and use more emergency hospital care than those without mental ill health. In 2013/14 this equated to 3.2 times the number of accident and emergency attendances and 4.9 times the emergency inpatient admission rate. [Quality Watch 2015, Focus on: people with mental ill health and hospital use, publ. The Health Foundation & Nuffield Trust.]

Mental health problems are a factor in a significant minority of hospital presentations with acute medical emergencies. Overdose and poisoning account for 8-10% of medical admissions [Blatchford et al 1999, BJ General Practice], and deliberate self-harm is one of the top five reasons for medical admission [House et al, 1989]. Up to 20% of medical inpatients have delirium [Ryan 2013, BMJopen], and 20% of over-70s admitted to hospital can be expected to have dementia [Travers 2013, Internal Medicine Journal]

Liaison Psychiatry services are dedicated psychiatry teams based in general hospitals, providing assessment and treatment of mental health problems in the emergency department and on medical wards. As a minimum, liaison psychiatry services are expected to improve the integrated care of physical and mental health problems, and to improve the patient and carer experience for people with mental ill health attending a general hospital. The NHS “Five Year Forward View for Mental Health” [Mental Health Taskforce, 2016, www.england.nhs.uk/mentalhealth/taskforce p.12] has recommended that “By 2020/21 no acute hospital should be without all-age mental health liaison services in emergency departments and inpatient wards”, and goes on to make specific recommendations on staffing levels.

The question addressed in this chapter is whether clinical outcomes are better for patients where liaison psychiatry services are available, and also whether the work of liaison psychiatry teams leads to care being provided more cost-effectively, for example by reducing waiting times in emergency departments, or reducing length of stay.

23.2. Review question: Do acute psychiatric services improve outcomes for patients with mental health disturbance presenting with an acute medical emergency?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

23.3. Clinical evidence

Seven studies were included in the review;¹⁰^,¹⁸^,¹⁹^,²¹^,³⁸^,⁵²^,⁵⁷ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). See also the study selection flow chart in Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in Appendix F and excluded studies list in Appendix H.

Table 2

Summary of studies included in the review.

Table 3

Clinical evidence summary: Liaison psychiatry consultation versus no liaison psychiatry consultation.

Narrative results

Length of stay

One of the studies reported that the length of hospital stay for patients in the intervention group (liaison psychiatry consultation) was 39.9 days compared with 35 days for patients in the control group.¹⁸

Another study reported length of stay according to the patient groups investigated (non-suicidal and suicidal). Non-suicidal patients who received the intervention (psychiatric liaison nurse specialist consultation) had a mean length of stay of 21.44 days compared to 25.33 days for non-suicidal patients in the control group. Suicidal patients who received the intervention had a mean length of stay of 16.0 days compared to 9.7 days for suicidal patients in the control group.⁵⁷

23.4. Economic evidence

Published literature

One health economic study published in 2 papers was identified and has been included in this review.⁴⁴^,⁵⁶ This is summarised in the health economic evidence profile below (Table 4) and the health economic evidence table in Appendix E.

Table 4

Health economic evidence profile: psychiatric liaison versus no psychiatric liaison.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

23.5. Evidence statements

Clinical

Seven studies compromising 1738 people evaluated the role of acute psychiatric services for improving outcomes in secondary care in adults and young people at risk of an AME, or with suspected or confirmed AME. Five of the randomised controlled trials looked at people aged 65 years and over. The evidence suggested that liaison psychiatry may provide a benefit in reduced length of stay (4 studies, low quality) and improved patient and/or carer satisfaction (1 study, very low quality). The evidence suggested that there was no difference in the discharge destination of those discharged to their own home (1 study, very low quality), readmission at 3 months (1 study, very low quality), number of re-hospitalisations at 6-21 months (1 study, low quality) and quality of life- Health of the Nation Outcome Scale 65+ (1 study, moderate quality). However, the evidence suggested that there was a possible increase in mortality (4 studies, very low quality), reduced quality of life with quality-adjusted life week score (1 study, very low quality) and increased time to next hospitalisation (1 study, low quality) with liaison psychiatry.

Economic

One comparative cost analysis found that psychiatric liaison was cost saving compared with usual care. This study was assessed as partially applicable with potentially serious limitations.

23.6. Recommendations and link to evidence

Recommendations	12. Provide access to liaison psychiatry services for people with medical emergencies who have mental health problems.
Research recommendation
Relative values of different outcomes	The guideline committee considered mortality, quality of life, admission prevention, reduced avoidable adverse events, patient and/or carer satisfaction and earlier hospital discharge (reduced length of stay) as critical outcomes. Readmission, early diagnosis and treatment, discharge destination (home versus care home − back to usual place of residence better) and staff satisfaction were considered to be important outcomes.
Trade-off between benefits and harms	Seven randomised controlled trials were included in the review. Five of the randomised controlled trials looked at people aged 65 years and over. The evidence suggested that liaison psychiatry may provide a benefit in reduced length of stay and improved patient and/or carer satisfaction. The evidence suggested that there was no difference in the discharge destination (those discharged to their own home), readmission at 3 months, number of re-hospitalisations at 6-21 months and quality of life (Health of the Nation Outcome Scale 65+). However, the evidence suggested that there was a possible increase in mortality, reduced quality of life years and increased time to next hospitalisation with liaison psychiatry. No evidence was identified for carer satisfaction, admission prevention, readmission within 30 days, early diagnosis and treatment, avoidable adverse events and staff satisfaction. The committee were of the view that a trend for increased mortality associated with psychiatric liaison had no plausible biological explanation. Cause of death was not reported in the studies. The committee did not think that these deaths were likely to be suicides. Only one study had a sub-population identified who were suicidal and there were no reported deaths in the suicidal sub-population. The committee noted wide confidence intervals for mortality reducing confidence in the point estimate. The committee also noted that the event rates for mortality were small. The committee considered whether an imbalance of risk factors at the start of the studies could have contributed to this unexpected result. One study reported a baseline difference of ischaemic heart disease (32% in the intervention versus 17% in the control arm). It was also noted that most of these studies mainly consisted of older patients and any changes to co-morbidities could have influenced mortality. The majority of the studies were in people aged over 65 years but the committee believed that the evidence was generalisable to all people with medical emergencies who have mental health problems. The committee agreed that given the evidence of improvement in length of stay and satisfaction, and likely confounding as an explanation for the mortality trend, psychiatric liaison should be recommended. However, they did not think the evidence was sufficiently secure to make a strong recommendation and opted to recommend hospitals to consider providing this service.
Trade-off between net effects and costs	One cost-consequence analysis showed that the addition of a psychiatric liaison service was cost saving (£2.7 million per year for City Hospital, Birmingham) due to a reduced mean length of stay and hospital readmission rates. The study was based on case matched data before and after the service was implemented at City Hospital, Birmingham. The evidence included in the review generally followed the same trend for length of stay and readmissions as discussed above. However, the review showed a trend towards higher mortality and reduced quality of life with psychiatric liaison both of which are key drivers of cost effectiveness. The committee believed that these results could have been due to imbalances in the patient groups rather than attributable to the intervention. The committee considered the impact that the included economic study had already had on current services and the increasing trend across the country towards psychiatric liaison services. They highlighted that, on the basis of the included economic study, the Department of Health have already started to support commissioners to introduce psychiatric liaison services across the country as a way of reducing unnecessary costs to the health service. Due to the conflicting clinical evidence, the committee felt that a strong recommendation could not be made. Further research would however be beneficial given that the economic evidence is based on a single hospital. Given that there is a study currently underway (LP – MAESTRO)¹ they decided it would be appropriate to recommend that psychiatric liaison services should be considered until the results of this study can be evaluated.
Quality of the evidence	Seven randomised controlled trials were included in this review. Quality of the evidence ranged from very low to moderate, this was mostly due to risk of bias and imprecision. The committee noted that one study that reported evidence for mortality used an older psychiatry liaison model which may not reflect current practice. Mortality could be confounded by case mix effects (age of patients in the studies and their health conditions). Only two studies examined models of liaison psychiatry resembling current practice. It was noted that usual care was poorly defined in these studies, making it difficult to distinguish intervention from control. None of the studies examined patients in the emergency department as they were all patients admitted to hospital. One cost-consequence analysis was included in this review and was assessed as partially applicable because it did not evaluate health outcomes. It was also considered to have potentially serious limitations because the unit costs were not described and because it was based on a single observational study.
Other considerations	Liaison psychiatry of some form is being provided by many hospitals in England, However, the make-up and the delivery of the services differs quite radically from place to place. The psychiatric liaison model called Rapid Assessment, Interface and Discharge (RAID) that involves the provision of a 24/7 psychiatric liaison service has been implemented in some hospitals. More hospitals are being encouraged to implement RAID; currently fewer than 50% currently offer this service. The next steps on the NHS five year forward view⁴² reports that specialist mental health care teams working 24/7 in A&Es today should increase fivefold to 74 by March 2019. The service will be available in nearly half acute hospitals by March 2019 compared with under one-in-ten in March 2017. A research project is underway to evaluate the cost-effectiveness and efficiency of particular configurations of liaison psychiatry for specified target populations (Liaison Psychiatry: Measurement and Evaluation of Service Types, Referral Patterns and Outcomes [LP-MAESTRO]).¹ This study may be useful to inform future updates of this guideline. The studies included in this review did not investigate liaison psychiatry in the emergency department (ED) population. Consideration should be given to evaluating the utility of liaison psychiatry at this earlier stage of the pathway where interventions might have the potential to improve admission avoidance and reduce delays in discharge. The Royal College of Psychiatrists and the British Association of Accident and Emergency Medicine London produced an advisory document on how to deliver psychiatric services to accident emergency departments. Although the document was written in 2003 more of the advice still holds true and could form a framework on to which services could be developed. Of note are the ideal response times (first line attendance 30 minutes and Section-12 Approved doctor attendance 60 minutes in urban areas) which although published 14 years ago are far from being reached in many areas. The service also needs to be more proactive (that is, seek out the issues early) rather than the reactive nature in which it can be delivered. It is important that the service has the capacity to deal with demand and patients of all ages in a timely fashion if it is to benefit the healthcare system.
NICE’s considerations	The Committee proposed that its consultation wording of the recommendation should be retained, i.e. ‘consider providing access to liaison psychiatry services for people with medical emergencies who have mental health problems.’ Final approval prior to publication is required from NICE. NICE noted that stakeholder comments received on the committee’s draft wording advocated strengthening it and gave good reasons for this. NICE also noted that NHS England’s seven day service standards require that: Liaison mental health services should be available to respond to referrals and provide urgent and emergency mental health care in acute hospitals with 24/7 Emergency Departments 24 hours a day, 7 days a week. Accordingly, NICE decided to strengthen the wording of the recommendation by changing it to ‘provide access to liaison psychiatry services for people with medical emergencies who have mental health problems.’

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Appendices

Appendix A. Review protocol

Table 5Review protocol: Liaison psychiatry

Review question: Do acute psychiatric services such as liaison psychiatry improve outcomes for patients with mental health disturbance presenting with an acute medical emergency?
Objective	Liaison Psychiatry ‘is a critical service…(comprising) multidisciplinary teams skilled to integrate mental and physical healthcare in people whose mental health problems arise in, or have an impact on, management of physical illness and symptoms’ [Working Group. Liaison psychiatry for every acute hospital. Royal College of Psychiatrists; Dec 2013]. Mental health problems occur in 30–60% of in-patients and outpatients (Academy of Medical Royal Colleges, 2010) and are the presenting feature in 5% of all emergency department attendances (Royal College of Psychiatrists & British Association for Accident and Emergency Medicine, 2004). In acute hospitals the liaison psychiatry service addresses ‘the mental health needs of people being treated primarily for physical health problems and symptoms’. The Royal College report states that liaison psychiatry services ‘improve quality of care, dignity and quality of life for patients, improve mental health skills in non-mental health professionals and reduce adverse events and other risks to the acute hospital’ and that ‘Financial benefits come from reduced avoidable costs and ineffective or inappropriately located management of mental health problems by reduced length of stay, readmissions and investigations, and improved care of medically unexplained symptoms, dementia and long-term conditions’. The purpose of this review therefore is to evaluate the utility of providing this service specifically for patients with acute medical illnesses.
Population	Adults and young people (16 years and over) with a suspected or confirmed AME with a mental health disturbance (for example, delirium, drug overdose or attempted self-harm).
Intervention	Liaison psychiatry consultation (psychiatric teams based in acute hospitals [anywhere in acute hospital], service specifically in acute hospital). Terms: psychiatric liaison, consultation liaison and psychological medicine. Terms are internationally recognised, RAID - Rapid assessment interface discharge (Birmingham Study).
Comparator	No liaison psychiatry consultation.
Outcomes	Patient outcomes: Early diagnosis and treatment IMPORTANT Earlier hospital discharge (reduced length of stay) CRITICAL Discharge destination (home versus care home – back to usual place of residence better) Admission prevention CRITICAL Readmission up to 30 days IMPORTANT Quality of life CRITICAL Mortality CRITICAL Reduced avoidable adverse events CRITICAL Patient and/or carer satisfaction CRITICAL Staff outcomes: Staff satisfaction IMPORTANT
Exclusion	Patients who do not have an AME. Non-OECD countries.
Search criteria	The databases to be searched are: Medline, Embase, the Cochrane Library, PsycINFO. Date limits for search: 1990. Language: English.
The review strategy	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Analysis	Data synthesis of RCT data. Meta-analysis where appropriate will be conducted. Studies in the following subgroup populations will be included in subgroup analysis: Frail elderly (difficult to manage – likely to stay longer). Dementia (difficult to manage – likely to stay longer). Substance abuse (drug and alcohol, difficult to manage – likely to stay longer). In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included in the subgroup analysis. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.

Appendix B. Clinical study selection

Figure 1Flow chart of clinical study selection for the review of liaison psychiatry

Appendix C. Forest plots

C.1. Liaison psychiatry consultation versus usual care/control

Figure 2Mortality

Figure 3Length of stay (days)

Figure 4Quality-adjusted life weeks

Figure 5Patient satisfaction

Figure 6Health of the Nation Outcome score 65+ (HoNOS65+) (scale 0-48)

Figure 7Number of re-hospitalisations (6-21 months)

Figure 8Readmissions at 3 months

Figure 9Time to next hospitalisation (days)

Figure 10Discharge to home

Appendix D. Clinical evidence tables

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Appendix E. Health economic evidence tables

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Appendix F. GRADE tables

Table 6Clinical evidence profile: Liaison psychiatry versus control/usual care

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Liaison psychiatry consultation	Control	Relative (95% CI)	Absolute	Quality	Importance
Mortality (follow-up 3 months, 8 weeks, 12 weeks, 6-8 months)
4	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious²	none	68/299 (22.7%)	53/309 (17.2%)	RR 1.30 (0.94 to 1.79)	51 more per 1000 (from 10 fewer to 136 more)	⨁◯◯◯ VERY LOW	CRITICAL
Length of stay (days) (follow-up 8 weeks. 6-15 months; Better indicated by lower values)
4	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	579	537	-	MD 1.83 lower (4.53 lower to 0.87 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality-adjusted life weeks (QALWs) (follow-up 12 weeks; Better indicated by lower values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious²	none	45	41	-	MD 1.5 lower (3.51 lower to 0.51 higher)	⨁◯◯◯ VERY LOW	CRITICAL
Patient satisfaction (follow-up 12 weeks)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious²	none	38/41 (92.7%)	29/43 (67.4%)	RR 1.37 (1.1 to 1.72)	250 more per 1000 (from 67 more to 486 more)	⨁◯◯◯ VERY LOW	CRITICAL
Health of the Nation Outcome Scale 65+ (score 0-48) (follow-up 6-8 weeks; Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	58	59	-	MD 0 higher (1.75 lower to 1.75 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Number of re-hospitalisations (follow-up 6-21 months; Better indicated by lower values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	256	252	-	MD 0.19 lower (0.57 lower to 0.19 higher)	⨁⨁◯◯ LOW	CRITICAL
Time to next hospitalisation (days) (follow-up 15 months; Better indicated by lower values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	256	252	-	MD 29.9 lower (54.78 to 5.02 lower)	⨁⨁◯◯ LOW	CRITICAL
Readmission at 3 months (follow-up 3 months)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	19/77 (24.7%)	21/76 (27.6%)	RR 0.89 (0.52 to 1.52)	30 fewer per 1000 (from 133 fewer to 144 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Discharge to home (follow-up 3 months)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	very serious²	none	27/47 (57.4%)	36/60 (60%)	RR 0.96 (0.69 to 1.32)	24 fewer per 1000 (from 186 fewer to 192 more)	⨁◯◯◯ VERY LOW	IMPORTANT

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Appendix G. Excluded clinical studies

Table 7Studies excluded from the clinical review

Study	Exclusion reason
Abidi 2003²	Observational study
Alaja 1995⁶	Observational study
Alaja 1997⁴	Observational study and no extractable outcomes
Alaja 1998⁵	Observational study
Alaja 1999³	Observational study
Alberdi 2011⁷	Observational study
Anderson 2005⁸	Observational study
Aoki 2004⁹	Comparison of 2 observational studies
Brakoulias 2006¹¹	Observational study
Buckley 1994¹²	Narrative of an observational study
Burton 1991¹³	Incorrect comparison – comparing results after a primary and second consultation
Caduff 2004¹⁴	Narrative study
Callaghan 2002¹⁵	Observational study
Carson 1998¹⁶	Observational study
Clarke 1995¹⁷	Observational study
Collinson 1998²⁰	Observational study
De Giorgio 2015²²	Observational study
De Jonge 2003²³	Observational study
Desan 2011²⁴	Incorrect study design – quasi-experimental study
Draper 2005²⁵	Low quality systematic review
Elisei 2013²⁶	Observational study
Fritzsche 2005²⁷	Observational study
Gala 1999²⁸	Observational study
Gater 1995²⁹	Incorrect study design – qualitative with no extractable outcomes
Goulia 2009³⁰	Incorrect comparison
Hosaka 1999³¹	Incorrect intervention, observational study
Koopmans 1995³²	Incorrect intervention – outpatient clinical referral by a general practitioner
Koopmans 1996³³	Incorrect intervention – outpatient clinical referral by a general practitioner
Kratz 2015³⁴	Observational study
Kurlowicz 2001³⁵	Observational study
Lamdan 1997³⁶	Observational study
Lamprecht 2005³⁷	Observational study
Mayou 1991B³⁹	Observational study
McCulloch 2007⁴⁰	Observational study
Newton 1990⁴¹	Incorrect study design – qualitative study
Nogueira 2013⁴³	Observational study
Priami 1997⁴⁵	Observational study
Sampson 2009⁴⁶	Observational study
Sampson 2013⁴⁷	Author reply about an irrelevant study
Saravay 1996⁴⁸	Narrative of studies
Schellhorn 2009⁴⁹	Observational study
Schrader 2005⁵⁰	Incorrect intervention
Shepherd 2012⁵¹	Observational study
Stiefel 2008⁵³	No extractable outcomes - outcome reported in study not in protocol
Swanwick 1994⁵⁵	Observational study
Su 2010⁵⁴	Observational study
Tsai 2012⁵⁸	Observational study
Verbosky 1993⁵⁹	Observational study with an incorrect comparison (patients suffering from depression compared with patients without depression)
Wood 2014A⁶⁰	Low quality systematic review

Appendix H. Excluded health economic studies

No health economic studies were excluded.

Bookshelf ID: NBK564934

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