Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds, UK
Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds, UK
Correspondence: Dr Rachel Ruddy, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds LS2 9LT, UK. Tel: +44 (0) 113 343 2741; fax: +44 (0) 113 243 3719; e-mail: R.A.Ruddy{at}leeds.ac.leeds.ac.uk
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed. The three areas were the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour.
Method Computerised database searching, secondary reference searching, hand-searching and expert consultation were used to identify relevant systematic reviews. Studies were reliably selected, and quality-assessed, and data were extracted and interpreted by two reviewers.
Results We found 64 high-quality systematic reviews. Only 14 reviews included meta-analyses.
Conclusions Many areas of liaison psychiatry practice are not based on high-quality evidence. More research in this area would help inform development and planning of liaison psychiatry services.
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INTRODUCTION |
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Our study was designed to identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed.
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METHOD |
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Areas of liaison psychiatry
We identified six key areas of liaison psychiatry practice by reading the
liaison psychiatry research literature and liaison psychiatry textbooks. These
six areas were:
We decided to focus our review on the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour. We excluded emergency presentations because review groups linked to the Cochrane Collaboration undertake systematic reviews covering the acute management of different psychiatric illnesses. We felt that the physical effects of psychological or psychiatric illness and treatment are generally the concern of physicians, general psychiatrists or general practitioners rather than liaison psychiatrists, and physical findings raising concerns about abuse are predominantly the concern of child and adolescent liaison psychiatry.
Within each of our three categories we further defined the scope of the review. Under somatoform disorders we decided to exclude interventions for somatoform pain disorder (except psychotropic drugs), because psychological interventions for pain had recently been covered in the UK's Department of Health review of psychological therapies (Department of Health, 2001). We also chose to exclude treatments for psychosexual problems, eating disorders, pregnancy and related disorders, traumatic brain injury, learning disabilities, and alcohol and recreational drugs misuse, because - although these areas may impinge upon a liaison psychiatry service - they are often dealt with by designated specialist services.
For the purpose of this review we classed dementia as a neurological disorder and therefore included psychiatric complications of dementia (such as behavioural disturbance and depression) in the category psychological effects of physical illness or treatment. We also included delirium as a medical illness in the category psychological effects of physical illness and treatment.
Participants
We reviewed interventions in adults (over 16 years old). Evidence on
interventions in child liaison psychiatry is covered comprehensively in a
report by the Royal College of Psychiatrists
(Scott et al, 2001).
We included reviews where it was implied that the majority of the participants
had a problem area consistent with the areas of liaison psychiatry being
reviewed, regardless of the length of illness. Reviews were not excluded on
the grounds of nationality or gender of participants. Reviews were excluded if
they were conducted before 1980 (because of changes in medical treatments) and
if the only treatment settings were primary care or prisons.
Types of intervention
We classified interventions under six headings:
Outcome measures
We recorded outcomes as reported by the authors, with special attention to
psychological outcome, medical outcome, social functioning and quality of
life, service outcomes, adverse effects, satisfaction and economic
outcomes.
Search strategy
The ACP Journal Club, the Database of Abstracts of Reviews of
Effects (DARE), the Cochrane Controlled Trials Register, Medline, EMBASE and
PsycINFO were searched from 1980 to the end of 2002 for systematic reviews of
all interventions listed above in all areas of liaison psychiatry. The scope
of the review was wide so the search strategy was extensive and used Medical
Subject Headings (MeSH) terms to cover physical and mental health problems;
the standard Cochrane Collaboration search strategy for systematic reviews was
also used. Next, the journal Evidence-based Mental Health (1998-2002)
and the December issue of Clinical Evidence Concise
(BMJ, 2002) were
hand-searched, and the references of all reviews found in this way were
searched. Experts in liaison psychiatry were consulted by circulating the
findings to members of the European Association of Consultation Liaison
Psychiatry and Psychosomatics, the Liaison Psychiatry JISCmail group and the
Trent, Yorkshire and North East Liaison Psychiatry Network.
Appraisal of quality
All Cochrane reviews were included as they are known to be methodologically
sound and are peer-reviewed against methodological criteria. Review articles
and meta-analyses that were not registered with the Cochrane Collaboration
were evaluated using quality criteria suggested by Oxman & Guyatt
(1988). Each review or
meta-analysis was assigned to one of three bands - high quality (all eight
criteria), medium quality (five, six or seven criteria) and low quality (fewer
than five criteria); R.R. rated all the reviews and A.H. rated a sample of 20%
of the papers independently. Any disagreement in rating was discussed and
reported. Only papers rated as being high quality or medium quality were
included.
Data extraction
Data relating to the methods of the review, including studies and
conclusions, were extracted from the reviews using a standardised form.
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RESULTS |
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Fourteen of the included reviews contained meta-analyses that provided a quantitative summary of the effectiveness of the intervention, with confidence intervals. Table 2 summarises these reviews and Table 3 summarises the other included reviews. Of the other 50 included reviews there were 13 in which the primary data used in the review were poor and no clear result was achievable. Even among the reviews with meta-analyses, in only four was there unequivocal evidence of an effective intervention. These interventions were antidepressants for depression in physical illness, antidepressants for physically unexplained symptoms, antidepressants for chronic headache and cognitive-behavioural therapy for chronic fatigue syndrome (O'Malley et al, 1999; Tomkins et al, 2001; Gill & Hatcher, 2002; Price & Couper, 2002).
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Table 4 shows the areas for which there was no good-quality systematic review. It demonstrates large gaps in review evidence for some of the most common components of a liaison psychiatry service, such as assessment and advice, and service level interventions; for one of the basic problems that a liaison psychiatry service deals with (adjustment to chronic illness); and for some of the most common medical conditions, such as renal, respiratory and cardiovascular disorders.
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Quality of the included studies
Tables 2 and
3 show the quality ratings for
the included reviews. Forty-three of the included studies were rated as
highest quality using the criteria of Oxman & Guyatt
(1988). This means that these
studies had a clear research question, a comprehensive search strategy and a
repeatable method for appraisal and data extraction and that the data
combination and conclusions were appropriate.
The other 21 studies were of medium quality. All of these studies had a clear research question and a comprehensive search strategy. Three reviews did not describe the methods used to determine which articles to include in the review (Howland, 1993; Krupnick et al, 1993; Guthrie, 1996). Ten reviews did not describe assessing the validity of the primary studies and therefore did not have reproducible methods (Howland, 1993; Kennedy & Feldmann, 1994; Carter et al, 1996; Guthrie, 1996; Moore, 1996; Gordon & Hibbard, 1997; Repper, 1999; Sheard & Maguire, 1999; Allen et al, 2002; Turner-Stokes & Hassan, 2002). Ten reviews described assessing the validity of the studies, but the method used was not reproducible (Cummings, 1992; Smith, 1992; Goodnick et al, 1995; Lovejoy & Matteis, 1997; Van der Sande et al, 1997; Akehurst et al, 2001; Miller & Cohen, 2001; Pratt et al, 2002; Rose et al, 2002; Whyte & Mulsant, 2002). Four reviews did not analyse (even descriptively) the variation in the findings of the primary studies (Cummings, 1992; Goodnick et al, 1995; Gordon & Hibbard, 1997; Sheard & Maguire, 1999). Several studies formed conclusions that were not supported by their findings (Kennedy & Feldmann, 1994; Goodnick et al, 1995; Moore, 1996; Gordon & Hibbard, 1997; Allen et al, 2002).
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DISCUSSION |
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Clinical implications
Lack of evidence implies that much of the clinical practice of liaison
psychiatry is based on lower-quality evidence or extrapolation from other
areas of psychiatry where there is high-quality evidence. It is hard to know
where to set the limits of such extrapolation
(Naylor, 1995). For example,
Gill & Hatcher (2002)
combined the results of trials of treatment for depression in a wide range of
physical illnesses despite possible clinical heterogeneity. It may be that use
of antidepressants for depression is not indicated in some physical illnesses
and that the costs and benefits of treating depression with antidepressants in
different medical disorders will vary.
In the absence of adequate evidence other factors must be influencing liaison psychiatry service development, which might help account for the current service variability (Ruddy & House, 2003). Clinical services cannot be packages of interventions that systematic reviews have shown to be effective. If we are to build rational services, then we need to be clearer about what factors other than clinical research should influence planning decisions. We should develop technologies for integrating each of these factors (values, policies, funding contingencies and so on) into planning, and indicate explicitly how we arrive at the trade-offs between them.
Research implications
The clinical practice of liaison psychiatry needs research in the form of
systematic reviews with meta-analyses and primary studies. Systematic reviews
are important because for the busy clinician they are a valuable, unbiased
summary of the current literature (Egger
et al, 2001). It is interesting to note that there is
currently no Cochrane group to cover the work in this psychiatric specialty,
which may be one of the reasons there are so few good systematic reviews. Even
in areas where there appears to be unequivocal evidence of benefit, it would
be difficult to use this evidence to guide service planning. Future research
should be more service-oriented, researching common interventions in liaison
psychiatry such as assessment and advice, and whole service interventions. It
should also focus on common problem areas encountered in clinical practice,
and ensure that outcomes of importance to patients are included.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication May 18, 2004. Revision received November 11, 2004. Accepted for publication January 6, 2005.
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