Written by Graca Cardoso in November 2018

Current situation and challenges of Consultation Liaison Psychiatry in Portugal

Consultation-Liaison (CL) Psychiatry started in Portugal, in the 1950s, following the creation of the first academic general hospitals that included departments of psychiatry (1). Its development can be roughly summarised in three phases.

The first phase, from the 50s to the 70s, saw the development of punctual experiences carried out in general hospitals by psychiatrists influenced by other countries experiences.

The second phase, between the 80s and the 90s, was associated with the transition of mental health care from the psychiatric hospitals to the general hospitals. CL Psychiatry, as a specific field of clinical psychiatry, was developed after some small but charismatic CL units were created in Lisbon and Porto, developing training and research. In 1989, a survey showed that 80% of the departments of psychiatry provided some type of CL care. The European Consultation Liaison Workgroup Collaborative Study, supported by a EU Grant, carried out between 1990-92, and followed by the Risk Factor Study and the Quality Assurance Study were determinant in putting together the mental health professionals working in the field, as well as in the spread of knowledge in and stirring of enthusiasm for CL.

The third phase, from the late 90s until now, saw the consolidation of CL services. Most of the general hospitals in Portugal started including a CL team or at least some organised CL service provision. A three-month internship in CL psychiatry became mandatory for residents in psychiatry in 1999.  Articulation and collaboration between mental health teams, particularly those working in the community, and primary health care centres was another important development. Two CL associations and one psychosomatics society were created, carrying out regularly national conferences and workshops on CL and psychosomatics.

The recent economic crisis and the austerity measures that followed brought important cuts in the health services between 2011 and 2015. This led to frequent reductions in the staff, an increase in work hours, and many professionals leaving the public sector.

To assess the possible crisis impact on the CL teams that were already in place an online survey was carried out in the first semester of 2017. Thirty-two departments of psychiatry in general hospitals in the continental area of Portugal, were approached and close to 70% agreed to participate, thus covering the whole country. The results showed that all departments provided CL services for the inpatients, and more than 85% for outpatients. More than half used a referral form and more than 70% were available between 9 am and 4pm. The large majority provided care for all the wards. Staffing of the CL units was mainly composed of psychiatrists and psychologists, with nurses in very few units.  Close to 70% of the units included residents in psychiatry in training.  More than half of the services provided regular meetings to discuss clinical cases and training for the residents and had carried out publications or presentations in the last 5 years. These results show that the CL services in the general hospitals are currently well established and functioning.

A post-graduate course in CL carried out in 2014, with the contribution of many Portuguese professionals in the field, and of Per Fink and Chris Dickens was a great success. It included 24 professionals and there is a plan to repeat it in a near occasion.

The main factors contributing to the development of CL psychiatry in Portugal include the expansion of mental health care in the general hospitals, the success of a few CL teams that functioned as role-models, the stimulus provided by international collaboration, and the promotion of training and research in CL related to the mandatory internship in CL for psychiatry trainees.

The main barriers to CL development in Portugal have been insufficient human resources that in many cases prevented the creation of full-time CL teams, the lack of knowledge about and the lack of recognition of CL by the health decision makers. Difficulties in working and fighting together for common causes among mental health professionals is another limitation.

The future challenges to be met are huge taking into consideration the impact of the economic crisis in health expenses. The first one relates to the financing of CL services and the possibility of defining effective financial incentives. Other challenges include the organization of professionals’ training and the implementation of CL service provision guidelines.

The resilience and inspiration shown by the CL professionals, however, encourages us to look at the future with high hopes.

Graça Cardoso, MD, PhD

Lisbon Institute of Global Mental Health

Chronic Diseases Research Center (CEDOC)/NOVA Medical School

NOVA University of Lisbon

gracacardoso@gmail.com; graca.cardoso@nms.unl.pt

References

  1. Cardoso G. Consultation Liaison Psychiatry in Portugal. J Psychosomatic Res 2006;61(2):279-280

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