LPA bendrosios medicinos ir psichosomatikos sekcija

Lietuvos psichiatrų asociacijos bendrosios medicinos psichiatrijos ir psichosomatikos sekcija (LPA Section of General Hospital Psychiatry and Psyhosomatic)

 G. Daubaras

 1991m. Vilniaus miesto psichiatrai, psichologai, psichiatrijos medicinos seserys, t.y., somatinėse ligoninėse, poliklinikose dirbantys specialistai ir medicinos personalas susibūrė į biopsichosocialinės terapijos grupę. Nuo 1992 m. vadinama LPA Bendrosios medicinos psichiatrijos ir psichosomatikos sekcija. Sekcijos darbe gali dalyvauti kiekvienas gydytojas, psichologas dirbantis somatinėje ligoninėje, poliklinikoje.

Psichiatrijos padaliniai somatinėse įstaigose padeda vykdyti pirminę, antrinę, tretinę psichikos sutrikimų prevenciją, padeda greičiau išaiškinti ligonius ir teikti reikiamą pagalbą, patikslinti sergančiojo asmens būseną, perteikia kitų specialybių gydytojams, viduriniam medicinos personalui biopsichosocialinę ligos vystymosi sampratą, o taip pat paremia struktūrinių gydymo įstaigų pakitimų vyksmą.

Šiandien kai kuriose Lietuvos somatinėse gydymo įstaigose jau yra psichiatrijos-psichosomatikos skyriai ir palatos; įkurti psichiatrijos, psichosomatikos, psichoterapijos kabinetai; veikia konsultacinės-liaison psichiatrijos padaliniai. Čia dažniausiai yra gydomi ir konsultuojami ligoniai, turintys organiniais psichikos sutrikimais (demencijos, delyrai, depresijos, nerimas); ligoniai, turintys somatiniais simptomais pasireiškiančius psichikos sutrikimus (krūtines, pilvo skausmais, tachikardija, dusulys, svaigimas, pykinimas ir t.t); ligoniai, kuriems būdingi tiek somatiniais, tiek psichikos sutrikimai.

1991-1994 m. LPA Bendrosios medicinos psichiatrijos ir psichosomatikos sekcija inicijavo LPA valdybą ir suvažiavimą priimti nutarimus dėl psichiatrinės pagalbos vystymo somatinėse gydymo įstaigose, taip pat rezoliuciją apie konsultacinės-liaison psichiatrijos etatinius normatyvus ir darbo krūvį. Deja, rimtesnės paramos bei finansavimo iš Sveikatos apsaugos ministerijos nesulaukta.

Penktus metus funkcionavusio konsultacinės-liaison psichiatrijos ir psichosomatikos padalinio Vilniaus Universitetinėje ligoninėje ir Vilniaus m. Antakalnio poliklinikos bazėse vyko psichiatrijos ciklai ir praktikos darbai bendrosios praktikos gydytojams, rezidentams.

Sekcijos susirinkimuose nagrinėti psichikos sutrikimų diagnostikos kriterijai (DSM-III-R, ICD-10), jų adaptavimas somatinėse įstaigose. Nuo 1995 m. sekcijos nariai padeda rengti seminarus, konferencijas kitų specialybių gydytojams. Jų metu aptariami nerimo, depresijų klasifikacijos, diagnostikos ir gydymo klausimai. Sekcija parengė du teminius “Sveikatos” žurnalus (1992 Nr.11, 1996 Nr.3) psichiatrijos ir psichosomatikos klausimais; inicijavo ir įdėjo daug pastangų bei darbo, išleidžiant knygas “Panika” (epizodinis nerimo paroksizmas) ir “Nerimas ir somatinės ligos”.

Sekcija pirmą kartą Lietuvoje (1992) paminėjo Pasaulinę psichikos sveikatos dieną.

1997 m. LPA Bendrosios medicinos psichiatrijos ir psichosomatikos sekcijos veikloje Vilniuje dalyvavo 10 narių. LPA 1997 konferencijoje sekcijos darbe dalyvavo daugiau nei 40 gydytojų.

Šiuo metu, vykstant medicinos reformoms, konsultacinė–liaison psichiatrija somatinėse gydymo įstaigose dėl nepatvirtintų normatyvų (priedas 1) ir finansavimo trūkumo negali būti vystoma.

Šiandien pagrindinis LPA Bendrosios medicinos psichiatrijos ir psichosomatikos sekcijos uždavinys – pirminės psichiatrinės pagalbos organizavimas ir darbo veiklos nustatymas poliklinikose, darbas su bendrosios praktikos gydytojais, bendradarbiavimas su kitų šalių bendrosios medicinos psichiatrijos ir psichosomatikos organizacijomis.

Priedas 1

Konsultacinės –liaison psichiatrijos (medicininės–chirurginės psichiatrijos) normatyvai.

1. Psichiatrai turi konsultuoti 3-5% visų, į stacionarą patekusių ligonių.
2. Ligoninei, kurioje kasmet gydosi ne mažiau kaip 10 000 ligonių, reikia vieno psichiatro ir vieno psichiatrijos slaugos etato.
3. Pusę darbo laiko medicininės psichiatrijos specialistas turi skirti ligonių konsultavimui, kitą laiką – darbo organizavimui ir medicinos personalo mokymui.
4. Konsultacijos (įskaitant ir pakartotinus vizitus) vidutinė trukmė stacionare –2.5 val.
5. Ambulatorinės psichiatrijos konsultacijos vidutinė trukmė 1.0-1.5 val.
6. Universitetinėms ligoninėms šie normatyvai dvigubai mažesni mažesni.

 Šaltinis: Lietuvos Psichiatrų Asociacijos veiklos apžvalga 1997 m.

Konsultacinė-liazon psichiatrija

Consultation/Liaison Psychosomatic and Psychiatry around the Baltic Sea

First findings from the ECLW Collaborative Study

Thomas Herzog*, Ulrik F. Malt**, Pekka Tienari***, Gintautas Daubaras****, Friedemann Ficker*****, Barbara Stein*, Frits J. Huyse*******, Antonio Lobo ******* and the European Consultation Liaison Workgroup (ECLW)

 Dept. of Psychotherapy and Psychosomatic Medicine, Freiburg University, Germany (West)

**             Dept. of Psychosomatics and Behavioural Medicine, Oslo University, Norway

***           Dept. of Psychiatry, Oulu University, Finland

****         Adult Policlinic, Vilnius University, Lithuania

*****       Dept. of Psychiatry, Medical Academy Dresden, Germany (East)

******     Dept. of Psychiatry, Free University Amsterdam, Netherlands

*******   Dept. of Psychiatry, Zaragoza University, Spain

 Manuscript for publication in:

    Speidel H & StrauB B (Eds.): “New Society – New Models in Medicine”, Stuttgart,    New York, Schattauer

 Abstract

Psychological disturbance in medically ill patients and the medical presentation of psychological disorder (e. g. somatization) have great impact on the well-being of patients, the quality and cost of health care. They are the central target of applied psychosomatics, esp. consultation/liaison (CL) services. The insufficient availability and low utilization rate of such services can lead to inappropriate treatments and unnecessary costs. Almost nothing is known about the impact of different organization of services and different traditions of psychological medicine on the provision of CL services and their outcomes, even though these issues are of great practical and political importance at a time of ever soaring health costs and diminishing recourses.

Previous research has focused on single site studies using more or less idiosyncratic measures. Supported by the European Community, the European Consultation Liaison Workgroup on General Hospital Psychiatry and Psychosomatics (ECLW) is engaged in a collaborative study of psychological (CL) practice across Europe in which approx. 70 centres from 12 European countries participate. By December 1992, approx. 4500 consecutive consultation episodes from 3 Norwegian, 6 Finnish, 1 Lithuania, 2 East-German and 10 West-German centres are registered using standardised reliable and comprehensive measures. A subset of these data (approx. n=4000 and relevant background informations are used to compare different CL services around the Baltic Sea and their respective impact.

 Introduction

Mental health disorders and psychosocial factors often complicate course and unfavourably effect the outcome of medical illness (co-morbidity), thereby increasing human suffering and economic costs (Zook & Moore 1980, Fulop et al. 1987). Among these disorders are psychiatric problems previously undetected (e. g. substance abuse), psychiatric complications of medical illness or treatment (e. g.  Confusional states), reactions medical illness (e. g. adjustment disorders) and psychiatric disorders presenting with physical symptoms (e. g. somatoform disorders). In 10-15% of medical/surgical general hospital patients, mental health disorders and problems need special assessment or treatment during inpatient stay (Mayuo & Hawton 1986, Stuhr & Haag 1989). This is the task of “consultation liaison” (CL) services, which can significantly improve diagnosis and treatment and reduce costs (e. g. shortening inpatient stay) (Strain et al 1991). Consultation means giving counsel to colleagues on specific request concerning a specific clinical problem. Liaison means the presence of a psychosocial consultant in the somatic department at least once a week independent of a request, e. g. through participation in ward rounds.

There is a great variety of approaches to physical, mental and social health care. Main issues are  1.)whether and how mental and physical health care can and should be integrated in one team or even one person and how this person/team can be trained towards this end, 2.) the relative importance of biological and psychological interventions, 3.) the adequacy of certain theoretical positions (psychoanalytic, learning, systemic and biological theories) and of the tochnological rules derived from them. These issues are important for the evaluation of the relative merits of liaison vs. “simple” consultation services and of specialised psychosomatics vs. general (hospital) psychiatry (for details see Herzog & Hartmann 1990, Herzog 1991, Herzog et al. 1993), but they have not been studied empirically across centresand orientations.

The term “psychosomatics” has several meanings and quite a different standing in different countries and traditions. We use it in a broad sense to encompass the diagnosis and treatment of (general hospital) patients with physical complaints or disorders by experts of psychosocial medicine. As a discipline it is best established in Germany, where it is distinct from psychiatry. We refer to data from West-German psychosomatic (“W-Psm”) and psychiatric (“W-Psy”) services in order to look at the possible impact of specialised services (Stein et al. 1993).

The ECLW Collaborative Study

The European Consultation Liaison Workgroup on General Hospital Psychiatry and Psychosomatics (ECLW) was founded as an informal group of CL practitioners and researches from 14 European countries in order to further clinical and scientific exchanges and to enhance the field with respect to research, training and the development of standards (Huyse & ECLW 1991; Mayou, Huyse & ECLW 1991). It has launched the collaborative study “The Effectiveness of Mental Health CL Service delivery in the General Hospital”, which is still in the last stages of data collection (Herzog et al. 1992, Huyse et al. 1992). The study is supported by the European Community and – in Germany – by the Robert Bosch Foundation. It’s goals are the multi-site description of CL services, the assessment of their impact, the identification of factors concerning the quality of their performance and the provision of European and national guidelines, thereby laying the ground for epidemiological and controlled intervention studies, the development of feasible screening instruments and the implementation of quality assurance programs. It focuses on adult inpatients. As some psychiatric disorders (e. g. depression) show seasonal variation, consecutive referral are documented over a one year period. By December, 1992, 250 CL practitioners from different professional, cultural and theoretical backgrounds in 70 centres in 12 European countries had registered 16000 cases.

The study required 1.) the development of a set of instruments to describe the relevant variables in sufficient detail across a large variety of mostly unknown settings (Table 1), 2.) the recruitment, training and (reliability) testing of participating consultants, 3.) the development of an administrative infrastructure and software technology for data entry and analysis.

Table 1: Instruments used in the ECLW collaborative study

Patient-Registration-Form (PRF)Admission characteristics Referral characteristics Sociodemographic variables Medical and psychiatric history up to 3 medical diagnoses (ICD-9) up to 3 psychiatric diagnoses (ICD-10) clinical states at CL intake and discharge CL input (time, diagnostic and therapeutic interventions)	Consultant Questionnaire (Form IV)sociodemographic variables general professional experience, training, status and theoretical orientation CL related experience, training and attitudes actual job description
Description of CL-Service (Form III)institutional characteristics personnel characteristics types and extent of existing CL cooperation special services provided availability and organization of services use of documentation and diagnostic systems research
Description of other Psychosocial Services (Form II)Detailed description of other (concurring) psychosocial services
Description of Hospital (Form I)type of hospital and owner populations served treatment places and specialities present number of admissions and length of stay way of calculating costs/way of payment patient characteristics (by department) personnel characteristics (by department)

A manual based comprehensive instrument for the description of patients, referral patterns and CL interventions, the patient registration form PRF, was developed based on previous work in the United States (MicroCares consortium), the Netherlands and Germany, extensive field testing and consensus meeting in the ECLW. Great care was taken to allow for the registration of cost-relevant aspects (time spent on consultations, concurrent and  previous treatment etc.) (ECLW 1990a).

Psychiatric diagnosis in medically ill patients presents special problems. The WHO International Classification of Diseases ICD-10 chapter F “Psychiatric Disorders” was adapted for  use in the general hospital environment (ECLW 1990b).

CL deals with a population of referred patients. Many key variables (e. g. consult rate) require detailed background information. A set of instruments was developed to obtain operationally defined background variables (cf. Table 1) concerning the general hospital, other available psychosocial services, the participating CL service and the participating individual consultants (Herzog, Stein & ECLW 1992). Established concepts of quality assurance (structural, process and outcome quality, “standards”, Huyse et al. 1992b) and psychotherapy (“generic model of psychotherapy”, Orlinsky & Howard 1986) provided the conceptual frame work. The consultant questionnaire (Form IV) allows to match consultant and patient characteristics and to explore questions regarding standards of training as well as individual influence of diagnostic and therapeutic procedures. The description of CL services (Form III) is at the heart of the study’s main questions and specifically required for the determination of standards. The detailed assessment of concurring other psychosocial services (Form II) protects against bias and helps to provide a “complete” description of all psychosocial services in the general hospital and a first estimate of their relative contributions. Without the description of hospital (Form I) little use could be made of the patient related data (Huyse et al. 1992). If possible the findings will be related to national surveys of CL services, in order to assess the scope of generalizations possible on the basis of the present study (e. g. Herzog & Hartmann 1990, Mayou & Lloyd 1985).

A standardized procedure for reliability training and testing of the use of the patient registration form and of the ICD-10 system was developed using set of case vignettes drawn from different centres and covering a large variety of settings and diagnoses. Most trainees met the high reliability standards required for acceptance as participant in the study (Malt et al. 1991). For those who were not reliable, further training and/or close case by case supervision by reliable participants was instituted.

CL around the Baltic Sea: National Backgrounds

22 centres from around the Baltic Sea participate in the study (Fig. 1). Colleagues from Denmark and Sweden were involved early on but for local reasons never started with the data collection. Before presenting first findings we give some backgrounds information needed for interpretation.

In Norway (N) since 1960 there is a chair of psychosomatic medicine at the National Hospital, virtually without own inpatient treatment facilities. Further development of psychosomatic/behavioral medicine is planned, but up to now psychological medicine is more or less identical with psychiatry and even psychiatric CL services are available only in a few centres. Psychosomatics is viewed rather pragmatically (Askevold 1985, Malt 1991). So far 3 services have submitted data to the study: a university and a non-university psychiatric CL service and the psychosomatic department at the National Hospital.

Psychosocial medicine in Finland (SF) is delivered by psychiatry. Psychiatric hospitals and departments serve defined psychiatric catchment areas. District general hospitals serve medical catchment areas. They have at least one CL psychiatrist plus a multidisciplinary team. There is a considerable interest in psychodynamic psychotherapy and family dynamics. CL is not an essential requirement in specialist training (Tienri et al. 1987, Tienari 1991). 3 university and 3 non-university psychiatric CL services participate in the ECLW study.

In Lithuania (LIT) psychiatry was misused political reasons. It was purely biological in orientation and is still based in ill equipped large mental hospitals. For these reasons it is quite unpopular. There was no psychosomatic movement and until 1990 no psychotherapeutic training.  General hospital psychiatric services are available only in two places (Daubaras 1992). Vilnius university policlinic which is specialized on anxiety disorders participates in the ECLW study with it’s inpatient consultations in a non-university general hospital.

In East Germany (D-E) cooperation in the care of inpatient was until recently exclusively the task of (neuro-)psychiatry. Only now are neurology and psychiatry separating from each other. Psychotherapy existed quite independent of psychiatry but was not involved in CL. Now, basically the West-German system is taking over. One university and one non-university centre participate. In West-Germany (D-W), there is a well developed system of publicly financed inpatient and outpatient psychotherapy. However, general hospital based CL services are underdeveloped. They are provided by psychosomatic units in about 2 % and by psychiatric units in about 10 % of general hospitals. Psychotherapy (psychodynamic and/or cognitive-behavioural) only now becomes an obligatory part of psychiatric training. In clinical practice “psychosomatics” deals with the whole range of non-psychotic and non-organic psychological disorders and complaints, esp. with functional, neurotic and personality disorders. Some experience in CL is required to become a psychiatrist. The new medical specialty of psychotherapeutic medicine will give CL a more prominent place (Herzog & Hartmann 1990, Herzog & Scheidt 1991, Herzog et al. 1993). 10 participating centres cover the whole range of services with fairly even distribution of cases: university and non-university, psychiatric and psychosomatic including behavioural medicine.

CL around the Baltic Sea: Trends

By December 1992, 74 Consultants in 22 centres had registered approx. 4500 CL episodes (Fig. 2). Data entry and analysis are still under way. The integration of background and patient oriented variables – precondition for most of the targeted analyses – remains to be done. There-fore we can only present some trends emerging from the preliminary data to illustrate some of the potential of study.

Treatment history of patients seen by CL

Two thirds of the patients seen by CL services in the general hospital have never had any mental health involvement in sharp contrast to their usually long history of medical and surgical contacts and often longstanding psychological disturbance. They are chronic utilizers of medical services and problem cases for the physicians and surgeons. CL can identify this significant subgroup of patients with often longstanding but unattended “mental problems” and effectively engage them in treatment (Haag 1984, Jordan et al. 1989).

Diagnostic groups seen by CL: “psychosomatic” disorders

Most relevant for the practice of psychosomatics in the broadest sense are patients with adjustment disorders (ICD-10 F43), often suffering from severe illness like cancer, with neurotic and somatoform disorders (the other subgroups of the ICD-10 F4) presenting with physical illness or only “unspecific symptoms” (ICD-9 780-789), those with “psychosomatic illness” in the classical sense (“Holy 7”) and others where “psychological factors are believed to be of importance” (ICD-10 F54/ICD-9: 316). One can identify these patients by looking at psychiatric (ICD-10)(Fig. 4) and/or at somatic diagnoses (ICD-9) (Fig. 5).

Patients with no physical diagnosis or unspecific symptoms contribute up to 40 % of all CL cases. Classical psychosomatic illness in most centres accounts for less than 5 % (Fig. 5). Those psychiatric diagnoses which constitute the focus of psychosomatics (F4, F54 and those with mere “problems”) are important in all services, but psychosomatic services see a much higher proportion of such patients, an indication of specialization (Fig. 4).

Neurotic, stressrelated and somatoform disorders (ICD-10 F4)

This important diagnostic group (ICD-10 F4) shows in all services a similar distribution of subgroups (adjustment disorders approx. 50 %, anxiety disorders approx. 25 %, somatization approx. 20 %). These patients are referred because of current psychiatric (total sample 50 %) and unexplained physical symptoms (28%). Problems of coping and compliance play a minor role (<5 % in psychiatric and up to 10 % in psychosomatic services). Specialized psychosomatic services see mostly referrals for unexplained physical symptoms (>50 % as compared to <25 % in psychiatric services). Marital and family problems (25 – 30 %) are the most frequent non-diagnostic problems leading to referral. For the remainder of this presentation we focus  on the F4 group in order to explore how “psychosomatic” patients are dealt with in different countries and by different kinds of service.

Even for this group of patients, liaison services are the exception and account for hardly more than 10 % of cases even in university psychosomatic services. Integration by cooperation within the classical consultation framework seems to be what is actually practiced.

The type of cooperation is reflected in the time spent for CL (Fig. 6). University based services and here again psychosomatic services spend much more time on a single case, with characteristic differences as to orientation: consultants from behavioural medicine (in a research setting!) spend only a short time on the first contact but see the patients quite frequently, altogether 5 hours on average, thereby distorting the average figure for German psychosomatics just as the intensive intake assessment at the National Hospital in Oslo which provided the majority of Norwegian cases distorts the average figure for time spent on the first CL contact. Psychodynamic practitioners take a long time for the first contact which is followed by hardly more than one additional visit on average whereas psychiatrists have less time both for the first and for follow-up contacts.

Psychological interventions involving family and staff are remarkably rare. Considering the amount of family related problems it is noteworthy how little the family or the spouse is approached even for information (in 9 – 14 %) let alone as an explicit “target of intervention” (<10 %). The staff is used as a source of information and seen as a special focus of intervention in about one third of episodes. Exceptions are the Finnish services (60 %) and the Lithuanian service (0%).

If they concern themselves at all with the general medical treatment (20 – 25 % in Germany East and West, 3 – 9 % in the other countries), consultants tend to suggest a decrease of diagnostic or therapeutic interventions 2 (psychiatric) to 6 (psychosomatic) times as frequently as an increase. The much higher activity of German consultants across all centres is striking and may reflect their medical training (internal medicine or neurology respectively, the latter being obligatory for psychiatrists) and the fact that they feel relatively established and well rooted in their respective traditions. The degree to which medication is prescribed (for the same type of patients!) varies widely (Fig. 7). We tentatively interpret this as due to  a)the different staffing and time available and b) to the tendency to do what one knows best, in this case: psychiatrists use drugs, psychosomatic practitioners, talk and listen. The latter tend to suggest the discontinuation of drugs. In addition, much of psychosomatic CL work is done by psychologists. An exploratory comparison of the preliminary German data on psychiatric and psychosomatic CL activities for patients matched for psychiatric diagnoses (ICD-10 F4) and other sociodemographic and clinical variables (Stein et al. 1992) involving 35 consultants who fairly well represent the whole spectrum of approaches (psychodynamic, cognitive-behavioural, “traditional” psychiatric) indicated that of all variables the theoretical orientation of the CL service allows best to predict what is done and suggested, clearly more so than diagnosis or other patient-related variables.

Discussion

The participants probably belong to the most dedicated services in the best staffed and equipped centres. At this point in time we do not yet have sufficient background information and cannot relate our findings to general hospital statistics. Thereby our view of patterns of utilization remains sketchy and – strictly speaking – any kind of comparison is unfounded. For example, breaking up the West-German sample into logically derived subgroup (psychiatric and psychosomatic services) shows how arithmetic means may disguise differences. One key task of the study will be thee detailed analysis of the relative influence of hospital, CL service and consultant variables on CL practice. The collection of the relevant background data is impeded by the many national and even local differences in organizational practices and data-handling and other idiosyncrasies. The sometimes striking differences between “countries” (figures 5 – 7) at present can be best interpreted along the lines suggested in the discussion about psychosomatics and psychiatry. As far as diagnostic distribution of patients seen concerned there are relatively great similarities between the “psychosomatic” services (W-Psm, Norway (National Hospital) and Lithuania) on the one hand and the psychiatric ones on the other. The relatively large proportion of classical psychosomatic disorders (“Holy 7” and F45) in German psychosomatic services may also reflect somewhat different disease concepts of the referring physicians. However, the differences between  “ psychosomatic” and psychiatric services seem to be confounded by availability of resources (esp. time, cf. Fig. 6) as well as training and tradition: where there is little time available and practically no psychotherapy training as in Lithuania and to some degree in East Germany, medication seems to be the most appropriate response to the plight of patient.

The limitations of interpretation at this stage notwithstanding we hope that the data presented will stimulate the reader’s reflection about his/her own practice of and notions about CL. Assuming similar base rates of medical diagnoses among admissions as well as sufficient diagnostic reliability, safeguarded by ECLW training, we tentatively conclude that patients with certain psychiatric diagnoses (neurotic, stressrelated and adjustment disorders, behavioural syndromes associated with psychological disturbances and physical factors) are grossly underrepresented where “ psychosomatic” CL services or a “ psychosomatic” orientation of CL service are lacking.

Our study is a venture into European cooperation across former divisions and research venture furthering psycho-somatic cooperation through CL by going beyond local biases. We close with some remarks on these two aspects.

Cooperation: The study is poorly financed. It’s very existence and the fact that it works with members from such tremendously diverse backgrounds is encouraging. The participant’ willingness to share detailed information about their everyday work is even more remarkable than their willingness to give of their time. Helpful for such cooperation are: 1.) some opportunity for informal meetings in pleasant surroundings, 2.) a core group with enough enthusiasm and stubbornness, 3.) a common interest felt to be neglected by the mainstream, 4.) it’s European nature: collaborating with colleagues from across the border mobilizes much less of the adverse effects of competitiveness and forces to listen and to explain each other very carefully, 5.) clear business rules on duties and rights and decision making procedures, 6.) a small but effective steering committee combining different approaches but able to compromise and get things done, i. e. an effective system of checks and balances between a strong and reliable study centre and representative of the collaborating centres.

Future of CL: In psychotherapy, method oriented approaches are slowly being superseded by patient oriented ones. To foster a similar development in CL we first need to know what we and our colleagues actually do and to improve our understanding of the rationales and background forces behind different approaches. We see the present study as an important step in this direction. Together with other research it indicates that the integration of psychosocial aspects with biological medicine can be economically improved by cooperation. With relatively little input (1 – 3 sessions in the classical consult model) one may obtain good results: immediate results for the patient, long-term results through the on-site education of medical and nursing staff. It must be decided locally what target seams most appropriate: to reach those 5 % of medical inpatients who are in need and motivated and have a physical or nurse concerned about their psychological state – or for a smaller percentage. Whether one focuses on classical consultation or on liaison, also should be left to local interest and opportunities. In practice the differences may blur: is it already liaison if one makes it a habit to routinely pay the intensive care unit a 5 minute morning visit? One thing must be clear, however: CL requires special competence, experience, time, place and support. A full-time consultant cannot see more than 250 – 400 patients a year (Herzog & Hartmann 1990, Herzog et al. 1992). A working consensus on a core data base is possible across Europe and across different specializations. For CL patients, the ICD-10 diagnostic system seems more appropriate than either ICD-9 or DSMIII-R. by introducing feasible descriptive and diagnostic standards the study allows for much better communication among different schools and traditions leading to improved identification of target problems. A European Association for Consultation Liaison Psychiatry and Psychosomatics (EACLPP), founded by clinicians and researchers from different professional backgrounds in October, 1992 aims to support and facilitate information, exchange and collaboration on the European level, e. g. concerning studies on evaluation quality assurance (information from the authors).

 Acknowledgments

The ECLW study is supported by the European Community (COMAC-HRS grant no. MR_{­­­­­­­}^*-340-NL) and – in Germany – the Robert Bosch Stiftung (grant no. 11.5.1030.0075.0) which is gratefully acknowledged. We are greatly indebted to the dedication and effort of the consultants in the altogether 22 centres in Norway, Finland, Lithuania, Germany East and West: Norway: Oslo: Blomhoff, Malt, Mogstadt, Tanum; Baerum: Bragason, Jakhelln; Bergen: Bodtker, Wilhelmsen; Finland: Oulou: Tienari, Rahikalla, Hiltunen, Ojanaho; Kuopio: Fohr, Hellen-Vuoti, Kesti, Ojala, Ollonen, Purhonen, Tacke, Viinamaki; Tampere: Alaja Riitta, Honkonen, Kampman, Karttunen, Lehtonen-Tuomi, Mattila, Seppala, Tri Tapio, Valtakoski, Virta; Helsinki: Heikkinen, Heinala, Kahkonen, Leppavuori, Quarshie; Espoo: Haarla; Kemi: Kolehmainen, Manninen; Lithuania: Vilnius: Daubaras; Germany East: Dresden: Cierpka, Felber, Ficker, Franz, Kaltofen, Reuner, Weigelt; Görlitz: Fiebiger; Germany West: Berlin(three centres): Diefenbacher; Knorr, Linke, Paaeetzmann; Saupe, Schutze; Freburg: Fritzsche, Herzog, Hoffmann, Hoffmeister, Huber, Kern, Scheidt, Stein, Wetzlar; Freudenstadt: Scneider; Gottingen: Eckhoff, Wachter; Hamburg: Haag; Kassel: Styloos, Wagner, Zeller; Quakenbruck: Voigt-Vehar, Kubler, Runze; Trier: Ehlert, Lupke.

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