Psychiatric Assessments on Medical Wards: a Guide for General Psychiatrists Tim Segal & Gopinath Ranjith

BJPsych Advances (2016), vol. 22, 8–15 doi: 10.1192/apt.bp.114.013961 ARTICLE Psychiatric assessments on medical wards: a guide for general psychiatrists Tim Segal & Gopinath Ranjith Tim Segal is a Year 4 Specialist are but a distant memory, include the vagueness SUMMARY Trainee (ST4) in general adult of the question being asked, the unfamiliar ward psychiatry at the South London and Psychiatric assessments on medical wards of routines and hierarchies, the lack of privacy Maudsley NHS Foundation Trust. He a general hospital are complicated by various has completed a 6-month placement and the challenge associated with the medical factors, including the lack of privacy, medical in liaison psychiatry during core illness itself, with patients often connected to illness-related factors such as cognitive deficits training and has a clinical interest in medical devices and multiple lines. In this article psychiatric illness in the medically and communication barriers, and the vagueness of unwell. Gopinath Ranjith is a the referral question asked. In this article, we try we provide a practical guide to approaching an consultant liaison psychiatrist with to guide general psychiatrists who do not routinely assessment on a medical ward from the moment a the South London and Maudsley carry out such assessments through practical referral is received to when the psychiatrist signs NHS Foundation Trust based at steps from receiving the referral to signing off off the case. St Thomas’ Hospital, London. He is also a visiting lecturer at the the case. The key differences in the process and In many general hospitals assessments are Institute of Psychiatry, Psychology content of psychiatric assessments are discussed, carried out by liaison psychiatrists or other and Neuroscience at King’s College as are diagnostic dilemmas. Subtle aspects of members of the liaison psychiatry team such as London and lead for foundation communicating the outcome of the assessments psychiatric liaison nurses. But in parts of the training at Maudsley Hospital. His to patients and referrers are emphasised with country liaison psychiatry services remain patchy, clinical and research interests are specific guidance on writing consultation notes. in mood disorders in the medically We conclude with a discussion of the principles with community mental health services providing ill, self-harm and suicidal behaviour, ‘in-reach’ services to patients from their catchment and process and outcome measures of biopsychosocial management and judging the in consultation-liaison services. outcomes of consultations on medical wards. area. Even where there are liaison psychiatry Correspondence Dr Gopinath services, they are often available only in office hours, LEARNING OUTCOMES Ranjith, South London and Maudsley leaving out-of-hours cover of the general hospital NHS Foundation Trust, Scutari Clinic, • Gain an appreciation of the differences between the responsibility of junior trainees supervised St Thomas’ Hospital, Westminster a standard psychiatric assessment and an by general psychiatrists. Given the move towards Bridge Road, London SE1 7EH, UK. assessment of a patient in a general hospital in- Email: [email protected] 24/7 working and consultant-delivered services in patient setting the National Health Service (NHS), it is probable • Learn about dealing with a referral from a medical that consultant general psychiatrists will become ward, from receiving the referral to formulating a more involved in assessments of patients in general management plan hospitals, making this article especially relevant. • Learn about communicating the outcome of the assessment to the referrer and judging the success of the consultation The referral DECLARATION OF INTEREST Receiving the referral None For a standard psychiatric assessment the reason for referral is usually pretty clear from the general practitioner’s (GP’s) letter, but this is not always Psychiatrists are experienced in carrying out the case for referrals from medical wards. The psychiatric assessments in a variety of settings, referral is usually made by a junior member of including inhospitable environments such as the medical or surgical team, who is carrying out police stations, chaotic psychiatric wards and busy tasks from a busy medical ward round and may emergency departments. However, even for an not know the patient well. The mode of referral experienced psychiatrist, performing a psychiatric varies between hospitals, from a telephone call to a assessment on a relatively settled medical or referral letter or, increasingly commonly, a generic surgical ward may prove daunting. Problems referral form often completed on an electronic the psychiatrist faces, particularly if their days system. A more formal referral system is helpful as of postgraduate training in the general hospital it ensures that all the essential basic information is 8 Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 06:18:54, subject to the Cambridge Core terms of use. Psychiatric assessments on medical wards 2010). It is therefore important to be able to BOX 1 Common reasons for referrals from read between the lines of a referral (Box 2). For medical wards example, a referral for medically unexplained • Assessment and management of psychiatric disorder symptoms may belie frustration with a patient who is being repeatedly admitted to hospital. A referral • Impact of pre-existing psychiatric symptoms on medical disorder for the management of agitation may involve a patient who is aggressive because his demands • Medically unexplained physical symptoms are not being met. Often it will become apparent • Advice regarding psychotropic medications on further discussion that it is the treating team’s • Management of agitated or challenging behaviour frustration with the patient that has resulted in • Suicide risk assessment and management the referral, rather than a psychiatric problem • Second opinion on decision-making capacity in the patient. Determining underlying reasons before starting the assessment will help guide your interview and, ultimately, your management plan. given and it focuses the attention of the referrer on the question being asked. The basic information Appropriateness of the referral required includes the patient’s demographic details The final aspect of dealing with referrals is to (name, date of birth, hospital number), location in decide whether to accept the referral. At one the hospital, the patient’s primary diagnosis and extreme is a general hospital psychiatric service reason for admission, the psychiatric concerns and ‘that never says “No” ’ (Smith 1998); at the other reason for referral, the urgency of the assessment is a strict screening system for referrals, with a and the referrer’s details. Common reasons for significant number rejected as subthreshold. In referral can be seen in Box 1. our opinion it is best to chart a midway course. Before an assessment, it is certainly reasonable to Clarifying the referral ask for further investigation to rule out medical Sometimes the reason for referral and the nature of causes, or to ask the referrer to talk to the patient the assessment required are unclear (House 2012). to get a better understanding of the psychiatric It is therefore often useful to contact the referrer concerns. If it is clear from talking to the referrer to get further information. In doing this you can that the problems relate to transient emotional get a better idea about the patient’s medical and reactions, purely antisocial behaviour unrelated psychiatric condition and the urgency of the referral, so that a timely response can be agreed. You can also identify exactly what question the BOX 2 Reading between the lines of a referrer wants answered. Practical issues can referral (a fictitious example) be broached, such as when the patient will be A 35-year-old woman admitted 2 weeks ago with available, where the assessment can take place and abdominal pain received multiple investigations that whether there are challenges to communication showed mild gastritis, nil other significant. Increasing such as a language barrier, tracheostomy or other anxiety interfering with management, complex family medical devices. It is also important to clarify dynamics. Nil psychiatric history. Please review for whether the referral has been discussed with the diagnosis/management of anxiety. patient and whether the patient has consented to On further discussion with the referrer, it becomes clear being seen by psychiatric services. Explaining to that what is described as anxiety actually refers to the the patient that a psychiatrist is coming to see patient becoming increasingly demanding on the ward. them prevents an awkward discussion on arrival She is requesting pain relief frequently and becoming with an unprepared patient who may feel offended verbally abusive when this is not given. Her family that a psychiatrist has been called. The patient has are often on the ward in large numbers, sometimes outside of visiting hours, and make regular threats of the right to refuse psychiatric assessment, and this complaints about what they perceive as staff negligence. should be respected if possible. In general, the only This is causing a significant strain on nursing and reason for carrying out a psychiatric assessment medical staff in terms of both time and morale. Armed of a non-consenting patient would be if there are with this information, the psychiatrist was aware that initial grounds for believing that

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