Abstract
Consultation–liaison (C-L) psychiatry is the branch of psychiatry that combines clinical service, teaching and research within a medical setting. 1 , 2 As a discipline, it has steadily grown over the last 60 years, and has become a vital component of general hospital psychiatry. 2 The literature has recognized that as many as two-thirds of mainstream health service patients with a medical illness may manifest some psychological symptoms. 3 , 4 The outcomes include diminished quality of care if the symptoms are not acknowledged and/or treated and prolonged length of stay in hospital when a patient has associated psychological symptoms. 5 , 6 In terms of aged care, nursing homes, in particular, have not traditionally received systematic mental health services, despite the finding that psychiatric symptoms are prevalent in nursing home residents. 7 , 8 Rural nursing homes, as with many rural health services, are under-resourced and in great need of mental health input. The literature supporting the implementation of a C-L psychiatric service to nursing homes is discussed. Recommendations for introducing such a service in rural Australia are presented.
NEED FOR SERVICES
For decades it has been recognized that the prevalence of psychiatric disorders in nursing homes is high. 9 It has been found that up to 80% of nursing home residents have coexisting psychiatric disorders, with dementia being the most prevalent, yet resourcing for psychiatric care of this disabled and segregated population has been much less than for other sections of the community. 8 – 12 In Australia, the Human Rights and Equal Opportunity Commission reported that most nursing homes had little or no contact with psychiatric services. 13 This is particularly concerning, given that as our population increases, more older Australians will be spending time in aged care residential facilities. 8 Limited access to, or use of, mental health services in nursing homes may result in poor recognition of symptoms, inappropriate treatment and greater pressure placed on acute psychiatric services. A study by Snowdon et al. found that 28% of nursing homes surveyed in central Sydney provided no ongoing education to staff about dementia or other mental health problems. 14 Yet, 76% of these nursing homes reported that they wanted increased provision of mental health services. Thus, it seems that part of the role of a C-L psychiatry service would be to educate nursing home staff and management about mental illness, as well as provide direct services.
Benefits of services for patients
Despite the apparent gaps in service provision, some international studies have offered support for regular psychiatric liaison to nursing homes. 15 – 17 Specifically, Goldman and Klugman found that provision of regular psychiatric input may impact upon diagnosis, management, identification of medication side-effects and better staff tolerance of behaviours. 18 Nursing home consultations have also been found to reduce hospital admissions. 19
Another investigation by Tourigny-Rivard and Drury focused on the effects of monthly psychiatric consultation for both nursing home staff and residents. 20 Nursing home staff provided written comments about the consultation process, and individual case files were reviewed in terms of patient outcomes over an 18 month period. The researchers found that the residents benefited through the staff's increased understanding of symptoms and improved attitudes towards mental health problems. It was also reported that therapeutic interventions were used more frequently after the psychiatric consultation started. Other reported benefits of the consultation included an improved relationship between the psychiatric consultant and nursing staff, and nursing home management being increasingly supportive of nursing staff's use of new interventions. Interestingly, Tourigny-Rivard and Drury noted that nursing home staff had initially expressed trepidation in receiving regular mental health services, fearing that more problems would be exposed without solutions. 20 The major limitation of this research is the small sample size (21 consultations over 18 months), and that only qualitative data are reported. Nevertheless, it does provide important information about the nature of relationships between C-L staff, nursing staff and nursing home administrators.
Benefits of services for staff
There are benefits of regular psychiatric input in nursing homes for staff as well as patients. Staff tolerance of challenging behaviours and knowledge of mental health issues has been recognized as important to the quality of care in nursing homes. 18 , 21 In particular, ‘burnout’ may have a detrimental effect on the effectiveness of patient care and may be related to the level of behavioural disturbance in patients with dementia. 22 Regular psychiatric liaison and education provision has been found to increase nurses' knowledge of mental illness and to also increase their ability to manage disturbed behaviour. 17 , 23 Given these considerations, it would appear valuable to measure staff stress/burnout as an indicator of the effectiveness of a C-L psychiatry service.
Research needs
The major problem with research in this area is that, for the most part, studies are descriptive in nature; there is a paucity of well-designed studies on the effectiveness of C-L services in nursing homes. Bartels et al. argued that more empirical research was required to ascertain whether C-L services to nursing homes resulted in improved clinical outcomes and reduced the use of acute services. 10 Introducing a psychiatry consultation service to nursing home facilities requires a long-term commitment from C-L staff, as well as a thorough set-up period to ensure that realistic and appropriate services are being provided. 24 Therefore, with the considerable effort required to implement such a service, conducting a sound evaluation study should be intrinsic to future research. 10
Although several international studies have been conducted, there is a lack of Australian research into mental health service provision to nursing homes. A study by Draper et al. investigated the nature of referrals from Sydney nursing homes to a psychogeriatric outreach programme. 7 It was found that of 106 referrals, behavioural problems were apparent in 82% of patients, and depression was identified in 31% of cases. The most frequent treatment recommendations were related to the nursing home environment, psychotropic medication, behavioural strategies and family interventions. The authors concluded that multidisciplinary consultation services were crucial to providing adequate mental health services to nursing homes. They also recommended that prospective evaluation studies be undertaken to determine the best model of mental health service delivery for nursing homes in Australia.
CONCLUSIONS AND RECOMMENDATIONS
Although the literature suggests the value of a C-L approach to providing psychiatric services to nursing homes, there has been a lack of empirical evidence to support this view. 12 , 14 Consequently, more robust evaluation studies that address various outcomes of providing such a service are required. 10 It is clear from a review of the relevant literature that regular psychiatric input in nursing homes is not only worthwhile, but a necessary component of best practice in aged care. The difficulty lies in the lack of well designed evaluative studies to support widespread implementation of C-L services in nursing homes. There are currently no known studies of C-L service provision to rural Australian nursing homes.
Therefore, based on this review, the following recommendations are warranted:
Future research in this area should adhere to rigorous evaluation methodology, and report outcomes in empirical as well as descriptive terms.
More Australian research needs to be undertaken to investigate the mental health needs of nursing home residents, the educational and service needs of nursing home staff and the effects of regular psychiatric input in nursing homes.
The relationship between nursing home staff and the mental health needs of nursing home residents demands more attention. In particular, it needs to be determined what association exists between stress in nursing home staff, their knowledge of mental illness and the level of mental health service provision to nursing home residents.
Studies in rural Australian nursing homes are required given this area that has been ignored.
It is hoped that with further research and a commitment on the part of those health professionals working in aged care, mental health service provision to older Australians becomes an integral part of health care reform.
Footnotes
Acknowledgements
We are indebted to Professor Fiona Judd for her helpful suggestions.