A day in the life of a Liaison Psychiatry Practitioner
Joel Petch, lecturer in Mental Health and Clinical Science, provides an insight into the day-to-day work of a Liaison Psychiatry Practitioner this World Mental Health Day.
Please note that this piece discusses serious mental health issues and may not be suitable for all readers. If you, or anyone you know, have been affected by the issues discussed in this piece, please see the article footnotes for suggested free resources.
06:00 – 09:00
I rise early and have breakfast before leaving for work. I’ve learnt to eat before starting work as each day is unique and brings a distinct set of challenges - the unpredictable nature of Liaison Psychiatry is what initially drew me to the service.
I drive to work wondering what the day will bring, arriving at 07:15. I make my way to the office to receive a handover from the night shift; as I enter the hospital, I hold a brief discussion with some paramedics I worked with on the previous shift - they thank me for my input. Forming such relationships is key to my role.
The office is small, and cramped when all of the team are inside, but it’s perfectly located in close proximity to the Emergency Department (ED). My colleague speaks of a relatively busy nightshift: three individuals who were assessed within the ED. I’m pleased that his shift wasn’t too busy - nightshifts are often the busiest of times, with the fewest staff available.
Of the three individuals assessed, my colleague informs me, two had taken overdoses and one had self-presented requesting input from the mental health team. All three had received biopsychosocial assessments with immediate and future management plans put in place. One of the three, a lady in her 40’s, remains on a medical ward receiving IV infusion post-overdose. My colleague asks me to review this individual later today, as she may require an admission to a mental health ward due to a severe depressive episode, once she is deemed stable enough for transfer. I make notes to best organise myself.
09:00 – 12:00
As I begin my shift, I’m informed that there are no individuals within the ED currently awaiting the input of Liaison Psychiatry. I’m pleased, but I know this can change rapidly. Despite no patients requiring my attention, I still walk into the ED to speak to the staff. This is partly to greet them, but also to make myself visible and to ensure that Liaison Psychiatry remains in the forefront of their minds. The ED staff greet me warmly, although I suspect that they see me as an addition to ‘their team’, as oppose to one of ‘the team’. I reflect on how we appear to have arrived at a somewhat disjointed relationship between physical and mental health services; although I’m also aware that this is part of my role to reduce this divide through dialogue and developing relationships.
In addition to emergencies coming through the doors of the ED, we have a caseload of in-patients across the hospital that require ongoing assessment and treatment. I return to the office to review their notes and see what input from Liaison Psychiatry is planned for today. The essence of Liaison Psychiatry is working in partnership with other hospital specialty teams, to care for individuals with co-existing health conditions. People with medical conditions are more likely to have a mental health problem, and vice versa. I’d go as far to say that there is little more than an arbitrary line between physical and mental illness, and that it may be more beneficial to simply consider ‘health’.
I attend an older adult medical ward to review a man who has been experiencing acute-on-chronic confusion. This seems to be the result of a urinary tract infection, superimposed on a background of Alzheimer’s dementia. I speak to the ward staff and the man’s wife before reviewing him. I perform cognitive assessments and assess him for distress, anxiety and agitation to compare with earlier assessments and monitor progression. It’s pleasing to see that the infection has now passed, and that the acute confusion and agitation appears to be resolving. The essence of providing care for his condition is watchful waiting, monitoring the trajectory of his cognitive state, alongside behavioural and environmental measures to reduce distress – largely, all of these are provided by skilled nursing teams.
I discuss his progress and my impression with his wife and the ward staff, agreeing that we’ll review again. All are in agreement and satisfied that his mental state is returning to his baseline. As write up my notes, my pager chirps and I take a referral from the ED.
12:00- 15:00
I return to the office to review background information related to the referral I’ve just accepted - I also request an encounters summary from the individuals GP. The referral relates to a 19 year old male who has “superficially” harmed himself- experience tells me to know that the intent behind the injury is a greater indicator of risk than the extent of injury. Self-harm is an expression of distress and often, a mechanism to relieve it - with this, I wonder about the context of his presentation.
I attend the ED, and see a young male accompanied by his parents. All three appear upset and distressed. I ask the individual if his parents can join us, he agrees. I undertake a biopsychosocial assessment including a mental state examination. The individual states that the injury was undertaken in response to ‘voices’- I explore the topic and see evidence of psychosis. The individual discusses his concerns, although is somewhat vague at times; his parents offer additional information adding history and context to the assessment that supports my impression of a first episode of psychosis. I review the GP summary and hold further discussion with our team Consultant, who agrees and we plan to take on for the Early Intervention in Psychosis service. This team is one of the specialist teams available. As I discussed the proposed plan, the individual and his parents, appear satisfied and relieved that assistance is being provided.
I begin the write up my assessment documentation, but I’m disturbed by my pager- it’s a referral from one of the wards, this time anxiety related. I accept the referral and continue to write my notes before receiving another referral, this time it’s from the maternity suite; it sounds like a postpartum psychosis, which immediately promotes the urgency with which our team must provide assessment, advice and management.
15:00- 18:00
Returning to the office, I speak to my colleague who has, thankfully, just become available. We discuss the referral from the maternity suite, and she agrees to undertake the assessment. This allows me to review the individual that my colleague saw last night. I speak to the ward where the individual is, who confirm that she is ‘medically fit’- I’m still unclear what this phrase means; it is sufficiently broad enough term to mean different things to different people, and is often ‘agenda-laden’. In addition, I wonder what this says about attitudes toward those with mental health problems [if this individual is medically fit- why I am being requested to attend?]. I suspect it often represents an arbitrary boundary designed to demarcate different teams’ perceived responsibilities to a patient.
I attend the ward and speak to the individual. I undertake a mental state examination and I see evidence of severe depressive disorder. This is marked with significant loss of appetite, weight loss, lack of energy, and an ongoing wish to end her life. I’m alarmed at the severity, and concerned that at home she will continue to deteriorate. Once more, I speak to my Consultant who agrees to assess with a view to an admission to a mental health ward given the pervasive and serious nature of the depression. I rush back to the office- I still have two sets of clinical documentation to complete, and I need to handover to the evening shift. Once more, I’m thankful that I didn’t skip breakfast.
18:00…
I leave work later than expected but I accept that this sometimes happens with the nature of the role. I drive slowly, taking my time to reflect upon the day and consider the people that I’ve seen; people with confusional states, psychosis, and depression. I wonder how the new mum is doing- I’ll be sure to find out tomorrow. As another busy day draws to a close, I think once more about how such a small team can have such a large impact upon an acute hospital, and the people within. As I reach my home address, I consider how long this will last before we finally reach ‘Parity of Esteem’.
Notes:
Joel Petch is a lecturer in mental health and clinical science in the Faculty of Health and Wellbeing at Canterbury Christ Church University. Joel’s clinical background is, broadly, within Liaison Psychiatry at various hospitals in the South East. Joel can be found debating all things mental health and neuroscience related on Twitter @joelpetch.
Special thanks to Dr Dan Joyce for his contribution to this Blog. Dan is an SpR in neuropsychiatry at Guys and St Thomas’ Hospital and clinical lecturer at Institute of Psychiatry, Psychology and Neuroscience at King's College London. He can be found on Twitter @dan_w_joyce.
Liaison Psychiatry is a specialist mental health service providing support to individuals within an acute hospital- this includes the Emergency Department, medical and surgical wards. Liaison Psychiatry also offers training and education related to working with those with mental health conditions to acute hospital staff, and seeks to lessen the pervasive nature of Cartesian dualism for the betterment of us all.
Further information:
Study Mental Health Nursing
https://www.rcpsych.ac.uk/college/faculties/liaison.aspx
https://www.mentalhealth.org.uk/a-to-z/p/parity-esteem
https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf