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The British Journal of Psychiatry (2005) 187: 109-120
© 2005 The Royal College of Psychiatrists

REVIEW ARTICLE

Meta-review of high-quality systematic reviews of interventions in key areas of liaison psychiatry

RACHEL RUDDY, MRCPsych

Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds, UK

ALLAN HOUSE, MRCPsych

Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds, UK

Correspondence: Dr Rachel Ruddy, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds LS2 9LT, UK. Tel: +44 (0) 113 343 2741; fax: +44 (0) 113 243 3719; e-mail: R.A.Ruddy{at}leeds.ac.leeds.ac.uk

Declaration of interest None. Funding detailed in Acknowledgements.


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ABSTRACT
 
Background When planning and delivering a liaison psychiatry service it is important to have an understanding of the research evidence supporting the use of interventions likely to be delivered by the service.

Aims To identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed. The three areas were the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour.

Method Computerised database searching, secondary reference searching, hand-searching and expert consultation were used to identify relevant systematic reviews. Studies were reliably selected, and quality-assessed, and data were extracted and interpreted by two reviewers.

Results We found 64 high-quality systematic reviews. Only 14 reviews included meta-analyses.

Conclusions Many areas of liaison psychiatry practice are not based on high-quality evidence. More research in this area would help inform development and planning of liaison psychiatry services.


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INTRODUCTION
 
There are several reasons to provide liaison psychiatric services. General hospital staff see high rates of psychiatric illness compared with rates in the community, as well as acute presentations of psychiatric problems, patients with comorbid psychiatric and chronic physical illness, and patients with somatisation disorders who will not attend a community mental health service but may see psychiatric specialists in the general hospital setting (Peveler et al, 2000). Despite this large potential need, liaison psychiatry services are often underdeveloped and provision varies greatly (Howe et al, 2003; Ruddy & House, 2003). In planning more comprehensive and coherent liaison services for the future, we will require knowledge about which interventions work for the common psychiatric problems seen in general hospitals. We therefore conducted this meta-review of high-quality systematic reviews of interventions for clinical problems likely to be treated by liaison psychiatry services. We focused on systematic reviews because they are the highest quality of evidence in any hierarchy of evidence; they are good for identifying the limits of current knowledge and for prioritising areas for future research.

Our study was designed to identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed.


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METHOD
 
Types of studies
All relevant systematic reviews and meta-analyses were included.

Areas of liaison psychiatry
We identified six key areas of liaison psychiatry practice by reading the liaison psychiatry research literature and liaison psychiatry textbooks. These six areas were:

  1. psychological effects of physical illness or its treatment;
  2. somatoform disorders;
  3. self-harming behaviour;
  4. emergency presentations of acute psychiatric illness to general hospitals;
  5. physical effects of psychological or psychiatric treatment;
  6. physical findings or behaviour raising concerns about possible physical or sexual abuse.

We decided to focus our review on the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour. We excluded emergency presentations because review groups linked to the Cochrane Collaboration undertake systematic reviews covering the acute management of different psychiatric illnesses. We felt that the physical effects of psychological or psychiatric illness and treatment are generally the concern of physicians, general psychiatrists or general practitioners rather than liaison psychiatrists, and physical findings raising concerns about abuse are predominantly the concern of child and adolescent liaison psychiatry.

Within each of our three categories we further defined the scope of the review. Under somatoform disorders we decided to exclude interventions for somatoform pain disorder (except psychotropic drugs), because psychological interventions for pain had recently been covered in the UK's Department of Health review of psychological therapies (Department of Health, 2001). We also chose to exclude treatments for psychosexual problems, eating disorders, pregnancy and related disorders, traumatic brain injury, learning disabilities, and alcohol and recreational drugs misuse, because - although these areas may impinge upon a liaison psychiatry service - they are often dealt with by designated specialist services.

For the purpose of this review we classed dementia as a neurological disorder and therefore included psychiatric complications of dementia (such as behavioural disturbance and depression) in the category ‘psychological effects of physical illness or treatment’. We also included delirium as a medical illness in the category ‘psychological effects of physical illness and treatment’.

Participants
We reviewed interventions in adults (over 16 years old). Evidence on interventions in child liaison psychiatry is covered comprehensively in a report by the Royal College of Psychiatrists (Scott et al, 2001). We included reviews where it was implied that the majority of the participants had a problem area consistent with the areas of liaison psychiatry being reviewed, regardless of the length of illness. Reviews were not excluded on the grounds of nationality or gender of participants. Reviews were excluded if they were conducted before 1980 (because of changes in medical treatments) and if the only treatment settings were primary care or prisons.

Types of intervention
We classified interventions under six headings:

  1. assessment and advice by a mental health specialist;
  2. physical interventions: for example, medication, electroconvulsive therapy, surgery, physiotherapy, nursing, feeding and bathing;
  3. psychological interventions: these include all types of therapies mentioned in the Department of Health document covering treatment choice in psychological therapies and counselling (Department of Health, 2001);
  4. service interventions: for example, out-patient clinics, admission to a medical ward, admission to a psychiatric ward, specialist units, day hospitals, helplines and provision of crisis cards;
  5. packages of interventions: two or more of the above interventions, or one or more of the above coupled with a social intervention (for example, occupational therapy, home support, housing, financial support or social activities);
  6. no intervention: included because it is possible that not receiving an intervention from a liaison psychiatry service might be more beneficial than receiving one.

Outcome measures
We recorded outcomes as reported by the authors, with special attention to psychological outcome, medical outcome, social functioning and quality of life, service outcomes, adverse effects, satisfaction and economic outcomes.

Search strategy
The ACP Journal Club, the Database of Abstracts of Reviews of Effects (DARE), the Cochrane Controlled Trials Register, Medline, EMBASE and PsycINFO were searched from 1980 to the end of 2002 for systematic reviews of all interventions listed above in all areas of liaison psychiatry. The scope of the review was wide so the search strategy was extensive and used Medical Subject Headings (MeSH) terms to cover physical and mental health problems; the standard Cochrane Collaboration search strategy for systematic reviews was also used. Next, the journal Evidence-based Mental Health (1998-2002) and the December issue of Clinical Evidence Concise (BMJ, 2002) were hand-searched, and the references of all reviews found in this way were searched. Experts in liaison psychiatry were consulted by circulating the findings to members of the European Association of Consultation Liaison Psychiatry and Psychosomatics, the Liaison Psychiatry JISCmail group and the Trent, Yorkshire and North East Liaison Psychiatry Network.

Appraisal of quality
All Cochrane reviews were included as they are known to be methodologically sound and are peer-reviewed against methodological criteria. Review articles and meta-analyses that were not registered with the Cochrane Collaboration were evaluated using quality criteria suggested by Oxman & Guyatt (1988). Each review or meta-analysis was assigned to one of three bands - high quality (all eight criteria), medium quality (five, six or seven criteria) and low quality (fewer than five criteria); R.R. rated all the reviews and A.H. rated a sample of 20% of the papers independently. Any disagreement in rating was discussed and reported. Only papers rated as being high quality or medium quality were included.

Data extraction
Data relating to the methods of the review, including studies and conclusions, were extracted from the reviews using a standardised form.


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RESULTS
 
After screening 4084 abstracts and the references of 341 reviews to see if they met the inclusion criteria, we found 64 relevant systematic reviews (including 10 completed Cochrane reviews). Most of the other reviews were excluded because they did not summarise data from intervention studies or were of poor quality. Table 1 summarises the number of reviews included in each area of our meta-review. It can be seen that there is an imbalance in the number of reviews for different areas; the availability of evidence does not match well with government priority areas or with the prevalence and severity of the conditions. For example, we found five reviews of treatment for irritable bowel syndrome but only one for cardiovascular disorders. We identified 13 relevant Cochrane reviews that were only at protocol stage and so could not be included in this meta-review.


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  		Table 1 Number of systematic reviews included for each area of the meta-review

Fourteen of the included reviews contained meta-analyses that provided a quantitative summary of the effectiveness of the intervention, with confidence intervals. Table 2 summarises these reviews and Table 3 summarises the other included reviews. Of the other 50 included reviews there were 13 in which the primary data used in the review were poor and no clear result was achievable. Even among the reviews with meta-analyses, in only four was there unequivocal evidence of an effective intervention. These interventions were antidepressants for depression in physical illness, antidepressants for physically unexplained symptoms, antidepressants for chronic headache and cognitive-behavioural therapy for chronic fatigue syndrome (O'Malley et al, 1999; Tomkins et al, 2001; Gill & Hatcher, 2002; Price & Couper, 2002).


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  		Table 2 Included reviews with meta-analyses (14 reviews)

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  		Table 3 Included reviews without meta-analyses (48 reviews)

Table 4 shows the areas for which there was no good-quality systematic review. It demonstrates large gaps in review evidence for some of the most common components of a liaison psychiatry service, such as assessment and advice, and service level interventions; for one of the basic problems that a liaison psychiatry service deals with (adjustment to chronic illness); and for some of the most common medical conditions, such as renal, respiratory and cardiovascular disorders.


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  		Table 4 Areas covered by our review for which there is no quality systematic review of the literature (bullet point indicates absence of reviews)

Quality of the included studies
Tables 2 and 3 show the quality ratings for the included reviews. Forty-three of the included studies were rated as highest quality using the criteria of Oxman & Guyatt (1988). This means that these studies had a clear research question, a comprehensive search strategy and a repeatable method for appraisal and data extraction and that the data combination and conclusions were appropriate.

The other 21 studies were of medium quality. All of these studies had a clear research question and a comprehensive search strategy. Three reviews did not describe the methods used to determine which articles to include in the review (Howland, 1993; Krupnick et al, 1993; Guthrie, 1996). Ten reviews did not describe assessing the validity of the primary studies and therefore did not have reproducible methods (Howland, 1993; Kennedy & Feldmann, 1994; Carter et al, 1996; Guthrie, 1996; Moore, 1996; Gordon & Hibbard, 1997; Repper, 1999; Sheard & Maguire, 1999; Allen et al, 2002; Turner-Stokes & Hassan, 2002). Ten reviews described assessing the validity of the studies, but the method used was not reproducible (Cummings, 1992; Smith, 1992; Goodnick et al, 1995; Lovejoy & Matteis, 1997; Van der Sande et al, 1997; Akehurst et al, 2001; Miller & Cohen, 2001; Pratt et al, 2002; Rose et al, 2002; Whyte & Mulsant, 2002). Four reviews did not analyse (even descriptively) the variation in the findings of the primary studies (Cummings, 1992; Goodnick et al, 1995; Gordon & Hibbard, 1997; Sheard & Maguire, 1999). Several studies formed conclusions that were not supported by their findings (Kennedy & Feldmann, 1994; Goodnick et al, 1995; Moore, 1996; Gordon & Hibbard, 1997; Allen et al, 2002).


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DISCUSSION
 
Meta-reviews are important because they summarise the highest-quality research evidence in a field, identify gaps in the research literature and explain the reasons for discordant conclusions between systematic reviews. It is clear from our meta-review that there are large gaps in the systematic review evidence, not only in clinical areas such as renal, respiratory and cardiovascular disorders, but also in some of the most common interventions such as assessment and advice, and service level interventions. Even in the areas that are covered there is often no clear conclusion because of the poor quality of the primary data or because the reviews provide conflicting results, for example concerning the role of neuroleptics in behavioural disorders in dementia (Lanctot et al, 1998; Davidson et al, 2000). Some of the review results are difficult to interpret clinically. For example, Price & Couper (2002) found that cognitive-behavioural therapy was helpful in preventing deterioration in physical functioning in people with chronic fatigue syndrome up to 6 months after treatment ended. However, it is unclear what overall impact this would have on someone who is living with chronic fatigue syndrome. The review of the use of antidepressants in chronic headache (Tomkins et al, 2001), which provides a number needed to treat of four for one patient to improve, suffers from the lack of evidence in the primary studies to indicate whether this effect is independent of depression.

Clinical implications
Lack of evidence implies that much of the clinical practice of liaison psychiatry is based on lower-quality evidence or extrapolation from other areas of psychiatry where there is high-quality evidence. It is hard to know where to set the limits of such extrapolation (Naylor, 1995). For example, Gill & Hatcher (2002) combined the results of trials of treatment for depression in a wide range of physical illnesses despite possible clinical heterogeneity. It may be that use of antidepressants for depression is not indicated in some physical illnesses and that the costs and benefits of treating depression with antidepressants in different medical disorders will vary.

In the absence of adequate evidence other factors must be influencing liaison psychiatry service development, which might help account for the current service variability (Ruddy & House, 2003). Clinical services cannot be packages of interventions that systematic reviews have shown to be effective. If we are to build rational services, then we need to be clearer about what factors other than clinical research should influence planning decisions. We should develop technologies for integrating each of these factors (values, policies, funding contingencies and so on) into planning, and indicate explicitly how we arrive at the trade-offs between them.

Research implications
The clinical practice of liaison psychiatry needs research in the form of systematic reviews with meta-analyses and primary studies. Systematic reviews are important because for the busy clinician they are a valuable, unbiased summary of the current literature (Egger et al, 2001). It is interesting to note that there is currently no Cochrane group to cover the work in this psychiatric specialty, which may be one of the reasons there are so few good systematic reviews. Even in areas where there appears to be unequivocal evidence of benefit, it would be difficult to use this evidence to guide service planning. Future research should be more service-oriented, researching common interventions in liaison psychiatry such as assessment and advice, and whole service interventions. It should also focus on common problem areas encountered in clinical practice, and ensure that outcomes of importance to patients are included.


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Clinical Implications and Limitations
 
CLINICAL IMPLICATIONS
  • There is a lack of systematic review evidence for interventions in liaison psychiatry.
  • Much practice in liaison psychiatry must therefore be based on lower-quality evidence or extrapolation.
  • Deciding on the implications of this evidence for planning and delivering liaison psychiatry services is not straightforward, since evidence must be integrated with other factors such as policy, financial constraints and values.

LIMITATIONS

  • We included only systematic reviews, but in some areas there may be large clinical trials that guide practice.
  • Areas of practice that might be considered a part of liaison psychiatry were excluded.
  • This meta-review will soon become out of date, as new reviews are published.


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ACKNOWLEDGMENTS
 
This meta-review was sponsored by Priorities and Needs, Research and Development funding from the Leeds Mental Health Trust. We thank members of the European Association of Consultation Liaison Psychiatry and Psychosomatics, the Liaison JISCmail group and the Trent, Yorkshire and North East Liaison Psychiatry Network who supplied references for inclusion.


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Received for publication May 18, 2004. Revision received November 11, 2004. Accepted for publication January 6, 2005.


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