This document discusses the role of liaison psychiatry in treating alcohol use disorders. It begins by providing statistics on alcohol consumption and alcohol-related hospital admissions and costs in the local area. It then describes what liaison psychiatry is and its scope. National guidance calls for dedicated in-house liaison psychiatry services in every hospital. A local pilot program established liaison psychiatry teams to provide assessment, treatment and referral for patients with alcohol issues. The document presents some case examples and outlines current referral pathways and plans for future expansion and integration of liaison psychiatry services.

1. Alcohol Use Disorders:
The Role of Liaison
Psychiatry
Dr Alex Thomson
Consultant Liaison Psychiatrist
Northwick Park & Central Middlesex Hospitals
Clinical Lead for Substance Use in Mental Health
Psychological Medicine
alex.thomson@nhs.net
Psychological Medicine

2. Future
Develop-ment
Psychological Medicine
Alcohol in
the
General
Hospital
Alcohol &
Liaison
Psychiatry
What is
Liaison
Psychiatry
The North
West
London
Pilot
What Does
Liaison
Psychiatry
Contribute
Case
Examples
Current
Activity &
Pathways

3. Psychological Medicine

4. Per capita alcohol consumption and alcohol-related
Psychological Medicine
deaths 1984-2008
Source: 'Future Proof: Alcohol
Consumption, Mortality and
Morbidity - Key Findings'
Professor Martin Plant , 2009

5. Psychological Medicine

6. Psychological Medicine

7. Psychological Medicine
Source: Hospital Episode Statistics
(HES), NHS Information Centre for
Health & Social Care and Office for
National Statistics mid-year
population estimates for 2008.
Analysed by London Regional Public
Health Group and London Health
Observatory.

8. Acute Hospital Bed Days in Brent and Harrow
Psychological Medicine
2008-9
Brent Harrow
Alcohol-attributable Admissions 6,118 3,949
Alcohol-related Admissions 14,074 11,487
Average Daily Bed Occupancy 55 42
Total Costs £10.4m £7.7m
Source: Closing time: counting the cost of alcohol-attributable hospital admissions
in London. London Health Observatory 2012

9. Liaison Psychiatry
• Mental health service to patients in a general medical hospital
– Inpatients, outpatients & attenders at the Emergency Department
– Much wider scope than crisis / A&E liaison work
• Complex medical conditions with psychiatric symptoms
• Co-occurring psychiatric and medical conditions
• Harmful drug or alcohol use & its complications
• Medically unexplained physical symptoms
• Distress due to medical conditions
• Suicide or self-harm
• Dementia, learning disability etc.
Psychological Medicine

10. National Guidance
“Every hospital should have a dedicated
in-house liaison psychiatry service”
“Healthcare professionals who care for people
in acute alcohol withdrawal should be skilled in
the assessment and monitoring of withdrawal
symptoms and signs”
Psychological Medicine

11. NCEPOD Report
“All patients presenting to acute services with a
history of potentially harmful drinking, should
be referred to alcohol support services”
“Each hospital should have a 7-day Alcohol
Specialist Nurse Service... to provide
comprehensive physical and mental
assessments, Brief Interventions and access to
services within 24 hours of admission”
“A multidisciplinary Alcohol Care Team, led by a consultant with
dedicated sessions, should be established in each acute hospital
and integrated across primary and secondary care.”
Psychological Medicine

12. NW London Liaison Psychiatry Pilot
Pilot Sites Team Composition
Psychological Medicine
• Consultant Psychiatrists
• Psychiatric Liaison Nurses
• Occupational Therapists
• Alcohol Nurse Specialists
• Clinical Psychologists
• Specialist Pharmacists
•CNWL
•WLMHT

13. Liaison Psychiatry & Alcohol Use Disorders
Medical Management
Diagnosis
Prescribing Advice
Management of acute withdrawal
Delirium Tremens / Wernicke’s
Abstinence aids
Attitudes, Clinical
Management, Nursing
Psychological Medicine
Medicolegal
Capacity Assessment
Mental Health Act
Discharge planning / placement
Detailed Assessment
Cognitive Testing
Functional / OT assessment
Psychiatric comorbidity
Psychosocial
Interventions
TRAINING:
Information and Brief Advice
Motivational Interviewing
Education
Relapse Prevention
Written Information
LIAISON:
•Primary care
•Secondary care
•Community
mental health
•Addiction services
•Social services
•Housing
•CAB
•Non-statutory
agencies
•Victim Support
24h SERVICE
7 DAYS A WEEK

14. Neuropsychiatric Complications of
Alcohol Dependence
• Withdrawal syndrome
• Seizures
• Delirium tremens
• Wernicke’s encephalopathy
• Cognitive impairment / Korsakoff’s
• Central Pontine Myelinolysis
• Depression/Anxiety/Hallucinosis
Psychological Medicine

15. 34 y.o. Male Manual Worker
• Drinking 1 btl vodka / day – stopped suddenly
• Unwell, agitated, wanting to leave
• Medicolegal advice given by Liaison Psychiatry
– Detained using Mental Capacity Act
• Advice on delirium tremens treatment given
– Full recovery
• Abstinence-Orientated Advice given
• Referred to community alcohol service
Psychological Medicine

16. 40 y.o. Male Shop Worker
• Admitted with 2 weeks’ vomiting
• Severe gastritis
• Drinking 2-4 cans beer / day
– No withdrawal symptoms
• Heavy whisky drinking for 1 month
• Disorientated, forgetful, staggering gait
• Wernicke’s identified by Liaison Psychiatry
• Treated with IV Thiamine, full recovery
Psychological Medicine

17. 37 y.o. Male
• Repeat ED attendances with alcohol
withdrawal seizures
– Hallucinating, disorientated, agitated
• Given high-dose chlordiazepoxide & thiamine
– Partial recovery – “for placement”
• Liaison Psychiatry OT assessed community
support network
– Safe discharge home & follow-up arranged
– Placement & DTOC avoided
Psychological Medicine

18. 67 y.o. Male Salesman
• Admitted for foot operation
• Drinking 250ml whisky / night – detox started
• No withdrawal symptoms observed/reported
• Referred to Liaison Psychiatry
– No need for detox – meds stopped
• Psychosocial intervention delivered
– Educated about effects of alcohol on health and
interaction with medicines
Psychological Medicine

19. Referral Criteria
• All patients admitted to a ward receiving
alcohol detoxification
• Patients with alcohol-related neuropsychiatric
complications
• Patients with medical/psychiatric conditions
related to other drug use
Psychological Medicine

20. Current Pathways
Harrow
Admission to ward
Alcohol dependence identified
Referral to Liaison Psychiatry
Acute management,
Comprehensive assessment
Information & Brief Advice,
Written information,
Abstinence aids
Referred on to Compass
Liaison
Psychological Medicine
Brent
Admission to ward
Alcohol dependence identified
Referral to Liaison Psychiatry
Acute management,
Comprehensive assessment
Information & Brief Advice,
Written information,
Abstinence aids
Referred to Cobbold
Road

21. Future Directions
• Staff expansion
• MI / IBA training for all
our staff
• Standardised
assessment and
intervention package
• Expand range of written
info
Psychological Medicine
• Review Trust guidelines
• Tighter integration with
Gastroenterology &
Acute Medicine
• Junior doctor training
• New admission &
transfer pathways
• Audit & implementation
of NICE guidance