Why refer to a psychiatrist?

practice is now firmly established. Numerous studies have demonstrated the high prevalence of psychiatric disorder among general hospital patients, which is up to twice that of the population at large. Furthermore, psychological problems that may not amount to a specific psychiatric disorder have an important bearing on the presentation and course of many medical conditions. These problems include non-adherence to treatment, abnormal eating habits, lack of capacity to consent to treatment, and denial or exaggeration of symptoms. Few physicians now doubt that much of their clinical time is spent dealing with the emotional problems which complicate their patients’ illnesses and symptoms. They also have to manage the medical consequences of deliberate self-harm and substance misuse, provide preliminary psychological interventions and arrange for more specialised treatment where appropriate. Many of these problems are successfully managed by physicians and their teams without the help of psychiatrists or any other mental health professionals. It is highly appropriate that this should continue. Nevertheless, we know that much psychiatric morbidity among medical patients goes unrecognised and therefore untreated. It is evident that physicians continue to experience difficulties in diagnosing their patients’ psychological problems, initiating treatment and knowing when to refer for expert psychiatric or psychological assessment. To help overcome these difficulties, the Royal College of Physicians and the Royal College of Psychiatrists convened a joint working party to prepare a practical guide for physicians and other healthcare professionals.1 This report, which updates and complements a previous report on the same theme,2 addresses the particular psychological problems likely to be experienced by patients attending general hospitals, either in secondary or tertiary care. It also makes the clearest possible case for ensuring that the psychological care of medical patients is given higher priority than hitherto within the service agreements between general hospital trusts and their commissioners. Its recommendations are shown in Table 1. n EDITORIALS