International cooperation to improve the psychiatric care of the general hospital patient: The ECLW collaborative study

The series of articles by the ECLW Collaborative Study in this issue represents a remarkable milestone for Consultation-Liaison (C L) psychiatry world-wide. The ECLW study sets the standard for cooperativity and inter-rater reliability among C-L practitioners and researchers. At a time when forces of disunion seem to be outweighing forces of union, 226 psychiatrists, psychosomatists, and psychologists from 56 C L services in 11 European natiohs met and established a working group. Among ECLW accomplishments are: (1) developing an operationally defined data collection instrument--the Patient Registration Form--that built upon a well established C-L database by Drs Jeffrey Hammer and James J. Strain, and that was adapted to the needs of multiple nations; (2) demonstrating that inter-rater diagnostic reliability using ICD-10 may be achieved, even cross nationally, by the use of training manuals, clinical case vignettes, and reliability testing; (3) describing the effectiveness of mental health service delivery in the medical/surgical inpatient; and, (4) highlighting national similarities and differences in the organization and practice of general hospital psychiatry in Europe. However, several problematic study design features must be acknowledged: (1) the consultants and nations were self selected and therefore may not be representative of the practice of C-L psychiatry within the specific countries, or of Europe; (2) the training period began prior to the full introduction of ICD-10, and was limited to a small number of case vignettes; (3) the unavoidable referral bias inherent in examining only inpatients referred to a psychiatrist limits the utility of the findings; and (4) differences in patient characteristics, national C-L service structure and financing, and national diagnostic traditions combine to confound interpretation of the findings. In fact, the drive toward achieving inter-rater reliability across nations may potentially "throw the baby out with the bath water" since differences between raters or nations on the clinical vignettes may reveal important conceptual and practice variability among C-L services. Future studies by the ECLW should also include additional rating or diagnostic scales to further enhance the validity of the study findings. With these caveats in mind, it is notable that the World Health Organization has requested access to the training and test cases used in the ECLW