Introduction
Consultation–Liaison Psychiatry is a centuries-old field of medical practice and research that bridges the biological, psychological, and social domains of psychiatric and medical illnesses. Since 2003, it has been recognized by the American Board of Medical Subspecialties as the psychiatric subspecialty Psychosomatic Medicine, based upon its historical nomenclature. The practice of Consultation Psychiatry usually occurs within general hospital settings. The standard consultation is performed at the request of the primary clinician, and is a neutral collaboration with colleagues and patients in nonpsychiatric settings. Interview techniques in consultations may be open-ended for an individual patient’s diagnostic evaluation or structured to screen for psychiatric disorders in a general population. Often a combination of both techniques is utilized. A central role of the consultation psychiatrist is to educate colleagues and patients about the psychiatric presentations or complications of medical illness and about illness behavior. Liaison Psychiatry expands the role of the psychiatrist to facilitate comprehensive treatment approaches within a system of care and to enhance communication among disciplines and across divisions in health care systems. The liaison psychiatrist is often a member of a multidisciplinary care team, performing psychiatric screenings, for example in organ transplant surgery or oncology, when the risks of psychiatric comorbidity are expected to be higher.
In the United States, the historical roots of psychiatry in the general hospital are found in the 1751 charter of the Pennsylvania Hospital, which provided for the care of “persons distempered in mind and deprived of rational faculties.” At that time, outpatient psychiatric clinics both in the Philadelphia Hospital and New York’s Bellevue Hospital were developed. Reports from these early centers contain themes emphasizing the significant rates of psychiatric disorders in medically ill patients, and the need to integrate services.
In the modern era, the scientific approach to the relationship between psychiatric disorders and medical illness began with early studies in psychosomatic medicine which examined the relationship between psychological and medical disorders. Psychosomatic medicine as an area of research began with psychoanalytic studies of the mind–body relationship. Beginning in 1900, Sigmund Freud, as a young neurologist, described conversion hysteria as psychological symptoms imbued with deep psychic meaning, which manifested as or converted to somatic (physical) illness. In 1910, Sandor Ferenczi related conversion symptoms to the autonomic nervous system. In 1934, Franz Alexander proposed that ‘psychosomatic symptoms’ were due to prolonged autonomic system arousal linked to repressed psychic conflict. Psychosomatic medicine advanced in the 1940s and 1950s with psychophysiological studies such as those by Hans Selye who described the human stress response in relation to adrenocortical hormones. Sociocultural researchers Thomas Holmes and Richard Rahe in 1975 linked disease likelihood to the severity and number of stressful life events, and further expanded the psychosomatic medicine framework. Zbigniew Lipowski in 1970 and George Engel in 1977 utilized systems theory to examine environmental influences on the mind–body–culture paradigm. All these works have shaped the biopsychosocial perspective of psychosomatic medicine extant today.
Concurrent with the development of psychosomatic medicine theories, psychiatrists returned to the general hospital they had left during the late 19th century asylum movement. No longer isolated in psychiatric sanatoria or cloistered in consulting rooms, psychiatrists had begun to treat patients in general hospitals. In 1929, George Henry advocated the benefits of general hospital psychiatry that offered consultative services, and was instrumental in the advancement of consultation practices. In addition to the emphasis he placed on the diagnosis and treatment of psychiatric disorders seen in the medically ill, such as delirium, dementia, depression, and anxiety, he recognized that medical students and residents were more likely to utilize psychiatry for patients in medical settings rather than in isolated psychiatric facilities. Psychiatric consultation services developed further with support from the Rockefeller Foundation and grew with funding from the Psychiatry Education Branch of the National Institutes of Mental Health. By the end of the 20th century, there was a significant cadre of trained consultation–liaison psychiatrists working within hospital settings and medical schools.
In May 2003, the American Board of Medical Subspecialties recognized the practice of consultation and liaison psychiatry in the general hospital as a discrete psychiatric subspecialty that requires advanced training and qualification by an examination conducted by the American Board of Psychiatry and Neurology. In recognition of its earliest scientific bases, the subspecialty was named Psychosomatic Medicine by the American Board of Medical Subspecialties to distinguish it from other consult practices in medical subspecialties. In June 2005, the American Board of Psychiatry and Neurology administered the first examination to certify subspecialists in Psychosomatic Medicine. Psychiatric fellowship training programs in Psychosomatic Medicine qualify physicians in the skills and techniques of consultation–liaison psychiatry within the domain of psychosomatic medicine and related research.
How does the work of a psychiatrist in a nonpsychiatric setting improve patient care? Numerous studies in the past decade have demonstrated that psychiatric consultation contributes to reduced costs in health care delivery, and improves access to mental health care. Most importantly, psychiatric consultation improves the detection of psychiatric illnesses, many of which are life threatening. It is well known that, left undetected and untreated, psychiatric comorbidity increases hospital lengths of stay (and concomitant costs), even when demographics, medical diagnosis, and reasons for admission are taken into account.
Many studies have shown that patient outcome is markedly affected as a consequence of under-recognized or misdiagnosed psychiatric illness in nonpsychiatric settings. In primary care, where most patients with psychiatric illness present, the vast majority of patients do not receive treatment for psychiatric illness. Many factors collude in the limitation of care: Psychiatric symptoms are difficult to distinguish from medical symptoms; patients fear stigma and minimize complaints; time constraints, or inadequate training or the primary physicians’ reluctance to stigmatize the patient may impede them from treating psychiatric symptoms.
Studies clearly demonstrate that psychiatric consultation in the hospital lowers morbidity, mortality, length of stay and cost through the earlier recognition and treatment of psychiatric disorders, and has an impact on quality of life measures of self-care. These findings mandate psychiatric education of colleagues, case-finding through psychiatric screening, and expansion of services by the consultation–liaison psychiatrist.
Psychosomatic medicine was first popularized when psychoanalytic theories of mind–body relationships suggested that psychotherapy could modify the course of medical disease. Although speculative, such theories posited that early life experiences (fostering unconscious conflicts) coupled with genetic (biological) vulnerability could cause disease states such as peptic ulcer or asthma. Although many of these ideas were erroneous, there is significant data in both animal and human research to demonstrate an effect of early life experiences on physiology and illness behavior.
Modern psychosomatic research has abandoned much of these early theories, but continues to investigate the role of psychosocial variables in causing or maintaining disease states. It utilizes a variety of empirically based strategies; as an example, structured psychiatric interviews and reliable psychometric inventories are paired with biologic probes and immunologic measures to answer complex questions about the interrelationship between psychosocial and biologic variables.
An example of current research is the study of the biopsychosocial relationship between depression and cardiovascular disease. Landmark research in psychosomatic medicine beginning in the 1980s has revealed that individuals with major depressive disorders have significantly increased mortality risk following uncomplicated myocardial infarction (MI). The depressive episode often predates the acute coronary syndrome and is not a mere “reaction” to the cardiac event. Hostility and anger have been implicated in acute coronary syndromes. Biological factors that play a role in the genesis of coronary artery disease in depressed individuals include reduced heart rate variability, platelet dysfunction, and elevated cytokines. A shared genetic vulnerability for depressive disorders and cardiovascular disease underpins these truly psychosomatic relationships. The advent of sophisticated genetics and molecular biology holds the promise that such relationships will be further elucidated.
This chapter will consider the techniques, settings and core concepts of Consultation–Liaison Psychiatry and Psychosomatic Medicine. At present, the general practice of the consultation–liaison psychiatrist includes the recognition and management of the following: (1) the impact of psychiatric disorders on medical illness, (2) comorbid psychiatric and medical disorders, (3) the etiologic role of medical illness in psychiatric disorders, (4) suicidal, homicidal, and violent behavior in medical-surgical settings, (5) legal and ethical principles in the psychiatric care of the medically ill, (6) pharmacological and therapeutic intervention in comorbid illnesses, (7) behavioral responses to medical illness, and (8) the physician–patient relationship.
The chapter will condense Consultation–Liaison Psychiatry and Psychosomatic Medicine into two sections: Clinical Consultations and Core Concepts in Psychosomatic Medicine. The first section on Clinical Consultations presents the standard skills and techniques utilized by practitioners in a general hospital, organized as follows: consultation–liaison psychiatry basics; diagnostic evaluation skills; screening techniques to identify psychiatric patients in general populations; consultation treatment; legal issues; emergency assessments; and finally, liaison psychiatry. The second section on Core Concepts in Psychosomatic Medicine presents the general conditions that the consultant is likely to encounter. These Core Concepts of diagnosis are based upon the framework proposed by Lipowski in 1967:
Psychiatric Disorders Caused by Medical Conditions
Psychiatric Disorders Affecting Medical Conditions
Psychological Reactions to Medical Illness
Somatic Presentations of Psychiatric Disorders
For detailed discussions of specific psychiatric diagnoses and treatments, the reader will be directed to relevant chapters in the book. A concluding section suggests future directions for clinical practice and research in the field of psychosomatic medicine.
Clinical Consultations
The psychiatric consultant should serve as an ally to patient care provided by the physician (or primary team), the associated health care disciplines, and the system of care. In this alliance, adaptability and diplomacy enhance the care provided by the psychiatric consultant.
Adaptability is necessitated by the challenge of working in a general hospital. The modern hospital is a busy and crowded environment that usually limits privacy and is often unfamiliar to both patients and mental health professionals. Many hospital floors do not have interview rooms. Medical treatment rooms are often not conducive to psychiatric interviewing. Evaluations may have to be performed in hospital rooms occupied by other patients. Thus, the consultant must be both practical and flexible. Speaking in a soft voice to allow confidentiality is sometimes the only option. Patients may be critically ill and attached to devices such as intravenous lines, catheters, and respirators. If a patient cannot speak due to a tracheotomy or attachment to a ventilator, a signing board or pad and pen may be necessary. The interview may be interrupted by medical or nursing staff, or by transport personnel for ad hoc procedures. Patients may be obtunded or unable to give a comprehensive history; use of other sources of information is often necessary but raises concern about the right to privacy. Such issues challenge the consultant but also establish the psychiatrist as a physician with unique skills necessary in modern healthcare teams.
Diplomacy in consultation is rarely discussed but inherently useful in practice. It is based upon the following qualities: awareness of the hierarchical and multidisciplinary nature of health care systems; respect for the roles and tasks a provider within a system assumes or is required to perform; regard for the boundaries or limitations of care, whether internal or external to the provider or system, affecting the patient’s experience (e.g., economics determining hospital length of stay); and a collaborative or altruistic spirit that bolsters the care by the primary team through education and altered practice patterns. Examples of these qualities are the implementation of psychiatric care for organ transplantation patients and development of psychiatric screening in primary care settings. Consultation psychiatrists are ambassadors for the profession of psychiatry in large health care settings where communication between specialists can be limited.
Consultations requests may have many origins and serve varied needs for the patient, team and system of care. Requests can be made by the patients, primary providers, multidisciplinary teams, and by the family members. Requests can arise when a physician ponders the clinical status of the patient in regard to mood or affect (e.g., depressed after surgery), cognition (e.g., ability to make medical decisions), or behavior (e.g., agitated or threatening). Requests may seek assistance anywhere along the continuum of diagnosis, evaluation, treatment and management. They may focus on a particular aspect of care, such as suicide risk assessment, or be more general in scope, such as the evaluation of a patient’s reaction to medical illness.
Contacting the referring provider is important to understand the broader nature of the consultation request. The personal history of a psychiatric disorder may prompt a request for evaluation, although the consultant often is the first psychiatrist to evaluate the patient, even when the patient has a prior history of psychiatric symptoms. Some requests are urgent (e.g., “wants to leave against medical advice”) in which case contacting the referring clinician can provide important information to expedite the consultation. Often, a simple request such as asking for help in treating depression is really “the tip of the iceberg” heralding broader psychosocial difficulties within the patient and social system. Contacting the referring provider is the best way to elicit the “real story” behind the consultation request.
Collection of behavioral data from primary sources (nurses, medical students) is the next step. Prior to seeing the patient, consultants discuss the patient’s status with nursing personnel who know the patient and are able to share observations regarding the patient’s clinical status and interaction with family members. Nurses’ notes are a trove of information about patient behavior (e.g., “lost returning from the bathroom”) that can guide the review. Medical students also can offer keen observations of patient behavior.
Review of medical records can be approached in the manner of detective work. A discerning review of medical notes provides clues to the patient’s behavior, cognitive status, and physical function. Admission summaries and off-service summaries are concise records from which to obtain a time-line for the hospital course. Pertinent laboratory results and medication records reveal underlying medical conditions or areas that need further investigation. If the consultant is not clear about a medical illness, a review of the condition from available medical texts is done.
The review of medical records should search for medication that acts on the central nervous system (CNS), whether intended or as a side effect, and look for possible drug interactions (e.g., through cytochrome isoenzyme substrates and inducers). Substance-induced psychiatric disorders are common, not only for substances of abuse but also for prescribed medications (e.g., steroid-induced psychosis). In addition, a sedating (e.g., benzodiazepine) or activating (e.g., beta-agonist inhaler) medication administered prior to the evaluation can affect the assessment.
Review of pertinent laboratory investigations is informative. Metabolic derangements and end-organ disease can affect cognitive status. Awareness of the physiological status can focus the consultation examination and aid in the differential diagnosis. Radiological studies can hone the assessment.
Consent to interview the patient is obtained ideally by the primary team, prior to the consultant’s interview, and this can be verified with the patient. The consultant should obtain permission from the patient to conduct the interview and to communicate findings with the treatment team. The consultant should adopt a neutral stance in order to increase patient participation. This way, the consultant is obtaining consent neither as a member of the medical team nor as a patient advocate. Patients with a prior psychiatric history may anticipate that individual psychiatric treatment is confidential; thus they should be alerted to the consultant’s role, particularly the need to confer with the primary team on the patient’s behalf.
Diagnostic interviews aim to gather sufficient information to develop an answer to the consultation request. Following the preliminary actions described, the consultant introduces himself or herself as a psychiatric physician. Firstly, ascertain whether the patient has been told that a psychiatric consultation has been requested. If the patient has not been informed, elicit his or her feelings about it and request permission to conduct the interview. Secondly, it is important that the patient be given privacy to speak openly to the psychiatrist. For this reason, it is better if a visitor or family member is excused from the interview. Even when assurances are offered by the patient to allow their involvement, privacy can be presented as a matter of policy for the initial interview. Patients are often in a vulnerable position and unable to ask openly for privacy; the psychiatrist should assume responsibility.
The approach to the interview must be guided by immediate safety concerns in emergent evaluations; this may require restricting the interview to a focus on acute intervention and behavioral management, as is discussed in more detail in II. F. Emergency Consultations (see also Chapter 48). Often, a consultation is requested to assess the patient’s level of anxiety or depression. The underlying task may be to assess how the patient is adjusting to an illness. A range of inquiries can provide an understanding of the patient’s capacity to cope:
- When and how was the disease diagnosed?
- Were there delays in coming to treatment? Was there patient denial? Were there limitations to access?
- How has the patient reacted to the treatment, medical or surgical, and to the primary team?
- Have any medications been particularly difficult to take? Have any helped?
- What knowledge does the patient have of others with similar disorders?
- What has been the psychosocial and financial burden of the disease?
- Has the illness forced changes in family roles and responsibilities? Is there a confidante?
- Is there a support system? Is there neighborhood/religious/cultural/community support?
- Does the patient have an accurate understanding of the prognosis? How does it affect the reaction to the illness?
- Are there end-of-life issues that the patient is unable fully to address? Do supports know about the situation?
Some consultations focus on cognitive capacity and whether an individual has dementia or delirium. This mandates careful attention to the nursing notes and understanding the effects of the underlying disease process or medication upon the CNS. A careful assessment of mental status is required for all patients, allowing for detection of psychopathological phenomena, affective symptoms, and cognitive integrity. Many patients fluctuate in their ability to attend; serial examinations can provide a more accurate assessment. Some patients are fearful that they will be judged “crazy” if they are experiencing hallucinations (e.g., due to medications such as opioids). Active inquiry about whether the patient has been confused or uncertain about their situation allows them to reveal their cognitive problems. Formal testing for cognitive status via the Folstein Mini-Mental Status Examination (MMSE) provides a baseline cognitive assessment for the initial evaluation; the score is easily recognized by other specialists, and can be followed serially.
General review of symptoms from the domains of mood, anxiety, psychosis and substance use should be elicited. Even when they are not the focus of the consultation request, they may inform differential diagnosis and treatment plans. A detailed discussion of the principles of interviewing is discussed elsewhere (see Chapter 4). Frequently, in medically ill patients, symptoms of prior concern to the patient are not reported to the primary team for a variety of reasons, whether omitted by the patient or missed by the team. The psychiatric consultant offers the patient a new opportunity to be heard, and can serve also as a medical translator. If possible, the patient should give verbal consent during the interview to contact other sources of information.
Collateral information is important in situations in which the patient is unable to communicate accurately (e.g., altered consciousness, unreliable historian, cognitive impairments). The sources include spouse, family members, friends, case managers, or outpatient providers. The consultant must protect the patient’s privacy; ideally patients can give consent to speak with others, but this is not always possible if the patient is impaired. In emergency situations, collateral information obtained from other sources can be vital, even if the consultant cannot provide information in return. Communication with family members can be essential. Reports from family members may differ from that of the patient and highlight problems. It is common to see elderly patients who consider that they can return to independent living arrangements while family members report numerous reasons to the contrary. Some patients deny substance abuse while family members contradict them. It is also useful to ascertain the patient’s past adherence to treatment.
Consultation reports should summarize the data collected in a clear and legible manner; electronic charting is ideal for cogent communication. If consultations are dictated, put a brief note in the medical record immediately following the consultation with diagnostic or treatment suggestions that can be considered immediately. If time permits, a concise yet thorough summary of findings, expressed in an organized, standard format is indicated (see Fig. 49–1). Differential diagnoses, diagnostic workup, symptomatic treatment and, in most cases, cognitive capacity are documented. When the consultant seeks to narrow the differential diagnosis, it should be communicated to the treatment team that further investigations such as neuroimaging or specialized laboratory investigations are required (see Fig. 49–2).
Recommendations include further testing and medication advice. When psychopharmacologic recommendations are included it is essential to outline side effects that may occur, since the referring provider or treatment team may not be aware of them. The medically ill patient is particularly sensitive to drug side effects, and may tolerate only a reduced dose. Over-sedation may lead to aspiration while eating, and drug–drug interactions can cause toxic side effects. The consultant should warn about possible problems in the consultation report and in person with the consulting provider. Working with nurses and allied health professionals to ascertain the behavioral effects of medications is within the scope of consultation practice. Recommendations to assist with psychiatric disposition and capacity to live independently may rely on collaboration with social work services and liaison with outpatient mental health providers. Recommendations regarding cognitive status may include referral to or liaison with social workers or legal counsel, in accordance with hospital policies and local statutes. Consultation psychiatrists should be informed about the policies and laws that protect patient rights in every setting (see Chapter 50).
Discussions about end-of-life issues commonly arise in the medical setting, often when discussing the patient’s coping strategies. Hospitalization itself can evoke fear in a seriously ill patient who is unprepared for death. Others may seek relief from suffering and express a passive wish to die interpreted by staff as suicidality, prompting a psychiatric consultation request. Family histories may reveal an early demise from a condition similar to that of the patient, causing the patient to be concerned about the current situation. This psychological connection may not be readily identified by the patient but expressed behaviorally, for example by a refusal of procedures reminiscent of the deceased’s medical course. A review of the patient’s expectations for the future should be included in the initial diagnostic interview, although rapport should be developed sufficiently for the patient to explore his or her own mortality; premature introduction of a discussion of death may be unnecessarily alarming and better deferred to a follow-up session.
Follow-up of the patient is provided in collaboration with the treatment team, and the frequency of contact determined by the patient’s clinical status. For example, a patient experiencing delirium while the team conducts a search for the underlying causes may require daily mental status examinations by the psychiatric consultant to monitor progress. Alternatively, a patient unable to make decisions regarding a procedure may require little or no follow-up once a surrogate decision-maker has been identified. Follow-up after the initial consultation may allow the consulting psychiatrist to determine whether there should be changes in the initial recommendations. Each contact should be documented.
In comprehensive medical and surgical care, often in outpatient settings, screening for comorbid psychiatric disorders can be time-efficient and cost-effective. Screening tests help nonpsychiatrists to uncover a symptom profile that heralds the need for evaluation by a psychiatrist. Screening tests are not a substitute for a psychiatric interview, but serve as a technique for early detection.
Endorsement of psychiatric symptoms may be elicited by self-administered patient questionnaires or by clinician-administered, structured interviews. Although myriad questionnaires are available, the self-administered questionnaire that is well standardized to detect depression, anxiety, and alcohol use in the primary care setting is the PRIME-MD Patient Health Questionnaire (PHQ). The PHQ-9 screens for depression and is available through its initial publication. The PHQ-2 is an abbreviated, standardized subset of the PHQ-9 that screens for depression in a general population, with high sensitivity (0.83) and specificity (0.92). The PHQ-2 is often added to a battery of health care questions completed in the outpatient waiting room. The Folstein Mini-mental State Examination (MMSE), a structured, clinician-administered screen for dementia, is available through its initial publication. The MMSE is used in screening for cognitive disorders such as delirium, but is standardized only for dementia. The Mini-Cog is an abbreviated, standardized test that utilizes the 3-object recall item of the MMSE combined with the Clock Drawing Test; it has comparable sensitivity and specificity to the MMSE but taps additional regions in the brain. The CAGE questionnaire, a simple screen for detecting alcohol use is utilized by psychiatric and nonpsychiatric clinicians, and can prompt referral to substance treatment programs (see Chapter 15).
If the patient requires further evaluation after a positive screening questionnaire, referral to the psychiatric consultant is the next step. Patients reluctant to seek care in a psychiatric clinic may agree to evaluation by the consulting psychiatrist who, as a member of the primary care team, avoids the stigma of psychiatric referral. Consultation psychiatrists assist primary physicians who manage general psychiatric disorders directly and reserve referrals to psychiatric care for patients who are acutely ill or require a complicated medication regimen. There are good reasons for these strategies. Even though medical conditions, especially chronic conditions, increase the likelihood of a psychiatric condition, a minority of patients with a psychiatric disorder will be evaluated by mental health specialists. Moreover, half of all visits to physicians by patients with diagnosable psychiatric disorders occur in primary care clinics, and primary care physicians write most of the prescriptions for antidepressants and anxiolytics.
Psychiatric care provided in the medical setting in situ
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