Consultation-Liaison Psychiatry

Consultation-liaison (C-L) psychiatry is the study, practice, and teaching of the relation between medical and psychiatric disorders. In C-L psychiatry, psychiatrists serve as consultants to medical colleagues (either another psychiatrist or, more commonly, a nonpsychiatric physician) or to other mental health professionals (psychologist, social worker, or psychiatric nurse). In addition, C-L psychiatrists consult regarding patients in medical or surgical settings and provide follow-up psychiatric treatment as needed. C-L psychiatry is associated with all the diagnostic, therapeutic, research, and teaching services that psychiatrists perform in the general hospital and serves as a bridge between psychiatry and other specialties.

In the medical wards of the hospital, C-L psychiatrists must play many roles: skillful and brief interviewer, good psychiatrist and psychotherapist, teacher, and knowledgeable physician who understands the medical aspects of the case. The C-L is part of the medical team and makes a unique contribution to the patient’s total medical treatment.

DIAGNOSIS

Knowledge of psychiatric diagnosis is essential to C-L psychiatrists. Both dementia and delirium frequently complicate medical illness, especially among hospital patients. Delirium occurs in 15 to 30 percent of hospitalized patients. Psychoses and other mental disorders often complicate the treatment of medical illness, and deviant illness behavior, such as suicide, is a common problem in patients who are organically ill. C-L psychiatrists must be aware of the many medical illnesses that can have psychiatric symptoms. Lifetime prevalence of mental illness in chronically physically ill patients is more than 40 percent, particularly substance abuse and mood and anxiety disorders. Interviews and serial clinical observations are the C-L psychiatrist’s tools for diagnosis. The purposes of the diagnosis are to identify (1) mental disorders and psychological responses to physical illness, (2) patients’ personality features, and (3) patients’ characteristic coping techniques to recommend the most appropriate therapeutic intervention for patients’ needs.

TREATMENT

The C-L psychiatrists’ principal contribution to medical treatment is a comprehensive analysis of a patient’s response to illness, psychological and social resources, coping style, and psychiatric illness, if any. This assessment is the basis of the patient treatment plan. In discussing the plan, C-L psychiatrists provide their patient assessment to nonpsychiatric health professionals. Psychiatrists’ recommendations should be clear, concrete guidelines for action. A C-L psychiatrist may recommend a specific therapy, suggest areas for further medical inquiry, inform doctors and nurses of their roles in the patient’s psychosocial care, recommend a transfer to a psychiatric facility for long-term psychiatric treatment, or suggest or undertake brief psychotherapy with the patient on the medical ward.

The C-L psychiatrists must deal with a broad range of psychiatric disorders, the most common symptoms being anxiety, depression, and disorientation. Treatment problems account for 50 percent of the consultation requests made of psychiatrists.

Common Consultation-Liaison Problems

Suicide Attempt or Threat.

Suicide rates are higher in persons with medical illness than in those without medical or surgical problems. High-risk factors for suicide are being a man over 45 years of age, having no social support, having an alcohol dependence, having made a previous attempt, and having a incapacitating or catastrophic medical illness, especially if accompanied by severe pain. If suicide risk is present, the patient should be transferred to a psychiatric unit or started on 24-hour nursing care.

Depression.

As mentioned, suicidal risk must be assessed in every depressed patient. Depression without suicidal ideation is not uncommon in hospitalized patients, and treatment with antidepressant medication can be started if necessary. A careful assessment of drug-drug interactions must be made before prescribing, which should be undertaken in collaboration with the patient’s primary physician. Antidepressants should be used cautiously in cardiac patients because of conduction side effects and orthostatic hypotension.

Agitation.

Agitation is often related to the presence of a cognitive disorder or associated with withdrawal from drugs (e.g., opioids, alcohol, sedative-hypnotics). Antipsychotic medications (e.g., haloperidol [Haldol]) are very useful drugs for excessive agitation. Physical restraints should be used with great caution and only as a last resort. The patient should be examined for command hallucinations or paranoid ideation to which he or she is responding in an agitated manner. Toxic reactions to medications that cause agitation should always be ruled out.

Hallucinations.

The most common cause of hallucinations is delirium tremens, which usually begins 3 to 4 days after hospitalization. Patients in intensive care units who experience sensory isolation may respond with hallucinatory activity. Conditions such as brief psychotic disorder, schizophrenia, and cognitive disorders are associated with hallucinations, and they respond rapidly to antipsychotic medication. Formication, in which the patient believes that bugs are crawling over the skin, is often associated with cocainism.

Sleep Disorder.

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