Overview of practice of Consultation-Liaison Psychiatry

INTRODUCTION

The first revolution in psychiatry is generally acknowledged to be the unchaining and moral treatment offered to mental patients. The second revolution was heralded by the invention of electroconvulsive therapy. It was the first effective and easily feasible treatment option for a variety of mental illnesses. Another leap for psychiatry was the introduction of psychotropic agents, chlorpromazine to be particular in the year 1952 and the later discovery of a series of antidepressants, antianxiety, antipsychotic, and other neuroleptic drugs. It changed the face of psychiatry forever and allowed domiciliary treatment. This is generally regarded the third revolution of psychiatry and combined with the treatment of the mentally ill outside the four walls of the mental hospital has revolutionized the outcome of mental illnesses.

Addressing comorbidities of mental illnesses with chronic physical illnesses will be the fourth revolution in psychiatry. Mind and body are inseparable; there is a bidirectional relationship between psyche and soma, each influencing the other. Psychological factors must be taken into account when considering all disease states. Physical diseases have a large overlap with mental disorders. All physical illnesses and their management cause a psychological reaction. This may or may not reach morbid levels; similarly, mental illnesses and stress predispose to a large variety of physical illnesses. A bidirectional relationship has been established and the evidence grows by the day. Plausible biochemical explanations are appearing at an astonishing rate. We are all aware of the neurochemical response, immune response, and endocrine response to stress.

Almost 1/5^th of the global burden of disease is attributed to neuropsychiatric disorders. Most significantly, common mental disorders such as anxiety, mood disorders, and substance use disorders contribute to overall mental health burden. Most of the patients with these common and mild forms of disease are seen by nonmental health professionals (MHPs), especially medical settings. Moreover, these disorders often go undiagnosed and poorly treated and only a small proportion is actually presenting to psychiatrist. Higher percentage of mental disorders coexists with physical disorders, necessitating the need of linkage between medical and mental health-care system.

Consultation-liaison (CL) psychiatry (CLP) has the potential to help reduce the burden of mental problems in both developed and developing countries from a public health standpoint.

An increased involvement of CL psychiatrists in the development of primary care services is an important step forward.

DEFINITION

The area of clinical psychiatry that covers clinical, teaching, and research activities of psychiatrists and allied MHPs in the nonpsychiatric divisions of a general hospital.

The designation “Consultation-Liaison suggests two interrelated functions of the consultants as proposed by Lipowski. Expert opinion regarding diagnosis and management of patient’s mental and behavioral disorders at the request made by other health professional is considered as consultation. Whereas, the term “Liaison” indicates connecting and linking the groups to serve the objective of effective collaboration. In CL psychiatry, a consultant psychiatrist ensures active liaison among patients, caregivers, and other health professionals of the treating team.

An effective model of collaborative care with primary care physician can be established by CL psychiatrist. The active component of such care includes effective screening, training and sensitization of staff, and regular supervision by a psychiatrist.

There is a growing need for CL psychiatry to become integral and larger part of patient management across all medical settings, which require more commitment and time from the respective departments.

Presently, most of the CL services are restricted to the wards only and their extension to outdoor services would have an added benefit of carrying over the established therapeutic alliance for future consultation.

The role of CL psychiatry in tertiary care institute should also involve developing cost-effective treatment models and specific nonpharmacological intervention, thus making patients more adjustable to medical disorders and their treatment compliance in long term.

There are situations when the patients referred in CL psychiatry may not fulfill diagnostic criteria for particular mental disorder, yet they may need support for their psychological issues. It is equally important that CL psychiatry must follow the principles of evidence-based medicine.

Much emphasis needs to be given to improve CL psychiatry services and training in India. Escalation of research and training in CL psychiatry as well as involvement of other MHPs in the process of CL psychiatry may help in this regard. The focus of research should also include assessment of cost-effective models in CL psychiatry to help policy makers understand the benefits of CL service and its implementation.[9]

The CL psychiatry as an evolving branch has tremendous scope in dealing with global mental health challenges. Expansion in primary care services and improvement in the existing CL services can be achieved by the initiatives of the consultant psychiatrist who may also guide the new-generation psychiatrist by training and teaching and encouraging them to participate in research to develop cost-effective modules of CL psychiatry.

HISTORY OF CONSULTATION-LIAISON PSYCHIATRY

CL psychiatry can be considered a landmark developmental milestone that has remarkably changed the face of psychiatry practice. With an increasing number of general hospital psychiatric units (GHPUs), mental health issues have been brought much closer to general health care and community. This has resulted in greater acceptance of psychiatric practices in other medical and surgical specialties and ample of opportunities for training and management of physically ill patients with psychiatric comorbidities.

Some of the landmark developments in the history of CL psychiatry are mentioned in Table 1.

Table 1.

History of consultation-liaison psychiatry

Year	Landmark developments
1818	Johann Heinroth
	Coined term “psychosomatic”
1922	Felix Deutsch
	Proposed the concept of “psychosomatic medicine”
Late 1800s	Jackson Putnam
	Considered being the first consultation psychiatrist
1902	JM Mosher
	Established the first general hospital psychiatric unit in Albany Hospital
1929	Henry’s
	Landmark paper on “Some Modern Aspects of Psychiatry in General Hospital Practice”
1934	Rockefeller Foundation
	Funded for establishment of five psychiatric liaison units in university hospitals
2003	C-L Psychiatry was approved for subspecialty status in psychiatry under the term “Psychosomatic Medicine”

CL – Consultation-liaison

Mental health services in India were restricted to mental hospital setups until 1930, when the first GHPUs was established by Dr. Girindra Shekhar of R. G. Kar Medical College and Hospital in Calcutta in 1933 to introduce CL psychiatry as a subspecialty. A rapid escalation in the number of GHPUs took place in the late 1960s and early 1970s. Since then, the concept and popularity of GHPU has gained momentum and presently, most of the postgraduate psychiatry studies take place in general hospitals; however, the focus on CL psychiatry has not been emphasized much despite this fact. The need of the hour is that CL psychiatry should be given a subspecialty status. There are different models of consultation liaison psychiatry that are in practice across the globe [Table 2].

Table 2.

Models of consultation-liaison psychiatry

Based upon	Approach
Focus of consultation, function and focus of work	Patient oriented
	Crisis oriented
	Consultee-oriented
	Situation oriented
	Expanded psychiatric consultation
Function	Consultation model
	Liaison model
	Bridge model
	Hybrid model
	Autonomous psychiatric model
Focus of work	Critical care model
	Biological model
	Milieu model
	Integral model

NEED FOR CONSULTATION-LIAISON PSYCHIATRY

Mind and body have a close link, and a bi-directional association is presumed to exist between psyche and soma, influencing each other. Physical and mental disorders have a lot in common and psychological factors need to be considered in all disease states. The psychological response of these physical disorders and their management may not reach a morbid level.

Remarkably, emerging evidences suggest biological explanations. Neurochemical, immunological, and endocrine responses to stress are well known. The following points highlight the need of CL psychiatry.

1. Approximately 20% to 46% patients with physical disorders admitted to medical or surgical wards have at least one diagnosable psychological comorbidity. Furthermore, this group has a substantially higher prevalence of psychiatric disorders than that of the general population

2. Even subclinical or subthreshold symptoms of a concomitant psychiatric disorder have been linked to unfavorable health outcomes in hospitalized patients, such as longer lengths of stay and excessive use of health-care resources

3. By focusing on comorbid psychiatric symptoms or illnesses, CL psychiatry treatments improve overall health outcomes

4. In patients with comorbid physical and mental disorders, earlier referral to CL psychiatry is linked to a shorter length of stay

5. The engagement of CL psychiatry in providing care for patients with medical and psychiatric comorbidity has been linked to a lower rate of readmission after discharge from the hospital over the next few days to months

6. Early recognition and management of subclinical psychological distress that does not rise to the level of a psychiatric disease has been shown to improve the course and outcome of medically ill patients while also lowering health-care expenditures

7. Interventions provided by the CL psychiatry team have also been linked to enhanced quality of life and other qualitative metrics such as subjective experiences for both patients and carers during and after their hospital stay

8. Imparting teaching and training to other health professionals regarding the associated psychological component in CL psychiatry may enhance their acquaintance with the concept and better and cost-effective treatment outcome.

   • Patient-oriented approach – The consultant’s primary interest is in the patient, his personality and reaction to sickness. It also involves overall assessment of the patient
   • Crisis-oriented approach – Patient’s problem and coping methods are quickly assessed and instant remedial interventions are provided to address the problem
   • Consultee-oriented approach – The focus of this approach is to address the purpose of consultee and his/her related concern and expectations
   • Situation-oriented approach – This approach involves interpersonal interactions of all the members of the clinical team as an objective to understand the patient’s behavior and the consultee’s concern about it
   • Expanded psychiatric consultation model – This approach involves a group of the patient, the clinical staff, other patients, and the patient’s family while keeping the patient at the priority
   • Consultation model – Patient is the center of focus
   • Liaison model – The consulting physician is the focal point of the liaison model, which includes teaching the physician and the clinical team about the psychological and behavioral components of the patient’s problem in addition to providing advice for the patient
   • Bridge model – CL psychiatrist plays a teaching role for the primary care physicians
   • Hybrid model involves psychiatrist as part of multidisciplinary team
   • Autonomous psychiatric model – The CL psychiatrist is not affiliated to any department but is hired by primary care services
   • Critical care model – In this model, critical care units (ICU and CCU) have CL psychiatrist attached with it who is expected to be involved in patient care and addressing the issues of staff
   • Biological model – Focus is on neuroscience, psychopharmacology, and psychological management
   • The Milieu model is founded on interpersonal theory and incorporates group components of patient care, staff reaction and interaction, and understanding of ward environment
   • Integral model is usually based on an agency, and it entails delivering psychological care as a necessary component of clinical and administrative needs.

REACTIVE VERSUS PROACTIVE CONSULTATION LIAISON PSYCHIATRY

Reactive CLP refers to the practice of CLP where patient is seen by an MHP only after the referral is made from the primary treating team from other specialty. Whereas proactive CLP involves participation of MHP as an active component of behavioral intervention team (BIT), which is a proactive multidisciplinary psychiatric consultation service associated with the medical/surgical unit. Proactive model has the advantage of identifying and reducing risk factors interfering with effective care before the problems get entirely manifest. BIT works closely in association with the medical team. It helps through formal and informal consultation, management of behavioral problems, education and training of medical staff, and prompt and direct care of complex patients with behavioral problems. BIT also helps in identifying and facilitating transition to proper outpatient or inpatient psychiatric unit. Proactive CLP has several benefits as follows:

• Easy access to mental health service

• Reducing length of stay in hospital

• Early detection and treatment

• Education and training of peers regarding management of behavioral problems

• Developing better relationship with other specialties. Table 3 approach towards promotion of consultation liaison.

Table 3.

Approach towards promotion of consultation-liaison

Strengthening and focus on psychiatry as specialty in undergraduate

During postgraduation adequate emphasis must also be given on CL psychiatry and trainee must be exposed to different aspects of CL psychiatry

Ensuring effective collaboration with other specialties in terms of knowledge exchange and proper referral disposal

Expanding the horizon of mental health by discussing different mental health issues at different platforms and not merely restricted to psychiatric illnesses

Research in CL psychiatry can provide additional support to vouch for its effectiveness in policy makings

CL – Consultation-liaison

CATEGORIES OF PATIENTS IN CONSULTATION-LIAISON PSYCHIATRY

According to the European Association of CL Psychiatry and the Academy of Psychosomatic Medicine’s consensus guidelines, the majority of patients encountered in CL psychiatry practice fall into one of the six groups listed below:

1. Individuals with comorbid physical (medical) and psychiatric disorders where the management of each disorder complicates the management of the other. Person with comorbid physical and mental disorders where management of one disorder may complicate the treatment of other

2. Patients presenting with medically unexplained symptoms presenting in the clinical services. Patients presenting in clinical service with medically unexplained symptoms

3. Mental and behavioral disorders attributed to general medical conditions or their management

4. Patients with psychiatric disorders presenting to medical setting for diagnostic or therapeutic procedures

5. Person presenting with suicidal or self-harming behavior in emergency or medical unit. Individuals presenting with suicide or self-harming behavior in the medical setting

6. Patients with health behavior, personality traits, cognitive function, or social condition that may influence the management of medical condition.

ROLES OF CONSULTATION-LIAISON PSYCHIATRIST

Liaison psychiatry’s expertise is critical in providing complete, integrated care for patients with long-term illnesses and medically unexplained symptoms.

Liaison psychiatry professionals are expected to be experts in the following areas:

Ability to develop assessment formulation and treatment plan of complex cases

Skills to manage complexity in patients care when there is interaction between physical and psychological factors.

Active collaboration within health-care system

Explicit knowledge of health-care system, enabling them to establish effective liaison with different service systems to ensure appropriate treatment as per the requirement of the patients.

Management of patients requiring both medical and psychiatric expertise

Ability to assess relative contribution of physical and psychological factors in patient’s presentation and management including:

• Adverse effects and potential drug interaction of medications

• Understanding of medical investigations

• Acknowledging patient’s concern about his/her illness.

Teaching and training

Teaching and trading are an integral part of liaison psychiatry.

• Ad hoc training: on day-to-day basis during daily clinical work

• Formal training: Scheduled sessions.

SCOPE OF CONSULTATION-LIAISON PSYCHIATRY

1. Opportunity to assess patients with psychiatric morbidity and their management in medical/surgical units

2. Opportunity to delineate the impact of medical illness on origin and presentation of psychiatric disorders and their manifestations and vice versa

3. Opportunity to formulate a comprehensive biopsychosocial assessment and management plan in consultation with other specialties to provide effective and holistic treatment

4. Opportunity to assess reaction to physical illness and differentiate the presentation psychiatric illnesses in medical/surgical units

5. Opportunity to have a deep insight into common pathways of illness and their implications in treatment outcome of the disease

6. Opportunity to assess and manage physical symptoms with no plausible underlying cause

7. Opportunity to explore and manage different neuropsychiatric disorders especially delirium

8. Opportunity to understand particular need of special population with psychiatric comorbidity such as adolescents, the elderly, and those with intellectual disabilities and their management. Table 4 depicts obstacles in the practice of CL psychiatry.

Table 4.

Obstacles in CL psychiatry

Inadequate focus on psychiatry in medical curriculum

Poor acquaintance with the subject in other specialties

Poor understanding and acceptance of mental health issues in patients and their care givers

Deficiency of effective men power in mental health.

Stigma associated with mental disorder

ROLE OF CONSULTATION-LIAISON PSYCHIATRY IN MEDICAL PRACTICE [FIGURES 1 AND 2]

Figure 1.

Management by mental health professionals

Figure 2.

Steps in consultation-liaison psychiatry

Medical practice has largely been benefited by CL psychiatry. Evidently, CL psychiatry has significantly highlighted mental and behavioral consequences of medical disorders as well as how psychological issues influence medical illness in terms of origin, course, and outcome.

Significant emphasis has been given in CL psychiatry regarding management of psychiatric disorders associated with medical conditions, drug interactions of psychotropic medications with other medicines, and psychological symptoms caused by psychotropic medications. There has been a great deal of research in several medical conditions associated with psychiatric symptoms or disorders such as diabetes, heart diseases, cancer, and cardio vascular accident.

The role of social psychiatry in emergency setup is widely known and accepted. Similarly, families and caregivers of the patient with critical condition are helped by a CL psychiatrist in dealing with the crisis situation and acceptance of the situation without much stress.

In recent years, CL psychiatry has become an integral part of organ transplant team for both donors and recipients.

CL psychiatry has also played a significant role in the treatment of various psychosomatic disorders in general hospital setup, thus reducing the cost of treatment. Sympathy toward patient and caregivers as well as effective communication with them by treating team has also been significantly influenced by the CL psychiatrist who imparts teaching and training, which also focuses on this aspect of soft skills which are very important in day-to-day clinical practice.

MANAGEMENT OF PATIENTS WITH PHYSICAL ILLNESS

In 1958, Weissman and Hackett suggested sensory deprivation caused by postoperative bilateral patching and immobilization, thus making it apparent to ophthalmologists to revise their postoperative management strategies.

Kornfeld et al. in 1965 reported development of delirium following open-heart surgery which disappeared shortly after patient left the cardiac surgery recovery room, which led to reform the architecture of intensive care units (ICUs) and patient management. For example, outside windows were included, wall clocks were placed, and provisions in nursing operation were made to ensure undisturbed sleep.

An essay on Friedman et al.’s work in 1971 regarding the effect of sleep deprivation on the performance of intern had tremendous impact on medical education.

Spiegel et al. reported in the Lancet in 1989 that a year of weekly group therapy for women with metastatic breast cancer reduced distress and increased life expectancy. Later research by Fawzy et al. found a similar impact in melanoma patients.

Robinson et al. looked into stroke prognosis and discovered that depression is linked to a greater fatality rate. Their findings on the usefulness of antidepressants in these patients have been incorporated into the US Public Health Service’s therapeutic guidelines for poststroke rehabilitation.

Interferon, an antiviral drug used to treat hepatitis C, multiple sclerosis, and malignant melanoma, can cause depression and suicidality in up to one-third of patients. Musselman et al. suggested that using paroxetine prophylactically 2 weeks before therapy greatly lowered the risk of this happening.

In the 1970s and 1980s, knowledge about panic attacks and its relevance in the CL psychiatry demonstrated large number of patients with chest pain and normal coronary angiograms as panic disorder, thereby making panic disorder an important diagnosis to be ruled out in patients with cardiac symptoms, thus reducing the frequency of unnecessary investigations and ensuring appropriate treatment.

The Indian Journal of Psychiatry (IJP) has published a number of different papers.

N. N. Wig (1968) documented examples of postvasectomy syndrome in the general hospital’s psychiatric clinic, with the most common pattern being a persistent and disabling neurasthenic hypochondriac state. These elements, however, have not been studied much in Indian psychiatry.

In the IJP, there is some research paperwork from the army setup. Major R. S. Mathur (1977) conducted a survey of 638 troops hospitalized in a military hospital for physical illnesses or trauma and found that 34.5% of them had psychological morbidity, manifesting primarily as sadness and anxiety. In the Indian context, a lot of work has been documented in the subject of deliberate self-harm and suicide. R. K. Chadda and S. Shome (1996) discovered that psychiatric consulting services are underutilized by a significant proportion of practitioners.

COST–BENEFIT ANALYSIS

CLP service has the potential to improve quality of care and reduce cost of treatment.

Psychiatric consultation brought down the average patient’s stay from 28 days to 16 days at Denver General Hospital as reported by Billings et al. in 1937.

Levitan and Kornfeld reported positive outcome of a liaison psychiatrist service assigned to an orthopedic service for the patients of fractured femur. With early detection and management of psychiatric problems, length of stay was significantly shortened with increased chances of returning home. This led to reduction in overall treatment cost.

Smith et al. published their findings in 1986 about educating primary care physicians of how to apply psychiatric principles to the treatment of hypochondriasis outpatients. These strategies decreased medical costs by 49% to 53% without affecting patients’ health or satisfaction.

TEACHING

For consultation-liaison psychiatrists, continuing medical education of medical practitioners has long been a top emphasis. In their article “Psychiatry and Medical Practice in a General Hospital,” published in the New England Journal of Medicine in 1956, Bibring and Kahana classified patients into personality categories. They avoided psychiatric jargon in favor of language that would help practitioners to recognize these patients in their day-to-day work. They further explained what disease meant to each patient type and how doctors might best handle their predictable behaviors.

Groves published two essays, “Taking care of the hateful patient” and “management of the borderline patient on a medical or surgical ward,” in which he attempted to assist our colleagues in dealing with tough clinical situations by applying our knowledge of psychopathology and psychodynamics. Without a doubt, psychiatry has helped innumerable patients by assisting physicians in developing the skills needed to speak with patients proficiently, ask questions that expose a patient’s actual concerns, and make a good psychiatric referral.

END-OF-LIFE CARE

Muskin, writing in the Journal of the American Medical Association in 1998, highlighted that there are no discussions in the medical literature on the true significance of such a request from any individual patient. If a psychiatrist has a part in right-to-die legislation, it is mainly confined to determining competency. Muskin emphasized the importance of including the motivation’s possible complexity in such a request, as well as the role psychiatric principles can play in determining its genuine meaning.

“Physicians think of death as a defeat and typically react accordingly,” Sherwin Nuland wrote in How We Die. Physician must learn what more can be done, once “doing” is redefined to include comfort in its various forms as a suitable function for a physician. Physicians who are comparatively acquainted with the emotional requirements of physically ill patients, such as consultation-liaison psychiatrists, can take the lead in teaching junior physicians how to effectively deal with dying patients and their families.

CLINICAL GENETICS

The ethical difficulties and psychological ramifications of rapidly developing genetic knowledge are now being confronted by medicine. Clinicians must decide how to effectively deal with new gene markers when they emerge. When and how should this kind of knowledge be applied? What are the consequences of using it? Each genetic test comes with its own set of emotions. As more genetic links are discovered, issues arise, and answers for many specific patients are rarely found in statistical likelihood estimates provided by a genetic counselor. Psychiatrists that provide CL services can assist patients deal with dysphoria and identify the best solutions for them.

CONSULTATION-LIAISON PSYCHIATRY IN INDIA

The referral rates for psychiatric services in general hospital are much lower in India (0.15–%–3.6%) compared to the higher rates (about 10%) of referral in Western countries. A recent online survey from ninety training centers on practice of CLP in India reported that CL services are provided as “on-call services” in three-fourths of the institutes in India.

Only a handful CLP centers include other MHPs such as psychiatric nurses, psychiatric social workers, and clinical psychologists. In the majority of CLP teams (60%), the junior resident is the initial respondent. Delirium, substance use disorders, self-harm, and depression are the most common diagnostic categories seen in CLP practice across different centers.

There is no specific CLP posting for junior and senior residents at the majority of the centers, and less than half of the centers perform joint academic activities involving various specialties. There are very few research initiatives in which the lead investigator is a psychiatrist.

Equal or more importance was emphasized to be given to CLP in postgraduate training programs than other subspecialties such as child psychiatry, addiction psychiatry, and geriatric psychiatry by most of the respondents.

At most centers, psychiatry training is primarily given in a psychiatry inpatient or psychiatry outpatient setting. In the CLP setup, there are only a few institutes that provide psychiatry training to undergraduates. The majority of participants regarded CL services as average in their institute. They suggested that CL services be improved by forming a dedicated CLP team.

DIFFICULTIES IN ESTABLISHING CONSULTATION-LIAISON PSYCHIATRY

CLP in India has still not been considered as an important subspecialty of psychiatry, despite the fact that a large number of referrals from other specialties for consultation and management of behavioral disturbances associated with physical illness take place.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.