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This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate
and manage patients with medical illnesses. The guideline is intended to delineate the
knowledge base, professional expertise, and integrated clinical approach necessary to
effectively manage this complex and diverse patient population. This guideline was
drafted by a work group consisting of psychiatrists with clinical and research expertise
in the field, who undertook a comprehensive review of the literature. The guideline was
reviewed by the executive council of the Academy of Psychosomatic Medicine and re-
vised prior to final approval. Some of the topics discussed include qualifications of C-L
consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharma-
cotherapy), medicolegal issues, and child and adolescent consultations.
(Psychosomatics 1998; 39:S8–S30)
S8 PSYCHOSOMATICS
Practice Guidelines
edge that are generally necessary to guide the MEDICAL NEED AND STAFFING
clinician’s approach to the patient.1
In general, the aims of psychiatric consul- Population at Risk and
tation in the medical/surgical setting are 1) to Case Identification
ensure the safety and stability of the patient
within the medical environment, 2) to collect In the general medical setting, as many as
sufficient history and medical data from appro- 30% of patients have a psychiatric disorder.13–15
priate sources to assess the patient and formu- Delirium is detected in 10% of all medical in-
late the problem, 3) to conduct a mental status patients16 and is detected in over 30% in some
examination and neurological and physical ex- high-risk groups. Two-thirds of patients who are
aminations as necessary, 4) to establish a differ- high users of medical care have a psychiatric
ential diagnosis, and 5) to initiate a treatment disturbance: 23% have depression, 22% have
plan. anxiety, and 20% have somatization.17,18
Consultation-liaison (C-L) psychiatry is the Clearly, psychiatric comorbidity has an impact
subspecialty of psychiatry concerned with med- on health care economics.19–23 The presence of
ically and surgically ill patients.2 The C-L con- a psychiatric disturbance has repeatedly been
sultant must have an extensive clinical under- shown to be a robust predictor of increased hos-
standing of physical/neurological disorders and pital length of stay.24–27 Nearly 90% of 26 stud-
their relation to abnormal illness behavior. The ies have demonstrated either an increased length
C-L consultant must be a skilled diagnostician, of stay or an increased medical readmission rate
be able to tease apart and formulate the patient’s in patients with psychiatric comorbidity.28 Only
multiaxial disorders, and able to develop an ef- a small subset of the population at risk is cur-
fective treatment plan. The C-L consultant must rently being adequately identified. The percent-
also have knowledge of psychotherapeutic and age of patient admissions receiving psychiatric
psychopharmacological interventions as well as consultation varies from institution to institu-
knowledge of the wide array of medicolegal as- tion,29 ranging from 1% to 10%.29–32
pects of psychiatric and medical illness and hos- Intervention studies have suggested that el-
pitalization. The psychiatric physician, by virtue derly patients with hip fractures benefit from
of his/her professional stature and knowledge, psychiatric consultation; they have shorter
has the ability to supervise a multidisciplinary length of hospital stays and are more often dis-
team. charged home, rather than to a nursing
These proposals for care supplement those home.33–34 A liaison approach with increased
developed for Psychiatric Training in C-L Psy- case identification and earlier psychiatric inter-
chiatry by the Academy of Psychosomatic vention and treatment resulted in a marked de-
Medicine (APM)3,4 and the practice guidelines crease in the need for transfer to inpatient psy-
developed by the American Psychiatric Associ- chiatric facilities.35
ation (APA).1,5–9 These current proposals are The principal methods of case identification
also related to the recommendations reported in and psychiatric service delivery to the medi-
Psychological Care of Medical Patients, drafted cally/surgically ill patient embrace the principles
by the Joint Working Party of the Royal College of C-L psychiatry.36 In contrast to the standard
of Physicians and Psychiatrists10 and to the goals medical-referral model, in which the consulta-
of Fellowship Training in C-L Psychiatry put tion psychiatrist waits to be called, the liaison
forth by the Academy of Psychosomatic Medi- model is based on an early detection strategy to
cine.11 Although primarily based on consensus, identify potential problems. As part of the multi-
they include, to the extent possible, the desir- disciplinary medical team, the liaison psychia-
able attributes (e.g., validity, clinical applicabil- trist may participate in ward rounds and team
ity, clarity) delineated by the Institute of Medi- meetings while addressing the behavioral issues
cine.12 of patients. Education of nonpsychiatric physi-
cians and allied health professionals about medi- a treatment plan, teams composed of health pro-
cal and psychiatric issues related to a patient’s fessionals with complementary skills may also
illness is a core component of the liaison model. be used. The leader of such a multidisciplinary
Liaison services lead to heightened sensitivity team should be the psychiatrist with specialized
by medical staff, which results in earlier detec- C-L training.
tion and more cost-effective management of pa- The Recommended Guidelines for C-L Psy-
tients with psychiatric problems. chiatric Training in Psychiatry Residency Pro-
grams specify that the faculty of a C-L service
Guideline be certified by the American Board of Psychiatry
and Neurology and have specific expertise in
Each institution is responsible for the con- C-L psychiatry.3 The ideal C-L service has fac-
tinuing medical education of medical/surgical ulty who are fellowship-trained in C-L psychi-
staff about the psychological consequences of atry or who have extensive clinical experience.
illness and the indications for psychiatric con-
sultation. Areas of focus should include the rec- Guideline
ognition of substance abuse, delirium, dementia,
affective disorders, anxiety disorders, and sui- All providers of psychiatric consultation in
cidal ideation. These issues should also be in- the general medical setting must be licensed
corporated as part of undergraduate and post- physicians. All students and trainees must be
graduate residency and fellowship medical
training. TABLE 1. Required skills for the evaluation and
treatment of patients with psychiatric
QUALIFICATIONS OF CONSULTANTS disorders in the general medical setting
1. Ability to take a medical-psychiatric history
Training and Skills Assessment 2. Ability to recognize and categorize symptoms
3. Ability to assess neurological dysfunction
Evaluation of the mental health of patients 4. Ability to assess the risk of suicide
with serious medical illness, formulation of their 5. Ability to assess medication effects and drug–drug
problems and diagnosis, and organization and interactions
implementation of an effective treatment plan 6. Ability to know when to order and how to
involve complex clinical skills that require spe- interpret psychological testing
cialized training (Table 1). In addition to the 7. Ability to assess interpersonal and family issues
usual psychiatric examination, specialized 8. Ability to recognize and manage hospital stressors
knowledge about diagnosis, medicolegal issues, 9. Ability to place the course of hospitalization and
and psychotherapeutic and psychopharmacol- treatment in perspective
ogical interventions is necessary. The consulting 10. Ability to formulate multiaxial diagnoses
psychiatrist must be familiar with the routines of 11. Ability to perform psychotherapy
the medical/surgical environment and knowl- 12. Ability to prescribe and manage
psychopharmacological agents
edgeable about medical and surgical illnesses.
13. Ability to assess and manage agitation
The psychiatric consultant must also be aware
14. Ability to assess and manage pain
of the effects that illnesses and drugs have on
15. Ability to administer drug detoxification protocols
behavior, especially when they contribute to or
16. Ability to make medicolegal determinations
confound the diagnosis or treatment. Further-
17. Ability to apply ethical decisions
more, the psychiatric consultant must be sup-
18. Ability to apply systems theory and resolve
portive of the patient and remain sensitive to the
conflicts
effects of the patient on the staff.
19. Ability to initiate transfers to a psychiatry service
Despite the fact that the psychiatric consul-
20. Ability to assist with disposition planning
tant possesses all the necessary skills to organize
S10 PSYCHOSOMATICS
Practice Guidelines
closely supervised, with documentation of train- TABLE 2. Problems that commonly lead to
ing cases appropriately recorded and main- requests for psychiatric consultation in
the medical/surgical setting
tained. All consultants must have appropriate
credentials and privileges at the hospital or out- 1. Acute stress reactions
patient setting where their consultations are per- 2. Aggression or impulsivity
formed. 3. Agitation
4. AIDS or HIV infection
5. Alcohol and drug abuse (including withdrawal
Indications for Consultation states)
6. Anxiety or panic
Psychiatric consultation is indicated when- 7. Assessment of psychiatric history
ever another doctor asks for help with a patient. 8. Burn sequelae
Consultation requests cover a wide range of top- 9. Change of mental status
ics (Table 2). Commonly, the overt reason for 10. Child abuse
initiating a consultation may not be as serious as 11. Coping with illness
a comorbid, but unrecognized, problem. 12. Death, dying, and bereavement
13. Delirium
14. Dementia
THE CONSULTATION PROCESS
15. Depression
16. Determination of capacity and other forensic
It can take a considerable amount of time before issues
the consultant is accepted by and becomes fa- 17. Eating disorders
miliar with the practices of a medical team.32 18. Electroconvulsive therapy
Outside consultants, unknown to other physi- 19. Ethical issues
cians, unfamiliar with the particular hospital sys- 20. Factitious disorders
tem and unable to provide immediate response 21. Family problems
when necessary, should not replace consultation 22. Geriatric abuse
23. Hypnosis
services.37
24. Malingering
25. Pain
Guideline 26. Pediatric psychiatric illness
27. Personality disorders
Institutions should follow the Recom- 28. Posttraumatic stress disorder
mended Guidelines for Consultation-Liaison 29. Pregnancy-related care
Psychiatric Training in Psychiatry Residency 30. Psychiatric care in the intensive care unit
Programs for staffing a C-L psychiatry service. 31. Psychiatric manifestations of medical and
In all medical settings, there must be adequate neurological illness
staffing to provide psychiatric consultation 24 32. Psychological factors affecting medical illness
33. Psychological and neuropsychological testing
hours/day, throughout the year. In settings where
34. Psycho-oncology
psychiatric residents perform consultations, fac-
35. Psychopharmacology of the medically ill
ulty staffing must be adequate to provide super- 36. Psychosis
vision 24 hours/day. 37. Restraints
Psychiatric consultations should be per- 38. Sexual abuse
formed by psychiatrists with expertise in the 39. Sleep disorders
medical setting and credentials and privileges at 40. Somatoform disorders
the institution where the consultation is per- 41. Suicide
formed. Treatment may be delegated to another 42. Terminal illness
mental health professional under the direct su- 43. Transplantation issues
pervision of the consulting psychiatrist. Psychi-
Note: AIDS4Acquired immunodeficiency syn-
atric consultation involves an initial consultation drome; HIV4Human immunodeficiency virus.
and follow-up examinations (two on average).
If inpatient psychiatric treatment is required cause the overt cause for referral may reflect a
for the medically compromised patient to ensure more serious problem. For example, the patient
continuity of medical care, psychiatric treatment who appears withdrawn may be suicidal; an un-
should, when possible, be provided at the same cooperative patient with mild agitation may be
facility where the patient is receiving medical delirious. Delay in the detection and diagnosis
care. The ideal setting is in a location where of these disorders may have dire consequences.
medical and psychiatric capabilities are inte- To provide appropriate and timely care for
grated. patients, each institution must ensure that the
Follow-up outpatient psychiatric care for C-L service not be restricted from performing
patients with psychiatric problems related to a psychiatric consultations when medically indi-
serious or persistent medical condition (e.g., ac- cated for any individual or group of patients
quired immunodeficiency syndrome [AIDS], within the institution.
cancer, organ failure requiring transplantation)
should, when possible, be provided at the same Guideline
treatment facility where the patient receives pri-
mary medical care. When the consultee asks for a psychiatric
Referral of patients with complex medical– consultation, the consultant should establish the
surgical illness in the outpatient setting should urgency of the consultation (i.e., emergency or
be facilitated: routine—within 24 hours). Commonly, requests
for psychiatric consultation fall into several gen-
1. When requested by the primary care phy- eral categories:
sician in the outpatient setting,
2. When requested by any physician in a spe- 1. Evaluation of a patient with suspected psy-
cialty medical clinic, chiatric disorder, a psychiatric history, or
3. In response to a patient’s request for a re- use of psychotropic medications. The eval-
evaluation or second opinion, or uation aims to properly assess the underly-
4. As a referral for follow-up by any C-L con- ing psychiatric syndrome and to mitigate its
sultant who evaluated the patient while in effect on the medical/surgical condition.
the hospital. 2. Evaluation of a patient who is acutely agi-
tated. The evaluation should carefully re-
ASSESSMENT view the medical and psychiatric reasons for
agitation (e.g., psychosis, intoxication,
Reasons for Referral withdrawal, dementia, delirium) and should
delineate possible etiologies (e.g., toxic
Consultations are usually requested by phy- metabolic disturbances, cardiopulmonary,
sicians who are directly responsible for the care endocrine, neurologic disorders).
of the patient. In some settings, this is the at- 3. Evaluation of a patient who expresses sui-
tending physician, in others it is the house staff cidal or homicidal ideation. Any patient who
(under supervision by the attending physician). voices such ideation should be evaluated by
At some institutions, other health professionals, a psychiatric consultant. In situations where
such as nurses and social workers, may initiate the consultant is not immediately available,
a consultation in emergency situations. In insti- appropriate precautions should be recom-
tutions with ongoing liaison activities with mended by the consultant (e.g., placing the
medical or surgical services, the psychiatrist as patient under constant observation until the
part of the team may accept a referral and eval- psychiatrist arrives at the bedside).
uate any patient admitted to the service. 4. Evaluation of a patient who wishes to die,
The so-called “routine consultation” may including one who requests hastened death,
have life-and-death implications for a patient be- physician-assisted suicide, or euthanasia.
S12 PSYCHOSOMATICS
Practice Guidelines
No presumption should be made that such consultants, Emergency Room services, or the
requests are “rational” until a complete C-L service itself. Interventions and recommen-
evaluation has been performed. dations for emergency consultations may in-
5. Evaluation of a patient who is at high risk clude the following: 1) use of physical restraints;
for psychiatric problems by virtue of serious 2) use of pharmacologic sedation; 3) constant
medical illness. In some circumstances observation (1:1); 4) recommendations for fur-
(e.g., organ transplantation), a medical or ther medical evaluation and workup; 5) imple-
surgical service or protocol may require mentation of treatment over the patient’s objec-
psychiatric evaluation of all patients. Psy- tions; 6) involuntary psychiatric commitment;
chiatric consultation in specific settings has and 7) other behavioral interventions.
proven valuable and should be encouraged.
6. Evaluation of a patient who requests to see Psychiatric History and the Consultation Note
a psychiatrist. Any patient who requests to
speak with a psychiatrist should be evalu- 1. Medical-Psychiatric History. Contrary to
ated only after the physician responsible for the usual medical or psychiatric examination,
the patient’s care has been contacted about the medically ill patient seldom initiates or re-
the case. quests a psychiatric consultation and may even
7. Evaluation of a patient in an emergency sit- assume an adversarial attitude toward the C-L
uation. In emergencies, a consultation may consultant. To obtain a psychiatric history that
be requested by any health professional in- is more than superficial, the consultant must be
volved with the care of the patient (subject skilled at rapidly establishing the context of the
to the rules of procedure of the institution). psychiatric disorder in the medical setting.
The patient should be prevented from harm- In the Practice Guidelines for Psychiatric
ing him- or herself or others (constant ob- Evaluation of Adults,1 the outline of a compre-
servation) until the consultant arrives. hensive examination is discussed at length. The
8. Evaluation of a patient with a medicolegal C-L consultant may determine that to address a
situation (e.g., where there is a question of specific consultation question, not all domains
a patient’s capacity to consent to or refuse are necessary to complete or to record in the
medical or surgical treatment). consultation note. However, an assessment ad-
9. Evaluation of a patient with known or sus- equate to formulate and organize DSM-IV mul-
pected substance abuse. tiaxial diagnoses must be made.
An assessment of the medically/surgically
Emergency Consultations ill patient requires that the C-L consultant be
prepared to take a history and to make inquiries
The process for conducting emergency that go beyond the usual domains of a standard
evaluation of adults has been outlined by the psychiatric evaluation. These areas of special in-
APA in its Practice Guideline for Psychiatric quiry include the following.
Evaluation of Adults.1 In the general medical a. Clarification of the Consultee-Stated vs.
hospital setting, there are no established proce- Consultant-Assessed Reasons for Referral.
dural definitions for which clinical situations are The overt reason expressed for the need for
designated as emergencies; rather, the emer- consultation may be incomplete, or a request
gency designation is based on the requesting may be made for the assessment of one problem
physician’s perceived need for prompt service.38 (e.g., depression) when another more serious
problem (e.g., delirium) is unrecognized. Re-
Guideline quests may be vague if made by someone other
than the person who observed the behavior of
Coverage for emergencies should be avail- concern. Therefore, direct contact with the in-
able on a 24-hour basis by on-call psychiatric dividual who initiated the request is beneficial
for obtaining exact information about the pa- ommend other modes of treatment (e.g., physi-
tient’s behavior, which may not appear in the cal therapy, anesthetic interventions, or surgical
record. evaluation).40,41a
b. Assessment for the Extent the Patient’s General principles of pain assessment and
Psychiatric Disturbance is Caused by the Medi- management include the following elements:
cal/Surgical Illness. obtaining information about the pain complaint;
Many of the patients seen by C-L consul- having an awareness of how pain contributes to
tants have complex medical conditions. The specific illnesses (e.g., cancer, sickle cell dis-
medical chart must be reviewed for pertinent ease, arthritis); having an awareness of how psy-
medical factors that could contribute to the pa- chiatric disorders and symptoms contribute to
tient’s current state. Attention must be given to pain complaints and vice versa (e.g., anxiety in
the description of the mental status and the be- acute pain, depression in chronic pain); and
havior noted by the medical staff. making a detailed assessment of all analgesics
c. Assessment for the Adequacy of Pain and adjuvant medications. It is crucial to have
Management. an understanding of the factors that contribute
Seemingly exaggerated complaints and/or to undertreatment of pain, the appropriate diag-
abnormal behaviors are often associated with in- nostic workup for pain complaints, and the ele-
sufficiently treated pain.39 The consultant should ments of integrated, multimodal assessment and
review with the patient the nature of the pain management of patients in pain.41b,42
and the effectiveness and duration of effect of d. Assessment for the Extent the Psychiatric
any analgesics. Fears of unremitting pain, as Disturbance Is Caused by Medications or Sub-
well as feelings of unattended suffering and stance Abuse.
helplessness, need to be addressed. The consul- The patient’s medication list and recent
tant should carefully review the record of anal- changes in medication are critically important to
gesic administration (narcotics and others). review. Psychiatric symptoms are frequently
Clinicians should have familiarity with the produced by medications (e.g., corticosteroids)
following topics: the types of pain (acute, prescribed for medical disorders. These symp-
chronic, recurrent, and cancer-related); the dis- toms can be produced at therapeutic levels, may
tinction between pain, nociception, suffering, emerge at times of withdrawal, or may arise as
and pain behaviors; the multidimensional nature a result of drug-drug interactions. Analgesics,
of pain (physiological, sensory, affective, cog- sedatives, anticonvulsants, anesthetics, psycho-
nitive, behavioral, and psychopathological, i.e., tropics, and anticholinergics are groups of med-
as a symptom of psychiatric illness); pain mea- ications commonly associated with psychiatric
surement and assessment; pain management disturbances.
(therapeutic goals, pharmacological and non- The type, quantity, and frequency of pre-
pharmacological strategies, multidisciplinary scription drug use as well as illicit drug and al-
and multimodal management, monitoring of cohol use should be assessed. Previous episodes
strategies and side effects); and the impact of of structured outpatient or inpatient treatment
pain and unrelieved pain (on recovery from ill- should be inquired about, as well as prior ex-
ness or surgery, on the individual, on the family). periences associated with drug withdrawal.
Clinical skills include the following: evaluation Urine and serum toxicological screening may be
and monitoring of psychopharmacological requested when there is suspicion of, or the need
agents; ability to administer or appropriately re- to document, substance abuse.
fer a patient for psychological and behavioral e. Assessment for Disturbances in Cogni-
interventions (e.g., cognitive–behavioral ther- tion.
apy, relaxation therapy, hypnosis, biofeedback, Because so many psychiatric, behavioral,
stress management, and education of patients medical, and legal considerations depend on as-
and their families); and knowing when to rec- sessment of cognition, the search for even subtle
S14 PSYCHOSOMATICS
Practice Guidelines
disturbances in cognition is crucial to every psy- distinguished. Inquiry about the patient’s under-
chiatric evaluation of the medically ill patient. If standing of the physical illness—its course and
a disturbance in cognition is identified, the C-L prognosis—allows the consultant a unique op-
consultant should then determine if the change portunity to correct cognitive distortions on the
in mental status is chronic and due primarily to part of the patient. In some situations, it is nec-
the consequences of an underlying disorder essary to assess the capacity of the patient to
(e.g., Alzheimer’s disease, multi-infarct demen- refuse treatment and to help the patient set rea-
tia) or acute and arising secondary to the effects sonable limits on further treatment. To do so, the
of illness, medication, or a combination of fac- consultant must be familiar with the medical
tors. treatment and/or hospital course to ascertain the
f. Assessment of Psychiatric Symptomol- patient’s understanding of his/her illness and its
ogy and Behavior. possible course, with or without treatment.43
“Is the patient’s behavior a normal response
to the stress of illness and/or hospitalization and, 2. Physical and Neurological Examination.
therefore, likely to resolve with improvement in The psychiatric consultant should review the re-
physical health?” In this assessment, the pa- sults of the physical examination with special
tient’s perspective of possible precipitating, ex- regard to the neurological examination. Addi-
acerbating, or resolving factors is most perti- tional physical or neurological examinations by
nent. Review of prior response to illness or the psychiatric consultant may be necessary,
psychiatric treatment can facilitate proper diag- based on the results of the psychiatric interview
nosis and treatment. The consultant should be and on the list of potential diagnoses created
able to assess how well the patient is coping and during the formulation of the case. Specific areas
whether he/she will be able to endure the course of physical examination that relate to psychiatric
of illness. disorders may include an organ-specific evalu-
g. Evaluation of the Patient’s Character ation for unexplained somatic complaints or po-
Style. tential medication side effects; observable signs
As opposed to the usual “What does this of self-injury or intravenous drug abuse; or the
patient have?” the C-L consultant must assess, presence of frontal release signs, tremor, and
“What kind of patient has the illness?” Infor- parkinsonian symptoms.
mation from several domains (e.g., developmen-
tal history, social history, occupational history) 3. Mental Status Examination. In addition to
must be integrated to form a dynamic life nar- an examination to elicit signs and symptoms of
rative leading up to the current illness. Medical psychiatric disorder, the purpose of the mental
illness, surgery, and the many stresses of hos- status examination for the medically ill is to
pitalization are managed differently by individ- elicit the patient’s capacity to understand and
uals with different character styles or DSM-IV cope with the illness and to make decisions
Axis II personality disorders. Understanding about care. The level of detail for assessment of
how character influences the experience of cognitive function varies depending upon the
physical illness is critical for explaining abnor- patient’s combined medical and psychiatric con-
mal patient behaviors, emotions, and demands. dition. The mental status examination can be tai-
h. Inquiry About Thoughts of Dying. lored to the patient’s clinical presentation, which
Many patients think about dying, especially may include judgment about the patient’s capac-
when their illness is protracted, exhausting, or ity to participate in exams with formal rating
critical. Some patients express their wish to die scales.
to the medical staff; this may lead to a request
for a psychiatric consultation. Thoughts of dying 4. The Consultation Note. Although the com-
related to life-threatening physical illness and prehensive consultation requires attention to all
suicidal ideation related to depression need to be domains, the consultation note is best if brief and
S16 PSYCHOSOMATICS
Practice Guidelines
chiatric settings, and/or initiation or discontin- setting (e.g., the cardiac care unit, cancer service,
uation of psychotropic medications should be otolaryngology service, etc.).74–78
accompanied by adequate monitoring until other
health professionals can assume responsibility Guideline
for the patient.
The psychotherapeutic approach to the med-
ically ill should be considered carefully, and the
INTERVENTIONS
modality introduced should be primarily selected
in response to the patient’s needs. No single psy-
Psychotherapy
chotherapeutic modality will be effective with all
patients, at all times, in the medical setting.
A C-L consultant must have the ability to The C-L consultant should have extensive
apply a variety of psychotherapeutic techniques knowledge and clinical experience dealing with
to the medically ill. In many cases, an under- the psychological stresses inherent in medical
standing of how the patient’s behavior and emo- illness (e.g., separation anxiety, fear of pain, fear
tions fit known patterns affects the ability of the of loss of control, impending death, guilt about
consultant to obtain a relevant history, arrive at dependency, and grief). The C-L consultant
a diagnosis, and develop an effective treatment should be experienced in the treatment of pa-
plan. tients with complex personality disorders and
An understanding of an individual’s innate comorbid medical/surgical illness, and the C-L
defensive, cognitive, and interpersonal styles consultant should be prepared to deal with the
(i.e., the core character and personality) enables emotional reactions of health care providers to
the consultant to provide coping strategies for their patients.
the patient. Additionally, individuals with per-
sonality disorders are prone to stereotypical mal- Pharmacotherapy and
adaptive behaviors and emotions in response to Other Somatic Therapies
medical illness and may stimulate negative or
hostile reactions in health care providers.58,59 Psychopharmacological interventions are
Goal-directed cognitive–behavioral therapy an essential part of the management of the med-
crafted to the individual patient can often facili- ically ill. It is estimated that at least 35% of psy-
tate cooperation and compliance. In patients chiatric consultations include recommendations
with terminal illness, complex medical condi- for medications.79 About 10%–15% of patients
tions, chronic pain, or with patients undergoing require reduction or discontinuation of psycho-
repeated testing, open-ended supportive psycho- tropic medications because they are contributing
therapy may be necessary. to the clinical presentation. Numerous physical
Medical psychotherapy encompasses a body conditions may cause, exacerbate, or first pres-
of clinical techniques (e.g., crisis interventions, ent themselves as psychiatric syndromes, and
short-term therapy, supportive therapy, interper- appropriate use of psychopharmacology neces-
sonal therapy, group therapy, cognitive–behav- sitates a careful consideration of the underlying
ioral therapy, hypnosis) that may be applied sin- medical illness, drug interactions, and contrain-
gly, in combination, or alternately in different dications. In addition, many medications used in
stages of an illness.60–72 Extensive review of the the treatment of medical/surgical illness are as-
literature73 reveals the benefits of a wide range of sociated with psychiatric syndromes (e.g., hal-
psychotherapeutic modalities, especially when lucinations with L-dopa, anxiety with broncho-
they are structured for the specific illness or con- dilators, psychosis with steroids). Therefore, the
dition (e.g., cancer or heart disease) and when the C-L consultant must be knowledgeable about
psychiatric consultant is familiar with the prob- the psychiatric effects of medications as well as
lems encountered in the specific medical/surgical the specific indications for psychopharmacol-
S18 PSYCHOSOMATICS
Practice Guidelines
ogical interventions. Pharmacotherapy of the pregnancy); and the potential for drug–drug
medically ill often involves modification in dos- interactions;
age (e.g., to account for older patients with an 4. Recognition of drug-induced psychiatric
increased volume of distribution, a decreased syndromes (e.g., depression, psychosis, de-
rate of metabolism, and an increased physiologic lirium);
reactivity).80 Furthermore, modifications may be 5. The use of psychotropic agents for the treat-
necessary because of liver, kidney, or cardiac ment of substance-induced psychiatric dis-
disease, or because of potential for multiple orders (e.g., withdrawal syndromes) and
drug–drug interactions.81–84 Pregnancy presents substitution algorithms for detoxification
another challenge, with concerns regarding po- protocols. Because noncompliance and sub-
tential teratogenicity.85–88 therapeutic use of psychotropics are com-
The decision to use pharmacological agents mon, the C-L consultant must make addi-
follows immediately upon the differential diag- tional efforts to ensure appropriate and
nosis, and appropriate agents should be pre- timely compliance with pharmacological
scribed when major psychiatric syndromes arise. recommendations arising from inexperience
C-L psychiatrists should be familiar with current on the part of the consultee or resistance on
reviews and databases in the literature for phar- the part of the patient. Obtaining medication
macotherapy of the medically ill.89–93 blood levels should be considered when
The C-L psychiatrist must be knowledge- available; and
able about electroconvulsive therapy (ECT) and 6. The appropriate indications for ECT.
recognize when to introduce it in depressed, cat-
atonic, or critically ill patients. Referral, Outpatient Follow-Up,
and Signing Off
Guideline
1. Referral and Requests for Services of Other
Consultants. The C-L consultant should rec-
The C-L psychiatrist must be a licensed ommend that other professionals be brought into
physician with extensive clinical experience and the case when additional expertise is required.
knowledge about the use of pharmacological Such expertise includes neurology, pain, sub-
agents. stance abuse, geriatrics, and neuropsychology; it
The psychiatric consultant should recom- may be provided by practitioners from a variety
mend and prescribe medications whenever a ma- of disciplines (e.g., psychology, social work, oc-
jor psychiatric syndrome is diagnosed and when cupational therapy, physical therapy, pastoral
the benefits of treatment outweigh its risks. care, and psychiatry as in behavioral medicine
As an essential skill, the C-L consultant or ECT) or from patient representatives or es-
must have additional pharmacological knowl- pecially knowledgeable nonmedical volunteers.
edge related to the following:
Guideline
1. Variations in diagnoses and the natural pro-
gression of psychiatric disorders in the med- Psychiatric consultants should recommend
ically/surgically ill; consultation with other physicians and nonphys-
2. Indications for initiation, reduction, and dis- ician specialists, when appropriate. The request
continuation of therapy with specific psy- for additional consultation(s) should in general
chopharmacological agents; be arranged by the physician of record (i.e., the
3. Appropriate adjustments of dosage depend- original consultee). When appropriate, the psy-
ing on the patient’s age, gender, and medical chiatric consultant may end his/her involvement
condition; physiologic abnormality (includ- with the patient when another specialist is pre-
ing liver, renal, and cardiac disease or pared to deliver the necessary care to the patient.
When the consultant recommends psychotropic the patient’s medical record with information as
medications, he/she should continue to follow to how the C-L consultant can be reached,
the patient for the duration of the hospitalization, should the need arise.
until psychotropics have been discontinued, or
until the consultee no longer requires the con- Constant Observation and Restraints
sultant’s services.
The decision to use constant observation
2. Outpatient Follow-Up and Disposition. It and restraints is extremely serious. Because of
is the responsibility of the psychiatric consultant the delicate balance between medical necessity
to recommend patients for outpatient psychiatric and individual liberty, the implementation of
follow-up when necessary and to discuss the rec- these measures requires documentation of medi-
ommendations with both the patient and the con- cal need, follow-up monitoring, and reporting of
sultee. The eventual disposition of a patient is consequences. Constant observation and re-
determined by the nature of the psychiatric prob- straints should be implemented for the shortest
lem and the physical, psychological, economic, possible time with the least restrictive, though
and social resources of the patient. The psychi- effective, means available; these interventions
atric consultant should work with the primary must not be made solely for the convenience of
care physician, the social worker, and the pa- medical staff. Assessment and treatment of un-
tient’s family to arrange the best disposition for derlying psychiatric conditions that contribute to
the patient.37 the patient’s need for these measures should be
expeditiously undertaken.
Guideline
1. Constant Observation. Constant observa-
It is the responsibility of the consultant to tion is often necessary to ensure patient safety
suggest outpatient psychiatric treatment and to in the medical/surgical setting. It is typically
discuss these recommendations with both the provided by nursing staff and at times with the
patient and the consultee. assistance of family members.95 Patients who re-
quire constant observation typically fall into one
3. Signing Out and Signing Off. Psychiatric of three categories: patients who have attempted
consultation for patients in the general medical suicide; patients with an altered mental status
setting must be available 24 hours/day, 7 days/ (e.g., secondary to dementia or delirium) who
week. A system of coverage should be arranged may inadvertently harm themselves or others;
to provide this level of care. Problem patients and patients with psychopathology (e.g., severe
who require close follow-up and patients who depression or psychosis) who are at risk for sui-
are under observation for suicidal and/or homi- cide or assaultive behaviors.96,97 Other catego-
cidal ideation should be formally “signed out,” ries of patients who may require constant obser-
either in writing or verbally to the person who vation include those with mental retardation and
will be responsible for their care. those who are attempting to leave the hospital
The decision to terminate involvement with against medical advice. Because patients moni-
a patient should be made in concert with the con- tored with constant observation often require in-
sultee and discussed with the patient.94 patient psychiatric hospitalization, it is reason-
able to request psychiatric consultation on all
Guideline patients who require this type of treatment.98
S20 PSYCHOSOMATICS
Practice Guidelines
considerations appropriate to the patient, the oc- control. This may be a review of all cases seen
casion, and the community standard. over a specified period of time (e.g., a week or
a month of a resident’s rotation), or reviews may
Psychiatric Commitment and target an area of clinical interest. For example,
Transfer to Psychiatry a review of attempted suicides in hospitalized
patients might reveal environmental risks (e.g.,
As part of a complete psychiatric evalua- windows that can be opened by patients) that
tion, the consultant should consider the appro- could be minimized.116
priateness of inpatient psychiatric treatment. All untoward events should be reviewed
This determination requires familiarity with the thoroughly and problems dealt with by a quality
voluntary and involuntary legal statutes of the assurance committee. Areas in need of remedi-
state and local mental health acts; an evaluation ation should be identified and addressed appro-
of the suitability of the type of intended psychi- priately by staff education, by recommendations
atric unit (e.g., locked or open, dual diagnosis, for alterations in protocols and policy, by rec-
rehabilitation/detoxification, medical–psychiat- ommendations for alterations in the physical
ric, conventional psychiatric or geriatric units) plant, or by changes regarding staffing and su-
and an evaluation of the capacity of the psychi- pervision.
atric unit to provide the necessary medical/sur-
gical care required by the patient. Guideline
S22 PSYCHOSOMATICS
Practice Guidelines
havioral, and psychological problems as mani- cial to consider the impact of developmental is-
fest in children, adolescents, and families in the sues and regression observed in children
medical setting.132 Often this role includes an hospitalized with serious medical illnesses.135
awareness of the special psychiatric needs of this By virtue of their complexity, pediatric consul-
population in a pediatric setting, particularly in tations typically take longer than consultations
children facing traumatic medical procedures with adults.
and hospitalization. In addition to an ability to
identify the social, environmental, and cultural Legal and Ethical Issues
factors relevant to any psychiatric consultation,
the consultant should be able to appreciate de- The consultant should have a thorough
velopmental and family issues as they apply to knowledge of the relevant local laws that apply
diagnosis and intervention.133 It is essential that to this population. These include the mandatory
the consultant have expertise in areas that in- reporting of suspected cases of sexual or physi-
clude behavioral effects of medications, non- cal abuse or abandonment; the obligation to re-
compliance with treatment, treatment of chronic port suspected maternal use of drugs during the
pain, reaction to acute and chronic medical ill- neonatal period; the child’s right to treatment
ness, disorders of attachment, parent–infant re- (particularly when this conflicts with the par-
lationship difficulties, speech and language dis- ents’ desire to refuse or withhold treatment in
orders, learning disabilities, and psychiatric the case of critically ill neonates or due to pa-
disorders specific to childhood. The C-L con- rental religious beliefs); the legal age for consent
sultant should have an in-depth understanding of and the legal definition of an emancipated minor,
medical illness, as well as a general knowledge which may vary according to state and according
of procedures, medications, hospital routines, to the nature of the illness or problem (e.g., in
and outcomes for children and adolescent pa- the area of reproductive rights); and the invol-
tients. untary medical or psychiatric treatment of mi-
C-L consultant qualifications for this role nors.136
should include board eligibility or board certi- The limits to confidentiality implicit in a
fication in child and adolescent psychiatry and psychiatric consultation become even more
the ability to perform in a leadership role within complicated when the consultation involves mi-
a multidisciplinary team. nors, especially with regard to the issue of sexual
behavior, teen pregnancy, criminal behavior, or
Clinical Procedure substance abuse. These limitations should be
clarified with both the family and the child at the
Before starting the consultation, the consul- time of the consultation.134 It is important to
tant should ascertain that both the child and the safeguard the documentation of sensitive infor-
parents or legal guardians have been informed mation in the medical record; this concern ex-
about the purpose of the consultation. Given the tends to disclosure of information to contacts
importance of the family to the child, the fre- made at schools and other outside agencies.
quent contribution of family dynamics to the
child’s symptoms, and the impact of the child’s Interventions
medical illness on the family system, it is essen-
tial that the consultant obtain information from Knowledge of treatment modalities should
family members. An alliance with the family is encompass cognitive and behavioral interven-
essential for successful intervention. When rele- tions (including hypnosis); psychotherapy (in-
vant, consultation should include contact with cluding individual, family, and group modali-
others (e.g., members of the school system, the ties); and expertise in the area of pediatric
primary pediatrician, the caseworker, the pro- psychopharmacology.137 In addition, the consul-
bation officer, or the therapist).134 It is also cru- tant should have familiarity with the local out-
S24 PSYCHOSOMATICS
Practice Guidelines
patient referral resources, support groups for ited by Cassem NH, Stern TA, Rosenbaum JF,
parents and children, and special educational re- et al. St. Louis, MO, Mosby-Year Book, 1997
sources. The American Psychiatric Press Textbook of
Consultation-Liaison Psychiatry, edited by Run-
Future Research and Review dell JR, Wise MG. Washington, DC, American
Psychiatric Press, 1996
Given the relative shortage of research in The MGH Guide to Psychiatry in Primary
this field, consultants should promote and de- Care, edited by Stern TA, Herman JB, Slavin
velop research in the areas of assessment, inter- PL. New York, McGraw-Hill, 1998
vention, and prevention of illness in children and
adolescents in a pediatric setting.138 Finally, Reference Database
given the complexity of the issues relating to
psychiatric consultation in children and adoles- Strain JJ, Hammer JG, Himelein C, et al:
cents, a large-scale survey of this field should be Further evaluation of a literature database soft-
undertaken with the goal of developing more de- ware and content. Gen Hosp Psychiatry 1996;
tailed practice guidelines for this patient popu- 18:294–299
lation.
Societies
Guideline
The Academy of Psychosomatic Medicine
The principles of psychiatric consultation The American Psychosomatic Society
with children and adolescents are similar to The American Academy of Child and
those of adult consultation. However, special Adolescent Psychiatry
knowledge and clinical experience related to the Society of Pediatric Psychology
pediatric population are required. Association of Medicine and Psychiatry
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