Overview of practice of Consultation-Liaison Psychiatry

Abstract

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 1/5th 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 psychiatryMental 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 psychiatryNEED 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. 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 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 By focusing on comorbid psychiatric symptoms or illnesses, CL psychiatry treatments improve overall health outcomes In patients with comorbid physical and mental disorders, earlier referral to CL psychiatry is linked to a shorter length of stay 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 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 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 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-liaisonCATEGORIES 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: 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 Patients presenting with medically unexplained symptoms presenting in the clinical services. Patients presenting in clinical service with medically unexplained symptoms Mental and behavioral disorders attributed to general medical conditions or their management Patients with psychiatric disorders presenting to medical setting for diagnostic or therapeutic procedures 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 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 Opportunity to assess patients with psychiatric morbidity and their management in medical/surgical units Opportunity to delineate the impact of medical illness on origin and presentation of psychiatric disorders and their manifestations and vice versa Opportunity to formulate a comprehensive biopsychosocial assessment and management plan in consultation with other specialties to provide effective and holistic treatment Opportunity to assess reaction to physical illness and differentiate the presentation psychiatric illnesses in medical/surgical units Opportunity to have a deep insight into common pathways of illness and their implications in treatment outcome of the disease Opportunity to assess and manage physical symptoms with no plausible underlying cause Opportunity to explore and manage different neuropsychiatric disorders especially delirium 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 psychiatryROLE OF CONSULTATION-LIAISON PSYCHIATRY IN MEDICAL PRACTICE [FIGURES 1 AND 2]Figure 1: Management by mental health professionalsFigure 2: Steps in consultation-liaison psychiatryMedical 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 to their postoperative management in development of delirium following which after patient the which to the of care units and patient management. outside were were and in were made to ensure An on work in regarding the of deprivation on the of tremendous impact on medical in the in that a year of group for with distress and increased life research by a impact in patients. into and that is linked to a greater rate. on the of in these patients have been into the therapeutic for an drug to and can cause and in to of patients. suggested that before the risk of this In the and knowledge about and its in the CL psychiatry large number of patients with and as disorder, making disorder an important diagnosis to be in patients with thus reducing the of investigations and appropriate treatment. The of Psychiatry has a number of different of in the general psychiatric with the most common a and however, have not been much in psychiatry. In the there is research from the R. a of hospitalized in a hospital for physical illnesses or and that of them psychological as and In the a lot of work has been in the of and R. and that psychiatric consulting services are by a significant proportion of CLP service has the potential to improve quality of care and reduce cost of treatment. consultation brought the patient’s stay from days to days at Hospital as by in and outcome of a liaison psychiatrist service to an service for the patients of With early detection and management of psychiatric problems, length of stay was significantly with increased of This to in overall treatment their in about primary care physicians of how to psychiatric principles to the treatment of medical by to without health or consultation-liaison medical education of medical has long been a In their and Medical in a in the of in and patients into personality psychiatric in of that would help to these patients in their day-to-day disease to each patient and how their two care of the and of the patient on a medical or surgical in which to in dealing with clinical situations by knowledge of and a psychiatry has helped patients by physicians in developing the skills to with patients that a patient’s and a psychiatric in the of the Medical Association in highlighted that there are no in the medical on the of such a request from any a psychiatrist has a part in it is to emphasized the of the complexity in such a as well as the role psychiatric principles can in its of as a and in We must more can be is to include in its various forms as a for a who are with the of physically ill patients, such as consultation-liaison can take the in teaching physicians how to deal with patients and their The and psychological of developing knowledge are by medicine. must how to deal with when they and how should this of knowledge be are the consequences of with its of more are issues and for specific patients are in provided by a that provide CL services can patients deal with and the for CONSULTATION-LIAISON PSYCHIATRY IN The referral for psychiatric services in general hospital are much lower in India to the higher of referral in A recent from training on practice of CLP in India that CL services are provided as in of the in India. a CLP include other MHPs such as psychiatric psychiatric social and clinical In the majority of CLP the is the substance use disorders, and are the most common diagnostic seen in CLP practice across different There is no specific CLP for and at the majority of the and than of the activities various specialties. There are very few research initiatives in which the is a psychiatrist. or more was emphasized to be given to CLP in postgraduate training than other such as psychiatry, psychiatry, and psychiatry by most of the most psychiatry training is given in a psychiatry inpatient or psychiatry outpatient In the CLP setup, there are only a few that provide psychiatry training to The majority of regarded CL services as in their suggested that CL services be by a CLP team. IN CONSULTATION-LIAISON PSYCHIATRY CLP in India has not been considered as an important subspecialty of psychiatry, despite the that a large number of from other specialties for consultation and management of behavioral associated with physical illness take support and of interest There are no of

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