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Consultation-Liaison Psychiatry

67. PSYCHIATRIC CONSULTATION IN THE GENERAL HOSPITAL


Michael K. Popkin, M.D.

1. When is psychiatric consultation indicated or advisable? Most general hospital psychiatric consultation services see 3-5% of all admissions to the medical-surgical units of the hospital. Consultation is requested for many reasons: disturbances in behavior; changes in cognition, thinking, or mood; maladaptive responses to the physical illness process or hospitalization; legal issues, such as competency, informed consent, desire to leave against medical advice; and problems in the doctor-patient relationship. Psychiatric disorders are common in the general hospital population: 20-30% of of medicalsurgical inpatients have current depressive disturbances; an equal or higher percentage manifest symptoms of anxiety; and 5-1 0% experience an episode of delirium during hospitalization. Collectively these data suggest high rates of psychiatric disorders in the general hospital, but only select patients are referred for psychiatric consultation. Consultation is prompted routinely by issues such as violence or profound noncompliance. Frequently, difficulties in the interaction between the patient and physician are crucial to the decision to seek consultation. Hard and fast rules do not apply here, but consultation is advisable when: First-line or standard psychiatric remedies have not resolved the issue Diagnostic expertise is required The primary physician is at bay in the engagement and management of the patient An objective, external review is needed to weigh a proposed course of action.

2. What are the consulting psychiatrists goals in the initial dialogue with the referring physician or nurse? Direct dialogue with the referring physician is crucial to the consultation process; seldom does a written request suffice. In this first exchange, the consultants principal task is to identify a specific question or questions. The consultants ability to assist is largely a function of pinpointing the concern or issues generating the referral. Surprisingly, physicians often are reluctant to explain their reasons for consulting a psychiatrist. The consultant may need to ask, What would you like to have done? The more precise the answer, the better the chance that the consultant may render a service. (The phrase Please evaluate is unlikely to yield the desired endpoint.) Next, the consultant must ensure that the request for psychiatric consultation has been discussed with the patient. The unexpected arrival of a psychiatrist usually is met with hostility. Finally, the consultant should inform the referring physician of the proposed consultative steps, including when impressions and recommendations will be conveyed and how further communication will be achieved.
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3. How should the consultation interview be conducted? At the outset, the consultant should inquire whether the patient has been advised of the consultation and its purpose. A negative answer usually requires postponing of the interview. Once the primary physician has informed the patient of the request for consultation and the objectives in this step, the consultant may proceed. Begin the interview with basic questions concerning age, place of origin, family, education, marital status, and number of children, to obtain important background information. The answers, along with the details of the medical situation, offer nonthreatening topics with which to develop rapport. In the first meeting, the goal is to facilitate an alliance and maintain neutrality (see Chapter 1). Encourage the patient to tell his or her own story, and pay attention to the style of presentation. Generally the consultant should be friendly and tolerant, but also should signal clearly if the patients interpersonal conduct is inappropriate or out-of-bounds. The interview must be flexible in timing and format, less formal than that conducted in the office or clinic setting. Strive to maintain privacy; this may require asking a roommate to depart for a time or herding away direct care personnel. Advise the patient at the start how much time will be needed; similarly, at the close, the patient deserves a summary statement regarding observations and the plan of action. It is important that followup be specified. Although its goal is largely investigatory, the initial interview can, and should, be therapeutic as well. Even humor can have its place in the sometimes all-too-serious medical setting.

4. Any suggestions for interacting with a reticent patient? Often in conducting the consultation interview, pursuit of specific content or data is frustrated. Either intentionally or unwittingly, the patient obstructs or blockades the consultants efforts to secure information. When this occurs repeatedly and threatens to disrupt the sequence, consider changing gears by addressing the process of the interview. For example, Im here to try to be of assistance, but for the last 10 minutes youve refused to allow me to understand what you are feeling or experiencing. How will this be helpful to you? The theme is not necessarily confrontation; rather, it is shifting focus to the process unfolding between the consultant and the patient (as opposed to the pursuit of data). 5. What is the role of corroborative history in the consultation setting? The elderly and cognitively impaired comprise a significant percentage of patients referred for psychiatric consultation. Histories and accounts provided by these patients may be marred or jeopardized by questionable reliability, altered levels of consciousness, and cognitive dysfunction (in an otherwise clear sensorium). Accordingly, corroborative or alternative histories often are vitally important in the consultation-liaison setting. The consultant is obligated to review carefully the available medical records and to elicit the input of direct care personnel familiar with the patient. Corroborative reports from family members and significant others should be gathered after the patient is interviewed; contact before engaging the patient can make the consultant an agent of the family and disrupt the consultants link to the patient.
6. What should be included in the consultation report? The consultation report is a legal document which should concisely address (and, hopefully, answer) the original consultation questions. Lengthy reports typically are not read by consultees; the tendency is to skip to the conclusions and recommendations. One strategy, now common with psychiatric consultation services, is to present resultant diagnoses and recommended actions first, followed by the case synopsis or summary and mental status examination (MSE). The consultant must convey an awareness of the patients medical/surgical issues, but it is not necessary to reiterate the full chronology of the medical situation. Psychiatrically, the focus should be on the history of the present illness, rather than a lengthy reconstruction of early childhood or adolescent trauma. In most cases, no more than a page-long synopsis of the problem is indicated, in addition to the MSE, differential diagnosis, and recommendations.

Psychiatric Consultation in the General Hospital


Elements of the Consultation Report and Suggested Sequence of Presentation Resultant psychiatric diagnosis (per DSM-IV) in order of reason for the consultation Recommendations, prioritized and specific One page synopsis of the psychiatric problem History of presenting complaint(s) Pertinent psychiatric history, including familial and medical history Mental status examination Psychiatric differential diagnosis

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7. What psychiatric disorders are most commonly encountered by the consulting psychiatrist? Formal studies of the distribution of psychiatric diagnoses assigned by psychiatric consultation services show clustering into a relatively brief list. 25% Affective disorders (primary, or secondary to medical condition) 25 % Delirium, dementia, amnesia, other cognitive disorders Adjustment disorder (maladaptive response to identified stressors, 15% including medical illness) each < 10% Somatoform disorders, anxiety disorders, personality disorders Data on the the distribution of Axis I1 disorders in consultation-liaison are limited. The interface of psychiatry and medicine has long posed problems with regard to psychiatric diagnosis and nosology. This is most readily exemplified in the problem of depression emerging in the context of medical illness. The usual guideposts for the diagnosis of major depression are sleep, appetite, energy, libido, and the like; such vegetative parameters often are confounded in the medical-surgical patient with a disseminated malignancy or poorly controlled diabetes. Substitute criteria and guidelines for judgments regarding the relative contributions of the medical illness have not achieved strong consensus to date. In DSM-IV, clinicians can identify depressions as well as psychotic and anxiety disorders due to medical conditions, putting Axis 111 directly in the Axis I diagnosis.
8. To what extent are the recommendations of consulting psychiatrists followed? Studies with specific concordance criteria indicate a hierarchy in which more than two thirds of consultants recommendations for psychotropic medications are implemented, but only half the directives for diagnostic steps are instituted. Referring physicians also are unlikely to demonstrate an interest in, or an appreciation for, the consultants psychiatric diagnoses: fewer than 50% of these diagnoses are accurately represented in discharge summaries of the hospitalization. Thus, the psychiatric consultant can expect heightened receptivity to management suggestions, but less concern for proposals that involve further assessment and matters of diagnostic classification. The data suggest that consultees are largely concerned with practical or empiric steps to control behavior or improve mood. In the busy medical-surgical setting, the pursuit of psychiatric diagnosis or clarification of psychiatric factors often is overlooked or set aside. Most strikingly, some data suggest that medical work-up and management frequently are abbreviated in patients with comorbid psychiatric conditions, compared to patients without psychiatric issues.

9. What factors govern concordance with consultants recommendations?


When concordance studies were first initiated, investigators expected that a major factor in achieving concordance would be the individual consultants. As some consultants are more skilled, articulate, and compelling than others, it seemed logical that consultants identities and the particular pairings with referring physicians would be crucial to the outcomes achieved. However, concordance is not a function of the identities of the consultants or consultees. Concordance rates are surprisingly consistent no matter who performs the two roles. Additionally, concordance with recommendations for psychotropic drugs or diagnostic actions is not a function of which class of drug (antipsychotic, anxiolytic, or antidepressant) or which diagnostic measure (laboratory test, procedure, or consultation) is advised.

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What explains concordance? There is no single or simple answer. However, best concordance rates are achieved when recommendations are briej prioritized, and unequivocal. Conditional recommendations (i.e., do A if the following things happen) often are perceived as a sign of an indecisive or uncertain consultant. Most consultees want a pragmatic set of directives, not a lengthy academic discussion of possibilities.

10. Describe the primary characteristics of consultant work. The main task of the psychiatric consultant is to help the medical-surgical patient cope with the demands of hospitalization. Consultation work is pragmatic. It is based in the present. Its objectives are to identify and strengthen the patients own defensive constellation and proclivities in the shortterm; consultation-liaison (CL) is seldom confrontational. CL work favors an active approach in which establishing a direct personal linkage with the patient is vital. 11. What are the usual interventions provided by the consulting psychiatrist? Many regard supportive intervention as the psychiatric consultants primary function: reassuring, comforting, listening, and coordinating. At the heart of the intervention are genuine concern for the patients plight and a willingness and ability to empathize. The psychiatrist must be attuned to themes of uncertainty, fear, and abandonment. The repertoire must include skills in grief work, engaging the spouse or significant other and family, and anticipating the likely progression of events in the hospitalization and medical course. In addition, the CL psychiatrist must be conversant with a range of psychopharmacologic interventions to manage agitation, delirium, depression, anxiety, drug-induced psychotic disorders, and psychiatric presentations due to a general medical condition. Regrettably, the use of psychotropics in the medically ill has had limited systematic study. Thus, the consultant often assumes liaison or educational functions with referring physicians and nursing staff. Psychosocial interventions are emphasized by some clinicians (especially in Europe). Cognitive and behavioral interventions occasionally are employed. Note that 5-10% of CL interventions result in a psychiatric hospitalizatiodtransfer. The number of patients referred for outpatient treatment or followup is presently undefined but is growing.

12. Is medical depression the same as primary depression?


The idea that depression arising in the patient with a medical illness might differ from depression found in patients without physical disease has only lately gained a measure of acceptance. Because physical illness confounds many of the vegetative signs by which depression is routinely diagnosed, investigators generally have avoided the nosologic and diagnostic complexities of medical depression. Many have found it simpler to assume that medical depression is the same as primary depression. However, some data suggest that this is not so: The prevalence of primary depression in women is twice that of men, but medical depression is equally prevalent in both genders. Primary depression has strong genetic loading; medical depression appears independently of of familial affective history. A shortened REM latency is a useful biologic marker of primary depression, but REM latency has been shown to be normal in medical depression. Depression in the medically ill (predominantly pathophysiologic rather than reactive) responds less favorably to antidepressant medication than does primary depression.

13. List some prevalence rates of major depression in medical illness. In several major neurologic illnesses (Parkinsons disease, Huntingtons disease, stroke,Alzheimers), lifetime prevalence rates of major depression are surprisingly consistent (30-50%). Multiple sclerosis is an exception. In multiple sclerosis, the prevalence of depression in patients with only spinal involvement is less than 10%; for those with cortical disease, the rate of occurrence of depression exceeds 30%. Lifetime prevalence rates of depression in systemic medical illnesses are more variable, ranging from 20-30% in diabetes mellitus and coronary artery disease, and 3 3 4 7 % in Cushings disease.

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14. Is depression in the medically ill a discrete entity? Collectively, evidence argues that depression occurring in the medically ill is a discrete entity, with features all its own. Rather than the old construct that depression is best understood in these patients as a reactive response to the stress of medical illness, it is increasingly appreciated that depression may constitute an independent risk factor in the progression of an Axis I11 condition. This has been most sharply demonstrated in recent studies concerning cardiovascular disease. The critical question is whether intervention aimed at the psychiatric condition arrests or retards the progression of the Axis 1 1 1condition.
15. Are these depressions generic, or specific to the physical illness? Unknown.

16. How should a medical depression be treated by the psychiatric consultant? This remains an area of controversy. Literature indicates that electroconvulsive therapy may be the intervention most likely to benefit the patient with marked medical depression. However, such data are retrospective rather than prospective. In the medically ill, some traditional tricyclic antidepressants have questionable efficacy and carry substantial side effects.6,8 Selective serotonin reuptake inhibitors (SSRIs) await further study in populations of medically ill patients, but hold some potential (benefits include single daily dosing without increments and a more tolerable side effect profile). The combination of an SSRI and supportive psychotherapy is a reasonable first step in the face of medical depression. Subsequent steps may be necessary as the medical illness waxes and wanes, hospitalization concludes, and additional stressors emerge.
BIBLIOGRAPHY
1. Fava GA, Sonino N, Wise TN: Management of depression in medical patients. Psychother Psychosom 49:81, 1988. 2. Hackett TP, Cassem NH: Handbook of General Hospital Psychiatry. Littleton, MA, PSG Publishing, 1987. 3. Hales RE: The benefits of a psychiatric consultation-liaison service in a general hospital. General Hosp Psychiatry 7:214-218, 1985. 4. Huyse F: Systematic Interventions in CL. Amsterdam, Free University Press, 1989. 5. Levenson JL, Hammer RM, Rossiter LF: Relation of psychopathology in general medical inpatients to use and cost of services. Am J Psychiatry 147:1498, 1990. 6. Lustman PJ, Grifith LS, Clouse RE, eta]: Effects of nortriptyline on depression and glycemic control in diabetes. Results of a double blind placebo-controlled trial. Psychosom Med 59:241-250, 1997. 7. Musselman DC, Evans DL, Nemeroff CB: The relationship of depression to cardiovascular disease: Epidemiology, biology, and treatment. Arch Gen Psychiatry 55(7):580-592, 1998. 8. Nelson JC, Kennedy JS, Pollock BG, et al: Treatment of major depression with nortriptyline and paroxetine in patients with ischemic heart disease. Am J Psychiatry 156: 1024-1028, 1999. 9. Pasnau RO: Consultation-liaison psychiatry: Progress, problems and prospects. Psychosomatics 29: 1, 1988. 10. Popkin MK, Mackenzie TB, C a l k s AL: Consultation-liaison outcome evaluation system: Consultation-consultee interaction. Arch Gen Psychiatry 40: 125, 1983. 11. Popkin MK, Tucker GJ: Secondary and drug-induced mood, anxiety, psychotic, catatonic, and personality disorders: A review of the literature. J Neuropsychiatry Clin Neurosci 4:369-385, 1992. 12. Seward LN, Smith GC, Stuart G W Concordance with recommendations in a consultation-liaison psychiatry service. Aust N Z J Psychiatry 25:243-254, 1991. 13. Stoudemire A, Fogel BS: Psychiatric Care ofthe Medical Patient. Oxford, Oxford University Press, 1993. 14. Thompson T (ed): Research advances in consultation-liaison psychiatry. Psychiatr Med 9 5 0 6 4 4 8 , 1991. 15. Wells KB, Golding JM, Bumham MD: Psychiatric disorder in a sample of the general population with and without chronic medical conditions. Am J Psychiatry 145:976, 1988.