|Year : 2021 | Volume
| Issue : 1 | Page : 49-54
Consultation-liaison psychiatry: A Step toward achieving effective mental health care for medically ill patients
Siddharth Sarkar1, Swarndeep Singh2
1 Associate Professor, Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
2 Senior Resident, Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
|Date of Submission||09-Feb-2021|
|Date of Acceptance||06-Mar-2021|
|Date of Web Publication||17-Jun-2021|
Dr. Siddharth Sarkar
Department of Psychiatry and NDDTC, Room No. 4096, Teaching Block, AIIMS, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Consultation-liaison (CL) psychiatry is at the interface of psychiatry and other medical/surgical specialties and deals with providing clinical services or care to medically ill patients seen at the medical or surgical inpatient or outpatient departments. This review article aims to highlight the scope of CL psychiatry practice and the need for having effective CL psychiatry clinical services, with special emphasis on discussing how developing CL psychiatry services could help in overcoming existing barriers in the delivery of effective mental health care in the general hospital or primary health care settings. An electronic literature search was performed using the PubMed and Google Scholar search engines for selecting papers related to theme of CL psychiatry and effective mental health care or treatment. The CL psychiatry services improve the overall course and prognosis of both physical and mental health disorders in patients admitted under the medical or surgical hospital wards, with a reduction in length of stay, rehospitalization rates, and total health costs incurred to the medical systems. It can help in bridging the existing mental health treatment gap by overcoming existing barriers such as poor recognition of mental health problems, inadequate treatment, and high mental illness-related stigma.
Keywords: Consultation-liaison, consultation-liaison psychiatry, mental disorders
|How to cite this article:|
Sarkar S, Singh S. Consultation-liaison psychiatry: A Step toward achieving effective mental health care for medically ill patients. Indian J Psy Nsg 2021;18:49-54
|How to cite this URL:|
Sarkar S, Singh S. Consultation-liaison psychiatry: A Step toward achieving effective mental health care for medically ill patients. Indian J Psy Nsg [serial online] 2021 [cited 2021 Sep 21];18:49-54. Available from: https://www.ijpn.in/text.asp?2021/18/1/49/318665
| Introduction|| |
Consultation-liaison (CL) psychiatry is at the interface of psychiatry and other medical/surgical specialties and deals with providing clinical services or care to medically ill patients admitted under the primary care of nonpsychiatric physicians at the medical or surgical inpatient or outpatient departments. It encompasses teaching activities involving education of patients and other medical staff about the various different aspects related to the identification and management of psychosocial problems among patients admitted in medical and surgical wards. Further, research is also conducted about various different aspects related to CL psychiatry services such as the effectiveness of different interventions delivered by CL psychiatry, comparison of cost-effectiveness of different service delivery models, and assessing the changing pattern of CL psychiatry services utilization to inform the training needs for CL psychiatrists and ensure delivery of effective interventions to improve mental health of medically ill patients. Thus, CL psychiatry is an umbrella term which has been used to refer to a broad range of activities described above and has also been rightly recognized as a distinct psychiatric sub-specialty known as the Psychosomatic Medicine in the United States of America in 2003. Subsequently, its importance has also been recognized by other developed countries such as Europe and Australia; with the European Association of CL Psychiatry and the Academy of Psychosomatic Medicine releasing a set consensus guidelines or recommendations defining the scope of practice, processes, and competencies for mental health professionals (e.g., psychiatrists and psychologists) involved in providing CL psychiatry services in the Western settings. However, the scope and practice of CL psychiatry in developing countries like India are still not yet fully recognized. Thus, the present review aims to highlight the scope of CL psychiatry practice and the need for having effective CL psychiatry clinical services, with special emphasis on discussing how developing CL psychiatry services could help in overcoming existing barriers in the delivery of effective mental health care in the general hospital or primary health care settings.
| Methods|| |
An electronic literature search was performed using the PubMed and Google Scholar search engines for selecting papers related to theme of CL psychiatry and effective mental health care or treatment. Further, references of the selected papers were scanned for finding additionally relevant articles. Only articles available in the English language were used for synthesizing the results presented in this narrative review.
| Results|| |
Scope of consultation-liaison psychiatry practice
The CL psychiatry services have been popularly described as the “tip of the spear.” This underscores CL psychiatry practice as one of the most forward sub-specialties of psychiatry offering treatment services for a wide range psychosocial or psychological problem encountered while providing patient care to patients seeking treatment across different medical and surgical specialties. The consensus guidelines released by the European Association of CL Psychiatry and the Academy of Psychosomatic Medicine state that the majority of patients seen in CL psychiatry practice falls in either of the following six categories: (a) Individuals with comorbid physical (medical) and psychiatric disorders where the management of each disorder complicates the management of the other; (b) Patients presenting with medically unexplained symptoms presenting as in the clinical services; (c) Psychiatric symptoms or disorders due to general medical conditions or their treatment; (d) patients with psychiatric disorders presenting to medical setting for diagnostic or therapeutic procedures; (e) individuals presenting with suicide or self-harming behavior in the medical setting; and (f) patients with health behaviors, personality traits, cognitive function or social situation which may affect the treatment of medical condition.
Models of consultation-liaison psychiatry
Initially, the practice of CL psychiatry originated from inpatient departments of other medical and surgical specialties in a general hospital. However, it has evolved with time to provide CL psychiatry services in emergency and outpatient settings too. A detailed discussion about the advantages and disadvantages of various different models of CL psychiatry is beyond the purview of this review. It should suffice to say that there are different models for providing CL psychiatry services depending upon the focus of consultation and the level of coordination or integration between the mental health service providers (e.g., CL psychiatrist) and the primary treating medical or surgical team (e.g., physician treating the medically ill). Broadly, there are two models which have been practiced in most of the treatment settings in developing countries like India. First and the most commonly practiced is the consultation model, in which psychiatrist assesses the patients upon receiving a request or referral from the nonpsychiatric physician under whom they are admitted in medical or surgical wards. Only inputs regarding the clinical management of issues for which referral has been sought is provided, with no teaching activity. Second is the liaison model, in which more active co-operation and communication takes place between the psychiatrist and primary care physician under whom the patient is admitted. A dedicated psychiatrist is available on a regular basis with the medical or surgical team of doctors and is also involved in structured teaching activities educating them about the do's and don'ts for effective management psychiatric comorbidity in medically ill patients. Further, a few tertiary care multi-specialty hospitals have also experimented with hybrid or refined models of CL psychiatry for delivering mental health care to medically ill patients in low-resource settings like India.
Need for having effective consultation-liaison psychiatry clinical services
The available literature suggests that about 20%–46% of the medically ill patients hospitalized in medical or surgical wards suffer from at least one diagnosable psychiatric comorbidity.,,10], Further, the prevalence of psychiatric disorders in this group is much greater than that reported in the general population. Moreover, it is important to note that even sub-clinical or sub-threshold symptoms of a comorbid psychiatric disorder have been associated negative health-related outcomes in hospitalized patients in the form of increased length of stay and excessive utilization of health service resources., For example, poorly treated depression and/or anxiety symptoms worsen the course and outcome in coronary heart disease patients with a bidirectional relationship between the medical and psychiatric disorders.
A recent systematic review and meta-analysis assessed the health-economic outcomes among patients with medical-psychiatric comorbidity and hospitalized in medical or surgical wards. It showed greater total length of stay, rehospitalization rates, and total medical costs incurred to the healthcare system by such patients. Similar findings have been shown for different sub-groups of patients based on specific disorder (e.g., cardiovascular disease) or specific age-groups (e.g., geriatric population)., It has been suggested that effective CL psychiatry services could cater to the multiple and complex treatment needs of these sub-group of patients in collaboration with the primary treating clinical team.
It has been shown that integrated holistic care by CL psychiatry services along with primary medical or surgical care result in better health-related prognosis as both course and outcome of several chronic medical illnesses has been shown to be negatively affected by the psychiatric or psychosocial problems/factors and vice-versa. Thus, CL psychiatry services improve the overall health-related outcomes by targeting the comorbid psychiatric symptoms or disorders. A systematic review assessing the effectiveness of CL psychiatry services in general hospital settings showed that CL psychiatry services involvement was associated with reduced total length of stay among medically ill patients with psychiatric comorbidity. Further, studies have shown that earlier referral to CL psychiatry was associated with a shorter length of stay even after controlling for the severity of comorbid medical illness among hospitalized patients., Further, CL psychiatry involvement in providing care for patients with medical-psychiatric comorbidity has been associated lower re-admission rates following discharge from the hospital over the period of next few days to months. In addition, early detection and treatment of even sub-clinical psychological distress not amounting to the level of a psychiatric disorder have been reported to improve course and outcome in medically ill patients and reduce health care costs. Apart from the above described favorable quantitative outcome measures, interventions delivered by CL psychiatry team have also been associated with improved quality of life and other qualitative measures such as subjective experiences for both patients and caregivers during their hospital stay and afterwards.
Role of consultation-liaison psychiatry in overcoming barriers in delivering effective mental health care
Poor recognition of psychiatric or psychosocial problems
Both nonpsychiatric physicians from other medical or surgical specialties and other health care staff (e.g., nurses) involved in providing care to medical ill patients have been reported to be not adequately skilled enough identify patients with psychological distress in order to initiate timely referral to CL psychiatry services., Furthermore, patients might have limited insight or self-awareness about their own psychiatric disorder symptoms or might not be aware about the availability of CL psychiatry services upon their request. Thus, models of CL psychiatry in which a mental health professional (e.g., CL psychiatrist) educate other members of the primary treating medical or surgical team about the possible signs and symptoms of psychosocial problems and psychological distress and periodically emphasize about the importance of screening or identifying them in medically ill patients would help in the early detection and treatment of mental health problems.
Inadequate and improper treatment of psychiatric disorders by the primary care physician or surgeon
The available literature suggests that a team of nonpsychiatrist doctors involved in treating the medically ill patients admitted in general medical settings often provide sub-optimal treatment for comorbid psychiatric disorders. For example, prescribing benzodiazepines and not staring any antidepressant medication to improve sleep disturbances or restlessness in a patient suffering from depression. This might be because of missed or wrong diagnosis due to lack of adequate knowledge or training. Studies comparing psychiatric diagnosis made by the referring physician and the CL psychiatry team reported concordance between diagnosis in roughly half of the cases only., Further, the nonpsychiatric physicians were even less adept at making accurate diagnosis of psychiatric disorders such as depression, bipolar, personality, or psychotic disorders as compared to neurocognitive or substance use disorders. Another possible reason for reluctance on part of doctors to start psychotropic medications such as antidepressants is the lack of comfort or familiarity with its use in their routine clinical practice.
Stigma associated with mental illness and mental health treatment
Despite the availability of safe and effective pharmacological and nonpharmacological for psychiatric disorders, the available literature suggests that there is still a high degree of stigma related mental disorders and mental health treatment. This often prevents people from seeking treatment for their psychological problems at the psychiatry department. Further, nonpsychiatric physicians also partially share the stigma associated with mental health treatment and are often reluctant to refer patients for formal psychiatric treatment., Studies have shown that effective CL psychiatry clinical and teaching services could help in reduce this stigma among patients and physicians.
Drop-out from psychiatric treatment after discharge from medical or surgical ward
The available literature suggests that a significant number of patients either discontinue treatment for psychiatric disorder or do not follow-up with mental health professional after discharge from the hospital. CL psychiatry services have been shown to help in improving linkage of patients to the existing outpatient-based mental health services, ensuring improved rates of receiving follow-up psychiatric care among medically ill patients after discharge from hospital.
Major challenges and way ahead
The development of different CL psychiatry services is still in early stages and has a long way to go before being established as a sub-specialty of clinical psychiatry in developing countries like India. The major challenges faced by the CL psychiatry in delivering effective mental healthcare in developed countries are equally if not of more relevant to the developing countries. We discuss three such challenges and the possible ways in which those could be tackled in future.
First, the referral rates for CL psychiatry services from medical and surgical departments continue to remain low despite of sufficient evidence supporting its effectiveness for treating psychiatric morbidity in medically ill patients and improving the overall health outcomes. The available literature suggests that referral rates for CL psychiatry services ranged from 0.01% to 3.6% among inpatients; 1.42% to 5.4% in emergency departments; and 0.06% to 7.17% among outpatients across different studies from India. This is comparable to that reported from other developed and developing countries and is significantly lower than the prevalence of psychiatric comorbidity reported in this group of patients. This might be because of interplay between various systemic, referrer, and patient-related factors. Thus, service models with a dedicated or more proactive liaising by CL psychiatry services and collaborative screening of patients for psychological problems could improve the referral rates. Further, regular engagement of nonpsychiatric physicians with the CL psychiatrist in the form of combined rounds, multidisciplinary teams, and teaching or training sessions to emphasize about screening for the early identification of psychiatric comorbidity and available effective treatment options in their patients may facilitate more frequent involvement of CL psychiatry services. A study from tertiary care multi-specialty hospital from India showed that a change from the traditional consultation on demand model (psychiatrist attends the patient upon receiving request/referral by the primary clinician) to hybrid model (psychiatrists was routinely available to assess patients requiring psychiatric evaluation/intervention) led to about 1.5 times increase in CL psychiatry service utilization among medically ill patients in the emergency department (1.7%–2.4%). Similarly, the liaison model has been advocated over the on-demand consultation model of CL psychiatry for better delivery of services and care to medically ill inpatients with psychiatric comorbidity in studies available from the Western settings. Further, there is a need to increase the level of exposure to CL psychiatry services during psychiatry rotations occurring as part of the undergraduate and postgraduate training of doctors. This will help in sensitizing them about the importance of identifying and treating psychiatric disorders among patients admitted in the medicine or surgery wards for physical disorders.
Second, the need for a large number of mental health professionals (e.g., psychiatrists, psychologists, and mental health nurses) required for providing a more collaborative or integrated care following the liaison-model of CL psychiatry is also considered as a barrier in the scaling up of more effective CL psychiatric services. This is even more problematic for low- and middle-income countries such as India, where there is a scarcity of mental health resources for taking care of mental health care needs of patients with common and severe mental disorder alone. According to survey assessing the existing CL psychiatry services in different institutes providing postgraduate training from India, some form of on-demand CL psychiatry services was available in only three-fourth of them. Further, a three-tier CL psychiatry team consisting of a dedicated junior resident, senior resident, and consultant was available on-call basis in only one-third of the institutes. This gap could be partly addressed by the use of digital Internet-communication technology and electronic health record keeping in hospitals to provide CL psychiatry services by limited number of mental health professionals remotely through telepsychiatry and tele psychotherapy services to a large majority of medically ill patients with mild-to-moderate severity of psychiatric disorders., In addition, other available health-care professionals like nurses could be trained and involved in strengthening of CL psychiatry services as discussed in detail later.
Third, there is a lack of robust research evidence-base supporting the cost-effectiveness of different CL psychiatry interventions and service delivery models from developing countries. Research findings from studies conducted in other developed countries cannot be directly translated to developing countries like India due to the differences in the health care structure, resources, and help-seeking behaviors. Furthermore, there is a need to conduct research using alternative techniques to fully understand and capture the benefits of CL psychiatry services in medically ill patients with multiple and complex needs. Innovative methodological tools and qualitative outcomes also need to be incorporated while evaluating the effectiveness of CL psychiatry.
Role of nurses in strengthening of consultation-liaison psychiatry services
Interestingly, nurses were found to be better at identifying medically ill patients with underlying psychiatric comorbidity as compared to other medical staff (e.g., nonpsychiatric physicians). Thus, there is a need to involve nurses routinely in assessing and triaging patients with psychosocial or mental health problems; and giving feedback to other medical staff for timely appropriate referral. Further, a few studies have suggested that structured nonpharmacological interventions delivered by trained CL nurses could be effective for alleviating symptoms of psychological distress in lesser severe cases of anxiety and/or depressive (e.g., anxiety before and after a medical or surgical procedure, feelings of depression experienced after getting hospitalized in ward full of patients with varying level of disease severity). These often involved providing supportive psychotherapy with the help of clearly defined instructions based on a treatment manual developed specifically for patients experiencing symptoms of depression or anxiety in the general hospital medical/surgical ward settings.
| Conclusion|| |
In developing countries, general hospital psychiatry has been a major resource in providing mental health care over the last few decades. The CL psychiatry services improve the overall course and prognosis of both physical and mental health disorders in patients admitted under the medical or surgical hospital wards, with a reduction in length of stay, rehospitalization rates, and total health costs incurred to the medical systems. There is a need to develop and adapt existing CL psychiatry service delivery models and CL psychiatry interventions which are effective, feasible, and could be scaled up in low-resource settings like ours going forward. There is a lack of long-term prospective studies assessing different qualitative and quantitative health related outcomes of CL psychiatry interventions, with no study assessing the cost-effectiveness of different CL psychiatry service models in developing countries like India. Research findings from studies conducted in other developed countries cannot be directly translated to developing countries due to differences in the health care structure, resources, and help-seeking behaviors. More research is needed to better understand the existing referral pattern and cost-effectiveness for different CL psychiatry models in the Indian settings. Apart from this, training and advocacy efforts for increasing knowledge and awareness about CL psychiatry among the medical fraternity members and policy makers are needed. Development of robust CL psychiatry services to deliver integrated holistic care in collaboration with the other medical and surgical specialties could provide effective mental health care to a large section of the population. It can help in bridging the existing mental health treatment gap by overcoming existing barriers such as poor recognition of mental health problems, inadequate treatment, and high mental illness-related stigma.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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