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X . Consultation-Liaison Psychiatry

67. PSYCHIATRIC CONSULTATION IN THEGENERA L HOSPITAL

Michael K Popkin, M .D.

1. When is psychiatric consultation indicated or advisable?Most general hospital psychiatric consultation services see3-5 of all admissions to the med-

ical-surgical units of the hospital. Consultation is requested for many reasons: disturbances in be-havior; changes in cognition, thinking, or mood; maladaptive responses to the physical illnessprocess or hospitalization; legal issues, such as competency, informed consent, desire to leaveagainst medical advice; and problems in the doctor-patient relationship.

Psychiatric d isorders ar e common in the general hospital population:20-30 of of medical-surgical inpatients have curren t depressive dis turba nces; an equal or higher percenta ge manife stsymptoms 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 hosp ital, but onlyselect patients are referred for psych iatric consultation.

Consu ltation is prom pted routinely by issues such as violence or profound noncom pliance.Frequently, difficulties in the interaction between the patient and physician are crucial to the de-cision to seek consultation. Hard and fast rules do not apply here, but consultation is advisablewhen:

First-line or standard psychiatric remedies have not resolved the issueDiagnostic expertise is requiredTh e primary physician is at bay in the engagement and m anagementof the patientAn 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 physi-cian or nurse?

Direct dialogue with the referring physician is crucial to the consultation process; seldo mdoe s a written req uest suffice. In this first exch ang e, the consultants principal task is to identifya specific question or questions. The con sultants ability to assist is largely a function of pin-pointing the concern or issues gen erating the referral. Surprisingly, phy sicians often are reluc-tant to explain their reasons for consult ing a psychiatr ist . The consultant may need to ask,What would you like to have done? Th e more precise the answer, the better the chan ce thatthe consultant may render a service. The phrase Please evaluate is unlikely to yield the des iredendpoint.)

Next, the consultant must ensure that the request for psychiatric consultation has been dis-cussed with the patient. Th e unexpected arrival of a psychiatrist usually is me t 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 commu nica-tion w ill be achieved.

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3. How should the consultation interview be conducted?At the outset, the consu ltant should inquire w hether the patient has been ad vised of the consul-

tation and its purp ose. A negative answ er usually req uires postp onin g of the interview. Onc e theprimary ph ysician has informed the patient of the request for consultation and the objectivesin this

step, the consultant may proceed.Begin the interview w ith basic q uestio ns concernin g age, place of origin , family, edu cation ,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 developrapport. In the first meeting, the goal is to facilitatean alliance and maintain neutrality see Chap ter1).Encou rage the patient to tell his or h er 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 pa-tients interpersonal con duct is inap propriate or out-of-bounds.

The interview m ust be flexible in timing and form at, less formal than that cond ucted in theoffice or clinic setting. Strive to maintain privacy; this may requ ire askinga roomm ate to depart for at ime or herding away direct care personnel. Ad vise the patient at the star t how m uch tim e will beneeded; similarly, at the close, the patient deserves a sum mary statement regarding observations andthe plan of action. It is important that followup be specified.

Although its goal is largely investigatory, the initial interview can, and should, be therapeutic aswell. Even hum or can have its placein 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 o r data is frustrated.

Eithe r intentionally or unwittingly, the patient obstruc ts or block ades the consu ltants effor ts tosecu re information. W hen this occu rs repeatedly and threatens to disrupt the sequence, consid er

changing gears by ad dressing the process of the interview. For exam ple, Im here to try to be ofassistance, but for the last10 minutes youve refused to allowme to understand what you are feel-ing or experiencing. How will this be helpful to you? The them e isnot necessarily confrontation;rather, it is shifting foc us to theprocess unfolding between th e cons ultant and the patient as op-posed to the pursuit ofdata) .

5. What is the role of corroborative history in the consultation setting?The elderly and cognitively impaired com prise a significant percentage of patients referred fo r

psychiatric consultation. Histories and accounts provided by these patients m ay be m arred or jeopar-dized by question able reliability, altered levels of consciousness, an d cognitive dysfunction in an

otherwise clear sensorium). Accordingly, corroborative or alternative histories often are vitally im-portant in the consultation-liaison setting. The co nsultant is ob ligated to review carefully the avail-able 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 pa-tient is interviewed; c ontac t befo re engag ing the patient can make the co nsulta nt an agent of thefamily and d isrupt the consultants link to the patient.

6. What should be included in the consultation report?The consultation report is a legal docu m ent which shou ld concisely add ress and, hopefully,

answer) the original consultation questions. Lengthy reports typically a re not read by con sultees; the

tendency is to skip to the conclusions an d recommendations. On e strategy, now com mo n with psy-chiatric consultation services, is to present resultant diagno ses and recomm ended actions first, fol-lowed by the case synopsisor sum mary and mental status exam ination M SE). The consultant mustconvey an awareness of the patients medical/surgical issues, but it is not necessary to reiterate thefull chronology of the medical situation. Psychiatrically, the focus should be on the history of thepresent illness, rather than a lengthy reconstruction of early childhood o r adolescent trauma. In m ostcases, no more than a page-long syn opsis of the problem is indicated, in addition to the M SE, differ-ential diagnosis, and recomm endations.

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Elements of the Consultation Report and Su ggested Sequenceo Presentation

Resultant psychiatric diagnosis perDSM-IV) in orderof reason fo r the consultationRecomm endations, prioritized and specificOne page synopsisof the psychiatric problem

Historyof presenting complaint s)Pertinent psychiatric history, including familial and medical h istoryMental status examinationPsychiatric differential diagnosis

7 What psychiatric disorders are most commonly encountered by the consulting psychia-

Formal studies of the distribution of psychiatric diagnoses assigned by psychiatric consultation

Affective disorders primary , or secondary to medical condition)Delirium, dementia, am nesia, other cognitive disordersAdjustm ent disorder maladap tive response to identified stressors,

Somatoform disorders, anxiety disorders, personality disordersData on the the distribution of Axis I1 disordersin consultation-liaison are limited. The interface

of psychiatry and m edicine has long posed problems with regard to psychiatric d iagnosis and nosol-ogy. This is most readily exemplified in the problem of depression emerging in the context of med-ical illness. The usual guidepo sts for the diagnosis of m ajor depression a re sleep, appetite, energy,libido, and the like; such vegetative parameters often are confounded in the medical-surgical pa-tient with a disseminated malignancy or poorly controlled diabetes. Substitute criteria and guidelinesfor jud gm ent s regarding the relative contribu tions of the med ical illness have not achieved strongconsensu s to date. In DSM -IV, clinicians can identify dep ressions as well as psychotic and anxietydisorders due t o m edical cond itions, putting A xis 111 directly in the AxisI diagnosis.

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services show clustering in to a relatively brief list.

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each < 10including medical illness)

8. To what extent are the recommendations of consulting psychiatrists followed?Studies with specific concordance criteria indicatea hierarchy in which more than two thirds of

consultants recommendations for psychotropic medications are implem ented, but only half the di-rectives for diagn ostic steps are instituted. Referring physicians also are unlikely to de mon strate aninterest in, or an appreciation for, the consultants psychiatric diagnoses: fewer than50 of these di-agnoses a re accurately represented in discharge sum maries of the hospitalization.

Thus , the psychiatric consultant can expect heightened receptivity to m anagement suggestions,but less concern fo r proposals that involve further assessm ent and matters of diagnostic classifica-tion. The data suggest that consultees are largely concerned with practical or empiric steps to controlbehavior or improve mood. In the busy medical-surgical setting, the pursuit of psychiatric diagnosisor clarification of psychiatric factors often is overlooked o r set aside. Most strikingly, so m e datasug-gest that medical work-up and management frequently are abbreviated in patients with com orbidpsychiatric 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 factori n

achieving concord ance wo uld be the individual consultants. As s om e consultants a re more skilled,articulate, and compelling than others, it seemed log ical that consultants identities and the particularpairings with referring physicians would be crucial to the outcomes achieved. However, concordanceis not a function of the identities of the consultants or con sultees. Concordance rates are surprisinglyconsistent no matter who performs the two roles. Additionally, concordance w ith recommendationsfor psychotropic drugs or diagnostic actionsis not a function of which classof drug antipsychotic,anxiolytic, or antidepressant) or w hich diagnostic measure laboratory test, procedure,or consulta-tion) is advised.

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What explains concordance? T here is no single or simple answer. However, best concordancerates are achieved when recommendations arebriej prioritized, and unequivocal. Cond itional rec-omm endations i.e., doA if the following things happen) o ften are perceived as a sign of an inde -cisive or uncertain cons ultant. Most co nsulte es want a prag ma tic set of directive s, 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. Itis based in the present. Its objectivesare to identify and strengthen the patients own defensive constellation and proclivities in the short-term ; consultation-liaison CL) is seldom con fron tational. C L work favors an active approach inwhich establishing a direct personal linkage with the patientis vital.

11. What are the usual interventions provided by the consulting psychiatrist?Many regard supportive intervention as the psychiatric consultants primary function: reassur-

ing, comforting, listening, and coordinating. At the heart of the intervention are genuine concern fo rthe patients plight an d a willingness and abilityto empathize. The psychiatrist m ust be attuned tothemes of uncertainty, fear, and aban donm ent. The repertoire mu st include skills in grief work, en-gaging the spouse o r significant other and family, and anticipating the likely progression of events inthe hospitalization and medical course.

In addition, the C L psychiatrist m ust be conversant with a range of psychoph armacologic inter-ventions to manage agitation, delirium, depression, anxiety, drug-induced psychotic disorders, andpsychiatric presentations due to a general medical condition. Regrettably, the use of psychotropicsin the medically ill has had lim ited system atic study. Thu s, the consultant often assu mes liaison oreducational functions with referring physicians and nursing staff.

Psychosocial interventions are empha sized by some clinicians especially in Europe). Cognitiveand behavioral interventions occasionally are employ ed.

Note that 5-10 of CL interventions result in a psychiatrichospitalizatiodtransfer. The numberof patients referred for ou tpatient treatment o r 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 d epres-

sion found in patients without ph ysical disease has only lately gained a measu re of acceptance.Because physical illness confound s many of the vegetative signs by which d epression is routinely di-agnosed, investigators generally have avoided the nosologic an d diagn ostic complexities of medicaldepression. Many have found it sim pler to assume that medical dep ression is the same as primarydepression. How ever, some data sugg est that this is notso:

The prevalence of primary depression in wom en is twice that of men , but medical depressionis equally prevalent in both genders.

Primary depression has strong genetic loading; medical depression appears independently ofof familial affective history.

A shortened REM latency is a useful biologic m arkerof primary depression , but REM latencyhas been shown to be normal in medical depression.

Depression in the medically ill predominantly pathophysiologic rath er than reactive) respondsless favorably to antidepressant med ication than do es primary depression.

13. List some prevalence rates of major depression in medical illness.n several m ajor neurologic illnesses Parkinsons disease, Huntingtons disease, stroke, Alzheimers),

lifetime prevalence rates of major depression are surprisingly consistent(30-50 ). Multiple sclerosisis an exception. In multiple sclerosis, the prevalence of depression in patients with only spinal involve-ment is less than 10 ; for those with cortical disease, the rate of occu rrence of depression excee ds30 . Lifetime prevalence rates of depression in systemic medical illnesses are more variable, rangingfrom 20-30 in diabetes m ellitus and coronary artery disease, and3 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 occu rring in the medically ills a discrete entity,

with features all its ow n. Rather than the old construct that depression is best understood in these pa-tients as a reactive response to the stress of m edical illness, it is increasingly appreciated that depres -

sion may constitute an independent risk factor in the progression of an Axis I11 condition. This hasbeen most sharply demonstrated in recent studies concerning cardiovascular disease. The criticalquestion is whether intervention aimed at the psychiatric condition arrestsor retards the progressionof the Axis 111 condition.

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 dep ression. How ever, suchdata are retrospective rather than prospective. In the medically ill, some traditional tricyclic antide-pressants have questionable efficacy and carry substantial side effects.6,8

Selective serotonin reuptake inhibitors SSR Is) await further study in populations of med-ically ill patients, but hold som e potential benefits include single daily do sing without incre-ments an d a more tolerable side effect profi le) . The com bination of an SS RI and suppo rtivepsychotherapy is a reasonable first stepin the face of medical depression. Su bseq uen t steps maybe necessary as the medical illnes s waxes and wanes, hospitalization con clude s, and add itionalstressors emerge.

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