What is C-L Psychiatry?
Consultation-Liaison (C-L) Psychiatry, formerly psychosomatic medicine, is a subspecialty of psychiatry aiming to bridge the gap between physical and mental health care. C-L psychiatrists work in a variety of settings, both inpatient and outpatient, collaborating with providers from other medical disciplines to provide integrated mental health care for medically and surgically ill patients. The psychiatric consultant must have clinical competency in the physical and neurological disorders that often lead to abnormal emotional states and behaviors. In addition, a competent consultant is a good diagnostician with an ability to supervise and collaborate with a multidisciplinary team, offering the most up-to-date and evidence-based recommendations on psychopharmacological and psychotherapeutic interventions. In addition, the consultant is well informed about federal, state, and regional medicolegal aspects of psychiatric and medical care.
C-L Psychiatrists have additional expertise in a variety of medically and neurologically informed psychiatric disciplines including, but not limited to, HIV Psychiatry, Psycho-oncology, Addiction Medicine, Transplant Psychiatry, Perinatal Psychiatry, Traumatic Brain Injury, Behavioral Neurology, and Neuropsychiatry.
Goals of a Psychiatric Consultation
The five primary goals of the psychiatric consultation, adopted from the Academy of Consultation-Liaison Psychiatry practice guidelines, are:
- To ensure the safety and stability of the patient within the medical environment
- To collect sufficient history and medical data from appropriate sources to assess the patient and formulate the problem
- To conduct a mental status examination and, if applicable, a neurological and/or physical examination
- To establish a differential diagnosis
- To initiate a treatment plan using the biopsychosocial model
Psychiatric Consultation-Liaison Service in Medical Hospitals
An inpatient C-L service is a valuable resource for medical hospitals. Most inpatient psychiatrists work at psychiatric hospitals where patients are admitted primarily for psychiatric disturbances. However, C-L psychiatrists work in the inpatient medical setting where patients are admitted primarily for medical or surgical issues (but not always). The primary role of the C-L psychiatrist is to help medical and surgical teams manage patients who have neuropsychiatric disturbances either as a result of their medical/surgical condition or as a result of an exacerbation of a preexisting psychiatric disorder. Common reasons for psychiatric consultation include Dementia, Delirium, Depression, Substance use disorders, or psychiatric sequelae of primary neurological diseases (e.g., Parkinson’s disease, Huntington’s disease, Traumatic Brain Injury, Epilepsy, etc.)
Workflow of an Inpatient Psychiatric Consultation-Liaison Service
Psychiatry Consultation Requests From Other Medical Teams
Medical and surgical teams usually request a psychiatric consultation by either calling the service directly or by placing a consultation request in the electronic medical record. Upon receiving the consultation request, the first step for the C-L psychiatry team is to contact the team directly to discuss the case and clarify the reason for consultation. It is important to confirm that the team requesting the consultation has informed the patient about the consultation and reason for consultation. It is unprofessional, inappropriate, and damaging to the therapeutic alliance for the consulting psychiatrist to visit the patient’s room without the patient being informed first.
What To Ask
When clarifying the consultation request, ask about the patient’s specific behaviors rather than asking about specific disorders. For example, instead of asking “is the patient depressed or anxious?” it is much more useful to ask “what is the patient saying or doing that is concerning to you?” By asking the question this way, it allows the primary team to express their concerns more generally so the consultant can help focus the question. Consider the following conversation as an example:
Consult Psychiatrist: “Hello, this is Dr. Ingram from the psychiatry team. We have received your consult request and would like to discuss the case to get a better idea of how we can help you.”
Primary Team: “Hi! Thank you for calling. We have a patient who appears very depressed and lethargic. We are concerned about her and believe she would benefit from seeing a psychiatrist while in the hospital.”
Consult Psychiatrist: “Sounds concerning. Thank you for allowing us to help. Would you mind telling me a little bit about the patient’s history and why she was brought to the hospital to begin with.”
Primary Team: “Sure. This is a 74 year old female with history of diabetes, coronary artery disease, hypertension, and alcohol use who was brought in 3 days ago by her husband for unexplained weight loss, generalized weakness, and poor appetite.”
Consult Psychiatrist: “What is the patient’s baseline level of functioning prior to coming in to the hospital. The patient’s husband would be the best source to find out what she is like normally and whether this is an acute change or an insidious change.”
Primary Team: “We haven’t spoken to the patient’s husband yet. Can you call him we are very busy?”
Consult Psychiatrist: “We are happy to help but need additional information to help guide us so that we may best assist you. Before we see the patient, please reach out the the patient’s husband and find out what she is like at baseline and let us know as soon as you find out. In the meantime, can you describe her to me? What is she saying and/or doing that is concerning you?”
Primary Team: “She just looks depressed. She isn’t really talking with us or making eye contact. She isn’t eating or drinking. When we enter the room, she opens her eyes briefly and looks our way then closes them again. She didn’t actually say she was feeling depressed, we are just concerned she might be. Or maybe something else is going on?”
Consult Psychiatrist: “This is very helpful. Let’s work together to see if we can help her. We will review her chart and evaluate her but in the meantime, please call the husband and find out how the patient functions at home. Here is my pager number for more direct communication. Is there a good way to contact you?”
Primary Team: “Sounds good. Here is my contact information. We will get the information you need. Thank you for your help!”
In the above scenario, the initial consult request was for “depression,” but it is clear after asking a few simple questions that there may be more going on than just depression. The patient may be experiencing an episode of hypoactive delirium, catatonia, severe depression, or other neurological insult such as stroke, seizure, etc.
Clarifying the reason for consultation gives the consulting psychiatrist key information to help focus the assessment.
After receiving the consultation request and clarifying the reason for consultation, the psychiatrist should review the patient’s chart in the electronic medical record with special attention to the initial H&P, notes from any other mental health providers, neurology notes, and the most recent progress note from the primary team. Vital signs, pertinent labs and imaging should be reviewed. Additionally, any available collateral information should be reviewed. If the consultant finds additional labs or imaging necessary, he or she may recommend ordering these labs or imaging prior to assessing the patient.
Evaluating The Patient
Upon arriving at the patient’s room, it is important to wash your hands. Note any special precautions outside of the room and, if a sitter, rounder, or nurse is present, ask about the patient’s behavior. This not only prepares the consultant for the initial interview but also gives the consultant important information about the patient’s behaviors over a longer time frame.
When entering the patient’s room, verify the patient’s name and introduce yourself immediately by stating your name, your specialty, and the reason you are there. Next, ask the patient’s permission to enter the room. Whenever seeing patients at bedside, always find a chair and sit down. There is good evidence that sitting down in patient’s room, regardless of time spent, communicates to the patient that you are there to listen and that you care about them. Interestingly, most patients will believe that you have spent a significant amount of time with them if you sit down next to them, even if it’s only for a few minutes!
Next, ask the patient what his or her understanding is about why he or she is in the hospital and the reason for psychiatry involvement. Then, try asking an open ended question such as, “How can we help you?” It is recommended to allow the patient to speak for 2-3 minutes uninterrupted before asking more focused questions. Obtain a focused history and if necessary, a neurological and/or physical examination.
Prior to ending the encounter with the patient, be sure to ask the patient what their goals are and review the treatment plan and future steps with them to keep them informed. Lastly, obtain informed consent for calling collateral and for psychotropic medications, if necessary.
As part of the evaluation and with permission from the patient, it is always good practice to call the patient’s family, close friends, neighbors, or other healthcare providers for more information.
Communicating With The Primary Team
Immediately after evaluating the patient and/or once recommendations have been formalized, the consultant should call the primary medical or surgical team directly and inform them of these recommendations. In addition, be ready to answer any questions that may have come up. Lastly, it is important to inform the rest of the psychiatric team about the treatment plan, including any new diagnoses or legal status changes (for example, the patient needs to be on a psychiatric hold for danger to self, danger to others, or grave disability OR an existing psychiatric hold can be discontinued as the patient no longer meets psychiatric hold criteria).
Consultation-Liaison Psychiatry Practice Guidelines
- Levenson, James L. Essentials of Psychosomatic Medicine. Washington, DC: American Psychiatric Pub., 2007. Print.
- Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
- Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
- Arciniegas, Yudofsky, Hales (editors). The American Psychiatric Association Publishing Textbook Of Neuropsychiatry And Clinical Neurosciences. Sixth Edition.
- Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
- Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. Sixth Edition
- Academy of Consultation-Liaison Psychiatry (ACLP): www.clpsychiatry.org