Basics for Physicians and Psychiatrists for Effective Practice of Consultation-Liaison Psychiatry Services.

INTRODUCTION

In India, most psychiatry training occurs in General Hospital Psychiatric Units (GHPUs).[1] These units provide ample scope for the practice of consultation-liaison (CL) psychiatry. Despite the existence of GHPUs for a long time, CL psychiatry has not received as much attention as it deserves in India. At most places in India, the CL psychiatry services are not well developed.[1] Overall the referral rates to the CL psychiatry services are low.[1]

There could be many reasons for low referral rates to the psychiatrists. This guideline examines the various issues related to the practice of CL psychiatry, which can be considered as a barrier to the practice of CL Psychiatry and resultant lower referral rates. Accordingly, certain recommendations are being made, both for the psychiatrists and the physicians, to improve CL psychiatry practices and improve collaborative care.

PSYCHIATRY MORBIDITY IN MEDICALLY ILL PATIENTS

Psychiatric morbidity in patients with various medical-surgical illnesses or among those attending the medical-surgical setting is widespread. The psychiatry morbidity among medically ill inpatients is estimated to be about 30%, whereas the same is estimated to be 50% among those attending the primary care setting.[2] The incidence of delirium among critically ill patients admitted to intensive care units (ICUs) and requiring mechanical ventilation could be as high as 80%.[3] The psychiatric morbidity in persons with medical illnesses is associated with multiple negative outcomes, in the form of higher utilization of health-care services, prolonged hospital stay, frequent hospitalizations, poor adherence with medication, and higher and earlier mortality.[456] If one takes the example of delirium, the available data suggest that delirium is associated with higher rates of mortality (even after controlling for all possible confounders),[7] a significant increase in the length of hospital stay,[8] increased health-care costs,[9] increase in institutional care,[10] and an increase in functional decline.[11] Delirium has also been a significant risk factor for dementia.[12] The experience of delirium is also very distressing for the patients and the caregivers.[13141516] However, all medically-surgically do not receive psychiatric consultation.

WHAT ARE THE PSYCHIATRY REFERRAL RATES?

Unfortunately, most psychiatry morbidity is missed, and only a tiny proportion of the patients having psychiatric morbidity are referred for psychiatric consultations. The rates of consultation for psychiatric conditions vary among different institutions, and these have been reported to be as low as <1% to as high as 13%.[2] A study from India showed that although the prevalence of delirium in the ICU was 68.5%, the referral rate from the same ICU was only 1.71%.[17] Another study involving elderly patients presenting to the medical emergency showed a prevalence of psychiatric morbidity among 65.5% of the participants. In contrast, referral rates from the same setup were only 2.4%.[1819] A review of data from India suggests that the referral rates from the inpatient setting across different institutes vary from 0.01% to 3.6%, for emergency setting the same range from 1.42% to 5.4%, and at the outpatient setting range from 0.06% to 7.17%.[20] The lower referral rates could be attributed to a wide range of barriers.

WHAT ARE THE BARRIERS TO MAKING PSYCHIATRY REFERRALS?

The barriers to the psychiatric referrals could be at the level of the physicians, patients and/or their relatives, and the psychiatrists. In terms of the physician-related barriers, one of the primary reasons for missing out on this psychiatric morbidity and resultant lower referral rates includes insufficient exposure to psychiatry during the undergraduate training and subsequent training. Other reasons for missing out the psychiatric morbidity include a negative attitude of the physicians toward mental disorders,[21] and considering the mental health outcomes of physical illnesses as expected outcomes, improving with improvement in physical health. Data also suggest that physicians and surgeons do not refer their patients for psychiatric consultation.[22] This could be due to the physicians’ belief that their patients may consider them incompetent if they refer their patients to other specialists. Other factors that also possibly influence patients’ referral with psychiatric ailments to the mental health professional include losing a patient, managing whom, perhaps does not require much effort on the part of the physician. Stigma toward mental illness among physicians and the general public could also be responsible for lower referral rates to a mental health professional.[2324] On the other hand, having better knowledge about mental illness and using antidepressants are also associated with lower referral rates.[25] The clinician’s variables that are associated with higher referral rates include being female, considering psychotherapeutic intervention to be effective, and using psychosocial techniques in managing their patients.[26]

Available data suggest that patients/caregivers do not take the psychiatry referral very constructively and do not comply with the same.[27] Some studies suggest that young, male, and those from low-socioeconomic status patients less often attend the psychiatric services after being referred. Other factors linked with poor adherence to the psychiatric referral include transport and rapport issues with the primary physician.[2829] The commonly reported reasons on the part of the patient for not attending the psychiatric services include forgetting, illness, work commitments, and clerical errors.[30]

The lower psychiatric referral rates can also be due to the attitudinal problems at the level of the psychiatrists, which can include their discomfort in evaluating patients with physical illnesses. Psychiatrists often do not routinely carry out a physical examination of their patients in every visit. It is suggested that this attitude of the psychiatrists has given rise to CL psychiatry subspecialty, which does not exist in any other branch of medicine (Sartorius, 2013). Some psychiatrists are even scared to manage primary psychiatric illnesses with comorbid physical diseases.[31]

So, in a nutshell, it can be said that there are many barriers at the physicians, patients/relatives, and the psychiatrists that influence the psychiatry referrals.

BARRIERS IN ACCEPTING PSYCHIATRIC REFERRALS BY THE PSYCHIATRISTS

In some settings, it is also seen that psychiatrists do not prefer to accept psychiatric consultations because of perceived unnecessary responsibility. At times, it is seen that the physicians or surgeons request the psychiatrists to shift the patient with delirium to the psychiatry inpatient setting,[32] which possibly arises due to their poor understanding of the etiology and management of delirium.[33] Similarly, many physicians refuse to see patients with psychiatric ailments, even though they come with physical symptoms. Data from the United States suggest that nonmental health professionals have negative attitude towards people with mental illnesses, that influences clinical decision-making, providing services, and treatment adherence.[34] Similar data is also available from India to suggest that physicians negatively affect patients with mental illnesses.[21] Due to this, psychiatrists are sometimes not prepared to take primary responsibility for the patients with physical comorbidities. However, providing collaborative care could be more beneficial for the patients.

CONSULTATION-LIAISON PSYCHIATRY SERVICES: DEVELOPED COUNTRIES VERSUS INDIA

In developed countries, a CL psychiatrist is often consulted for the patient care; teaching and training the other specialists, primary care physicians, nurse, and other nonmental health professionals; supervising the clinical work of the specialists, physicians, primary care health workers; resolving crisis (interpersonal problems) between patient/family members and other treating team members, between different members of treating team and research. The psychiatrists provide these services on an on-call basis or as an in-house psychiatrist or a psychiatrist sitting remotely and providing the services through telepsychiatry.[35] In contrast to this, in India, most CL psychiatry is practiced as on-call services or referral of patients with medical illnesses to the psychiatry outpatient services.[32] Further, providing CL services in India does not involve much discussion between the psychiatrists and the consultee in terms of talk about the patient or any kind of academic discussions to improve the physicians’ knowledge about mental disorders.[3236] Accordingly, it can be said that the CL psychiatry services in most of the institutes in India are cursory.

IS THERE A NEED TO IMPROVE THE REFERRAL RATES AND PRACTICES IN THE INDIAN SETTING?

The answer to this question is a definite “yes.” However, this can only happen if both the physicians and psychiatrists are prepared to work as a team to improve the outcome of their patients. This requires a lot of attitudinal change among the physicians and also the psychiatrists. The physicians need to understand the basic principles of how and when to make a psychiatry call and prepare their patients for a psychiatric evaluation. On the other hand, the psychiatrists also need to be aware of the basic principles to carry out a psychiatric referral.

WHAT CAN PSYCHIATRISTS DO TO IMPROVE PSYCHIATRIC REFERRALS?

It is suggested that a referral can only be effective if there is an excellent consultee-consultant relationship, which involves awareness about the needs and idiosyncrasies on the part of both the consultee and the consultant.[37] This can only be achieved by one-to-one interaction with each other while working in a hospital. The other important thing that can improve the physicians’ referral rates includes their awareness about the available mental health care services and competent psychiatrists/mental health professionals in their setting.[37] Hence, psychiatrists should make their colleagues aware of the availability of mental health services, including CL psychiatry services and psychotherapeutic services. These can help in improving the referral rates. The psychiatrists should also take the physician’s perspective, i.e., understand that the physician-surgeons have to deal with patients with different kinds of medical emergencies, where timely care can save people’s lives. Hence, people with psychiatric ailments are not a priority for physicians. Communicating to the physicians that you are aware of their situations and their preferences can help build healthy working relationships, which can go a long way in building beneficial CL psychiatry services and practices. Hence, whenever a physician makes a call, psychiatrists should timely evaluate the patient and discuss the issues of the patient and appreciate how the timely referral by the physician-surgeon to the psychiatric service has helped the patient. Another vital aspect that psychiatrists should keep in mind is to make clinicians aware that all their interventions and efforts can go in vain if the psychiatric morbidity is not recognized. For example, if the psychiatrist can communicate to a surgeon that if the delirium is not recognized and treated, it is associated with increased mortality, irrespective of the surgeon’s effort in carrying out a meticulous surgery postoperative care. This kind of information is more likely to get the physicians’ and surgeons’ attention than just harping physicians’ not recognizing the psychiatric morbidity and not referring patients to psychiatrists.

The psychiatrists should not expect the physicians and surgeons to carry out a detailed psychiatric evaluation and make a psychiatric diagnosis. Instead, the psychiatrists should make the clinicians aware of screening questionnaires or simple questions to ask the patients or their caregivers to screen patients for various psychiatric ailments. Similarly, the psychiatrist should also help the clinician pick up certain behaviors (poor eye contact, disorientation, forgetfulness, restlessness, sleep disturbances, anxiety, etc.) in the routine clinical practice to consider the possibility of a psychiatric disorder. The psychiatrists should also respond to the phone calls and messages, including E-mails, from the physicians’ colleagues to strengthen the working relationship and feel that they can be relied upon at the time of need. Once the patient is referred to the psychiatrist, they should diligently follow-up with the patient and update the physician colleague about their progress.

Further providing feedback about the anticipated problems (example, patients or relatives unhappiness with the primary treating team) or ongoing problems (example, interpersonal problems between patients/relatives with the treating team) to the clinicians can further help in improving the collaboration. The psychiatrists should also refrain from not accepting the calls, even when the referrals overload them. Taking the call and discussing the situation can be further helpful.[37] Additionally, psychiatrists should be understanding of the issue, if a patient has a severe mental disorder, and the clinician is uncomfortable in keeping the patient in their ward. In that case, the psychiatrist should have a reasonable threshold for managing the patients with comorbidities in a psychiatric setup. The physicians are prepared to review the patient from time to time and take over the patient in case of a medical emergency. If this is not possible, the psychiatrist should address the physicians’ concerns, including violence, agitation, suicidality, etc., while managing a patient with a severe mental disorder in a medical ward. A regular proactive follow-up of the patient can help build the physicians’ confidence and develop a long-term strategy for managing patients with comorbidities. While evaluating the patients referred from a physician, especially in private practice, the psychiatrist should reassure the patient that their physicians have not abandoned them and they can go back to their clinicians. If the patient requires a psychotropic medication, discussing the drug interactions often helps in collaboration. Usually, the physicians are themselves interested in managing patients with medically unexplained symptoms (MUS) or those with depression or anxiety. In such a situation attending the calls and guiding the clinicians to use the psychotropics and principles of psychological therapies can further help in improving collaboration. A final word of caution, even if a patient with a psychiatric ailment has been managed for a long duration by the physician and has possibly led to delayed or incorrect treatment, the psychiatrist should refrain from criticizing the physician.

Another critical aspect that requires the attention of psychiatrists is to discuss the issue of preparing the patient and the family members for a psychiatric consultation with the physicians from time to time. At times the physicians tend to refer the patient without a clear explanation to the patient. Further psychiatric referrals vary for medically ill inpatients or medical-surgical emergency and those attending the general physician at the outpatient with MUS.

In patients with MUS, the clinicians consider referral a good way of reassuring or thinking an effective strategy when they feel pressurized. At times referral to a psychiatrist is considered when the patient becomes demanding or starts blaming the physician for lack of improvement in their symptoms.[3839] A psychiatry referral in the case of MUS is often interpreted as, “I don’t believe you” or “You’re deliberately making this up.”[39] Clinicians often find the patients with MUS as “difficult,” vexing, and unappealing to treat. The clinicians at times end up mentioning that “nothing is the matter” that instills adverse reactions and anxiety in patients. At times clinicians believe that “patients are reluctant to have their psychosocial lives intruded upon,” but studies of patient’s expectations and wishes suggest otherwise. Due to this, they do not explore these issues.[38] Available evidence indicates that patients discuss stress in their life. Still, physicians do not give much importance, are not interested in listening to the same, feel they are incompetent to handle the issues, do not fall in their purview, and are more interested in prescribing a pill.[38] The clinicians should follow certain basic principles in dealing with patients presenting with MUS or psychiatric disorders [Table 1]. A simple model which can be followed in evaluating the patients include the “BATHE” model [Table 2]. Further, the clinicians should be made aware that reassurance should not involve telling the patients things like, “nothing is wrong with you, you are absolutely fine, investigations have ruled out any abnormality, nothing much can be done about these symptoms, the symptoms could be due to psychological reason,” etc.

Table 1

Assessment and management principles to be followed by the physicians-surgeons in dealing with patients with medically unexplained symptoms and psychiatric disorders[38]

• Is this some emotional distress presenting as physical distress?

• Resist the impulse to label and dismiss the patient

• Spend more time in face-to-face exchange with the patient

• Allow the patient to narrate

• Do not interrupt the patient while speaking

• Encourage the patient to “tell me more” - A simple intervention sufficient to widen the discussion beyond a narrow litany of bodily symptoms

• Ask about “personal” concerns

• What is the patient’s model of illness? - Illness belief and perception of symptoms

• Is the patient in a predicament of some sort? consider especially dilemmas - Domestic violence, sexual/physical/emotional abuse, bullying, isolation, poverty

• Social, functional level, strain, and coping

• Avoid being in haste

• Carry out the physical examination in each visit

• Avoid premature proposals of psychological interpretation or referral

• Do not expect cure - Expecting to cure the “incurable” generally leads to exasperation, while a caring, rather than curing, approach to the patient is likely to produce an improvement over time

• Expectations from treatment and investigations

• Who are the patient’s allies?

Table 2

Background affect trouble handling empathy model for assessing patients presenting with psychosomatic problems or medically unexplained symptoms[40]

• B: Background - What is going on in your life? And what brings you in here today?

• A: Affect - How do you feel about that?

• T: Trouble - What bothers you the most about this situation?

• H: Handling - How are you handling it?

• E: Empathy - It must be very distressing for you

It is important to remember that the patients would not accept psychiatric consultations without a clear explanation to the patient and the relatives. The clinicians should be aware that making a psychiatric referral is not similar to making a referral to a pulmonologist or a cardiologist.[37] The patient may perceive a psychiatric referral as being considered as “mad.” Hence, the clinicians should prepare the patients for a psychiatric consultation. The preparation of patients/relatives for psychiatric consultation requires tact, time, and explanation.[37] If the clinicians have evaluated the ongoing stress in the life of the patient, then they can say that - ”I feel that stress in your life is also contributing to your symptoms. According to the available medical knowledge, stress can influence all life experiences, including pain, blood sugars, blood pressure, etc. Hence, I feel there is a need to have a further evaluation of your stress. As I sought the cardiologist’s opinion for your high blood pressure in the recent past, I also feel the need to consult a specialist, an expert in dealing with stress and its effect on the body. Even after you have seen the stress specialist, I would continue to see you and possibly implement the suggestions given by the specialist”. If the patient is receptive to this suggestion, the clinician can say that the stress specialist, I referred to is the Psychiatrist. Other ways to persuade the patients to see a psychiatrist are to say that - ”We cannot find a cure for your symptoms, but we need to help you find a way to live with them.”[41] Further, the clinicians should be made aware that, rather than saying that I am referring you to a psychiatrist, they can say something like, “Do you mind if I seek a second opinion from one of my colleagues, who can help me in understanding your illness/symptoms.”

Further, if you want, I can call him/her. The physician can make an actual call, and have a brief discussion in front of the patient as this can be more reassuring. It is important to note that patients and relatives may find the initial suggestion of psychiatric referral as awkward. At times, it is suggested that the physician can walk along with the patient to the psychiatrist’s office to build the patient’s confidence.[37] While making a referral, the clinicians can also assess the patient’s and relative’s views about psychiatry. Many times, they have distorted beliefs about psychiatrists and psychiatry. Addressing these issues can be very reassuring to the patients and the caregivers.

THINGS WHICH PHYSICIANS SHOULD DO BEFORE SEEKING A PSYCHIATRIC REFERRALS

An important issue, which is often encountered in the medical-surgical ward or emergency setup, is the request for psychiatric evaluation without patient being properly assessed by the physicians/surgeons themselves. This is usually seen for patients presenting with psychiatric symptoms or patients already diagnosed with mental illness and are under follow-up with the psychiatrist. Although understandably, the physicians and surgeons are under a lot of pressure to manage other life-threatening medical emergencies, there is a need to also focus on the mental health aspects of every patient to provide holistic care to the patients and their families. Hence, it is crucial to have basic knowledge about psychiatry and understand that medical illnesses can give rise to psychiatric emergencies like delirium and agitation. Patients with psychiatric ailments can have a medical emergency. Accordingly, should not discriminate against patients with mental illnesses or those presenting with psychiatric symptoms. These patients should be evaluated like any other patient before seeking an opinion of a psychiatrist. Referring a patient to a psychiatrist without proper assessment can put off the psychiatrists in timely response to the physicians’ calls and be counterproductive for collaborative care. At times, it is also seen, especially for patients with delirium or agitation, the physicians/surgeons recommend the use of injectable antipsychotics like haloperidol without proper evaluation or investigations. At times, antipsychotics can lead to QTc prolongation and sudden death. Other issues which emerge include not giving enough time to the psychiatrist to evaluate the patient. This mainly arises in making a call for the patient when the discharge from the inpatient setting is already being planned. This practice for patients who come with self-harm or poisoning could be very much counterproductive for the patients, especially when they have severe mental illnesses and are still suicidal. Hence, in such a scenario, a timely referral to the psychiatrist gives enough time to the psychiatrist to plan, intervene, and consider the patient’s admission. Another issue, which is sometimes encountered during the CL psychiatry practice, includes physicians not trusting the psychiatrist’s opinion, especially while managing patients with delirium. The physicians may often demand the psychiatrist to shift the patient to the psychiatric setup. This is usually a point of contention, and physicians-surgeons need to understand that delirium is a medical emergency due to underlying medical cause but with psychiatric manifestation. One of the most critical aspects of the management of delirium is the treatment of underlying medical illnesses, besides the nonpharmacological measures. Psychotropics should be used only in a small proportion of patients. Considering all these issues, physicians/surgeons should try to follow the ten commandments for seeking psychiatric opinion [Table 3] as these can help in improving collaborative care.

Table 3

10 commandments to be followed by physicians for referring a patient to a psychiatrist

• Improve your skills for basic psychiatric evaluation (and management) of the patient

• Do not initiate a call without examining the patient

• Do not initiate a consultation without informing the patient/caregiver

• Do not intervene without basic evaluations/investigations

• Trust the psychiatrist opinion

• Give enough time to the psychiatrist to evaluate, intervene and manage

• Do not stigmatize a patient with mental illness

• A patient with a psychiatric ailment can present with a medical emergency

• A patient with a medical emergency can present with psychiatric symptoms

Believe in collaborative care, rather than fragmented care

HOW TO REFER A PATIENT TO A PSYCHIATRIST

Different models of psychiatry referrals are followed in various institutes. These include sending a written call, paging a message, using a short message service, or making a telephonic call. Over the years, the consultation process has shifted to making a telephone call, which provides an opportunity to both the consultee and the consultant to interact and understand the need for and expectations for a psychiatry referral. However, due to the time constraints and other competing interests, the phone is limited to informing the psychiatrist as “come and see patient on bed number XX.” Ideally, the phone call should involve disclosing information about self (i.e., who is making the call), providing information about the patients’ demographic details, any anticipated language issues, primary physical illness and the reasons for admission, what are the psychiatric concerns for which a psychiatric consultation is sought and what is the urgency of the assessment [Table 4]. Having this information helps the psychiatrists prepare themselves for the psychiatric consultation and improves collaboration between the physician and the psychiatrist.

Table 4

Information to be given to the psychiatrists at the time of making a psychiatry referral

• Details of the person seeking opinion

• Patient’s demographic details (name, date of birth, hospital number)

• Anticipated language barriers

• Location in the hospital

• Patient’s primary diagnosis

• Reason for admission

• Psychiatric concerns and reason for referral

• The urgency of the assessment

HOW TO PROVIDE OR CONDUCT A PSYCHIATRIC CONSULTATION IN CONSULTATION-LIAISON PSYCHIATRY SETUP

Another critical aspect of providing psychiatric consultation includes the actual behavior of the psychiatrist at the time of receiving a call. Irrespective of the tone of the physician-surgeon, the psychiatrist is expected to be polite and collect the required information, which can help provide the necessary care for the patient and collaborate with the physician. The psychiatrist should seek further clarification to understand the patient/relatives’ awareness about the psychiatric consultation [Table 5]. If the patient/relatives have not been informed about the psychiatric consultation, the psychiatrist should urge the physician/surgeon to inform the patient/relatives about the psychiatry referral. The psychiatrists should always clarify to the physician/surgeon that the patient/relative have the right to refuse a psychiatric consultation. Other issues that the consultee could clarify include the timing of the ward rounds and schedule for the patient in terms of a patient being sent out of the ward for investigations or interventions. It is also pertinent to inquire about the availability of a quiet room or space where the patient’s privacy can be ensured, and they can be interviewed for mental health issues.[42] However, it is important to note that, in many places, especially in the inpatient setting, a quiet place may not be available. The psychiatrist should be flexible in assessing any environment. Further, on receiving the referral, it is usually a good practice to inform the consultee about the estimated time frame to attend the call.

Table 5

How to receive a psychiatric referral[42]

• Respond politely

• Seek further clarification on the issue for which consultation is sought

• When the patient will be available

• Are there any challenges to communication, such as a language barrier, tracheostomy, or other medical devices

• Has the referral been discussed with the patient and/or caregiver and whether the patient has consented to be seen by psychiatric services

• The patient has the right to refuse psychiatric assessment, and this should be respected if possible

• Ask the consultee to document in the file – The reason for the call

• Problems faced by the treating team in dealing with the patient/caregivers-is the referral an outcome of frustration on the part of the treating team

• The urgency of the need for consultation

Although the psychiatrists are very well versed with the basic principles of providing consultations, specific facts must be remembered while giving psychiatric consultation in the CL psychiatry setting [Table 6]. In contrast to other settings where the consent is implied as the patient’s walks to the psychiatrist, in the CL psychiatry setting, the psychiatrist evaluates a patient in the medical surgical ward. At times, the patient may not be aware of the psychiatry consultation. In terms of carrying out the consultation in the CL psychiatry setting (primarily in an inpatient setting), the psychiatrist should first review the available treatment records of the patient. The review of treatment records can provide invaluable clues about the possible factors contributing to the psychiatric manifestation. It is important to discuss with the consultee about their views about patients symptoms, the possible diagnosis, factors responsible for the symptoms of the patients, issues between the patient/relative and the treating team, required investigations, required environmental changes (for examples things to be done for patients with delirium or those who are suicidal) [Table 6]. It is also important to remember to convey the diagnosis and plan of management to the patient and their relatives and their role in the management [Table 6]. Pasnau[43] proposed Ten Commandments of medical etiquettes for psychiatrists [Table 7], which can be very helpful in effective management of the patients in the CL psychiatry setup.

Table 6

How to carry out a psychiatry consultation in the consultation-liaison psychiatry setting

• Review the treatment records in terms of the physical symptoms, diagnosis, available investigations, sleep chart, nurse’s observation records

• Introduce yourself to the patient and relative and seek verbal consent for carrying out a psychiatric evaluation

• If the patient lacks competence, ensure that you have the consent of the caregiver/relative for carrying out a psychiatric consultation

• Look for a private area to interview the patient/caregivers to ensure privacy: Quiet side-room creates a more conducive environment for carrying out a proper assessment

• Obtain a detailed history in terms of onset of the symptoms, type of symptoms including sleep-related issues, fluctuation of the symptoms, the relationship of the symptoms with treatment-emergent problems (for example, disclosure of a diagnosis, feeling of not being cared for, etc.)

• A thorough physical examination

• A detailed mental status examination

• Essential things to cover while assessing a patient: Self-reported symptoms, cognitive functioning, catatonic features, type of comorbidities present, substance use (quantity, last intake) including withdrawal/intoxication, medication overdose, and withdrawal, suicidality, sexual behavior, poisoning, trauma, nutritional issues, infections

• Once the interview with the patient and relatives is done, look for association of symptoms with treatment-related issues, including ongoing medications/starting of new medication, surgical intervention, hospitalization, disclosure of diagnosis, the behavior of the treating team, discrepancy in expectations from the treatment and the treatment received, impact of the environmental factors (lights, sound, indwelling tubes, neighboring patients/relatives)

• Talk to the consultee and other treating members about their views about the possible symptoms and contributing factors

• Provide feedback to the consultee about the consultation

• Inform the consultee about what all investigations you require (before considering a pharmacological intervention), what pharmacological management you are considering, required environmental changes including the institution of high suicidal risk, need for transfer of the patient to the psychiatry ward, and what all will be needed for you to consider the transfer of the patient to the psychiatry ward

• If there is an interpersonal issue or you are anticipating an interpersonal problem that may arise between the primary treating team and the patient/relatives-inform the primary team to address the same

• Prescribing: Should take into account medical Illnesses, ongoing medications, psychiatric symptoms, possible drug interactions

• Inform the patient about the possible diagnosis and management plan

• Inform the relatives/caregivers about the likely diagnosis and management plan and their role in the management of the patient’s problems

• Document the consultation in the primary treating team medical records and maintain separate treatment records for yourself

• Review the patient from time to time

• Follow-up, the patient even after discharge from the inpatient unit

Table 7

10 Commandments for consultation-liaison psychiatrist[43]

• Thou shalt love thy fellow physician as thyself: Talk to the consultee to understand the reason for referral and what they are expecting from the psychiatrist

• Thou shalt not procrastinate: Respond in a timely, inform about the time frame in which the referral will be attended to

• Thou shalt not obfuscate: Do not use jargon or irrelevant psychiatric details, write notes succinctly by using simple language which any physician can understand

• Thou shalt be concrete: Treatment recommendations are written clearly, which can be easily implemented by the physician

• Thou shalt honor thy patient’s spouse, children, and parents: Always involve the available family members and address their issues and inform them about their role in the management

• Thou shalt not hibernate: Discuss the findings and the treatment recommendations with the consultee

• Thou shalt persevere: Follow-up the patient during the hospital stay, and if required after that too

• Thou shalt not preach: Do not try to teach or give unnecessary advice to the physicians

• Thou shalt not steal thy fellow physician’s patients: Discuss with the consultee about the need for the long-term psychiatric treatment, discuss with the consultee about who will be the primary physician for the patient in long-term

• Thou shalt not shirk thy duty to thy hospital medical staff or thy local medical society: The psychiatrists should accept the leadership role and take part in the decision making of the organization

CONCLUSION

CL psychiatry is a young subspecialty of psychiatry, which deals with assessing and managing psychiatric issues in persons with various medical and surgical illnesses. Despite the high prevalence of psychiatric morbidity in persons with medical and surgical diseases, the referral rates to psychiatrists are dismal. The lower referral rates can be attributed to the different kinds of barriers at the level of the psychiatrists and physicians. There is a need for attitudinal change, both at the level of the psychiatrist and the physicians, to overcome some of the barriers. It is expected that overcoming the barriers with the attitudinal change, both in the physicians and psychiatrists, can help improve the referral rates and better collaborative care to improve the outcome of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.