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practice guidelines for psychiatric consultation in the general medical setting

practice guidelines for psychiatric consultation in the general medical setting

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02/04/2013

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S8
PSYCHOSOMATICS

The Academy of Psychosomatic Medicine
Practice Guidelines for Psychiatric Consultation
in the General Medical Setting

HAROLD E. BRONHEIM, M.D., GEORGE FULOP, M.D.

ELISABETHJ. KUNKEL, M.D., PHILIPR. MUSKIN, M.D.
BARBARAA. SCHINDLER, M.D., WILLIAMR. YATES, M.D.
RICHARDSHAW, M.D., HANSSTEINER, M.D.
THEODOREA. STERN, M.D., ALANSTOUDEMIRE, M.D.

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate
and manage patients with medical illnesses. The guideline is intended to delineate the
knowledge base, professional expertise, and integrated clinical approach necessary to
effectively manage this complex and diverse patient population. This guideline was
drafted by a work group consisting of psychiatrists with clinical and research expertise
in the \ufb01eld, who undertook a comprehensive review of the literature. The guideline was
reviewed by the executive council of the Academy of Psychosomatic Medicine and re-
vised prior to \ufb01nal approval. Some of the topics discussed include quali\ufb01cations of C-L
consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharma-
cotherapy), medicolegal issues, and child and adolescent consultations.

(Psychosomatics 1998; 39:S8\u2013S30)

From the Division of Consultation and Behavioral Medicine, Department of Psychiatry, Mt. Sinai Hospital, New York; Merck-Medco Managed Care, LLC, Montvale, New Jersey; the Department of Psychiatry, Jefferson Medi- cal College, Philadelphia, Pennsylvania; the Division of Consultation-Liaison Psychiatry, Columbia-Presbyterian Medical Center, New York; the Department of Psychiatry, Allegheny University Medical Center, Philadelphia, PA; the Department of Psychiatry, University of Oklahoma Health Sciences Center, Tulsa, Oklahoma; the Department of Psy- chiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California; the Avery D. Weisman, M.D., Psychiatry Consultation Service, Massachusetts Gen- eral Hospital, Boston, Massachusetts; and the Emory Central Clinic-Section of Psychiatry, Atlanta, Georgia. Address re- print requests to Dr. Bronheim, 1155 Park Avenue, New York, NY 10028.

Copyright\ue001 1998 The Academy of Psychosomatic
Medicine.
The purpose in developing psychiatric con-
sultation guidelines is to broadly instruct

and guide practitioners who care for patients with psychiatric symptoms in a general medical setting. These guidelines will review the assess- ments and interventions that are necessary for management of patients with comorbid medical and psychiatric conditions. The development of guidelines for psychiatric consultation is impor- tant because signi\ufb01cant numbers of patients with unrecognized, yet serious, neuropsychiatric dis- orders are inadequately assessed and managed, and psychological distress induced by the highly technological world of the general medical set- ting is often ignored.

These guidelines are not intended to delin- eate universal, professionally mandated regula- tions and actions. Instead, they are meant to serve as an outline for the training and knowl-

Practice Guidelines
VOLUME 39\u2022 NUMBER 4\u2022 JULY\u2013AUGUST 1998
S9
edge that are generally necessary to guide the
clinician\u2019s approach to the patient.1

In general, the aims of psychiatric consul- tation in the medical/surgical setting are 1) to ensure the safety and stability of the patient within the medical environment, 2) to collect suf\ufb01cient history and medical data from appro- priate sources to assess the patient and formu- late the problem, 3) to conduct a mental status examination and neurological and physical ex- aminations as necessary, 4) to establish a differ- ential diagnosis, and 5) to initiate a treatment plan.Consultation-liaison (C-L) psychiatry is the

subspecialty of psychiatry concerned with med- ically and surgically ill patients.2The C-L con- sultant must have an extensive clinical under- standing of physical/neurological disorders and their relation to abnormal illness behavior. The C-L consultant must be a skilled diagnostician, be able to tease apart and formulate the patient\u2019s multiaxial disorders, and able to develop an ef- fective treatment plan. The C-L consultant must also have knowledge of psychotherapeutic and psychopharmacological interventions as well as knowledge of the wide array of medicolegal as- pects of psychiatric and medical illness and hos- pitalization. The psychiatric physician, by virtue of his/her professional stature and knowledge, has the ability to supervise a multidisciplinary team.

These proposals for care supplement those
developed forPsychiatric Training in C-L Psy-
chiatryby the Academy of Psychosomatic

Medicine (APM)3,4and the practice guidelines developed by the American Psychiatric Associ- ation (APA).1,5\u20139These current proposals are also related to the recommendations reported in

Psychological Care of Medical Patients, drafted

by the Joint Working Party of the Royal College of Physicians and Psychiatrists10and to the goals ofFellowship Training in C-L Psychiatry put forth by the Academy of Psychosomatic Medi- cine.11Although primarily based on consensus, they include, to the extent possible, the desir- able attributes (e.g., validity, clinical applicabil- ity, clarity) delineated by the Institute of Medi- cine.12

MEDICAL NEED AND STAFFING
Population at Risk and
Case Identi\ufb01cation

In the general medical setting, as many as 30% of patients have a psychiatric disorder.13\u201315 Delirium is detected in 10% of all medical in- patients16and is detected in over 30% in some high-risk groups. Two-thirds of patients who are high users of medical care have a psychiatric disturbance: 23% have depression, 22% have anxiety, and 20% have somatization.17,18 Clearly, psychiatric comorbidity has an impact on health care economics.19\u201323The presence of a psychiatric disturbance has repeatedly been shown to be a robust predictor of increased hos- pital length of stay.24\u201327Nearly 90% of 26 stud- ies have demonstrated either an increased length of stay or an increased medical readmission rate in patients with psychiatric comorbidity.28Only a small subset of the population at risk is cur- rently being adequately identi\ufb01ed. The percent- age of patient admissions receiving psychiatric consultation varies from institution to institu- tion,29ranging from 1% to 10%.29\u201332

Intervention studies have suggested that el- derly patients with hip fractures bene\ufb01t from psychiatric consultation; they have shorter length of hospital stays and are more often dis- charged home, rather than to a nursing home.33\u201334A liaison approach with increased case identi\ufb01cation and earlier psychiatric inter- vention and treatment resulted in a marked de- crease in the need for transfer to inpatient psy- chiatric facilities.35

The principal methods of case identi\ufb01cation and psychiatric service delivery to the medi- cally/surgically ill patient embrace the principles of C-L psychiatry.36In contrast to the standard medical-referral model, in which the consulta- tion psychiatrist waits to be called, the liaison model is based on an early detection strategy to identify potential problems. As part of the multi- disciplinary medical team, the liaison psychia- trist may participate in ward rounds and team meetings while addressing the behavioral issues of patients. Education of nonpsychiatric physi-

Practice Guidelines
S10
PSYCHOSOMATICS

TABLE 1. Required skills for the evaluation and
treatment of patients with psychiatric
disorders in the general medical setting

1. Ability to take a medical-psychiatric history
2. Ability to recognize and categorize symptoms
3. Ability to assess neurological dysfunction
4. Ability to assess the risk of suicide
5. Ability to assess medication effects and drug\u2013drug

interactions
6. Ability to know when to order and how to

interpret psychological testing
7. Ability to assess interpersonal and family issues
8. Ability to recognize and manage hospital stressors
9. Ability to place the course of hospitalization and

treatment in perspective
10. Ability to formulate multiaxial diagnoses
11. Ability to perform psychotherapy
12. Ability to prescribe and manage

psychopharmacological agents
13. Ability to assess and manage agitation
14. Ability to assess and manage pain
15. Ability to administer drug detoxi\ufb01cation protocols
16. Ability to make medicolegal determinations
17. Ability to apply ethical decisions
18. Ability to apply systems theory and resolve

con\ufb02icts
19. Ability to initiate transfers to a psychiatry service
20. Ability to assist with disposition planning

cians and allied health professionals about medi- cal and psychiatric issues related to a patient\u2019s illness is a core component of the liaison model. Liaison services lead to heightened sensitivity by medical staff, which results in earlier detec- tion and more cost-effective management of pa- tients with psychiatric problems.

Guideline

Each institution is responsible for the con- tinuing medical education of medical/surgical staff about the psychological consequences of illness and the indications for psychiatric con- sultation. Areas of focus should include the rec- ognition of substance abuse, delirium, dementia, affective disorders, anxiety disorders, and sui- cidal ideation. These issues should also be in- corporated as part of undergraduate and post- graduate residency and fellowship medical training.

QUALIFICATIONS OF CONSULTANTS
Training and Skills Assessment

Evaluation of the mental health of patients with serious medical illness, formulation of their problems and diagnosis, and organization and implementation of an effective treatment plan involve complex clinical skills that require spe- cialized training (Table 1). In addition to the usual psychiatric examination, specialized knowledge about diagnosis, medicolegal issues, and psychotherapeutic and psychopharmacol- ogical interventions is necessary. The consulting psychiatrist must be familiar with the routines of the medical/surgical environment and knowl- edgeable about medical and surgical illnesses. The psychiatric consultant must also be aware of the effects that illnesses and drugs have on behavior, especially when they contribute to or confound the diagnosis or treatment. Further- more, the psychiatric consultant must be sup- portive of the patient and remain sensitive to the effects of the patient on the staff.

Despite the fact that the psychiatric consul-
tant possesses all the necessary skills to organize

a treatment plan, teams composed of health pro- fessionals with complementary skills may also be used. The leader of such a multidisciplinary team should be the psychiatrist with specialized C-L training.

TheRecommended Guidelines for C-L Psy-
chiatric Training in Psychiatry Residency Pro-
gramsspecify that the faculty of a C-L service

be certi\ufb01ed by the American Board of Psychiatry and Neurology and have speci\ufb01c expertise in C-L psychiatry.3The ideal C-L service has fac- ulty who are fellowship-trained in C-L psychi- atry or who have extensive clinical experience.

Guideline

All providers of psychiatric consultation in the general medical setting must be licensed physicians. All students and trainees must be

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