Consultation and liaison

psychiatry

Gábor Gazdag MD, PhD

Szent István and Szent László Hospitals,

Consultation--Liaison Psychiatric Service
Consultation
 Definition
ƒ Consultation-
Consultation-Liaison Psychiatry is a sub-
sub-
specialty of psychiatry that incorporates
clinical service, teaching, and research at
the borderland of psychiatry and medicine
medicine.
(Lipowski, 1983)
Where did the name (C-
(C-L) come from?
 What is consultation-
consultation-liaison
psychiatry?
psychiatry, also known as consultative
ƒ Liaison psychiatry,
psychiatry or consultation
consultation--liaison psychiatry (also,
medicine) is the branch of psychiatry
psychosomatic medicine)
that specialises in the interface between other
psychiatry, usually taking
medical specialties and psychiatry,
place in a hospital or medical setting.
setting. "Consults"
Consults are
called when the primary care team has questions about
a patient's mental health, or how that patient's mental
treatment.. The
health is affecting his or her care and treatment
psychiatric team works as a "liaison" between the
medical team and the patient. Issues that arise include
capacity to consent to treatment
treatment, conflicts with the
primary care team, and the intersection of problems in
both physical and mental health, as well as patients who
may report physical symptoms as a result of a mental
disorder[1]
disorder [1].. (Wikipedia)
 What is consultation-
consultation-liaison
psychiatry’s present position?
ƒ The American Board of Psychiatry and
Neurology: recommended subspecialty for
Consultation--Liaison Psychiatry renaming it
Consultation
Psychosomatic Medicine
ƒ June 2001: American Psychiatric Association
Board of Trustees supported application
ƒ 2003: American Board of Medical Specialties
approved the recommendation

ƒ Psychosomatic Medicine became the 7th

subspecialty in Psychiatry
 Historyy of Consultation – Liaison
Psychiatry
ƒ Its early origins reflect the emergence of General
Hospital Psychiatry.
ƒ In the 1920s psychiatry became closer to medicine
as hospitals started to establish psychiatric units .
ƒ The
Th conceptt off psychosomatic
h ti relationships
l ti hi and d
the role of emotions and psychological states in
the genesis and maintenance of organic diseases
emerged.
ƒ Thus,, Consultation – Liaison Psychiatry
y y became
an applied form of psychosomatic medicine.
Characteristics of p
psychosomatic
sychosomatic
y
medicine
ƒ 1) Studies the correlations of
psychological and social phenomena
with physiological functions
ƒ 2) Focuses on the interplay of biological
and psychosocial factors in the
development, course and outcome of
all diseases.
diseases
ƒ 3) Advocates the biopsychosocial
approach to patient care
care.
 Consultation style
ƒ Characteristics of effective psychiatric
consultant (Goldman, Lee, Rudd, 1983):

1. Talks with the referring physician, nursing

and other staff before and after
consultation. Clarifying the reason for the
consultation is the initial goal
goal.
2. Establishes the level of urgency.
 ASSESSMENT
The consultant should establish the URGENCY of
the consultation (i.e., emergency or routine—
routine—within
24 hhours).)
Commonly, requests for psychiatric consultation
fall into several general categories:
1. Evaluation of a patient with suspected psychiatric
disorder, a psychiatric history, or use of
psychotropic medications.
2. Evaluation of a patient who is acutely agitated.
Requests for psychiatric consultation
3. Evaluation of a patient who expresses
suicidal or homicidal ideation.
4. Evaluation of a patient who is at high risk for
psychiatric
p y problems
p byy virtue of serious
medical illness.
5. Evaluation of a patient who requests to see a
psychiatrist.
6 Evaluation of a patient with a medicolegal
6.
situation
7 E
7. Evaluation
l ti off a patient
ti t with
ith known
k or
suspected substance abuse.
Reasons for consultation ((own data))
3% Not known
3% 5%
1%
4%
Psychiatric symptoms

8% No organic basis for the

19% symptoms

N
Noncompliance
li

Positíve p
psychiatric
y history,
y
therapy revision request

Legal reason

follow up
57%

More contemporal reasons

Common p
psychiatric
y symptoms
y p as
reasons for consultation
ƒ Depression
ƒ Agitation
ƒ Disorientation
ƒ Hallucinations
ƒ Anxiety
ƒ Sleep disorder
ƒ Suicide
S icide attempt or threat
ƒ Behavioural disturbance
No organic basis for symptoms (8%)
ƒ Conversion disorder: different neurologic
symptoms(anesthesia, paresthesia, seizures,
etc) with autonomic nervous system symptoms
ƒ Somatization disorder ((Briquet
q sy):
y) multiple
p
body complaints
ƒ Factitious disorder: wish to be hospitalized (wish
for attention)-
attention)-provoking physical symptoms (e.g.
fever, hypoglycaemia)
ƒ Malingering: obvious secondary gain
(compensation case)
 Prevalence of somatization
ƒ Medically
M di ll unexplained
l i d symptoms
– Common in communityy samples
p
ƒ General practice / New out
out--pt referrals
– Up to 40% have symptoms for which no organic
cause is identified
ƒ ‘Much less common’ in in-
in-pt samples (8%)
– Majority of p
patien
atients
ts reassured
ƒ Minority persist or develop other symptoms
– Strong association between number of somatic
symptoms reported and likelihood of underlying
mental illness
 Aetiological factors
ƒ Childhood experience
– Illness
– Lack of parental care
– Physical illness triggers care and attention which otherwise
theyy would not receive
ƒ Lack of social support
ƒ Family re
re--inforcement
– Over
Over--solicitous care or ‘helpful advice’
ƒ Iatrogenic causes
 Iatrogenic causes
ƒ Medicalisation
M di li i off pt’s
’ symptoms
– Over
Over--investigation
g
– Inappropriate treatment
ƒ Especially by junior doctors
– Failure to provide clear explanation for
symptoms
ƒ Increasing uncertainty and anxiety
– Failure
F il tto recognise
i and
d ttreatt emotional
ti l
factors
Consequences of somatisation

– Unnecessary use of healthcare

ƒ Investigations
ƒ Admissions for treatment / operations
– Often making matters worse
– Prescribed drug misuse and dependence
– Disability and loss of earnings
ƒ Social disabilityy p
payments
y
– Poor quality of life
ƒ Impact on family / social network
 Functional somatic syndromes
Gastroenterology Irritable Bowel Syndrome
Functional dyspepsia
Cardiology Atypical chest pain
Neurology
gy Common Headache
Chronic fatigue syndrome
Rheumatology Fibromyalgia
Complex regional pain syndromes
(Reflex sympathetic dystrophy)
Gynaecology Chronic pelvic pain
Orthopaedics Chronic back pain
Approach to management

ƒ Identify features of organic disease

– Overlaying psychological elements
ƒ Establish degree
g of insight
g
– Extent to which they recognise
ƒ psychological basis for their problems
– Extent to which they ‘want out’
ƒ Determine the appropriate programme
– Physical / psychological / both
 Characteristics of effective p
psychiatric
y
consultant (Goldman, Lee, Rudd, 1983):
3. Reviews the chart and the data thoroughly.
4. Performs a complete mental status exam and
relevant portions of a history and physical exam.
5 Obtains medical history from family members or
5.
friends as indicated.
6 Makes
6. M k notes t as b brief
i f as appropriate.
i t
7. Arrives at a tentative diagnosis.
8. Formulates a differential diagnosis.
9 Recommends diagnostic tests
9. tests.
 Characteristics of effective psychiatric
consultant (Goldman
(Goldman, Lee
Lee, Rudd
Rudd, 1983):
10 Has the knowledge to prescribe psychotropic
10.
drugs and be aware of their interactions.
11 M
11. Makes
k specific
ifi recommendations
d ti th
thatt are
brief, goal oriented and free of psychiatric jargon
and discusses
disc sses findings and recommendation
with consultee – In person whenever possible.
12. Respects patient’s rights to know that the
identified “customer” is the consulting physician.
(maintaining
(m aintaining absolute Doctor-
Doctor-Patient
confidentiality is not possible for a psychiatric
consultant))
consultant
 Characteristics of effective p
psychiatric
y
consultant (Goldman, Lee, Rudd, 1983):
13. Follows
ollows-up patient until they are discharged from
the hospital or clinic or until the goals of the
consultation are achieved. Arranges out- out-patient
care--if necessary.
care
14. Does not take over the aspects of the patient’s
medical care unless asked to do so.
15. Follows advances in the other medical fields and
is not isolated from the rest of the medical
community.
 The ”formal”
”fformal
formal
ormal” consultant
Works in a the traditional psychiatric setting,
starts, and arrives back there

The liaison psychiatrist

Works on the ”Terra incognita” field
b t
between somatic
ti andd psychiatric
hi t i care.
 The ”f
”formal”
formal
ormal” The Liaison
consultant psychiatrist

‰ Consultation
ƒ Set up the diagnose – patient
ti t centred
t d
ƒ Treat ‰ Liaison
ƒ Act as a dispatcher
– team centred

ƒ The ”liberating
”liberating
‰ Member of the team
troop”
troop
 Patterns of liaisons
liaisons
Primary
P i care Primary care
physician physician

Patient Consultant Patient Consultant

T di i l setting
Traditional i C
Consultation
l i modeld l
Primary care
physician

Patient Consultant
Consultation--Liaison model
Consultation
 Psychiatric
y disorders in the
medical setting
ƒ As many as 30% of patients have a psychiatric
disorder.

ƒ 2/3 of p
patients who are high
g users of medical
care have a psychiatric disturbance.

ƒ Delirium
D li i iis d
detected
t t d iin 10% off all
ll medical
di l iin-
in-
patients & in over 30% in some high risk groups.

ƒ The presence of a psychiatric disturbance is

associated with increased hospital
p length
g of stay
y
OR an increased medical readmission rate.
 Psychiatric
y disorders in the medical
setting
ƒ Only a small subset of patients is currently
being identified.

ƒ The percentage of patients receiving

psychiatric consultation varies from 1% to
10%.

ƒ There is a great disparity between the amount

of psychiatric pathology that exists in the
medical setting and that which is identified by
medical staff.
 Psychiatric diff diagnoses in medical
settings
tti
Psychiatric presentations of medical
conditions
Psychiatric complications of medical
conditions or treatments
P
Psychological
h l i l reactions
ti to
t medical
di l conditions
diti
or treatments
M di l presentations
Medical i off psychiatric
hi i
conditions
Medical complications of Psychiatric
conditions or treatments
Comobid Medical and Psychiatric conditions
 The Consultation note

Is best if brief and focused on the referring

physician’s concerns with attention to all domains.
Avoid using jargons or other wording that is likely to
be unfamiliar to other physicians.
The note needs to be titled with mention “Psychiatry”
and “Consultation” .
The history y of p
present illness should include the
relevant data from the history that may have
significance
The consultant’s objective findings on mental status
The formulation, diagnosis, recommendations should
be written concisely.
 Diagnosis
The consultant should organize the diagnosis
section
ti according
di tot the
th DSM-IV’s
DSM IV’ multiaxial
lti i l
guideline.
Axis I or II diagnosis cannot always be made at
the time of the initial consultation.
Only the one or two central medical diagnoses
should be included on Axis III
Significant medical and psychological stressors
can be noted and documented on Axis IV.
Axes IV and V may be omitted if the consultant
feels they will not be useful or familiar to the
consultee.
 DSM--IV axes
DSM
ƒ Axis I: Clinical disorders, including major
mental disorders, and learning g disorders
ƒ Axis II: Personality disorders and mental
retardation
ƒ Axis III: Acute medical conditions and
physical disorders
ƒ Axis IV: Psychosocial and environmental
factors contributing to the disorder
ƒ Axis V: Global assessment of functioning g
 Diagnostic
g Testing
g and Consultation

The C-L
Th C L consultant
lt t mustt be
b familiar
f ili with
ith
diagnostic testing regarding:

ƒ The indications for anatomic brain imaging

g g or
neurophysiological screening by CT, MRI, EEG,
etc.

ƒ The indications for the administration of

neuropsychological testing
 Follow-Up
p
The scope, frequency, and necessity of follow-
up visits
i it depend
d d on the
th nature
t off th
the initial
i iti l
diagnosis and recommendations.

Follow-up p visits reinforce the consultant’s

recommendations and allow the consultant to
Evaluate results of recommendations
Prioritize relative importance of particular
interventions
Prevent breakdowns in communication between
consultants
lt t and d consultees.
lt
 Follow Up
Follow-Up

At least daily follow-up should be

yp of patients:
considered for several types p
Those in restraints
Constant observation
Agitated, potentially violent, or suicidal
Delirium
y
Psychotic or p
psychiatrically
y y unstable.
Acutely ill patients started on psychoactive
medications should be seen daily until
they have been stabilized.
 INTERVENTIONS
Psychotherapy:

ƒ The modality introduced should be

primarily selected
in response
p to the patient’s
p needs.

ƒ No single psychotherapeutic modality

will be effective with all patients, at all
times, in the medical setting.
 Pharmacotherapy and
Other Somatic Therapies
ƒ 35% off psychiatric
hi t i consultations
lt ti include
i l d
recommendations for medications.

ƒ About 10%–15% of p patients require

q reduction
or discontinuation of psychotropic
medications.

ƒ Appropriate use of psychopharmacology

necessitates a careful consideration of the
underlying medical illness
illness, drug interactions,
interactions
and contraindications.
ƒ Ph
Pharmacotherapy
th off the
th medically
di ll ill often
ft
involves modification in dosage because of liver,
kid
kidney, or cardiac
di disease,
di or because
b off
potential for multiple drug–drug interactions.

ƒ Pregnancy
g y presents
p another challenge,
g , with
concerns regarding potential teratogenicity.

ƒ The C-L psychiatrist must be knowledgeable

about electroconvulsive therapy (ECT)
Important field of C
C--L activity 1: Noncompliance

ƒ Negative transference between patient and

primary care doctor
ƒ Fear of medication or procedure
ƒ Impaired cognitive capacity
 Noncompliance study
(retrospective
( t ti chart
h t review)
i )
1020 consultations between 11/99 and 11/04
11/04.
In 22 cases the reason of the consultation was:
noncompliance (2(2,2%)
2%)

45%

55%
M l
Male

Female
Psychiatric
y syndromes
y behind
noncompliance
1; 5% No psychiatric diagnosis
2; 9%
4; 18% Affective disorder
1; 5%
Org.psychosyndrome

D
Dementia
ti
4; 18%
Addiction
9; 40%
4% Adjustment disorder

Schizofrenia
 hematolo gy
disorderss

dermatolo
ogy
Basic somatic disorder

endocrino
ology
y
oncology
rheumato logy
urology
diabetolo gy
ophtalmo logy
y
neurology
gastroenterology
hepatolog
gy
gy
nephrolog
pulmonology
cardiolog y
25

20

15

10

0
percent

compliance

all cases
Non
 Conclusions

In patients with chronic illness

¾Illness behavior frequently negative
(ambivalence, psychosocial factors)
¾Noncompliance can result rapid somatic
deterioration (DM) that can result hospital
admission
¾Noncompliance
N li can b
be a symptom
t off a
hidden psychiatric disorder
Important field of C-
C-L activity 2: delirium

ƒ D
Delirium
li i iis COMMON
ƒ Symptoms are alarming
ƒ 10
10--15% of patients on surgical ward and 15-
15-25%
on ggeneral ward experience
p episode
p of delirium
during hospital stay.
ƒ 30
30--40% of hospitalized patients over age 65
have had an episode of delirium.
ƒ 30%
30%--90% patient in ICU experience delirium
delirium.
Kaplan & Sadock’s Synopsis of Psychiatry. 8th Ed. Philadelphia, PA, 1998.
Liatker, D., Locala, J., Franco, K, Bronson, DL, Tannous, Z. Preoperative risk factors for postoperative delirium. Gen
Hosp Psychiatry. 2001; 23:84-
23:84-89.
 Definition of Delirium

A. Disturbance of consciousness
B Change in cognition
B.
C. Develops over a short period of time (usually hours to
days) Tends to fluctuate during the course of the day
days). day.
D. There is evidence from history, physical exam, or
laboratory findings that the disturbance is caused by the
direct physiological consequences of a general medical
condition, Substance Intoxication or Withdrawal, use of a
medication, or toxin exposure, or a combination of these
factors.

DSM--IV-
DSM IV-TR, 2000
 Associated Features
Psychomotor disturbance
Agitation
g ((related to disorientation or
confusion)
Apathy
p y and Withdrawal
Emotional disturbances and instability
Sleep Impairment

Merck Manual of Geriatrics

 Course
ƒ Symptoms usually develop over hours or days
ƒ In some they begin abruptly (e.g. after head injury)
ƒ More typically,
typically prodromal syndromes such as restlessness
restlessness,
anxiety, irritability, disorientation, distractibility, sleep
disturbance progress to full-full-blown delirium within a 1- 1-3 day
period.
period
ƒ May resolved in few hours to days or may persist for weeks
to months, part in elderlyy or people with pre-pre-existing g
dementia.
ƒ Duration largely controlled by course of underling condition
Symptoms of delirium typically become most severe at
night.

DSM--IV-
DSM IV-TR, 2000
Casey et al. Delirium: Quick recognition, careful evaluation, and appropriate treatment. Postgraduate Medicine, 1996, 100(1).
 Risk Factors
ƒ Advanced age
ƒ Young age (children)
ƒ Underlying brain disease such as dementia, stroke or
Parkinson’s
ƒ Multiple severe
severe, acute or unstable medical problems
ƒ Polypharmacy
ƒ Infection
ƒ Alcohol dependence
ƒ Sensory impairment
ƒ Malnutrition
ƒ Historyy of delirium
ƒ Low levels of social interaction
 Prognosis better ifif…

ƒ Underlying etiological factor is promptly

corrected.
ƒ Patient has better pre-
pre-morbid cognitive and
physical
p y function.
ƒ Patient has NOT had previous episode of
delirium.
delirium
 Elderly Patients

ƒ Persistent cognitive deficits common in

elderly suffering from delirium.
ƒ These deficits can be due to a pre-
pre-existing
d
dementiati th
thatt was nott fully
f ll appreciated.
i t d
ƒ Delirium may y be the onlyy indication of acute
illness in older patients suffering from
dementia.
dementia
 Differential diagnosis
Obs. Delirium Dementia Depression Psychosis

Onset Acute Insidious Variable Variable

Orientation Impaired Impaired Intact Intact
Sensorium Fluctuating Variable Intact Intact
Attentiveness Impaired Variable Usually intact Variable
Delusions Common Sometimes Rare Common
Hallucinations Visual Uncommon Rare Auditory
Duration Short Chronic Variable Variable

Delirium: Quick Recognition, careful evaluation and appropriate treatment,

Postgraduate Medicine, July 1996, 100 (1).
 Diagnosis: Delirium

WHAT IS CAUSING IT?

 I WATCH DEATH (acronym)

I Infection (pneumonias, UTI, sepsis,

cellulitis, menigitis,
g encepalitis, syphilis)
y )
W ithdrawal (bezos, ETOH, sedative-
sedative-
hypnotics)
A cute metabolic (electrolytes, acidosis,
renall ffailure,
il abnormal
b l glycemic
l i control,
t l
pancreatitis, )
T rauma (head injury, pain, fracture, burns)
 I WATCH DEATH
C NS pathology (tumor, AVM, encephalitis, abscess, normal
pressure hydrocephalus, seizures, stroke)
H ypoxia from COPD exacerbation, anemia,
carbon monoxide p
poisoning,
g, cardiac failure
D eficiencies BB--12, folate, water
E ndocrine thyroid
thyroid, cortisol
cortisol, cancer,
cancer hyper or hypoglycemia
A cute vascular MI, stroke, intracerebral bleed
T oxins or drugs medications, pesticides, solvents
H eavyy metals lead, mercuryy
Important field of C
C--L activity 3: dementia

Aim of a C C--L survey conducted in geriatric

inpatient population:
ƒ To asses comorbide psychiatric syndroms in
geriatric
i t i patients
ti t who
h are admitted
d itt d tto
internal medicine wards
ƒ To asses the impact of the psychiatric
disorders on the length of hospital stay
 Results: dementia (own survey)

Cognitive function (MMMS Number of patients (n=83) Mean length of hospital

points) stay (LOS)

Cognitive deterioration is 34 (41%) 12,4 days

possible (MMMS; ≥ 85 pont)

Detectable cognitive 14 (17%) 14,7 days

deterioration (75-
(75-84 point)

Moderate cognitive 21 (25%) 15,3 days

deterioration (60-
(60-74 point)

Severe deterioration (59 pont 14 (17%) 19,8 days

≥)
 Characteristics of dementia
dementia
ƒ Deterioration of memory and other cognition
functions in an alert person, impairing daily
activities
ƒ Onset is usually insidious
ƒ Course is over months - years; little daytime
fluctuation
ƒ Deficits persist even during a clear level of
consciousness
ƒ There must be a social impairment and decline
from previous functioning
 Differential diagnosis
Obs. Delirium Dementia Depression Psychosis

Onset Acute Insidious Variable Variable

Orientation Impaired Impaired Intact Intact
Sensorium Fluctuating Variable Intact Intact
Attentiveness Impaired Variable Usually intact Variable
Delusions Common Sometimes Rare Common
Hallucinations Visual Uncommon Rare Auditory
Duration Short Chronic Variable Variable

Delirium: Quick Recognition, careful evaluation and appropriate treatment,

Postgraduate Medicine, July 1996, 100 (1).
 Clock Drawing Test

ƒ Study showed that cognitive impairment was a

main factor in low Clock Drawing scores in elderly
patients.

ƒ Neither the presence or severity of delirium had

additional significant effect on clock drawing.

The performance of the Clock Drawing Test in elderly medical inpatients: does it have utility
in the identification of delirium? J Geriatric Psychiatry Neurol. 2005 Sep; 18 (3): 129-
129-33
Clock Drawing
g Test
 Important field of C-
C-L activity 4: chronic illneses
chronic viral hepatitis treated with IFN

ƒ Interferon- (IFN--α) is used for the therapy of a variety

Interferon-alfa (IFN
of oncological and chronic viral disorders
disorders..

IFN--α are based on the induction of

ƒ The CNS effects of IFN
the cytokine-
cytokine-cascade and the neuroendocrine system, as
well as the modulation of the several neurotransmitter
pathways..
pathways

ƒ Mood and anxiety disorders are common psychiatric

sequales of that treatment.
treatment. The CNS sideside--effects call for
the dropping IFN-α treatment or for dose reduction.
pp g out of IFN- reduction.
ƒ
ƒ It is challenge for the consultation psychiatrists to find a
therapeutic solution for patients who suffer from
psychiatric side- IFN--α.
side-effects of the IFN
Time Course of IFN Side Effects
Severity

Flulike Fatigue
symptoms

Depressive/anxiety
symptoms

0 1 2 3 4 5 6 7 8 9 10 11 12
IFN Treatment
(Weeks)
 Late--Appearing
Late pp g Interferon
Side Effects
ƒ Manifest as mood disturbance, anxiety,
and cognitive difficulties
ƒ Develop insidiously over weeks to months
ƒ Worsen with time
ƒ Coupled with fatigue, represent the principal
reason for IFN discontinuation
 Major
j Depression
p With
Interferon alfa
ƒ Prevalence is 30%–
30%–50%, depending on
diagnostic criteria and IFN dosage
ƒ Recent large study of patients receiving
peginterferon for hepatitis C suggests rates
of full major depression may be lower than
previously reported

Musselman DL, et al. N Engl J Med. 2001;344:961. Raison CL, et al. In preparation.
 Psychiatric
y side effects of IFN
treatment (own survey)

ƒ 21 patients
p
– 18 depression
ƒ Mild:5
ƒ Moderate:8
ƒ Severe:5
– 5 panic disorder (4 with co
co--morbide depression)
– 1 panic
i di
disorder
d with
ith agoraphobia
h bi
– 1 delirium
 Treating
g IFN
IFN--Induced
Depression

ƒ Peginterferon may need to be stopped

until antidepressant begins to work
ƒ Pretreatment with antidepressant shown
to significantly decrease development of
depression with high
high--dose IFN alfa
 Paroxetine Pretreatment Reduces the
Incidence of Major Depression During
the First 12 Weeks of IFN alfa
100
Ma
ajor De

80
Free of
epress

60

40
sion (%

Paroxetine
20 Placebo
%)

0
0 2 4 6 8 10 12
Weeks on IFN alfa
Musselman DL, et al. N Engl J Med. 2001;344:961.
 Other important fields of C
C--L activity

ƒ Transplantation
p ((Bone marrow, heart and
lung, liver, kidney)
ƒ Oncology
ƒ Legal issues (competency)
ƒ HIV, AIDS
ƒ Addictions
 Cost--Effectiveness of CLP
Cost
Studies
St di have
h repeatedly
t dl demonstrated
d t t d th
thatt C
C-L
L
service can significantly lower health care cost and at
the same time improve the quality of medical care of
medically ill patients with psychiatric symptoms.

There is a significant association between psychiatric

or psychological AND medical comorbidity and
i
increasedd length
l th off stay.
t

Early
E l detection
d t ti andd treatment
t t t may significantly
i ifi tl
decrease LOS and the expenditure of medical
resources
Thank you for your attention!