Consultation Liaison

Psychiatry
Guided by – Dr. Rahul Mathur
Assistant Professor
MGM Medical College Indore

Presenter – Dr. Priyash Jain

Content
• Introduction
• Basics
• Common Conditions
• Delirium
• Suicide
• Depression
• Agitation
• Hepatic Impairment
• Renal Impairment
• Cardiac Conditions
• HIV
• TB
• Fitness for surgery
Introduction
Introduction
• Consultation-liaison (C-L) psychiatry as a
subspecialty has been defined as the area of clinical
psychiatry that encompasses
• Clinical involvement
• Teaching
• Research activities
of psychiatrists and allied mental health professionals
in the non-psychiatric divisions of a general hospital.
Introduction
• “Consultation-Liaison" reflects two interrelated
roles of the consultants.
• "Consultation" refers to the provision of expert
opinion about the diagnosis and advice on
management regarding a patient's mental state and
behavior at the request of another health
professional.
• The term "Liaison" refers to linking up of groups for
the purpose of effective collaboration.
Introduction
• A state of complete physical, mental and social
well-being and not merely the absence of disease
or infirmity.
Basics
Basics

Consultee

Therapeutic
Patient
Team
Basics
• The basic aim of C-L Psychiatry is to integrate the
information so as to provide optimal health care to
patient and effective liaison with patient, consultee
and team.

• Hence for consultation to be most effective the

consultant psychiatrist need to have personal
contact with both the patient and those taking
care of him. 
Basics – Functional Models
1. Consultation Model: traditional model, has patient as the
focus.
2. Liaison Model: consulting physician as the focus, involves
teaching of psychiatric and psychological aspects of a problem
to the physician.
3. Bridge Model: basically involves the teaching role of a C-L
psychiatrist for the primary care physician.
4. Hybrid Model: has psychiatrist as a part of multidisciplinary
team.
5. Autonomous psychiatric model: C-L psychiatrist is not
affiliated to any department but is hired by primary care
services.
Basics – Characteristics of
effective CLP
• Talks with the referring physician, nursing and other staff
before and after consultation.
• Clarifying the reason for the consultation is the initial goal
(not an easy job sometimes).
• Establishes the level of urgency.
• Reviews the chart and the data thoroughly.
• Performs a complete mental status exam and relevant
portions of a history and physical exam.
• Obtains medical history from family members or friends as
indicated.
• Makes notes as brief as appropriate
Basics – Characteristics of
effective CLP
• Arrives at a provisional/tentative diagnosis.
• Formulates a differential diagnosis.
• Recommends diagnostic tests.
• Has the knowledge to prescribe psychotropic drugs
and be aware of their interactions (with somatic
therapies).
• Makes specific recommendations that are brief, goal
oriented and free of psychiatric jargon and discusses
findings and recommendation with consultee – In
person whenever possible.
Basics – Characteristics of
effective CLP
• Follows-up patient until they are discharged from
the hospital or clinic or until the goals of the
consultation are achieved. Arranges out-patient
care-if necessary.
• Does not take over the aspects of the patient’s
medical care unless asked to do so.(can advise
physician but never interfere)
• Follows advances in the other medical fields and is
not isolated from the rest of the medical
community.
Basics – Approach to the care
• Emphasis on proper Documentation
• Thanking you for referral
• Demographic Details
• Date
• Reason for referral
• Referred by whom
• Location of the patient
• Primary Diagnosis of the patient
• Informant (with comment on reliabilty)
• Chief complaints
Basics – Approach to the care
• Emphasis on proper Documentation
• Brief Hopi/ Past History/Treatment History
• Medical History -Renal, Cardiac And Liver Dysfunction
• Menstrual/ Marital: Check Last Menses And Pregnancy
• Check for current Investigations
• Check For Drugs For Medical Conditions
• Physical Examination
• MSE
• Provisional Clinical Impression/Diagnosis
• Differential Diagnosis
Basics – Approach to the care
• Emphasis on proper Documentation
• Management plan:
• Additional blood investigations
• Additional psychological investigations
• Additional rating scales
• Additional consultations advise
• Additional imaging or neurophysiological test
• Check tests already done carefully, don’t repeat it
unnecessarily
Basics – Approach to the care

GENERAL PRINCIPLES
Don’t experiment
unnecessarily
Be simple in Mono drug and
with drugs in
liaison psychiatry lower doses help.
medically sick
patients.
Common Conditions
Common Conditions
• Delirium
• Suicide
• Depression
• Agitation
• Hepatic Impairment
• Renal Impairment
• Cardiac Conditions
• HIV
• TB
• Fitness for surgery
Common Conditions
• Among the three most common psychiatric syndromes seen in
CLP setting, delirium figured as one of the three most common
diagnoses among 79 (87.8%) institutes, and this was followed by
substance use disorders (70%), self‑harm (60%), and depression
(38.9%). (Grover et al)

• In a study by our department the most common reason for

referral was having an abnormal behaviour (n=45, 26.2%),
followed by alleged suicide attempt or self-harm (n=42, 24.4%)

• The referral rate was found to be a meagre 1.1% which is too little
compared to incidence of psychiatric morbidities found in general
hospitals ranging from 18.8% to as high as 94.4%. (Grover et al)
Delirium
• Delirium is a transient organic mental syndrome of acute onset ,
characterized by global impairment of cognitive functions, a
reduced level of consciousness, attentional abnormalities,
increased or decreased psychomotor activity and a disordered
sleep wake cycle.

• An acute reversible mental disorder

• Important aspect in Consultation-Liaison Psychiatry

• delirium figured as one of the three most common diagnoses

among 79 (87.8%) institutes (grover et al)
Delirium - Nosology
• ICD-10
• For a definite diagnosis symptoms ,mild or severe, should be
present in each one of the following areas:
1. Impairment of consciousness and attention,
2. Disturbance of cognition
3. Psychomotor disturbances
4. Disturbance of sleep or the sleep-wake cycle,
5. Emotional disturbances

Rapid onset and fluctuations of the symptoms over the course of

the day.
Delirium - Nosology
• ICD-11 (6D70)
• Delirium is characterized by
• disturbed attention (i.e., reduced ability to direct, focus, sustain,
and shift attention) and awareness (i.e., reduced orientation to
the environment)
• develops over a short period of time and tends to fluctuate
during the course of a day,
• accompanied by other cognitive impairment such as memory
deficit, disorientation, or impairment in language, visuospatial
ability, or perception.
• Disturbance of the sleep-wake cycle (reduced arousal of acute
onset or total sleep loss with reversal of the sleep-wake cycle)
may also be present.
Delirium – Scales

Screening Diagnosis Severity

• Confusion • Delirium rating • Delirium
Assessment scale(DRS) Assessment
Method • Delirium rating Scale
• NEECHAM scale-revised • Delirium Index
Confusion version(DRS-R-
Scale 98)
Delirium – Management
• Medical emergency
• Identification and treatment of underlying cause
• Management of psychiatric aspect
• Effective coordination of both non-pharmacological
and pharmacological management
Delirium – Management
Delirium – Management
• Provide reorientation (view of clock, calendars, familiar objects)
• Encourage use of personal belongings
• Adequate lighting and temperature
• Encourage presence of family members
• Minimize transfers (perform procedure in room whenever
possible)
• Orient the patient to staff, surroundings, and situations repeatedly,
particularly before procedures
• Use of restrain only when….
• Increase risk of falls, injury, & delirium
• Use only in emergency, for as short a duration as possible with frequent
re-evaluations
• Repeatedly reassure the patient.
Suicide
• “N” number of factors associated with increased risk of
suicide in medical/surgical settings - Chronic illness,
Debilitating illness, Painful illness, Low pain tolerance,
Renal dialysis, Cardio-respiratory disease, AIDS.

• Must be assessed diligently and appropriate scales must be

used like SAD persons or SBQ.
Suicide
Suicide - Management
• Treatment of Psychiatric Disorders
• Ward Management
• Hospital must issue suicide precaution guidelines
• Staff must be guided
i. Remove any potential object
ii. Search luggage and possessions
iii. Monitor all objects coming in the room potentially hazardous
iv. Dispensing of the medications
v. Constant observation
• Physical restraint often required in unpredictable or impulsive patients
Suicide - Management
• The consultation note must carefully document the
Diagnosis and treatment plan.

• Note must include the level of suicide risk, clearly

stating the plan and reporting of interval when the
patient will be reassessed
Depression

• Not an uncommon finding in Inpatients

• Requires careful assessment
Depression

• Treatment with anti-depressants can be started if

required
• Careful assessment of drug-drug interactions in
collaboration with primary physician
Agitation

• Often related to neurocognitive disorder or withdrawal

from drugs(opioids, alcohol, sedative –hypnotics
• Antipsychotic medication (Haloperidol) are very useful
for excessive agitation.
• Physical restraint- great caution and last resort
• But first rule out agitation due to medical/surgical
causes like excessive pain.
Hepatic Impairment
Reduced
hepatic
blood flow

Hepatic
Impairment

Reduced Reduced
ability to capacity to
synthesise metabolise
Hepatic Impairment – General
Principles
• Prescribe as few drugs as possible.
• Lower starting doses
• Leave longer intervals between dosage increases
• cautious with drugs that are extensively hepatically
metabolized
• Avoid medicines with a long half-life
• Avoid drugs that are very sedative
• Avoid drugs that are very constipating
• Avoid drugs that are known to be hepatotoxic
Hepatic Impairment –
Antipsychotics
• Amisulpiride – Renal Excretion. No dose reduction
required.
• Aripiprazole – Extensively hepatic metabolism. Caution!
• Clozapine - Very sedative and constipating.
Contraindicated in active liver disease associated with
nausea, anorexia or jaundice, progressive liver disease
or hepatic failure.
• Flupenthixol/Zuclopenthixol - Both are extensively
hepatically metabolised. Caution! Depot best avoided.
• Haloperidol – Caution in liver disease!
Hepatic Impairment –
Antipsychotics
• Olanzapine - Although extensively hepatically
metabolised. Sedative and Constipating – Caution
advised!
• Quetiapine – Hepatic metabolism. Caution advised!
Start at lower dose.
• Risperidone – Extensive hepatic metabolism. Half
starting dose. If severe impairment, start 0.5mg BD
and increase at a maximum of 0.5mg bd.
Hepatic Impairment
• – Antidepressants
• All SSRIs are hepatically metabolised. May accumulate on
chronic dosing. Dose reduction is required (upto 50%).
Sertraline is preferred.
• All TCAs are hepatically metabolised and have high protein
binding.

• – Mood Stabilizers
• Dose reduction of all mood stabilisers by upto 50% with slow
titration and close monitoring of LFT.
• No dose reduction required with lithium.
Hepatic Impairment
• Benzodiazepines : Lorazepam, oxazepam,
temazepam considered to be safe.
Renal Impairment – General
Principles
• Be cautious when using drugs that are extensively renally
cleared (e.g. sulpiride, amisulpride, lithium).
• Start at a low dose and increase slowly because, in renal
impairment, the half‐life of a drug and the time for it to reach
steady state are often prolonged. Plasma level monitoring
may be useful for some drugs.
• Try to avoid long‐acting drugs (e.g. depot preparations). Their
dose and frequency cannot be easily adjusted should renal
function change.
• Prescribe as few drugs as possible. Patients with renal failure
take many medications requiring regular review. Interactions
and adverse effects can be avoided if fewer drugs are used.
Renal Impairment
• No antipsychotic clearly preferred over other.
• Sulpiride and Amisulpiride avoided
• Anticholinergic drugs to be avoided.
• FGA - haloperidol 2–6 mg/day
• SGA – Olanzapine – 5mg/day

• Among antidepressants sertraline suggested as

reasonable choice though no agent clearly
preferred over other.
Renal Impairment
• Among Mood Stabilisers lithium to be avoided.
Other mood stabilisers to be started at a lower
dose.
• Sedatives and hypnotics to be given with utmost
caution. Watch for excess sedation. Lorazepam and
zopiclone are suggested as reasonable choices.
Psychiatric medications and
cardiac conditions
Psychiatric medications and
cardiac conditions
• SSRIs are generally recommended in cardiac
disease but beware antiplatelet activity when co‐
administered with cardiac drugs.
• Sertraline is recommended post MI, but other SSRIs
and mirtazapine are also likely to be safe.
• Tricyclics have an established link to cardiac
arrhythmia.
Prescribing in HIV Patients
• Pharmacokinetic interactions between
antiretroviral and psychotropic drugs occur fre­
quently and are potentially clinically significant.

• Caution is advised while prescribing psychotropic

medications to patients already receiving anti-
retroviral therapy.
Prescribing in HIV Patients

Antiretroviral drug Potential adverse effect Implications for psychotropic prescribing

Zidovudine Bone marrow suppression Concurrent use with certain psychotropics (e.g.
clozapine) may increase the risk of
myelosuppression/neutropenia

Tenofovir Reduces bone mineral density May compound the reductions in bone mineral
density possible with prolactin‐elevating
antipsychotics

Atazanavir, didanosine, elvitegravir/cobicistat, Gastrointestinal disturbances May compound gastrointestinal disturbances

fosamprenavir, indinavir, lopinavir, nelfinavir, associated with
raltegravir, saquinavir, certain psychotropics
tipranavir, zidovudine
Prescribing in HIV Patients

Antiretroviral drug Potential adverse effect Implications for psychotropic prescribing

Darunavir, efavirenz, maraviroc, ritonavir, Seizure(s) May increase seizure risk associated with certain
saquinavir, zidovudine psychotropic drugs

All combination antiretroviral drugs Metabolic abnormalities risk of metabolic adverse effects associated with
certain psychotropic drugs

Atazanavir, darunavir, efavirenz, lopinavir, ECG changes May increase risk of arrhythmias associated
rilpivirine, ritonavir, with
Saquinavir certain psychotropic drug
Prescribing in TB patients
• Isoniazid, Ethambutol, Rifampicin, Cycloserine, 2nd
generation FQs, are known to cause psychiatric
disorders.
• Also various anti-tubercular drugs are known to
have multiple interactions with psychotropics.
• Hence Caution is advised while prescribing to
tubercular patients.
Prescribing in TB patients

Anti-Tb Drug Potential adverse effect Implications for psychotropic prescribing

Isoniazid Causes MAO inhibition May interact with SSRIs and TCAs theoretically
increasing risk of serotonin syndrome.

inhibition of CYP - 1A2, 2C9, 2C19 Caution while prescribing Carbamazepine,

Valproate, diazepam
Rifampicin Enzyme inducer of CYP Higher doses of psychotropics maybe required.

Linezolid Causes MAO inhibition risk of serotonin syndrome when used in

combination with anti-depressants
Psychiatric medications and
surgery
Drug class Consideration Safety in surgery

Anticonvulsants CNS depressant activity may reduce anaesthetic Probably, usually continued for people with
requirement epilepsy
Antidepressants – SSRIs Danger of serotonin syndrome if administered Probably, but avoid other serotonergic agents
with pethidine, fentanyl, pentazocine or
tramadol
Occasional seizures reported
Rule out hyponatremia in all surgical patient
Psychiatric medications and
surgery
Drug class Consideration Safety in surgery

Antidepressants – TCAs Danger of serotonin syndrome (clomipramine, Unclear, but anaesthetic agents need to be
amitriptyline) if administered with pethidine, carefully chosen
pentazocine or tramadol
Many drugs prolong QT interval so arrhythmia
more likely

Antidepressants – MAOIs Dangerous Probably not

Psychiatric medications and
surgery
Drug class Consideration Safety in surgery

Antipsychotic Most drugs lower seizure threshold Probably, usually continued to avoid relapse
Increased risk of arrhythmia
Benzodiazepines Reduced requirements for induction and Probably; usually continued
maintenance anesthetics
Take Home Message
• Over the years Consultation-Liaison (C-L) psychiatry has
contributed significantly to the growth of the psychiatry
and has brought psychiatry very close to the advances in
the medicine.
• C-L psychiatrist should have adequate knowledge of
mental and physical illnesses as well as how they affect
each other.
• And should know how various drugs and diseases interact
with psychotropics with special regards to their safety.
• C-L psychiatrist must look at the complete picture while
providing services to the general hospitals.
References
• Lipowski, Z., 1983. Current Trends in Consultation-Liaison Psychiatry*. The Canadian Journal of
Psychiatry, 28(5), pp.329-338.
• Grover S. State of consultation-liaison psychiatry in India: Current status and vision for future. Indian J
Psychiatry 2011;53:202-13
• Grover S, Avasthi A. Consultation-liaison psychiatry services: A survey of medical institutes in India.
Indian J Psychiatry 2018;60:300-6
• Mudgal V, Rastogi P, Niranjan V, et al. Pattern, clinical and demographic profile of inpatient psychiatry
referrals in a tertiary care teaching hospital: a descriptive study. General Psychiatry 2020;33:e100177.
doi:10.1136/ gpsych-2019-100177
• Taylor, D., Paton, C. and Kerwin, R., 2018. The Maudsley Prescribing Guidelines. 13th ed. Wiley
Blackwell.
• Sadock, B., Sadock, V. and Ruiz, P., 2009. Kaplan & Saddock's comprehensive textbook of
psychiatry, volume 1 and 2. Philadelphia: Lippincott Williams and Wilkins.
• Shah SU, Iqbal Z, White A, et al Heart and mind: (2) psychotropic and cardiovascular therapeutics
Postgraduate Medical Journal 2005;81:33-40.
• Doherty, A., Kelly, J., McDonald, C., O’Dywer, A., Keane, J. and Cooney, J., 2013. A review of the
interplay between tuberculosis and mental health. General Hospital Psychiatry, 35(4), pp.398-406.
• Alexander, T. and Bloch, S., 2002. The Written Report in Consultation–Liaison Psychiatry: A Proposed Schema.
Australian & New Zealand Journal of Psychiatry, 36(2), pp.251-258.
Appendix –Proforma for CLP
Thank You