Models of CLP

Dr. Ateev Chandna - Presenter

Dr. Kasturi Sakhardande - Mentor
Dr. Senthil Reddi - Chairperson
 Overview
• Introduction
• History
• Concepts of CLP
• Models of CLP
• Relevance to India
• Challenges & Complexities in developing new models
• Future Direction
BODY MIND

MEDICINE Consultation
Liaison
PSYCHIATRY
Psychiatry

MEDICAL PSYCHIATRIC
ILLNESS ILLNESS
 Consultation-Liaison Psychiatry

“Consultation-liaison (C-L) psychiatry as a subspecialty is the area of

clinical psychiatry that encompasses clinical, teaching and research
activities of psychiatrists and allied mental health professionals in the
non-psychiatric divisions of a general hospital”
-Lipowski 1983
 CLP as a subspecialty

“A specialized area of psychiatry whose practitioners have particular

expertise in the diagnosis and treatment of psychiatric disorders and
difficulties in complex medically ill patients”
- Gitlin 2004
 Practitioners

Inpatient mental health services

hospital based CL medical- integrated into primary care
psychiatrists psychiatric units
 Evolution of CLP

GLOBAL
Consolidation
phase
Development (1980 onwards)
phase (1950s- Consultation v/s
1980s) liaison
Lipowski Liaison nursing
Organization phase and behavioural
Development and
(1930s – 1950s) medicine
growth of models
Billings- “liaison
psychiatry”
APM was set up INDIA
Preliminary Development
phase Phase
(1900-1930) Organization (1980’s
Phase onwards)
First GHPU in Development
1902 (1960’s-1980’s)
of models
Rise of the
Preliminary GHPUs
phase
(1930’s -1960’s)
(Grover,IJP,2011)
First GHPU (Ali S, Curr Psychiatry Rep. 2006)
 Medical Expert

Scholar Communicator

Roles of Cl
Psychiatrist
Health
Collaborator
Advocate

Supervisor Manager

(EACLP Consensus Statement,2011)

 Rationale of CLP
Mental health
concerns
Improved
become Improvement in
access to Patient centred
relatable & patient
Mental Health care
understandable outcomes.
Services
for medical
colleagues

(Cochrane review 2015)

 Consultation liaison

Consultation Liaison

Consultation on
request Support
Education
Reactive Dealing with mental
Formal and informal
health issues of the
Patient and Consultee education
staff
specific

(Bulletin of Royal College of Psychiatrists,1986) (ACLP 2019)

 Context for models of CLP
• 27% of patients admitted to medical wards have a mental illness
fulfilling DSM-IV criteria (Silverstone, 1996).
• RCP - 80% of all hospital bed days occupied by people with co‐morbid
physical & mental health problems
• Psychological & psychiatric comorbidity - longer length of hospital
stay (Aoki, Sato & Hosaka, 2004).
• 1/3rd with chronic physical conditions have at least 1 co‐morbid
mental health problem, increase the cost of treatment by between
45% - 75% (Foley, 2013).
 Context for models of CLP
• “De facto mental healthcare system” - nonpsychiatric clinicians (Regier et
al., 1978).

• Failure to identify, evaluate, diagnose, treat, or achieve symptom

resolution
• Major cause –
• Absence of ready access to psychiatric expertise
• Organization of the healthcare system such that it is partitioned into medical
and psychiatric sectors (Wise 2008)
• Hence methods of optimally delivering psychiatry services to medical
setups came up as ‘models’
 Models of CLP
• Models – methods of service delivery
• Initial ‘consultation liaison’ model evolved from placing psychiatric
services in general hospitals – the GHPUs
• Intentions - provide rapid access to psychiatric care, improve mental
health skills among non psychiatric clinicians & improve patient
outcomes (Lipowski 1969)
• Over time there was fading away of the liaison part due to financial
constraints (Muskin,2017), they were also not backed by evidence (Toynbee,2021)
• Development of newer evidence based models like proactive &
collaborative care model in response
 Consultation Model
• Universally applicable
• Request by the consultee for the consultation

Interview by CL psychiatrist

Communication to ward team with recommendations for further care

• Follow up is on ‘as needed basis’
• Most widely prevalent in Indian context (Grover,2019,IJP)
 Consultation Model

Benefits Limitations
• Universality • No evidence that it is more
• Less Resource Intensive effective than usual medical care
(Toynbee,2021,General Hospital Psychiatry)
• Easier to implement
• Medical teams frequently don’t
• Most Familiar
act on the suggestions of the CL
Psychiatry team (Leentjens,2010,J
Psychosomatic)

• Since it is referral based, many

cases likely get missed
 Liaison Model
• No Broad Consensus but can be characterized as -
• A model where mental health worker provides specialist consultative services
to primary care provider who has central role in delivering health care .
• Extent of contact between the mental healthcare worker and patient varies
from model to model(Gilles,2015)

• “Linking up groups for better collaboration”(Lipowski 1982)

• Involves interpretation of attitudes of patients and their caregivers and
mediation between patients and members of the clinical team
 Liaison Model

• A major role of the psychiatrist is improving mental health expertise

of other health profession by providing
a)care management
b)case discussions
c) clinical support.
 Liaison Model
Benefits
• Evidence for improvement in
outcomes (Cochrane review 2015)
• Improvement in the knowledge
skills, interpersonal
communication, stigmatizing
attitudes of other health
professionals (Butler,2018,Int J Psychiatry)
Limitations
• More resource
intensive(Goodrich,2013,Current Psychiatry)
• Implementation depends on the
attitudes of other health
professionals and their relations
with the Mental Health
Provider(Fleury,2016,Mental Health Fam Med)
 Classification
of Models

Focus of Focus of Focus of

Consultation Function Work

Grover,2011,IJP
 Focus of Consultation

Patient Consultee
Crisis Oriented
Oriented Oriented

Expanded
Situation
Psychiatric
Oriented
Consultation
 • Patient - primary focus
Patient Oriented • Interview, assessment , psychodynamic evaluation of personality

• Rapid Assessment
Crisis Oriented • Immediate therapeutic interventions

• Motive of consultee, his expectations most important

Consultee Oriented • Managing his difficulties with the patient

• Interpersonal interactions of clinical team

Situation Oriented • Goal to understand patients behaviour and consultees concern

• Operational group involving the patient, staff , other patients and clinical team.
Expanded
Psychiatric • Primary focus being on patient
Consultation
 Focus of Function

Consultation Liaison Bridge

Hybrid Autonomous
 • Patient is the focus
Consultation

• Consulting physician is the focus

Liaison • Consultation + Educating colleagues

• Educating primary health physicians about mental health

Bridge problems to empower them to manage mental health issues

• Collaborative work between psychiatrist, behavioural health

Hybrid specialist and primary care physician
 Focus of Work

Basic Critical
Biological
Liaison Care

Milieu Integrated
 • CL psychiatrist attached to a Critical care unit
Critical Care • Patient Care as well as staff issues

• Emphasis on neurosciences, psychopharmacology and

Biological psychological management

• Based on Interpersonal theory

Milieu • Group aspects of patient care, reactions of staff, ward environment

• Psychological care is provided as an integral factor of clinical and

Integrated administrative need
 Proactive Model

Active systematic screening for all patients

Identifying patients who may benefit from timely mental health care

Provide care to these patients proactively

(Oldham,2019,General Hospital Psychiatry)

 Proactive Model

Benefits
• Rapid intervention anticipates
impending problems
• Daily and close contact between
behavioural and medical teams
Limitations
• Extremely resource intensive
• Doubts about its scalability
• Logistic issues with screening
• Interdisciplinary dynamics

• treatment recommendations are

understood, enacted, and reinforced
 Collaborative Care Model
• Developed in 1990’s based on Wagner's chronic care model

• Framework : patient self-management support, delivery system

redesign, use of clinical information systems, provider decision support,
linkage to community resources & health care organization support

• Over the past 2 decades significant evidence for this model in

management of chronic medical illnesses like diabetes, hypertension,
asthma, CHF and depression.
A multifaceted approach to patient care
provided by a primary care physician (PCP) and
a psychiatrist, in the context of the primary
care setting (katon,1995)

A structured management plan,

scheduled patients follow-up & enhanced
inter-professional communication
(Gunn,2006)
 Elements of Collaborative Care Model
1. Team Driven

2. Population Focused

3. Measurement Guided

4. Evidence Based

(The collaborative care model report,2016,ACLP)

EVIDENCE BASE
 Evidence
base for
these models

Patient Service
Outcomes Delivery
Evidence for the consultation based models

• Systematic review of 8 RCTs for Inpatient predominantly consultation

based models v/s Treatment as usual
• None of these models showed that consultation based models were more
effective than usual medical care in improving patient outcomes, reducing
LOS or hospital stay.

(Toynbee,2021,General Hospital
Psychiatry)
 Evidence for the Liaison based models
• Cochrane review 2015
• Positive effect on symptoms for up to 3 months
• Positive effect on treatment satisfaction and adherence up to 12 months
• No difference in symptoms from 3-12 months follow up between CLP and
standard care
• Cape 2010 - Meta-analysis of ‘No contact liaison models’
• no improvements in outcomes, treatment adherence in short or long term in
depression patients
• Andreoli 2003 – Systematic review on cost-effectiveness
• No clear benefits of favorable return on investments on switching to a liaison
model
 Evidence for the Proactive based Models
• Proactive geriatric consultation has shown to decrease delirium
incidence.(Lenartowicz,2012,Ann Surg)
• Proactive palliative care programmes have reduced Length of stay in
ICU(Mun,2016,Perm J)
• Oldham 2019 - Systematic Review of 12 studies
• compared proactive v/s treatment as usual
• Proactive - embedded and multidisciplinary team based care
• Reduced length of stay, favorable returns on investment.
• However no RCTs conducted till date
 Evidence for the Collaborative Care based
models
• Cochrane review 2012 –
• Significant improvement in patient outcomes in anxiety & depression for up
to 2 years
• Woltmann 2012 – metanalysis of 57 RCTs
• Positive effect on multiple disorders with regard to clinical symptoms, mental
& physical quality of life, and social role function
• No net increase in total health care costs.
• Sighinolfi,2014 - metanalysis from Europe focusing on 17 RCTs
• collaborative care was effective in short, medium & long term improvement
in outcomes as compared to treatment as usual
 Evidence for the Collaborative Care based
models
• Gilbody 2006- metanalysis of 36 RCTs
• No improvement in patient outcomes in Non American settings

• Steenbergen-Weijenburg 2010 - meta-analysis of cost-effectiveness

in 8 randomized controlled trials in primary care settings
• Care management model was more effective but cost more
 Studies comparing these models
Consultation Model v/s Liaison Model –

Grover,2015
• Compared efficacy of switching from consultation model to a liaison hybrid model in the
emergency department
• Increase in referrals with more core psychiatric diagnoses, more institution of medications
& psychotherapeutic interventions

Lucke,2017-
• Compared on-demand consultation model with a quasi-liaison model
• Liaison model suitable and cost-effective way of providing psychiatric care to hospital
patients in small-to-medium sized hospitals
 Studies comparing these models
Collaborative care vs Consultation Liaison Models

Hedrick,2003
• Comparison in Veterans with major depression & dysthymia
• More rapid improvement in depression symptomatology
• more rapid and sustained improvement in mental health status in
Collaborative Care model
Applications of the Service Models
 Liaison Models

Core 24 Enhanced 24 Comprehensive

 Core 24
• Liaison mental health service designed to operate in acute general
hospitals, providing care for people with significant mental health
needs.
• Training for non-mental health clinicians & hospital staff in supporting
people with mental health need
• Works 24 * 7
• NWL London Optimal model
• Frequent attendance was reduced and improvements in care were achieved

(NICE 2016 Supplement)

 Enhanced 24
• Liaison model - Core 24 services + specialist care
• Enhanced expertise in SUD and people with ID
• Serves Emergency + planned care pathways
• RAID model –
• Multidisciplinary service in the general hospital provides a single point of
access to all patients mental health and drug & alcohol problems, alongwith
formal and informal teaching
• rapid response - prompt assessment, intervention and discharge
• Significant cost savings due to decreased length of stay (Becker,2016)
 Comprehensive

• Includes a multidisciplinary team of CL psychiatrists, specialized

liaison nurses, behavioural health experts, occupational therapists,
physiotherapists
• Spans inpatients as well as has outpatients OPDs
• Also has Liason inpatient beds
 Proactive Models

Johns Hopkins University of

Yale
Proactive Hospital Rochester Proactive
Behavioural Intervention
based Initiative to Integration of
Team
provide Psychiatric Mental health care
Services (PRIME) Medicine
 Collaborative Care Models
• IMPACT model (Improving Mood—Promoting Access to Collaborative
Treatment)
• Trained depression care manager (DCM)—usually a nurse, social worker, or
psychologist—works with the patient, the patient’s primary care provider, and
a psychiatrist to develop and administer a course of treatment.

• DIAMOND model -(Depression Improvement Across Minnesota,

Offering a New Direction)
 CLP in the Indian Context
• “There is no specific philosophy or particular clinical context being
identified in liaison psychiatry in India.”(Parkar,2001,J postgrad med)

• The consultation model is primarily being followed in both the IP and

OP settings (Grover,2001,IJP)

• In a survey of 90 training centers, 75% were practicing ‘on-call

services’ model of CLP and only 33% had a three tiered centers.
Almost no centres had multidisciplinary team(Grover,2008,IJP)
 Efficacy –outcomes in Indian studies
• Paucity of literature related to outcomes between different models

• Major literature about referral patterns from 24 tertiary centres

• 0.01% -3.6% inpatients, 1.42% to 5.4% emergency, 0.06% to 7.17%
outpatients referred
• Depression, Delirium,DSH, anxiety disorders, and dissociative disorders most
common [Dua, et al. IJP. 2020]
 Factors halting progress of CLP in India
1. Limited staff
2. Administrative issues
3. Limited Research
4. Poor awareness among medical colleagues
5. Stigma

(Grover 2019)
 Challenges in creating new models
• Intensity of work with individuals v/s number of referrals that can be
seen
• Acute urgent work v/s non urgent complex work
• Desire to take over patient v/s be part of integrated team
• Use of evidence based care v/s innovative care v/s patient centred
care
• Specialisation v/s generalization
• Diversity of roles v/s continuity of roles

(House,2018,BMC)
 Complexities in scaling current models
• Models are rarely direct linear paths from resources to activities to
outcomes and impact

• ‘Emergence’ – When system changes so does behavior of it’s agents

and behavior of system as whole (Rohwer,2018)

• Many service level interventions lead to unintended consequences

like increase in the number of referrals, referral patterns & type of
interventions(Diefenbacher,2001,psychosomatics)
 Goal – to increase response times

Increase staff, Pressure on team

Number of referrals
improve referral to maintain
increase
system response times

Response times are

Less time spent in
maintained but
wards with
Length of stay
complex patients
increases
 Goal – To decrease Length of Stay
Educate other
Increased referrals
doctors about
Increase staff of more complex
which patients to
patients
referral urgently

Length of stay
Less staff available
decreases but
for emergency
response time
work
increased
Steps in setting up a ‘de-novo’ CLP service
In hospitals where liaison psychiatry support is currently
limited or non-existent

Set up a rapid-response generic service

Team has work balanced between emergency and inpatient

work.

Interventions prioritized towards groups where there is most

evidence like pediatric & geriatric in-patients

Training and supervision of all acute staff

The Way Ahead…
 For Liaison psychiatry to contribute
• Every General and acute hospital should have a dedicated in-house
liaison psychiatry service with goal to integrate psychiatry fully into
medical care

• It should be sustainable with scale & nature of operation based on

local needs

• CL Teams should be multidisciplinary involving clinical psychologists &

other allied behavioral health experts
(Parsonage,2012,NHS report)
 Future Directions
• The next stages in development is of outpatient clinics for the
treatment of mental health problems which cannot be resolved
during the limited time that most patients spend in hospital.

• Long-term development of liaison psychiatry is going to lie primarily in

the expanded provision of community-facing services specially mental
health problems in people with chronic physical conditions

(Parsonage,2012,NHS report)
 Take away points
• Consultation Liaison psychiatry core features –
• Assist patients with mental health concerns within a medical context,
• Make mental health concerns relatable & understandable for medical
colleagues
• improve patient lives via collaboration with medical colleagues
• Various complex service models have developed over the years
• Current trends being shift from the tradition consultation models to
more evidence based collaborative, proactive models
• Need to shift from the Inpatient setting to Outpatient and community
facing models for long term development of CLP
 References
• Toynbee M, Walker J, Clay F, et al. The effectiveness of inpatient consultation-liaison psychiatry service
models: A systematic review of randomized trials. General Hospital Psychiatry. 2021 Jul-Aug;71:11-19. DOI:
10.1016/j.genhosppsych.2021.04.003.
• Gilbody S et al. 2006. Collaborative care for depression, accumulative meta-analysis and review of longer-
term outcomes. Arch Intern Med 166:2314-2321.
• Walker A, Barrett JR, Lee W, West RM, Guthrie E, Trigwell P, Quirk A, Crawford MJ, House A. Organisation
and delivery of liaison psychiatry services in general hospitals in England: results of a national survey. BMJ
Open. 2018 Sep 1;8(8):e023091.
• Consultation Liaison Psychiatry in India – Where to go from here?Sandeep Grover, Ajit Avasthi Indian J
Psychiatry. 2019 Mar-Apr; 61(2): 117–124.]
• Oldham MA, Chahal K, Lee HB. A systematic review of proactive psychiatric consultation on hospital length
of stay. Gen Hosp Psychiatry. 2019 Sep-Oct;60:120-126.
• Fleury MJ, Grenier G, Gentil L, Roberge P. Deployment of the consultation-liaison model in adult and child-
adolescent psychiatry and its impact on improving mental health treatment. BMC Fam Pract. 2021 Apr
29;22(1):82
Thank you