Chapter 49. Consultation–Liaison Psychiatry

Consultation–Liaison Psychiatry is a centuries-old field of medical practice and research that bridges the biological, psychological, and social domains of psychiatric and medical illnesses. Since 2003, it has been recognized by the American Board of Medical Subspecialties as the psychiatric subspecialty Psychosomatic Medicine, based upon its historical nomenclature. The practice of Consultation Psychiatry usually occurs within general hospital settings. The standard consultation is performed at the request of the primary clinician, and is a neutral collaboration with colleagues and patients in nonpsychiatric settings. Interview techniques in consultations may be open-ended for an individual patient's diagnostic evaluation or structured to screen for psychiatric disorders in a general population. Often a combination of both techniques is utilized. A central role of the consultation psychiatrist is to educate colleagues and patients about the psychiatric presentations or complications of medical illness and about illness behavior. Liaison Psychiatry expands the role of the psychiatrist to facilitate comprehensive treatment approaches within a system of care and to enhance communication among disciplines and across divisions in health care systems. The liaison psychiatrist is often a member of a multidisciplinary care team, performing psychiatric screenings, for example in organ transplant surgery or oncology, when the risks of psychiatric comorbidity are expected to be higher.

History of Psychosomatic Medicine and Consultation–Liaison Psychiatry

History of Psychosomatic Medicine

In the United States, the historical roots of psychiatry in the general hospital are found in the 1751 charter of the Pennsylvania Hospital, which provided for the care of “persons distempered in mind and deprived of rational faculties.” At that time, outpatient psychiatric clinics both in the Philadelphia Hospital and New York's Bellevue Hospital were developed. Reports from these early centers contain themes emphasizing the significant rates of psychiatric disorders in medically ill patients, and the need to integrate services.

In the modern era, the scientific approach to the relationship between psychiatric disorders and medical illness began with early studies in psychosomatic medicine which examined the relationship between psychological and medical disorders. Psychosomatic medicine as an area of research began with psychoanalytic studies of the mind–body relationship. Beginning in 1900, Sigmund Freud, as a young neurologist, described conversion hysteria as psychological symptoms imbued with deep psychic meaning, which manifested as or converted to somatic (physical) illness. In 1910, Sandor Ferenczi related conversion symptoms to the autonomic nervous system. In 1934, Franz Alexander proposed that ‘psychosomatic symptoms' were due to prolonged autonomic system arousal linked to repressed psychic conflict. Psychosomatic medicine advanced in the 1940s and 1950s with psychophysiological studies such as those by Hans Selye who described the human stress response in relation to adrenocortical hormones. Sociocultural researchers Thomas Holmes and Richard Rahe in 1975 linked disease likelihood to the severity and number of stressful life events, and further expanded the psychosomatic medicine framework. Zbigniew Lipowski in 1970 and George Engel in 1977 utilized systems theory to examine environmental influences on the mind–body–culture paradigm. All these works have shaped the biopsychosocial perspective of psychosomatic medicine extant today.

History of Consultation–Liaison Psychiatry

Concurrent with the development of psychosomatic medicine theories, psychiatrists returned to the general hospital they had left during the late 19th century asylum movement. No longer isolated in psychiatric sanatoria or cloistered in consulting rooms, psychiatrists had begun to treat patients in general hospitals. In 1929, George Henry advocated the benefits of general hospital psychiatry that offered consultative services, and was instrumental in the advancement of consultation practices. In addition to the emphasis he placed on the diagnosis and treatment of psychiatric disorders seen in the medically ill, such as delirium, dementia, depression, and anxiety, he recognized that medical students and residents were more likely to utilize psychiatry for patients in medical settings rather than in isolated psychiatric facilities. Psychiatric consultation services developed further with support from the Rockefeller Foundation and grew with funding from the Psychiatry Education Branch of the National Institutes of Mental Health. By the end of the 20th century, there was a significant cadre of trained consultation–liaison psychiatrists working within hospital settings and medical schools.

Psychosomatic Medicine as Subspecialty of Psychiatry

In May 2003, the American Board of Medical Subspecialties recognized the practice of consultation and liaison psychiatry in the general hospital as a discrete psychiatric subspecialty that requires advanced training and qualification by an examination conducted by the American Board of Psychiatry and Neurology. In recognition of its earliest scientific bases, the subspecialty was named Psychosomatic Medicine by the American Board of Medical Subspecialties to distinguish it from other consult practices in medical subspecialties. In June 2005, the American Board of Psychiatry and Neurology administered the first examination to certify subspecialists in Psychosomatic Medicine. Psychiatric fellowship training programs in Psychosomatic Medicine qualify physicians in the skills and techniques of consultation–liaison psychiatry within the domain of psychosomatic medicine and related research.

Is There a Need for Consultation–Liaison Psychiatry and Psychosomatic Medicine?

Evidence from Nonpsychiatric Settings

How does the work of a psychiatrist in a nonpsychiatric setting improve patient care? Numerous studies in the past decade have demonstrated that psychiatric consultation contributes to reduced costs in health care delivery, and improves access to mental health care. Most importantly, psychiatric consultation improves the detection of psychiatric illnesses, many of which are life threatening. It is well known that, left undetected and untreated, psychiatric comorbidity increases hospital lengths of stay (and concomitant costs), even when demographics, medical diagnosis, and reasons for admission are taken into account.

Many studies have shown that patient outcome is markedly affected as a consequence of under-recognized or misdiagnosed psychiatric illness in nonpsychiatric settings. In primary care, where most patients with psychiatric illness present, the vast majority of patients do not receive treatment for psychiatric illness. Many factors collude in the limitation of care: Psychiatric symptoms are difficult to distinguish from medical symptoms; patients fear stigma and minimize complaints; time constraints, or inadequate training or the primary physicians' reluctance to stigmatize the patient may impede them from treating psychiatric symptoms.

Studies clearly demonstrate that psychiatric consultation in the hospital lowers morbidity, mortality, length of stay and cost through the earlier recognition and treatment of psychiatric disorders, and has an impact on quality of life measures of self-care. These findings mandate psychiatric education of colleagues, case-finding through psychiatric screening, and expansion of services by the consultation–liaison psychiatrist.

Evidence from Research in Psychosomatic Medicine

Psychosomatic medicine was first popularized when psychoanalytic theories of mind–body relationships suggested that psychotherapy could modify the course of medical disease. Although speculative, such theories posited that early life experiences (fostering unconscious conflicts) coupled with genetic (biological) vulnerability could cause disease states such as peptic ulcer or asthma. Although many of these ideas were erroneous, there is significant data in both animal and human research to demonstrate an effect of early life experiences on physiology and illness behavior.

Modern psychosomatic research has abandoned much of these early theories, but continues to investigate the role of psychosocial variables in causing or maintaining disease states. It utilizes a variety of empirically based strategies; as an example, structured psychiatric interviews and reliable psychometric inventories are paired with biologic probes and immunologic measures to answer complex questions about the interrelationship between psychosocial and biologic variables.

An example of current research is the study of the biopsychosocial relationship between depression and cardiovascular disease. Landmark research in psychosomatic medicine beginning in the 1980s has revealed that individuals with major depressive disorders have significantly increased mortality risk following uncomplicated myocardial infarction (MI). The depressive episode often predates the acute coronary syndrome and is not a mere “reaction” to the cardiac event. Hostility and anger have been implicated in acute coronary syndromes. Biological factors that play a role in the genesis of coronary artery disease in depressed individuals include reduced heart rate variability, platelet dysfunction, and elevated cytokines. A shared genetic vulnerability for depressive disorders and cardiovascular disease underpins these truly psychosomatic relationships. The advent of sophisticated genetics and molecular biology holds the promise that such relationships will be further elucidated.

Chapter Overview

This chapter will consider the techniques, settings and core concepts of Consultation–Liaison Psychiatry and Psychosomatic Medicine. At present, the general practice of the consultation–liaison psychiatrist includes the recognition and management of the following: (1) the impact of psychiatric disorders on medical illness, (2) comorbid psychiatric and medical disorders, (3) the etiologic role of medical illness in psychiatric disorders, (4) suicidal, homicidal, and violent behavior in medical-surgical settings, (5) legal and ethical principles in the psychiatric care of the medically ill, (6) pharmacological and therapeutic intervention in comorbid illnesses, (7) behavioral responses to medical illness, and (8) the physician–patient relationship.

The chapter will condense Consultation–Liaison Psychiatry and Psychosomatic Medicine into two sections: Clinical Consultations and Core Concepts in Psychosomatic Medicine. The first section on Clinical Consultations presents the standard skills and techniques utilized by practitioners in a general hospital, organized as follows: consultation–liaison psychiatry basics; diagnostic evaluation skills; screening techniques to identify psychiatric patients in general populations; consultation treatment; legal issues; emergency assessments; and finally, liaison psychiatry. The second section on Core Concepts in Psychosomatic Medicine presents the general conditions that the consultant is likely to encounter. These Core Concepts of diagnosis are based upon the framework proposed by Lipowski in 1967:

1. Psychiatric Disorders Caused by Medical Conditions

2. Psychiatric Disorders Affecting Medical Conditions

3. Psychological Reactions to Medical Illness

4. Somatic Presentations of Psychiatric Disorders

For detailed discussions of specific psychiatric diagnoses and treatments, the reader will be directed to relevant chapters in the book. A concluding section suggests future directions for clinical practice and research in the field of psychosomatic medicine.

Consultation–Liaison Psychiatry Basics

The psychiatric consultant should serve as an ally to patient care provided by the physician (or primary team), the associated health care disciplines, and the system of care. In this alliance, adaptability and diplomacy enhance the care provided by the psychiatric consultant.

Adaptability is necessitated by the challenge of working in a general hospital. The modern hospital is a busy and crowded environment that usually limits privacy and is often unfamiliar to both patients and mental health professionals. Many hospital floors do not have interview rooms. Medical treatment rooms are often not conducive to psychiatric interviewing. Evaluations may have to be performed in hospital rooms occupied by other patients. Thus, the consultant must be both practical and flexible. Speaking in a soft voice to allow confidentiality is sometimes the only option. Patients may be critically ill and attached to devices such as intravenous lines, catheters, and respirators. If a patient cannot speak due to a tracheotomy or attachment to a ventilator, a signing board or pad and pen may be necessary. The interview may be interrupted by medical or nursing staff, or by transport personnel for ad hoc procedures. Patients may be obtunded or unable to give a comprehensive history; use of other sources of information is often necessary but raises concern about the right to privacy. Such issues challenge the consultant but also establish the psychiatrist as a physician with unique skills necessary in modern healthcare teams.

Diplomacy in consultation is rarely discussed but inherently useful in practice. It is based upon the following qualities: awareness of the hierarchical and multidisciplinary nature of health care systems; respect for the roles and tasks a provider within a system assumes or is required to perform; regard for the boundaries or limitations of care, whether internal or external to the provider or system, affecting the patient's experience (e.g., economics determining hospital length of stay); and a collaborative or altruistic spirit that bolsters the care by the primary team through education and altered practice patterns. Examples of these qualities are the implementation of psychiatric care for organ transplantation patients and development of psychiatric screening in primary care settings. Consultation psychiatrists are ambassadors for the profession of psychiatry in large health care settings where communication between specialists can be limited.

Diagnostic Evaluation in the General Hospital

Consultations requests may have many origins and serve varied needs for the patient, team and system of care. Requests can be made by the patients, primary providers, multidisciplinary teams, and by the family members. Requests can arise when a physician ponders the clinical status of the patient in regard to mood or affect (e.g., depressed after surgery), cognition (e.g., ability to make medical decisions), or behavior (e.g., agitated or threatening). Requests may seek assistance anywhere along the continuum of diagnosis, evaluation, treatment and management. They may focus on a particular aspect of care, such as suicide risk assessment, or be more general in scope, such as the evaluation of a patient's reaction to medical illness.

Contacting the referring provider is important to understand the broader nature of the consultation request. The personal history of a psychiatric disorder may prompt a request for evaluation, although the consultant often is the first psychiatrist to evaluate the patient, even when the patient has a prior history of psychiatric symptoms. Some requests are urgent (e.g., “wants to leave against medical advice”) in which case contacting the referring clinician can provide important information to expedite the consultation. Often, a simple request such as asking for help in treating depression is really “the tip of the iceberg” heralding broader psychosocial difficulties within the patient and social system. Contacting the referring provider is the best way to elicit the “real story” behind the consultation request.

Collection of behavioral data from primary sources (nurses, medical students) is the next step. Prior to seeing the patient, consultants discuss the patient's status with nursing personnel who know the patient and are able to share observations regarding the patient's clinical status and interaction with family members. Nurses' notes are a trove of information about patient behavior (e.g., “lost returning from the bathroom”) that can guide the review. Medical students also can offer keen observations of patient behavior.

Review of medical records can be approached in the manner of detective work. A discerning review of medical notes provides clues to the patient's behavior, cognitive status, and physical function. Admission summaries and off-service summaries are concise records from which to obtain a time-line for the hospital course. Pertinent laboratory results and medication records reveal underlying medical conditions or areas that need further investigation. If the consultant is not clear about a medical illness, a review of the condition from available medical texts is done.

The review of medical records should search for medication that acts on the central nervous system (CNS), whether intended or as a side effect, and look for possible drug interactions (e.g., through cytochrome isoenzyme substrates and inducers). Substance-induced psychiatric disorders are common, not only for substances of abuse but also for prescribed medications (e.g., steroid-induced psychosis). In addition, a sedating (e.g., benzodiazepine) or activating (e.g., beta-agonist inhaler) medication administered prior to the evaluation can affect the assessment.

Review of pertinent laboratory investigations is informative. Metabolic derangements and end-organ disease can affect cognitive status. Awareness of the physiological status can focus the consultation examination and aid in the differential diagnosis. Radiological studies can hone the assessment.

Consent to interview the patient is obtained ideally by the primary team, prior to the consultant's interview, and this can be verified with the patient. The consultant should obtain permission from the patient to conduct the interview and to communicate findings with the treatment team. The consultant should adopt a neutral stance in order to increase patient participation. This way, the consultant is obtaining consent neither as a member of the medical team nor as a patient advocate. Patients with a prior psychiatric history may anticipate that individual psychiatric treatment is confidential; thus they should be alerted to the consultant's role, particularly the need to confer with the primary team on the patient's behalf.

Diagnostic interviews aim to gather sufficient information to develop an answer to the consultation request. Following the preliminary actions described, the consultant introduces himself or herself as a psychiatric physician. Firstly, ascertain whether the patient has been told that a psychiatric consultation has been requested. If the patient has not been informed, elicit his or her feelings about it and request permission to conduct the interview. Secondly, it is important that the patient be given privacy to speak openly to the psychiatrist. For this reason, it is better if a visitor or family member is excused from the interview. Even when assurances are offered by the patient to allow their involvement, privacy can be presented as a matter of policy for the initial interview. Patients are often in a vulnerable position and unable to ask openly for privacy; the psychiatrist should assume responsibility.

The approach to the interview must be guided by immediate safety concerns in emergent evaluations; this may require restricting the interview to a focus on acute intervention and behavioral management, as is discussed in more detail in II. F. Emergency Consultations (see also Chapter 48). Often, a consultation is requested to assess the patient's level of anxiety or depression. The underlying task may be to assess how the patient is adjusting to an illness. A range of inquiries can provide an understanding of the patient's capacity to cope:

• When and how was the disease diagnosed?
• Were there delays in coming to treatment? Was there patient denial? Were there limitations to access?
• How has the patient reacted to the treatment, medical or surgical, and to the primary team?
• Have any medications been particularly difficult to take? Have any helped?
• What knowledge does the patient have of others with similar disorders?
• What has been the psychosocial and financial burden of the disease?
• Has the illness forced changes in family roles and responsibilities? Is there a confidante?
• Is there a support system? Is there neighborhood/religious/cultural/community support?
• Does the patient have an accurate understanding of the prognosis? How does it affect the reaction to the illness?
• Are there end-of-life issues that the patient is unable fully to address? Do supports know about the situation?

Some consultations focus on cognitive capacity and whether an individual has dementia or delirium. This mandates careful attention to the nursing notes and understanding the effects of the underlying disease process or medication upon the CNS. A careful assessment of mental status is required for all patients, allowing for detection of psychopathological phenomena, affective symptoms, and cognitive integrity. Many patients fluctuate in their ability to attend; serial examinations can provide a more accurate assessment. Some patients are fearful that they will be judged “crazy” if they are experiencing hallucinations (e.g., due to medications such as opioids). Active inquiry about whether the patient has been confused or uncertain about their situation allows them to reveal their cognitive problems. Formal testing for cognitive status via the Folstein Mini-Mental Status Examination (MMSE) provides a baseline cognitive assessment for the initial evaluation; the score is easily recognized by other specialists, and can be followed serially.

General review of symptoms from the domains of mood, anxiety, psychosis and substance use should be elicited. Even when they are not the focus of the consultation request, they may inform differential diagnosis and treatment plans. A detailed discussion of the principles of interviewing is discussed elsewhere (see Chapter 4). Frequently, in medically ill patients, symptoms of prior concern to the patient are not reported to the primary team for a variety of reasons, whether omitted by the patient or missed by the team. The psychiatric consultant offers the patient a new opportunity to be heard, and can serve also as a medical translator. If possible, the patient should give verbal consent during the interview to contact other sources of information.

Collateral information is important in situations in which the patient is unable to communicate accurately (e.g., altered consciousness, unreliable historian, cognitive impairments). The sources include spouse, family members, friends, case managers, or outpatient providers. The consultant must protect the patient's privacy; ideally patients can give consent to speak with others, but this is not always possible if the patient is impaired. In emergency situations, collateral information obtained from other sources can be vital, even if the consultant cannot provide information in return. Communication with family members can be essential. Reports from family members may differ from that of the patient and highlight problems. It is common to see elderly patients who consider that they can return to independent living arrangements while family members report numerous reasons to the contrary. Some patients deny substance abuse while family members contradict them. It is also useful to ascertain the patient's past adherence to treatment.

Consultation reports should summarize the data collected in a clear and legible manner; electronic charting is ideal for cogent communication. If consultations are dictated, put a brief note in the medical record immediately following the consultation with diagnostic or treatment suggestions that can be considered immediately. If time permits, a concise yet thorough summary of findings, expressed in an organized, standard format is indicated (see Fig. 49–1). Differential diagnoses, diagnostic workup, symptomatic treatment and, in most cases, cognitive capacity are documented. When the consultant seeks to narrow the differential diagnosis, it should be communicated to the treatment team that further investigations such as neuroimaging or specialized laboratory investigations are required (see Fig. 49–2).

Recommendations include further testing and medication advice. When psychopharmacologic recommendations are included it is essential to outline side effects that may occur, since the referring provider or treatment team may not be aware of them. The medically ill patient is particularly sensitive to drug side effects, and may tolerate only a reduced dose. Over-sedation may lead to aspiration while eating, and drug–drug interactions can cause toxic side effects. The consultant should warn about possible problems in the consultation report and in person with the consulting provider. Working with nurses and allied health professionals to ascertain the behavioral effects of medications is within the scope of consultation practice. Recommendations to assist with psychiatric disposition and capacity to live independently may rely on collaboration with social work services and liaison with outpatient mental health providers. Recommendations regarding cognitive status may include referral to or liaison with social workers or legal counsel, in accordance with hospital policies and local statutes. Consultation psychiatrists should be informed about the policies and laws that protect patient rights in every setting (see Chapter 50).

Discussions about end-of-life issues commonly arise in the medical setting, often when discussing the patient's coping strategies. Hospitalization itself can evoke fear in a seriously ill patient who is unprepared for death. Others may seek relief from suffering and express a passive wish to die interpreted by staff as suicidality, prompting a psychiatric consultation request. Family histories may reveal an early demise from a condition similar to that of the patient, causing the patient to be concerned about the current situation. This psychological connection may not be readily identified by the patient but expressed behaviorally, for example by a refusal of procedures reminiscent of the deceased's medical course. A review of the patient's expectations for the future should be included in the initial diagnostic interview, although rapport should be developed sufficiently for the patient to explore his or her own mortality; premature introduction of a discussion of death may be unnecessarily alarming and better deferred to a follow-up session.

Follow-up of the patient is provided in collaboration with the treatment team, and the frequency of contact determined by the patient's clinical status. For example, a patient experiencing delirium while the team conducts a search for the underlying causes may require daily mental status examinations by the psychiatric consultant to monitor progress. Alternatively, a patient unable to make decisions regarding a procedure may require little or no follow-up once a surrogate decision-maker has been identified. Follow-up after the initial consultation may allow the consulting psychiatrist to determine whether there should be changes in the initial recommendations. Each contact should be documented.

Screening Techniques to Identify Psychiatric Patients

In comprehensive medical and surgical care, often in outpatient settings, screening for comorbid psychiatric disorders can be time-efficient and cost-effective. Screening tests help nonpsychiatrists to uncover a symptom profile that heralds the need for evaluation by a psychiatrist. Screening tests are not a substitute for a psychiatric interview, but serve as a technique for early detection.

Endorsement of psychiatric symptoms may be elicited by self-administered patient questionnaires or by clinician-administered, structured interviews. Although myriad questionnaires are available, the self-administered questionnaire that is well standardized to detect depression, anxiety, and alcohol use in the primary care setting is the PRIME-MD Patient Health Questionnaire (PHQ). The PHQ-9 screens for depression and is available through its initial publication. The PHQ-2 is an abbreviated, standardized subset of the PHQ-9 that screens for depression in a general population, with high sensitivity (0.83) and specificity (0.92). The PHQ-2 is often added to a battery of health care questions completed in the outpatient waiting room. The Folstein Mini-mental State Examination (MMSE), a structured, clinician-administered screen for dementia, is available through its initial publication. The MMSE is used in screening for cognitive disorders such as delirium, but is standardized only for dementia. The Mini-Cog is an abbreviated, standardized test that utilizes the 3-object recall item of the MMSE combined with the Clock Drawing Test; it has comparable sensitivity and specificity to the MMSE but taps additional regions in the brain. The CAGE questionnaire, a simple screen for detecting alcohol use is utilized by psychiatric and nonpsychiatric clinicians, and can prompt referral to substance treatment programs (see Chapter 15).

If the patient requires further evaluation after a positive screening questionnaire, referral to the psychiatric consultant is the next step. Patients reluctant to seek care in a psychiatric clinic may agree to evaluation by the consulting psychiatrist who, as a member of the primary care team, avoids the stigma of psychiatric referral. Consultation psychiatrists assist primary physicians who manage general psychiatric disorders directly and reserve referrals to psychiatric care for patients who are acutely ill or require a complicated medication regimen. There are good reasons for these strategies. Even though medical conditions, especially chronic conditions, increase the likelihood of a psychiatric condition, a minority of patients with a psychiatric disorder will be evaluated by mental health specialists. Moreover, half of all visits to physicians by patients with diagnosable psychiatric disorders occur in primary care clinics, and primary care physicians write most of the prescriptions for antidepressants and anxiolytics.

Psychiatric care provided in the medical setting in situ searches for untreated psychiatric patients. Psychiatric care within the setting of primary care closely resembles diagnostic evaluations in the general hospital in that it involves the direct collaboration with the primary provider in the treatment of comorbid medical and psychiatric conditions. However, in response to early detection, whether through screening or by the astute primary provider, psychiatric consultation in primary care settings serves a greater number of psychiatric patients than in general psychiatric settings.

Treatments in Consultation Psychiatry

Psychopharmacological Treatments

Special considerations are necessary in the treatment of medically ill patients with psychopharmacologic agents. The pharmacokinetic and pharmacodynamic properties of medications and the underlying clinical status of the patient are germane to the consultant's practice. A search for the cause of psychiatric symptoms is essential, but it also raises concern for the complex variables that affect the medicated, medically ill patient.

Pharmacokinetic changes in absorption, distribution, metabolism, and excretion often modify choice of agent and dosing regimens. Absorption of agents in patients who cannot take oral agents may be possible only via intramuscular, intravenous or rectal routes. Novel routes of administration such as buccal wafer and topical patch offer options for the treatment of patients who cannot swallow. Distribution of drugs is altered in patients who are hypovolemic. Antacids, commonly prescribed for hospitalized patients, may slow the distribution and limit the onset of action of oral benzodiazepines. In patients who are chronically ill there is often reduced protein-binding available which can create toxic levels of free agent. Metabolism by the liver transforms many psychotropic agents; thus the presence of liver disease mandates reduced dosing. Drug–drug interactions can raise or lower drug level via inhibition or induction of metabolism by cytochrome P450 isoenzymes. Many psychiatric medications have narrow therapeutic indices in which the agent (substrate) has a narrow path for metabolism via a specific isoenzyme; altered function of the isoenzyme, either through its inhibition (immediate) or its induction (delayed) can markedly affect the blood level of the agent. Medical literature and online resources such as micromedex.com can provide this information. Excretion via the kidneys is limited in acute and chronic renal failure; patients receiving medication dependent on renal function, such as lithium or bupropion, may require lower dosing. For patients on renal dialysis, lithium must be dosed very carefully. Only a single dose may be required following dialysis since it will not be excreted until the next dialysis.

Pharmacodynamic issues involve the alteration of a drug's intended pharmacologic effect by another drug or mechanism at the site of action. The serotonin syndrome exemplifies this phenomenon. Drugs such as meperidine or dextromethorphan interact with selective serotonin reuptake inhibitors (SSRI) to provoke a potentially fatal syndrome characterized by confusion, ataxia, hyperreflexia, clonus, nausea and hypertension. The putative effects of SSRIs in prolonging bleeding may have clinical consequences. The association of gastrointestinal bleeding in the elderly who are taking serotonin reuptake inhibitors should alert the clinician to minimize such agents in medical settings. Cumulative and excess anticholinergic effects from drugs can cause confusion and decrease bowel and bladder motility in vulnerable patients. Excess sedation in elderly patients can be due to the additive effects of sedatives such as benzodiazepines and hypnotics given together. Independent of sedation, benzodiazepines can increase the risk of falls in the elderly.

The use of medication in the medically ill requires careful attention to all the medications a patient is currently taking, the contribution of underlying medical conditions, possible drug interactions, and possible dosage adjustments. Other variables include nonadherence to prescribed medication, and polypharmacy in patients treated by several providers. Efforts to simplify medication regimens start with a polite inquiry into the indications for the prescribed agents, especially those suspected of CNS activity. Patients may be overwhelmed by the complexity of pill-taking, which may prompt recommendations that the regimen be streamlined while the patient is hospitalized and thus directly observed. Some hospital units provide “self-medication” programs, allowing the patient to retain some autonomy in self-care. This can serve as an opportunity to further monitor illness behavior.

Psychotherapy in the Medically Ill

Psychotherapy for the hospitalized patient is usually brief and supportive. The type of intervention will depend upon the patient's cognitive status, disease state, and treatments. If a patient has had delirium, often there are gaps in memory that can foster fears of embarrassment and distortion of what happened. The psychiatric consultant should inquire about such issues and fill in the periods of time the patient does not recall, replacing misperceptions with accurate information. The patient who has had frightening hallucinations due to opiates or steroids requires reassurance that these were drug effects.

Even when cognitively intact, patients may be depressed and express feelings of helplessness and hopelessness. Patients who have witnessed the unsuccessful resuscitation of a roommate can benefit from gentle inquiry into the emotional sequelae of such an event. Supportive psychotherapy includes not only eliciting fears and emotions but also initiating helpful measures. For example, when patients are distressed by the conditions of hospitalization, they may respond to dietary supplementation from home if allowed or from room change when a noisy roommate disturbs sleep. Simple measures like making a wall calendar available or locating eyeglasses can aid adaptation.

Common themes in brief psychotherapy are found in the exploration of the patient's ideas about the etiology of the illness, as well as the toll it has taken, and the exposure they have had to others with similar illnesses. Many patients fear discussing these issues with their primary physician. Distortions of causal factors, prognosis and treatment effects should be corrected. This can alleviate anxiety if the patient is overly pessimistic. A contrasting situation occurs when the patient minimizes serious disease or the need for intervention. The diagnosis of denial requires that the patient be told the nature of both disease and treatment. Denial wards off the terror of diagnosis and must be managed slowly and carefully. If denial wards off the implications of disease such that refusal of care is at stake, it is essential to utilize available family supports to understand the factors that promote denial and decide how to intervene.

Long-term psychotherapy is usually conducted in ambulatory or rehabilitation settings. Limited data confirm that this treatment has efficacy for somatic syndromes such as irritable bowel disorder or chronic fatigue syndrome. Cognitive behavioral therapy has been reported as effective for fibromyalgia. Graded exercise can help patients with chronic fatigue syndrome or fibromyalgia, whereas psycho-education is important for patients undergoing treatment for a variety of disorders. Evidence is growing that psychotherapy and psychopharmacological treatment are synergistic in the treatment of depressive disorders, better than either treatment alone. In the context of genetic testing for some diseases such as breast cancer or Huntington disease, the patient needs full knowledge of the risks and benefits of such knowledge. This may generate a role for psychotherapeutic consultation.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a first-line treatment in medically ill patients with suicidal depression, psychotic depression, depression during pregnancy, and in medical conditions that cause inanition or risk for cardiovascular collapse. Although generally reserved for refractory disorders and special circumstances, it is the most effective treatment for depressive disorders. The consulting psychiatrist may be in a position to initiate education of patient, family, and the patient's provider regarding the indications, potential side effects (retrograde amnesia, elevated blood pressure), and treatment outcomes of ECT. Many patients with a remote history of “shock treatment” require education about recent advances in ECT in order to inform them about the procedure.

Legal Issues in Consultation Psychiatry

The legal issues that arise in consultation psychiatry are most commonly those of confidentiality, competency (decision-making capacity) and whether a patient has a right to die despite attempts to treat. Documentation of the patient's wishes in advance of the need to know often obviates many legal issues. Requests to leave against medical advice are a subset of competency assessments.

Confidentiality is mandated comprehensively by the Health Insurance Portability and Accountability Act. The consultation psychiatrist has a relative exemption from strict confidentiality when sharing information with the health providers who are treating the patient. The consultation note, as well, is exempt from the Health Insurance Portability and Accountability Act confidentiality. When obtaining corollary information from family members, the clinician should attempt to get verbal consent if the patient retains decision-making capacity. In some situations, information the patient divulges should remain confidential. Intimate details of a personal nature with no bearing on the issues that led to the consultation request are confidential and should not be revealed to other medical professionals or in the treatment record. Psychotherapy notes are considered private under the Health Insurance Portability and Accountability Act regulations and separate from the medical record. This does not mean that data from consultation follow up visits that document diagnosis or response to treatment cannot be noted in the progress notes.

Competency is a broad concept that applies to a variety of acts and behavior. It is a legal issue, bestowed at birth. If the patient is impaired, a physician must provide evidence of erosion of competency to the legal system (in probate or “family” courts). Informed consent to a particular procedure or health care intervention, however, focuses upon the individual's ability to make a decision based upon the capacity to understand the information that must be provided in a clear and understandable manner; to recognize the options available (including the risks and benefits of each option); to use reason with regard to the information provided by the team; and finally to make a rational decision that is sustained over time. Decisional incapacity, which is determined ultimately by a probate judge or other legal representative, does not automatically indicate incompetence in other activities of living.

Discharges Against Medical Advice (AMA) evoke legal fears and risk management concerns. In order to oppose the patient's free will to leave, the consulting psychiatrist must diagnose a condition that impairs judgment, such as delirium, dementia or depression, of such severity that the patient's safety or the safety of others is threatened, either by direct threats to self or others, or by grave disability (unable to obtain food, shelter or clothing). Issues of competency assessment described previously may apply. The challenge is to discriminate subtly impaired decisions (due to mental conditions, with or without physical conditions) from bad decisions (e.g., marginal capacity to provide for self, homeless, refusing treatment). A rapid assessment of level of risk is required. Often efforts to address the pressing need for discharge reveal the origins of the AMA discharge request. Some patients require social worker assistance with responsibilities such as childcare, housing or work mandates that are valid but impracticable in the face of serious illness. Finally, patients who abuse substances sometimes request abrupt discharge. If no withdrawal state is observed, the consultant can enlist the help of family members to convince the patient to remain in the hospital; however, this is often impossible. In the circumstance where the patient demonstrates capacity to make a decision, albeit inconsistent with what is recommended, the patient retains the right to leave. Clinical status and attempts to contact support systems should be documented.

Right-to-die decisions require that the patient be judged competent and fully understand the nature of the disease state. Impairments in cognition or thought process (e.g., dementia or paranoia) may necessitate transferal of the decision to surrogates. Another complicated issue is of depression that causes a subtle erosion of decisional capacity. The seriously ill patient is often clinically depressed. If depression is aggressively treated, the wish to die may change. Family meetings in concert with the treatment team, and consultation with hospital ethics committees and legal counsel, maximize the opportunity for a fair appraisal of the request to withhold treatment.

Advanced Directives should be reviewed in the patient who has become cognitively compromised. Optimally, a surrogate decision-maker has been identified for a future period of incapacity, and the consulting psychiatrist renders a second opinion to the team declaring that the time has come to utilize or invoke it. Advance preparation pays off for these patients as they avoid the legal proceedings of competency. Social workers can assist with documentation of advanced directives; these should be recommended for every patient found to retain the capacity to make such decisions.

Emergency Consultations

A few situations need immediate attention, requiring a rapid assessment of a range of factors, including a scan of the physical situation (e.g., the patient might use medical equipment as a weapon) and the environment (e.g., multiple patient room or intensive care setting). Policies regarding clearing the room of sharp objects and having restraints available on medical and surgical floors, should be in place. However, it may not be routine for staff in the usual medical setting to follow such policies, increasing the need for psychiatric consultant assistance.

Violent patients may be suffering from delirium or substance withdrawal. Such information can be obtained from a review of the medical record, focusing upon the disease status (e.g., presence of a mass lesion in the CNS) or prescribed medication fostering an encephalopathy. In such situations it is imperative that staff and other patients be protected. The concurrent presence of security guards allows safe assessment. The emergency use of psychotropic medication can diffuse these dramatic situations. Involving a family member can be helpful but there may not be sufficient time to allow this.

Suicidal patients become emergencies if there is an attempt at self-harm or if drugs, knives, or weapons are detected that the patient is secretly storing to use for self-harm. Is the behavior a means of attention seeking, is it due to a mood or psychotic disorder, or is it an attempt to assume control when the situation has become so ominous that ending life is preferable to enduring a fantasized medical scenario? Following initial assessment, it is necessary to observe closely the patient who is acutely suicidal but too medically ill to be transferred to a psychiatric unit. Nursing personnel are trained in the monitoring of suicidal patients, but the psychiatric consultant may be sought for management advice. The care of high-risk individuals in such settings is eased by family supports, if available.

Liaison Psychiatry

The liaison psychiatrist is a regular member of a treatment team in transplant programs, cancer centers, or dialysis units. A subspecialized focus of liaison psychiatrists on diseases states (e.g., HIV psychiatry) or medical specialty (e.g., gynecology or pediatrics) has developed in recent years.

Transplantation psychiatry is important due to the psychological stress upon patients and families who undergo life saving procedures or wait on a list for a limited number of available organs. The organ to be transplanted dictates the common psychiatric issues within each procedure. For related-donor kidney transplants, the psychiatric consultant may evaluate both overt and covert family pressures that the putative donor experiences and how the potential recipient feels in response. Treatment adherence is important, especially in patients with diabetes who have not followed diabetic regimens. The essential issue in liver-transplantation recipients who have been substance abusers is their history of abstinence. If potential recipients are still using alcohol or other substances of abuse they need rehabilitation and abstinence before receiving a liver transplant, although candidacy is individualized and may vary according to the scarcity of the organ to be transplanted. Liaison psychiatrists may be called upon to assist with screening to identify latent psychiatric disorders, and to assist with the psychological stressors as discussed. For heart transplantation patients, ongoing support is necessary during the waiting period before an available organ is found. Such patients commonly experience anxiety and depression, and wrestle with mortality.

In oncology settings, central issues are depression in the terminally ill, delirious states due to diseases and treatments, and family reactions. In nephrology centers, patients who request termination of hemodialysis must be evaluated for delirium and dementia. The treatment of underlying depression may alter the request for cessation of hemodialysis. The role of the psychiatrist in nephrology also focuses upon patients who resist dietary and fluid limitations, often in the context of depression and dementia. The psychiatrist will have many opportunities to teach health professionals to recognize and manage psychiatric disorders in chronic illness and end-of-life care.

Psychiatric Disorders Caused by Medical Conditions

Psychiatric symptoms can occur as a direct consequence of an underlying medical condition. Many examples are catalogued in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision. “Mental Disorder Due to a General Medical Condition” is diagnosed when there is evidence that the medical condition caused the psychiatric manifestation of the illness. The categories of psychiatric illness classified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision as caused by or “due to” medical conditions are as follows: Delirium, Dementia, Amnestic Disorder, Catatonia, Personality Change, Psychotic Disorder, Mood Disorder, Anxiety Disorder, Sexual Dysfunction, and Sleep Disorder. Each of these diagnoses is associated with the behavioral phenomena of a psychiatric disorder; however, when there is evidence of a causative medical condition, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision does not regard these “due to” diagnoses as full-fledged primary psychiatric disorders. For example, Major Depression should not be diagnosed when there is a known medical etiology, but rather Mood Disorder due to General Medical Condition. Furthermore, the neurovegetative symptoms of Major Depression (see Chapter 18) could also represent a medical symptom (e.g., decreased energy due to depression or anemia, or both). The confound of medical and psychiatric symptoms identical in their physical expression leaves consultation–liaison psychiatrists in a bit of a quandary.

Most studies have led to the general consensus that all “potentially psychiatric” symptoms of the medical condition should be included in the diagnosis of the psychiatric disorder. In the case of depressive symptoms, for example, this strategy risks the psychiatric diagnosis of patients who do not meet full criteria of Major Depression (false positive), but avoids the failure to diagnose patients who do meet criteria (false negative).

Psychiatric symptoms caused by medical conditions have important implications, not only for diagnosis but also for evaluation, treatment and management of both medical and psychiatric conditions. Detection and diagnosis of the medical cause often relies upon the astuteness of the primary medical clinician; however the patient with psychiatric symptoms might not present to medical care, but rather to a psychiatric setting causing a possible delay in medical diagnosis. The patient with medically-induced psychiatric symptoms who presents to medical settings may be dismissed as not medically ill. Treatment of the presenting psychiatric symptoms, without detection of the underlying medical condition, may actually exacerbate the medical condition. Clinical wisdom suggests that any nonresponder to psychiatric treatment de facto merits a review of the medical evaluation obtained at baseline and a repeat or expanded evaluation to search for undetected medical causes. Consultation–liaison psychiatrists identify those patients who elude diagnosis in primary care due to the prominence of the psychiatric presentation. They educate medical and psychiatric colleagues about the medical masquerade, and may be a stalwart force toward completing the medical evaluation of a patient with psychiatric symptoms. The following section will highlight this principle by clinical examples.

The Patient with Cerebrovascular Disease and Depression

Stroke, a rapidly occurring disturbance of brain function attributed to vascular disease, is the third leading cause of death in America after heart disease and cancer. The neuropsychiatric complications of stroke include cognitive deficit, and behavioral and emotional dysregulation. Depression following stroke is a frequent and adverse neuropsychiatric sequela of stroke, yet it is undiagnosed by most nonpsychiatric physicians. Depression has a negative impact on the patient's quality of life, not only from a psychosocial standpoint, but also by impeding the recovery of motor function. Depression in the aftermath of stroke (Post-stroke Depression and Post-Stroke Pathological Affect) respond to aggressive treatment but escape detection when interpreted as an “understandable” response to the stroke. Post-stroke Pathological Affect is characterized by emotional dysregulation in which laughter or tears are expressed but are unrelated to mood, and are exacerbated by minor cues. Post-Stroke Pathological Affect can be severely disabling, causing patients to become isolative or agoraphobic. Post-stroke Depression and Post-Stroke Pathological Affect are both responsive to antidepressant treatment (see Chapter 18).

Patient Vignette 1

A 59-year-old divorced Caucasian man, right-handed graphic designer, with a history of hypertension, diabetes mellitus and nicotine dependence, was brought to the hospital by his son after the sudden onset of slurred speech and inability to walk. Physical examination revealed aphasia and a dense right-sided paralysis; diagnostic investigations confirmed an ischemic stroke. Mr. S. was stabilized medically for one week and was then referred for physical rehabilitation. Despite aggressive efforts over the ensuing weeks by rehabilitation staff, the patient was increasingly unmotivated for physical therapy, socially isolative, and at times refused to eat. He mentioned in passing to a nursing aide that he would be “better off dead,” prompting the team physician to request a psychiatric evaluation. Utilizing a communication board, Mr. S. expressed hopelessness about his career as a graphic designer, and worries about his future financial situation. He also ruminated about past layoffs from work and financially compromising alimony payments. His speech was garbled and a source of immediate frustration. He was unable to write or draw designs with his paretic right hand. After a complete medical workup for additional underlying causes, the patient was started on a low dose of an SSRI. He had an early response to treatment which was followed by improved participation in physical therapy.

Patient Vignette 2

An 80-year-old widowed woman, American Indian, tribal elder, and retired casino manager had an extensive history of hypertension, obesity, degenerative joint disease, and chronic obstructive pulmonary disease. Prior to admission, she developed the acute cardiac symptoms of nausea and atypical chest pains. In the emergency room, she had an abnormal electrocardiogram, subsequently undergoing emergency angiography followed by coronary artery bypass graft surgery. Post-operative care was provided in the surgical intensive care unit. Her management was complicated by difficulty in weaning from the respirator, as well as combative behavior despite soft restraints and sedation with parenteral benzodiazepine. Psychiatric consultation was requested to assist with behavior management. Starting with review of the inpatient and outpatient charts that was suggestive of substance abuse, collateral information from family members confirmed that the patient had utilized increasing amounts of long-acting opioid analgesics prescribed by multiple doctors for chronic pain. Of note, a recent episode of pneumonia as a complication of chronic obstructive pulmonary disease had been treated with antibiotics that caused hepatitis and psychiatric side effects. Laboratory investigations revealed metabolic derangements that were in the process of being corrected. Oxygen saturations were low when attempts were made to wean her off the respirator; moreover she had scratched a nurse during one of these episodes. The diagnosis of Delirium due to Multiple Etiologies was made; potential contributors included: (1) hypoxia, (2) opiate withdrawal, (3) psychiatric side effects of medications, (4) drug interaction, and (5) intraoperative cerebral event. A multifaceted approach to her care was recommended: (1) safety assessment (e.g., minimize use of restraints post-sternotomy, implementation of safety monitor), (2) social work consult to document surrogate decision-maker, (3) search for additional reversible etiologies (e.g., vitamin B12, thyroid stimulating hormone, possible head Computerized Tomography if no mental status improvement), (4) minimized use of benzodiazepines for agitation, and (5) possibly morphine to treat pain (degenerative joint disease and surgical wound) and the possible opiate withdrawal.

The Patient with Postoperative Delirium

Delirium is an acute cognitive disorder with global impairment in brain function, and fluctuating consciousness and attention. Associated features include hyperactivity, hypoactivity, and reversal of the sleep–wake cycle. Delirium is a common presentation in hospitalized elderly patients, affecting up to 30% of elderly surgical patients. The most common predisposing surgical procedures are emergency hip fracture repair, gastrointestinal surgery, coronary artery bypass grafts, and lung transplants (see Chapter 14).

The Patient with Psychosis and Substance Dependence

Psychotic disorders due to medical illness or to substance use can originate from many conditions, such as brain diseases (e.g., seizures, neoplasm, encephalitis, stroke), endocrine disorders (hyper- or hypo-thyroidism, Cushing's syndrome), metabolic disorders (hypoglycemia, hyponatremia, uremia, thiamine deficiency/Korsakoff), and chemicals, including drugs of abuse, medications or toxins. The most common substances that induce psychosis by intoxication are cocaine, amphetamines, and phencyclidine. The most common substances causing psychosis by withdrawal are sedative-hypnotics and alcohol. Psychosis due to general medical conditions or substance-related psychosis can be distinguished from a primary psychotic disorder by fluctuating level of consciousness, focal neurological signs, predominantly visual sensory involvement (e.g., visual hallucinations, illusions), perseverations in thought content, and abnormal vital signs (elevated blood pressure, heart rate) (see Chapter 15).

Psychiatric Disorders Affecting Medical Conditions

Psychiatric disorders may affect compliance with necessary medical treatment or even acceptance of the disease itself. Depression, hopelessness and anhedonia can abet nonadherence to medication, dietary regulation, or ongoing surveillance for the recurrence of disease. Eating disorders are common in diabetic patients and can seriously compromise metabolic regulation. Even defensive mechanisms such as denial, not a psychiatric disorder in itself, can affect a medical condition due to poor compliance. Psychiatric medications with metabolic side effects can induce or interfere with the management of chronic medical conditions, and warrant close monitoring in collaboration with primary providers (see Chapter 18).

Patient Vignette 3

A 45-year-old married man, construction worker, with a prior history of gastritis, pancreatitis and anemia, was admitted for lumbar discectomy. Although he denied alcohol consumption during the preoperative visit, by the fourth postoperative day he displayed marked signs of alcohol withdrawal, Delirium Tremens, associated with autonomic instability and frank visual hallucinations. When he began to act in response to the hallucinations by seeking to climb out of bed and talk to an empty chair, psychiatric consultation was requested. Search for reversible causes of the mental status change was completed and did not alter the diagnosis of Delirium Tremens. Treatment with intravenous thiamine, multivitamins, and high doses of an intermediate-acting benzodiazepine led to amelioration of autonomic instability, but the psychotic symptoms persisted until an antipsychotic agent was added. After a protracted hospital course, the patient was referred for substance rehabilitation treatment and outpatient psychiatric care.

Nonadherence to Treatment

Nonadherence is particularly common in certain medical illnesses. Psychiatric disorders such as depression or delirium can obstruct proper care. Whether hypertensive medication or more complicated treatments are involved, it is essential to understand the complexity of the regimen and the issues that prevent compliance, financial or psychological. A sense of hopelessness and lack of motivation can be fostered by premorbid characteristics, but also by depressive disorder. Multidisciplinary strategies to encourage compliance include collaboration with case managers, social work service, and primary clinicians who have longstanding relationships with patients. In patients with cognitive deficits, strategies to assist with medication compliance include dose-based pill boxes, simplification of dosing patterns, a switch to long-acting agents or an altered route of administration (e.g., topical patch), and parsimonious prescription patterns that reduce side effects. Written directions at the time of the visit, visiting nurse assistance, case management and the enlisting of family support enhance adherence. Ensuring that underlying psychiatric conditions are adequately treated is important as well; inadequate dosing and inadequate duration are commonly associated with refractory depression in primary care settings, but nonadherence is equally important. In addition, psychotropic agents that interfere with other medications can cause the patient to choose among them.

Patient Vignette 4

A 24-year-old single man was evaluated for noncompliant behavior resulting in recurrent decubitus ulcers. Two years prior to the consultation, he had been involved in a motorcycle accident causing spinal cord injury and paraplegia. Confined to a wheelchair, the patient inconsistently attended rehabilitation. He spent many hours driving around in a van that had been equipped with hand controls. He did not utilize weight shifting or other approaches to minimize decubitus formation and consequently was hospitalized repeatedly. Upon evaluation, the patient was sullen and hostile and initially had nothing to say. Upon further questioning, he was clearly depressed and noted, “Who wouldn't be?” The patient complained that he had recurrent sleep problems. He ruminated about his accident. He began to talk about his loneliness and depression. Background evaluation revealed that the patient had a premorbid personality style involving impulsivity and activity. Social history revealed that he was raised in a single parent family wherein his mother worked many hours to support his older sister and himself. He had dropped out of high school to work. Although his peers often used drugs he did not, but he did enjoy driving recklessly on a motorcycle he had purchased. Following his accident, his friends abandoned him.

After the evaluation, the psychiatric consultant held a few family meetings in which the evidence for depression was clear, as well as additional features of demoralization. The patient felt helpless and hopeless from his accident and saw no way to overcome his injury or life circumstances. Based upon these meetings, the physical therapist introduced him to another patient who had successfully coped with a spinal cord injury. Although the intervention was initially hospital-based, it was many months before he was able to accept his injury better, pursue proper care, and complete his high school education in order to pursue a career in design.

Chronic Psychiatric Disorder Affecting Medical Condition

Patients with schizophrenia or bipolar disorder have increased rates of mortality. The shortened lifespan is due to the psychiatric disorder itself, as well as to treatment with medications such as antipsychotic agents, which can induce a metabolic syndrome leading to cardiovascular disease and diabetes. It is essential for the psychiatric consultant to work collaboratively with community mental health programs to develop treatment plans that promote health. If antipsychotic agents are utilized, clinicians should monitor the individual's weight and girth on a regular basis to avoid the development of serious metabolic consequences. Psychiatric patients are further at risk for obesity if they are isolated, avoid exercise, and follow sedentary lifestyles. The risks to general health from psychiatric disorders are compounded by the high rates of substance dependence such as cigarette smoking which contributes to cardiovascular disease. Psychiatric consultation can have a role in prevention through education in primary care settings and collaboration with cessation programs.

Patient Vignette 5

A 52-year-old woman with a 30-year history of schizophrenia and repeated hospital admissions was evaluated in the emergency department for diabetic ketoacidosis. Admission to the hospital for stabilization and diabetes management prompted a psychiatric consultation. She had had a complicated clinical course with multiple hospitalizations and periods of homelessness. At the time of admission, she was living in a group home, maintained on risperidone. On this regimen, she gained 34 pounds and developed Type II diabetes. She was not compliant with a low-carbohydrate diet, and frequently snacked on fast foods. She was episodically not compliant with oral hypoglycemic agents prescribed by her physician. On evaluation, the patient presented as a disheveled, obese woman with hallucinations and delusions who recognized that these phenomena were due to schizophrenia. She was depressed about the impact of the disease upon her life. Treatment involved switching the patient to a medication with less weight gain (such as aripiprazole or ziprasidone) and ongoing checkups by a nurse who visited the group home. Attempts to create an exercise regimen were unsuccessful; nevertheless, the patient continued to take antipsychotic medication and attend a day program.

Patient with Depression and Cardiac Disease

Depression is an independent risk factor for ischemic heart disease. It predicts higher morbidity and mortality after uncomplicated MI. For 6 months after the infarction, even up to 5 years, depression has an impact on cardiac mortality, eclipsing standard cardiac variables such as left ventricular ejection fraction. The possible mechanisms for these phenomena include a three-fold increase in medication nonadherence, shared risk factors (smoking, diabetes, and obesity), lower heart rate variability, chronic inflammation (increased biomarkers such as C-reactive protein), platelet activation, and sympathoadrenal activation due to increased physiological stress. Studies to determine the role of psychiatric treatments aimed at lowering cardiac risk have indicated an improved quality of life, but no clear reversal of increased mortality.

Patient Vignette 6

A 49-year-old single man, advertising executive, is admitted to the intensive care unit after the sudden onset of crushing chest pain, with ischemic changes on electrocardiogram. Emergency efforts to treat the patient had no effect on the outcome of a profound MI. He was an active sportsman, community activist and competitor for promotion at the agency where he worked. Within days after his admission to the hospital, he appeared depressed to staff, and had no visitors. Efforts to discuss cardiac rehabilitation were rebuffed as unnecessary by the patient, who stated, “What is the use? The damage is done,” causing the medical team to become alarmed. Well-informed about the cardiac mortality risk with comorbid depression, the medical team requested immediate psychiatric consultation. During the interview, the patient expressed depressed mood and a pervasive hopelessness about returning to his productive life. A strong family history of early death due to MI weighed heavily on his mind. Neurovegetative symptoms were prominent, and were predominated by sleep disturbance in which the patient ruminated about the loss of independence. Unable to identify with rehabilitation patients who were older, he eschewed the idea of rehabilitation, or at least his stereotype of it. Search for other reversible etiologies for the depressed mood was negative, and the patient was started on an SSRI antidepressant, to which he responded within days. Social work services mobilized support for the patient, assuring that colleagues from work would be allowed to visit the patient. Outpatient referral to psychiatry was made, to monitor the response to medication, and to encourage compliance with cardiac rehabilitation. As the patient's mood lifted, he began to talk about his social isolation.

Psychological Reactions to Medical Illness

Medical illness creates a crisis. The patient is faced with multiple emotional, physical and financial challenges that can create serious psychological distress. The personal aspects of illness include pain, disability, and loss of function and autonomy due to the disease and or its treatment. Loss of exercise tolerance in congestive heart failure, or pain and dietary limitations in short bowel syndrome, exemplify such challenges. The interpersonal aspects of illness create changes in roles and status such as the ability to be a fully active parent or employee, to be independent and supportive of others. Patients with HIV/AIDS face stigmatization. The patient with terminal cancer may be isolated when supports do not know how to interact with a dying individual. Finally, there is an intrapsychic challenge to disease due to fears of death, disfigurement, and pain. People react differently to the challenges before them in accordance with their coping style, environmental circumstances, and the nature of the disease and its treatment.

Coping with Serious Illness

It is tempting to label a patient's reaction to a life-threatening illness such as cancer as understandable. This rarely explains fully the diagnosis of depression; depression due to a medical condition does not always correlate with the level of functional disability or problems in activities of daily living. Although only a minority of patients with cancer develops a formal major depressive disorder, those individuals need effective treatment with both pharmacotherapy and psychosocial support. It is essential to evaluate the level of family support, and the patient's ideas about the disease, knowledge about others with similar health problems, and the availability of community or national support groups.

The Hostile Patient

Premorbid personality style often shapes the reaction to a serious illness or hospitalization. The passive patient may tolerate a paternalistic approach, while the patient with obsessional and intellectual defenses will ask questions and seek more information. Patients with hysterical traits may be emotional and require compliments about the courage they display. Patients with borderline traits can split the medical team by idealization and devaluation of its hierarchical members; trainees may be particularly vulnerable to this behavior. Narcissistic patients have the sense that they are particularly important or deserving of preferential treatment. These broad-brushed descriptions are not pathological entities, but they describe coping mechanisms that emerge in stressful situations. Medical illness exaggerates such traits. The physician should not view these behaviors as challenges to professional competence or authority, but as demonstrations of fearfulness and regression during the crisis of illness.

Patient Vignette 7

A-47-year-old married woman, mother of two adult daughters, found a breast mass during routine self-examination. She quickly sought medical evaluation which revealed she had a breast neoplasm. She was successfully treated with lumpectomy and chemotherapy. Lymph node dissection was negative. Despite these results, she dwelt on the possibility that her neoplasm might return. She experienced frequent crying spells, loss of concentration, sleep difficulties, and fatigue. She had no family history of either mood disorders or breast cancer. Psychiatric evaluation revealed a woman who was sad and cried during the interview. She reported she was having difficulty getting out of bed in the morning and that she could barely manage her work due to problems in concentration. She was not suicidal. She revealed that she believed she developed breast cancer due to promiscuity as a young adult prior to her marriage. In collaboration with her oncologist, the psychiatrist judged that none of her complaints were aspects of her neoplastic disease. The patient was treated with an antidepressant that improved her sleep pattern and fatigue, and psychotherapy that allowed her to ventilate her guilty ruminations about her actions. As the treatment progressed, knowledge about her health dispelled beliefs that these were causal factors. Despite early side effects of nausea, she was encouraged to continue the medication. Over 6 weeks she improved. After 12 weeks, she reported no symptoms of depression. She said she was very lucky to have “caught my cancer so early.”

The Demoralized Patient

Demoralization does not qualify for a primary psychiatric diagnosis. It is common in medical and surgical settings in the context of a reaction to acute or chronic stress, such as the onset of illness, its treatment (if particularly disabling or disfiguring), or illness that is terminal. The management of demoralization involves promotion of the primary physician's role in soothing the patient's fears about the illness through relevant information about treatment options. Treatment also involves reassurance by the consulting psychiatrist that the patient does not have a psychiatric disorder, but that low mood or anxiety symptoms are part of a natural response to stress and would be manifested by many patients in similar circumstances.

Patient Vignette 8

A 65-year-old, thrice-married Hispanic man, firearm factory supervisor, with a history of MI at age 58, and emphysema related to nicotine dependence, was admitted to intensive care for cardiac arrhythmia and hematuria. One week prior to admission, he underwent cryo-ablation of a renal carcinoma that had been diagnosed two months prior to admission. During the hospitalization, the insertion of a urinary catheter had been complicated due to an enlarged prostate, and was painful for the patient. Shortly thereafter, the patient began speaking to nurses in a demeaning manner, using expletives and threats to call nursing supervisors. Medical interns, consulting urologists and cardiologists were impugned. Nursing staff avoided him and kept the door of his room closed. He demanded that his needs be prioritized. He was overheard yelling on the telephone, threatening his wife with divorce. Psychiatric consultation was requested. After a chart review and discussion with nursing, the hypothesis was offered that the outward aggression and anger was a mask for fear; his behavior was reframed as a response to medical illness, a life-threatening situation that had placed the patient, who valued being in charge of others at work and in his marriage, in a dependent position. Urological manipulations of his genitalia and use of the bedpan further humiliated him. Initially, at bedside, the psychiatry consultant listened only to his complaints for an extended period. The consultant then encouraged the patient to complain further to the highest authority in hospital administration, regarding his concerns about staff. Although petulant, the patient began to allow a discussion about the threats to his life of the recent diagnosis of cancer, and his cardiac status. (The intensive care setting required to treat the arrhythmia had rekindled worries about his remote cardiac history of MI.) Daily, brief visits by the psychiatry consultant reviewed the stressors in his life, and culminated in the patient's request for an outpatient mental health appointment for marital therapy which was arranged prior to discharge.

Somatic Presentations of Psychiatric Disorders

The common presentation of somatic concerns in primary care can be related to psychiatric disorder, most commonly anxiety or depression. Patients with major depression are more likely to present for care in primary care settings, and once there to complain of somatic illness. Chest pain is found in generalized anxiety and panic disorders. Fatigue, headache, and backache are common in major depressive disorders. These psychiatric illnesses are commonly under-recognized in busy outpatient settings. When the psychiatric disorder is identified and effectively treated, the somatic symptoms are alleviated.

Patient Vignette 9

A 50-year-old, separated Caucasian man, musician, with no prior history of psychiatric or medical illness, presented to the hospital with generalized fatigue, 35-pound weight loss, and mild depression for the past several months. At the urging of his friends, he agreed to an Emergency Room visit and was surprised by the doctor's plan to admit him. After three days on the general medical unit, a second doctor who had assumed his care after admission informed him that he had pancreatic cancer. The patient reacted calmly and seemed to accept the grim prognosis. Shortly thereafter, he expressed a wish to be discharged against advice, but agreed to a psychiatric consultation for evaluation of his capacity to make that decision. During the psychiatric interview, the patient expressed frustration with the system of care, complaining that the multitude of doctors and nurses, never the same one twice, prevented individualized attention. He was able to repeat the information that the doctor had given him regarding the diagnosis of cancer, but he did not demonstrate an understanding of the recommendations or treatment options. He was appalled at the idea of being a patient as it was not in keeping with his longstanding lifestyle of late nights relishing wine, women, and song. Most shocking to him in this, his only hospital experience, was his first sight in the mirror: a reflection of wasted temporal muscles and hollowed cheeks, in stark contrast to the formerly attractive countenance of which he had been proud. The mirror had been his true love, and now he was betrayed. Acutely demoralized, he held no hope for survival. The psychiatrist requested the primary physician return. He sat down to discuss treatment plans and instilled his hope for future comfort. The patient rescinded the request for discharge, and asked to speak again with the psychiatrist in follow-up.

Conversely, physical symptoms that are unexplained, not due to other psychiatric disorders such as depression and anxiety, and not intentionally produced, may be due to a somatoform disorder. Somatoform disorders are grouped together because they require the exclusion of medical and substance-induced causes, and are likely to present first to primary care or medical settings. Somatoform disorders include: somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder (see Chapter 22). Psychiatrists consulting to these settings may be asked to assist in the diagnosis and management of these patients who often exasperate caregivers. Strategies include maintaining the patient in primary care settings with one provider, when possible, and encouraging regular appointments that are scheduled at the end of each visit, not on an as-needed basis. In somatization disorder, the consultant may encourage the primary provider to “join in the patient's pessimism” by focusing on symptom management rather than cure.

The Patient with Hypochondriasis

When a patient has persistent fears about symptoms of an illness or beliefs about having an illness, and when no medical illness can be found, “worry” about illness becomes the disease itself: hypochondriasis. In this disorder, worry about illness is not only disabling, it becomes the focus of daily life. The course of illness tends to be chronic, but it has a better prognosis if the onset is acute and brief in duration, with no secondary gain.

Consultation psychiatry is the bridge between psychiatry and the rest of medicine. As medicine advances, there will be new psychological and emotional challenges for patients requiring the skills and techniques of consultation psychiatrists. Organ transplant technology will evolve into artificial organ transplant; the fear of pandemics such as that generated by SARS will have an emotional toll. These are just two examples that illustrate that there will be an increasing need for psychiatry at the interface with medicine. Consultation psychiatry is already dividing into subspecialized areas to accommodate the expansion of medicine. Consultation–liaison psychiatrists are focusing upon HIV/AIDS, oncology and nephrology as primary interests. Journals and books devoted to these topics complement the general consultation journals. Concurrently, the stresses of hospital life will continue, strained by the forces of economics and health care policies. The shift from hospital-based care to outpatient settings has expanded consultation services into outpatient clinics and specialized care facilities. As new psychiatric treatments emerge, the consult psychiatrist will provide them to patients underserved in nonpsychiatric settings. Newly recognized as a discrete subspecialty, yet centuries old in practice, psychosomatic medicine has a new role in the ancient art of medicine. Graduate education programs with dedicated fellowship training in psychosomatic medicine will advance the mission to improve patient care. With increasing technologies and advances in biomedical knowledge, this subspecialty will provide the biopsychosocial elements of comprehensive patient care and clinical research to improve clinical outcome and enhance quality of life.

Patient Vignette 10

A 47-year-old married man, practicing attorney, sought emergency evaluation for chest pain. He reported tightness in his chest, which he interpreted as cardiac in origin. After a normal electrocardiogram and laboratory studies, he was reassured. The following day he began to worry that the tests could have been in error, causing increased anxiety. He openly admitted he was a “worrier” but felt that the tightness in his chest was a harbinger of a MI. Repeated medical evaluations found his physical status to be normal. He had no lipid abnormalities, and his blood pressure was normal. He requested that his physician refer him for cardiac catheterization to insure that his coronary arteries were patent. He was referred for a psychiatric evaluation by his internist, after multiple negative medical evaluations for a variety of symptoms that the patient thought indicated cardiac disease. The patient reported that he exercised regularly and kept a careful diet but was preoccupied by the thought he would have a “heart attack.” He had no family history of cardiac disease but two of his legal associates had undergone bypass surgery in the previous 3 years. His wife reported that he tended to exaggerate minor viral illnesses or athletic injuries. His developmental history indicated that his mother always worried about his health. She prevented him from participating in normal sports activities when he was in school. Despite this, he became an outstanding tennis player. On full psychiatric evaluation he was anxious and somewhat depressed. He recognized that his fears were not fully realistic but could not get the ideation of cardiac disease out of his head. Treatment involved pharmacological intervention for generalized anxiety with an SSRI, and psychotherapy utilizing cognitive behavioral strategies. Over a period of 6 months he limited calls to his internists to scheduled times and began to feel better. He still worried about cardiac disease when he heard about others with cardiac illness but was able to invoke cognitive strategies that he learned in therapy to reduce his anxiety and prevent maladaptive behavior such as emergency phone calls.