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

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

HAROLD E. BRONHEIM, M.D., GEORGE FULOP, M.D. ELISABETH J. KUNKEL, M.D., PHILIP R. MUSKIN, M.D. BARBARA A. SCHINDLER, M.D., WILLIAM R. YATES, M.D. RICHARD SHAW, M.D., HANS STEINER, M.D. THEODORE A. STERN, M.D., ALAN STOUDEMIRE, M.D.

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the ®eld, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and re- vised prior to ®nal approval. Some of the topics discussed include quali®cations of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations. (Psychosomatics 1998; 39:S8±S30)

he purpose in developing psychiatric con- and guide practitioners who care for patients Tsultation guidelines is to broadly instruct with psychiatric symptoms in a general medical setting. These guidelines will review the assess- From the Division of Consultation and Behavioral Medicine, Department of Psychiatry, Mt. Sinai Hospital, ments and interventions that are necessary for New York; Merck-Medco Managed Care, LLC, Montvale, management of patients with comorbid medical New Jersey; the Department of Psychiatry, Jefferson Medi- and psychiatric conditions. The development of cal College, Philadelphia, Pennsylvania; the Division of Consultation-Liaison Psychiatry, Columbia-Presbyterian guidelines for psychiatric consultation is impor- Medical Center, New York; the Department of Psychiatry, tant because signi®cant numbers of patients with Allegheny University Medical Center, Philadelphia, PA; the unrecognized, yet serious, neuropsychiatric dis- Department of Psychiatry, University of Oklahoma Health Sciences Center, Tulsa, Oklahoma; the Department of Psy- orders are inadequately assessed and managed, chiatry and Behavioral Sciences, Stanford University School and psychological distress induced by the highly of Medicine, Stanford, California; the Avery D. Weisman, technological world of the general medical set- M.D., Psychiatry Consultation Service, Massachusetts Gen- eral Hospital, Boston, Massachusetts; and the Emory Central ting is often ignored. Clinic-Section of Psychiatry, Atlanta, Georgia. Address re- These guidelines are not intended to delin- print requests to Dr. Bronheim, 1155 Park Avenue, New eate universal, professionally mandated regula- York, NY 10028. Copyright ᭧ 1998 The Academy of Psychosomatic tions and actions. Instead, they are meant to Medicine. serve as an outline for the training and knowl-

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edge that are generally necessary to guide the MEDICAL NEED AND STAFFING clinician's approach to the patient.1 In general, the aims of psychiatric consul- Population at Risk and tation in the medical/surgical setting are 1) to Case Identi®cation ensure the safety and stability of the patient within the medical environment, 2) to collect In the general medical setting, as many as suf®cient history and medical data from appro- 30% of patients have a psychiatric disorder.13±15 priate sources to assess the patient and formu- Delirium is detected in 10% of all medical in- late the problem, 3) to conduct a mental status patients16 and is detected in over 30% in some examination and neurological and physical ex- high-risk groups. Two-thirds of patients who are aminations as necessary, 4) to establish a differ- high users of medical care have a psychiatric ential diagnosis, and 5) to initiate a treatment disturbance: 23% have depression, 22% have plan. anxiety, and 20% have somatization.17,18 Consultation-liaison (C-L) psychiatry is the Clearly, psychiatric comorbidity has an impact subspecialty of psychiatry concerned with med- on health care economics.19±23 The presence of ically and surgically ill patients.2 The C-L con- a psychiatric disturbance has repeatedly been sultant must have an extensive clinical under- shown to be a robust predictor of increased hos- standing of physical/neurological disorders and pital length of stay.24±27 Nearly 90% of 26 stud- their relation to abnormal illness behavior. The ies have demonstrated either an increased length C-L consultant must be a skilled diagnostician, of stay or an increased medical readmission rate be able to tease apart and formulate the patient's in patients with psychiatric comorbidity.28 Only multiaxial disorders, and able to develop an ef- a small subset of the population at risk is cur- fective treatment plan. The C-L consultant must rently being adequately identi®ed. The percent- also have knowledge of psychotherapeutic and age of patient admissions receiving psychiatric psychopharmacological interventions as well as consultation varies from institution to institu- knowledge of the wide array of medicolegal as- tion,29 ranging from 1% to 10%.29±32 pects of psychiatric and medical illness and hos- Intervention studies have suggested that el- pitalization. The psychiatric physician, by virtue derly patients with hip fractures bene®t from of his/her professional stature and knowledge, psychiatric consultation; they have shorter has the ability to supervise a multidisciplinary length of hospital stays and are more often dis- team. charged home, rather than to a nursing These proposals for care supplement those home.33±34 A liaison approach with increased developed for Psychiatric Training in C-L Psy- case identi®cation and earlier psychiatric inter- chiatry by the Academy of Psychosomatic vention and treatment resulted in a marked de- Medicine (APM)3,4 and the practice guidelines crease in the need for transfer to inpatient psy- developed by the American Psychiatric Associ- chiatric facilities.35 ation (APA).1,5±9 These current proposals are The principal methods of case identi®cation also related to the recommendations reported in and psychiatric service delivery to the medi- Psychological Care of Medical Patients, drafted cally/surgically ill patient embrace the principles by the Joint Working Party of the Royal College of C-L psychiatry.36 In contrast to the standard of Physicians and Psychiatrists10 and to the goals medical-referral model, in which the consulta- of Fellowship Training in C-L Psychiatry put tion psychiatrist waits to be called, the liaison forth by the Academy of Psychosomatic Medi- model is based on an early detection strategy to cine.11 Although primarily based on consensus, identify potential problems. As part of the multi- they include, to the extent possible, the desir- disciplinary medical team, the liaison psychia- able attributes (e.g., validity, clinical applicabil- trist may participate in ward rounds and team ity, clarity) delineated by the Institute of Medi- meetings while addressing the behavioral issues cine.12 of patients. Education of nonpsychiatric physi-

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cians and allied health professionals about medi- a treatment plan, teams composed of health pro- cal and psychiatric issues related to a patient's fessionals with complementary skills may also illness is a core component of the liaison model. be used. The leader of such a multidisciplinary Liaison services lead to heightened sensitivity team should be the psychiatrist with specialized by medical staff, which results in earlier detec- C-L training. tion and more cost-effective management of pa- The Recommended Guidelines for C-L Psy- tients with psychiatric problems. chiatric Training in Psychiatry Residency Pro- grams specify that the faculty of a C-L service Guideline be certi®ed by the American Board of Psychiatry and Neurology and have speci®c expertise in Each institution is responsible for the con- C-L psychiatry.3 The ideal C-L service has fac- tinuing medical education of medical/surgical ulty who are fellowship-trained in C-L psychi- staff about the psychological consequences of atry or who have extensive clinical experience. illness and the indications for psychiatric consultation. Areas of focus should include the rec- Guideline ognition of substance abuse, delirium, dementia, affective disorders, anxiety disorders, and sui- All providers of psychiatric consultation in cidal ideation. These issues should also be in- the general medical setting must be licensed corporated as part of undergraduate and post- physicians. All students and trainees must be graduate residency and fellowship medical training. TABLE 1. Required skills for the evaluation and treatment of patients with psychiatric QUALIFICATIONS OF CONSULTANTS disorders in the general medical setting 1. Ability to take a medical-psychiatric history Training and Skills Assessment 2. Ability to recognize and categorize symptoms 3. Ability to assess neurological dysfunction Evaluation of the mental health of patients 4. Ability to assess the risk of suicide with serious medical illness, formulation of their 5. Ability to assess medication effects and drug±drug problems and diagnosis, and organization and interactions implementation of an effective treatment plan 6. Ability to know when to order and how to involve complex clinical skills that require spe- interpret psychological testing cialized training (Table 1). In addition to the 7. Ability to assess interpersonal and family issues usual psychiatric examination, specialized 8. Ability to recognize and manage hospital stressors knowledge about diagnosis, medicolegal issues, 9. Ability to place the course of hospitalization and and psychotherapeutic and psychopharmacol- treatment in perspective ogical interventions is necessary. The consulting 10. Ability to formulate multiaxial diagnoses psychiatrist must be familiar with the routines of 11. Ability to perform psychotherapy the medical/surgical environment and knowl- 12. Ability to prescribe and manage edgeable about medical and surgical illnesses. psychopharmacological agents The psychiatric consultant must also be aware 13. Ability to assess and manage agitation of the effects that illnesses and drugs have on 14. Ability to assess and manage pain behavior, especially when they contribute to or 15. Ability to administer drug detoxi®cation protocols confound the diagnosis or treatment. Further- 16. Ability to make medicolegal determinations more, the psychiatric consultant must be sup- 17. Ability to apply ethical decisions portive of the patient and remain sensitive to the 18. Ability to apply systems theory and resolve con¯icts effects of the patient on the staff. 19. Ability to initiate transfers to a psychiatry service Despite the fact that the psychiatric consul- 20. Ability to assist with disposition planning tant possesses all the necessary skills to organize

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closely supervised, with documentation of train- TABLE 2. Problems that commonly lead to ing cases appropriately recorded and main- requests for psychiatric consultation in tained. All consultants must have appropriate the medical/surgical setting credentials and privileges at the hospital or out- 1. Acute stress reactions patient setting where their consultations are per- 2. Aggression or impulsivity formed. 3. Agitation 4. AIDS or HIV infection Indications for Consultation 5. Alcohol and drug abuse (including withdrawal states) 6. Anxiety or panic Psychiatric consultation is indicated when- 7. Assessment of psychiatric history ever another doctor asks for help with a patient. 8. Burn sequelae Consultation requests cover a wide range of top- 9. Change of mental status ics (Table 2). Commonly, the overt reason for 10. Child abuse initiating a consultation may not be as serious as 11. Coping with illness a comorbid, but unrecognized, problem. 12. Death, dying, and bereavement 13. Delirium THE CONSULTATION PROCESS 14. Dementia 15. Depression 16. Determination of capacity and other forensic It can take a considerable amount of time before issues the consultant is accepted by and becomes fa- 17. Eating disorders 32 miliar with the practices of a medical team. 18. Electroconvulsive therapy Outside consultants, unknown to other physi- 19. Ethical issues cians, unfamiliar with the particular hospital sys- 20. Factitious disorders tem and unable to provide immediate response 21. Family problems when necessary, should not replace consultation 22. Geriatric abuse services.37 23. Hypnosis 24. Malingering 25. Pain Guideline 26. Pediatric psychiatric illness 27. Personality disorders Institutions should follow the Recom- 28. Posttraumatic stress disorder mended Guidelines for Consultation-Liaison 29. Pregnancy-related care Psychiatric Training in Psychiatry Residency 30. Psychiatric care in the intensive care unit Programs for staf®ng a C-L psychiatry service. 31. Psychiatric manifestations of medical and In all medical settings, there must be adequate neurological illness staf®ng to provide psychiatric consultation 24 32. Psychological factors affecting medical illness hours/day, throughout the year. In settings where 33. Psychological and neuropsychological testing psychiatric residents perform consultations, fac- 34. Psycho-oncology 35. Psychopharmacology of the medically ill ulty staf®ng must be adequate to provide super- 36. Psychosis vision 24 hours/day. 37. Restraints Psychiatric consultations should be per- 38. Sexual abuse formed by psychiatrists with expertise in the 39. Sleep disorders medical setting and credentials and privileges at 40. Somatoform disorders the institution where the consultation is per- 41. Suicide formed. Treatment may be delegated to another 42. Terminal illness mental health professional under the direct su- 43. Transplantation issues pervision of the consulting psychiatrist. Psychi- ס atric consultation involves an initial consultation Note: AIDS Acquired immunode®ciency syn- .Human immunode®ciency virusסdrome; HIV and follow-up examinations (two on average).

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If inpatient psychiatric treatment is required cause the overt cause for referral may re¯ect a for the medically compromised patient to ensure more serious problem. For example, the patient continuity of medical care, psychiatric treatment who appears withdrawn may be suicidal; an un- should, when possible, be provided at the same cooperative patient with mild agitation may be facility where the patient is receiving medical delirious. Delay in the detection and diagnosis care. The ideal setting is in a location where of these disorders may have dire consequences. medical and psychiatric capabilities are inte- To provide appropriate and timely care for grated. patients, each institution must ensure that the Follow-up outpatient psychiatric care for C-L service not be restricted from performing patients with psychiatric problems related to a psychiatric consultations when medically indi- serious or persistent medical condition (e.g., ac- cated for any individual or group of patients quired immunode®ciency syndrome [AIDS], within the institution. cancer, organ failure requiring transplantation) should, when possible, be provided at the same Guideline treatment facility where the patient receives primary medical care. When the consultee asks for a psychiatric Referral of patients with complex medical± consultation, the consultant should establish the surgical illness in the outpatient setting should urgency of the consultation (i.e., emergency or be facilitated: routineÐwithin 24 hours). Commonly, requests for psychiatric consultation fall into several gen- 1. When requested by the primary care phy- eral categories: sician in the outpatient setting, 2. When requested by any physician in a spe- 1. Evaluation of a patient with suspected psy- cialty medical clinic, chiatric disorder, a psychiatric history, or 3. In response to a patient's request for a re- use of psychotropic medications. The eval- evaluation or second opinion, or uation aims to properly assess the underly- 4. As a referral for follow-up by any C-L con- ing psychiatric syndrome and to mitigate its sultant who evaluated the patient while in effect on the medical/surgical condition. the hospital. 2. Evaluation of a patient who is acutely agitated. The evaluation should carefully re- ASSESSMENT view the medical and psychiatric reasons for agitation (e.g., psychosis, intoxication, Reasons for Referral withdrawal, dementia, delirium) and should delineate possible etiologies (e.g., toxic Consultations are usually requested by phy- metabolic disturbances, cardiopulmonary, sicians who are directly responsible for the care endocrine, neurologic disorders). of the patient. In some settings, this is the at- 3. Evaluation of a patient who expresses sui- tending physician, in others it is the house staff cidal or homicidal ideation. Any patient who (under supervision by the attending physician). voices such ideation should be evaluated by At some institutions, other health professionals, a psychiatric consultant. In situations where such as nurses and social workers, may initiate the consultant is not immediately available, a consultation in emergency situations. In insti- appropriate precautions should be recom- tutions with ongoing liaison activities with mended by the consultant (e.g., placing the medical or surgical services, the psychiatrist as patient under constant observation until the part of the team may accept a referral and eval- psychiatrist arrives at the bedside). uate any patient admitted to the service. 4. Evaluation of a patient who wishes to die, The so-called ªroutine consultationº may including one who requests hastened death, have life-and-death implications for a patient be- physician-assisted suicide, or euthanasia.

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No presumption should be made that such consultants, Emergency Room services, or the requests are ªrationalº until a complete C-L service itself. Interventions and recommen- evaluation has been performed. dations for emergency consultations may in- 5. Evaluation of a patient who is at high risk clude the following: 1) use of physical restraints; for psychiatric problems by virtue of serious 2) use of pharmacologic sedation; 3) constant medical illness. In some circumstances observation (1:1); 4) recommendations for fur- (e.g., organ transplantation), a medical or ther medical evaluation and workup; 5) imple- surgical service or protocol may require mentation of treatment over the patient's objec- psychiatric evaluation of all patients. Psy- tions; 6) involuntary psychiatric commitment; chiatric consultation in speci®c settings has and 7) other behavioral interventions. proven valuable and should be encouraged. 6. Evaluation of a patient who requests to see Psychiatric History and the Consultation Note a psychiatrist. Any patient who requests to speak with a psychiatrist should be evalu- 1. Medical-Psychiatric History. Contrary to ated only after the physician responsible for the usual medical or psychiatric examination, the patient's care has been contacted about the medically ill patient seldom initiates or re- the case. quests a psychiatric consultation and may even 7. Evaluation of a patient in an emergency sit- assume an adversarial attitude toward the C-L uation. In emergencies, a consultation may consultant. To obtain a psychiatric history that be requested by any health professional in- is more than super®cial, the consultant must be volved with the care of the patient (subject skilled at rapidly establishing the context of the to the rules of procedure of the institution). psychiatric disorder in the medical setting. The patient should be prevented from harm- In the Practice Guidelines for Psychiatric ing him- or herself or others (constant ob- Evaluation of Adults,1 the outline of a compre- servation) until the consultant arrives. hensive examination is discussed at length. The 8. Evaluation of a patient with a medicolegal C-L consultant may determine that to address a situation (e.g., where there is a question of speci®c consultation question, not all domains a patient's capacity to consent to or refuse are necessary to complete or to record in the medical or surgical treatment). consultation note. However, an assessment ad- 9. Evaluation of a patient with known or sus- equate to formulate and organize DSM-IV mul- pected substance abuse. tiaxial diagnoses must be made. An assessment of the medically/surgically Emergency Consultations ill patient requires that the C-L consultant be prepared to take a history and to make inquiries The process for conducting emergency that go beyond the usual domains of a standard evaluation of adults has been outlined by the psychiatric evaluation. These areas of special in- APA in its Practice Guideline for Psychiatric quiry include the following. Evaluation of Adults.1 In the general medical a. Clari®cation of the Consultee-Stated vs. hospital setting, there are no established proce- Consultant-Assessed Reasons for Referral. dural de®nitions for which clinical situations are The overt reason expressed for the need for designated as emergencies; rather, the emer- consultation may be incomplete, or a request gency designation is based on the requesting may be made for the assessment of one problem physician's perceived need for prompt service.38 (e.g., depression) when another more serious problem (e.g., delirium) is unrecognized. Re- Guideline quests may be vague if made by someone other than the person who observed the behavior of Coverage for emergencies should be avail- concern. Therefore, direct contact with the in- able on a 24-hour basis by on-call psychiatric dividual who initiated the request is bene®cial

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for obtaining exact information about the pa- ommend other modes of treatment (e.g., physi- tient's behavior, which may not appear in the cal therapy, anesthetic interventions, or surgical record. evaluation).40,41a b. Assessment for the Extent the Patient's General principles of pain assessment and Psychiatric Disturbance is Caused by the Medi- management include the following elements: cal/Surgical Illness. obtaining information about the pain complaint; Many of the patients seen by C-L consul- having an awareness of how pain contributes to tants have complex medical conditions. The speci®c illnesses (e.g., cancer, sickle cell dis- medical chart must be reviewed for pertinent ease, arthritis); having an awareness of how psy- medical factors that could contribute to the pa- chiatric disorders and symptoms contribute to tient's current state. Attention must be given to pain complaints and vice versa (e.g., anxiety in the description of the mental status and the be- acute pain, depression in chronic pain); and havior noted by the medical staff. making a detailed assessment of all analgesics c. Assessment for the Adequacy of Pain and adjuvant medications. It is crucial to have Management. an understanding of the factors that contribute Seemingly exaggerated complaints and/or to undertreatment of pain, the appropriate diag- abnormal behaviors are often associated with in- nostic workup for pain complaints, and the ele- suf®ciently treated pain.39 The consultant should ments of integrated, multimodal assessment and review with the patient the nature of the pain management of patients in pain.41b,42 and the effectiveness and duration of effect of d. Assessment for the Extent the Psychiatric any analgesics. Fears of unremitting pain, as Disturbance Is Caused by Medications or Sub- well as feelings of unattended suffering and stance Abuse. helplessness, need to be addressed. The consul- The patient's medication list and recent tant should carefully review the record of anal- changes in medication are critically important to gesic administration (narcotics and others). review. Psychiatric symptoms are frequently Clinicians should have familiarity with the produced by medications (e.g., corticosteroids) following topics: the types of pain (acute, prescribed for medical disorders. These symp- chronic, recurrent, and cancer-related); the dis- toms can be produced at therapeutic levels, may tinction between pain, nociception, suffering, emerge at times of withdrawal, or may arise as and pain behaviors; the multidimensional nature a result of drug-drug interactions. Analgesics, of pain (physiological, sensory, affective, cog- sedatives, anticonvulsants, anesthetics, psycho- nitive, behavioral, and psychopathological, i.e., tropics, and anticholinergics are groups of med- as a symptom of psychiatric illness); pain mea- ications commonly associated with psychiatric surement and assessment; pain management disturbances. (therapeutic goals, pharmacological and non- The type, quantity, and frequency of pre- pharmacological strategies, multidisciplinary scription drug use as well as illicit drug and al- and multimodal management, monitoring of cohol use should be assessed. Previous episodes strategies and side effects); and the impact of of structured outpatient or inpatient treatment pain and unrelieved pain (on recovery from ill- should be inquired about, as well as prior ex- ness or surgery, on the individual, on the family). periences associated with drug withdrawal. Clinical skills include the following: evaluation Urine and serum toxicological screening may be and monitoring of psychopharmacological requested when there is suspicion of, or the need agents; ability to administer or appropriately re- to document, substance abuse. fer a patient for psychological and behavioral e. Assessment for Disturbances in Cogni- interventions (e.g., cognitive±behavioral ther- tion. apy, relaxation therapy, hypnosis, biofeedback, Because so many psychiatric, behavioral, stress management, and education of patients medical, and legal considerations depend on as- and their families); and knowing when to rec- sessment of cognition, the search for even subtle

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disturbances in cognition is crucial to every psy- distinguished. Inquiry about the patient's under- chiatric evaluation of the medically ill patient. If standing of the physical illnessÐits course and a disturbance in cognition is identi®ed, the C-L prognosisÐallows the consultant a unique op- consultant should then determine if the change portunity to correct cognitive distortions on the in mental status is chronic and due primarily to part of the patient. In some situations, it is nec- the consequences of an underlying disorder essary to assess the capacity of the patient to (e.g., Alzheimer's disease, multi-infarct demen- refuse treatment and to help the patient set rea- tia) or acute and arising secondary to the effects sonable limits on further treatment. To do so, the of illness, medication, or a combination of fac- consultant must be familiar with the medical tors. treatment and/or hospital course to ascertain the f. Assessment of Psychiatric Symptomol- patient's understanding of his/her illness and its ogy and Behavior. possible course, with or without treatment.43 ªIs the patient's behavior a normal response to the stress of illness and/or hospitalization and, 2. Physical and Neurological Examination. therefore, likely to resolve with improvement in The psychiatric consultant should review the re- physical health?º In this assessment, the pa- sults of the physical examination with special tient's perspective of possible precipitating, ex- regard to the neurological examination. Addi- acerbating, or resolving factors is most perti- tional physical or neurological examinations by nent. Review of prior response to illness or the psychiatric consultant may be necessary, psychiatric treatment can facilitate proper diag- based on the results of the psychiatric interview nosis and treatment. The consultant should be and on the list of potential diagnoses created able to assess how well the patient is coping and during the formulation of the case. Speci®c areas whether he/she will be able to endure the course of physical examination that relate to psychiatric of illness. disorders may include an organ-speci®c evalu- g. Evaluation of the Patient's Character ation for unexplained somatic complaints or po- Style. tential medication side effects; observable signs As opposed to the usual ªWhat does this of self-injury or intravenous drug abuse; or the patient have?º the C-L consultant must assess, presence of frontal release signs, tremor, and ªWhat kind of patient has the illness?º Infor- parkinsonian symptoms. mation from several domains (e.g., developmental history, social history, occupational history) 3. Mental Status Examination. In addition to must be integrated to form a dynamic life nar- an examination to elicit signs and symptoms of rative leading up to the current illness. Medical psychiatric disorder, the purpose of the mental illness, surgery, and the many stresses of hos- status examination for the medically ill is to pitalization are managed differently by individ- elicit the patient's capacity to understand and uals with different character styles or DSM-IV cope with the illness and to make decisions Axis II personality disorders. Understanding about care. The level of detail for assessment of how character in¯uences the experience of cognitive function varies depending upon the physical illness is critical for explaining abnor- patient's combined medical and psychiatric con- mal patient behaviors, emotions, and demands. dition. The mental status examination can be tai- h. Inquiry About Thoughts of Dying. lored to the patient's clinical presentation, which Many patients think about dying, especially may include judgment about the patient's capac- when their illness is protracted, exhausting, or ity to participate in exams with formal rating critical. Some patients express their wish to die scales. to the medical staff; this may lead to a request for a psychiatric consultation. Thoughts of dying 4. The Consultation Note. Although the com- related to life-threatening physical illness and prehensive consultation requires attention to all suicidal ideation related to depression need to be domains, the consultation note is best if brief and

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focused on the referring physician's concerns. 5. Diagnosis. Because it is important to syn- The consultant should avoid using acronyms, thesize affective, behavioral, cognitive, social, psychiatric jargon, or other wording that is likely and medical factors that contribute to the craft- to be unfamiliar or confusing to other medical/ ing of an individualized treatment plan, the con- surgical specialists. Medical records are legally sultant should organize the diagnosis section ac- available to patients, hospital review commit- cording to the DSM-IV's multiaxial guideline.45 tees, and insurance and managed care compa- Axis I or II diagnosis cannot always be made at nies, so the consultant must carefully select the time of the initial consultation. If this occurs, which con®dential information to include. The a statement about the need for further evaluation consultation note should be written with these or inclusion of a provisional or ªrule-outº label factors in mind. can be added. Several possible diagnoses can A structured consultation note that provides also be listed. Only the one or two central medi- a framework for providing information back to cal diagnoses should be included on Axis III, the referring physician is best.44 An identifying preferably the ones of greatest clinical relevance statement that succinctly summarizes the pa- to the disorders noted on Axis I or II. Signi®cant tient's presenting condition and the referring medical and psychological stressors can be physician's reason for consultation should be noted and documented on Axis IV, and the pa- present. The note needs to be titled with mention tient's overall functional level should be in- of ªPsychiatryº and ªConsultationº or some cluded as Axis V if it directly involves some equivalent terms. The names and position of the aspect of the treatment plan. Axes IV and V may consultant or residents involved with the assess- be omitted if the consultant feels they will not ment need to be included, and the note must be be useful or familiar to the consultee. signed. Documentation of the date and time of consultation is necessary; the consultant may Guideline elect to document the length of time involved in performing the consultation for billing purposes. The development of the medical-psychiatric The content of the consultation note should also history, as well as pertinent aspects of the physi- meet the requirements of federal (Health Care cal and mental status examination, must be in- Financing Administration [HCFA]) and state tegrated by the psychiatric consultant to yield a regulations that apply with regard to documen- carefully structured consultation note, i.e., one tation. that synthesizes the data, provides a diagnosis, Sources of information used for the consul- and recommends appropriate testing and treat- tation, if other than from the consultee, medical ment. record, or interview of the patient, should be recorded. The history of present illness should in- Diagnostic Testing and Consultation clude the relevant data from the history that may have signi®cant bearing on the diagnosis and/or In addition to the comprehensive clinical in- formulation or on the rationale for management terview and mental status examination, the con- and treatment. The consultant's objective ®nd- sulting psychiatrist may need to perform or re- ings on mental status examination and physical/ quest additional speci®c medical or neurological neurological examinations should be carefully examinations, specialized laboratory tests, psy- documented. The formulation, diagnosis, and chological and neuropsychological evaluations, recommendations should be written concisely. or consultations concerning legal and ethical is- Clear statements of follow-up and management sues. (by whom and when) are desirable. The C-L During the course of a clinical interview, the consultant should make an effort to communi- C-L consultant may use diagnostic assessment cate verbally to the consultee and to identify the instruments, cognitive screens (e.g., the Mini- procedure for follow-up contacts or questions. Mental State Exam [MMSE]46) depression in-

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ventories (e.g., the Geriatric Depression Scale47 Follow-Up or Hamilton Depression Scale [Ham-D],48 or instruments to screen for alcohol and drug abuse The scope, frequency, and necessity of (e.g., the CAGE [a test for alcoholism]49 and the follow-up visits depend on the nature of the ini- Michigan Alcohol Screening Test [MAST]50 tial diagnosis and recommendations. Follow-up Use of such psychometric inventories allows for visits reinforce the consultant's recommenda- ongoing follow-up via an empirical method that tions and allow the consultant to evaluate the facilitates enhanced communication with con- results of recommendations, help prioritize the sultees. relative importance of particular interventions, and prevent breakdowns in communication be- 53 Guideline tween consultants and consultees. Follow-up visits range in frequency from several times daily to none at all.54 Follow-up care allows for The C-L consultant must be familiar with the further development of a doctor±patient re- diagnostic testing regarding lationship, ongoing data collection, systems interventions, psychopharmacological monitor- 1. The indications for anatomic brain imaging ing, prevention of behavioral or psychiatric or neurophysiological screening by com- relapse, and increased compliance with treat- puted tomography (CT), magnetic reso- ment recommendations.55 In identi®able patient nance imaging, electroencephalogram, and groups with medical and psychiatric comorbid- 51 positron emission tomography scans. ity, more frequent follow-up examinations by 2. The indications for the administration of the C-L consultant improve psychosocial out- neuropsychological testing (e.g., Minnesota come, enhance adjustment to physical illness, Multiphasic Personality Inventory, Wechs- and decrease length of stay.56,57 ler Adult Intelligence Scale, and Trail Mak- 52 ing, parts A and B). Guideline 3. The use of instruments to aid in diagnostic interviews and screening or measuring se- The frequency of follow-up care by the verity of comorbid mental disorders (e.g., C-L consultant depends on the parameters of the MMSE, Ham-D). clinical situation; it varies from patient to pa- 4. The controlled administration of amytal or tient. At least daily follow-up should be consid- other hypnotics to interview for conversion ered for several types of patients: those in re- disorder or a barbiturate challenge test for straints or on constant observation; those who barbiturate dependence. are agitated, potentially violent, or suicidal; 5. The initiation of a dementia workup, in- those with delirium; and those who are psychotic cluding thyroid function tests, VDRL (test or psychiatrically unstable. Acutely ill patients for syphilis), B12, folate, urinalysis, chest X started on psychoactive medications should be ray, electrocardiogram, sequential multiple seen daily until they have been stabilized. analysis 20, complete blood count, human In some circumstances (e.g., for determi- immunode®ciency virus (HIV), and CT nation of capacity to consent or refuse treatment, 16 scan. for evaluation prior to organ transplantation, for facilitation of same-day transfer to an inpatient The psychiatric consultant must be prepared psychiatric setting, or for patients with a history to advocate for further surgical, medical, neu- of psychiatric disorder that is in remission), only rological, or other evaluations if there are indi- an initial consultation may be necessary. cations of an underlying medical condition that All recommendations for initiation of new may be contributing to the psychiatric distur- procedures or interventions, consultation with bance. other specialists, eventual transfer to other psy-

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chiatric settings, and/or initiation or discontin- setting (e.g., the cardiac care unit, cancer service, uation of psychotropic medications should be otolaryngology service, etc.).74±78 accompanied by adequate monitoring until other health professionals can assume responsibility Guideline for the patient. The psychotherapeutic approach to the medically ill should be considered carefully, and the INTERVENTIONS modality introduced should be primarily selected in response to the patient's needs. No single psy- Psychotherapy chotherapeutic modality will be effective with all patients, at all times, in the medical setting. A C-L consultant must have the ability to The C-L consultant should have extensive apply a variety of psychotherapeutic techniques knowledge and clinical experience dealing with to the medically ill. In many cases, an under- the psychological stresses inherent in medical standing of how the patient's behavior and emo- illness (e.g., separation anxiety, fear of pain, fear tions ®t known patterns affects the ability of the of loss of control, impending death, guilt about consultant to obtain a relevant history, arrive at dependency, and grief). The C-L consultant a diagnosis, and develop an effective treatment should be experienced in the treatment of pa- plan. tients with complex personality disorders and An understanding of an individual's innate comorbid medical/surgical illness, and the C-L defensive, cognitive, and interpersonal styles consultant should be prepared to deal with the (i.e., the core character and personality) enables emotional reactions of health care providers to the consultant to provide coping strategies for their patients. the patient. Additionally, individuals with personality disorders are prone to stereotypical mal- Pharmacotherapy and adaptive behaviors and emotions in response to Other Somatic Therapies medical illness and may stimulate negative or hostile reactions in health care providers.58,59 Psychopharmacological interventions are Goal-directed cognitive±behavioral therapy an essential part of the management of the med- crafted to the individual patient can often facili- ically ill. It is estimated that at least 35% of psy- tate cooperation and compliance. In patients chiatric consultations include recommendations with terminal illness, complex medical condi- for medications.79 About 10%±15% of patients tions, chronic pain, or with patients undergoing require reduction or discontinuation of psycho- repeated testing, open-ended supportive psychotropic medications because they are contributing therapy may be necessary. to the clinical presentation. Numerous physical Medical psychotherapy encompasses a body conditions may cause, exacerbate, or ®rst pres- of clinical techniques (e.g., crisis interventions, ent themselves as psychiatric syndromes, and short-term therapy, supportive therapy, interper- appropriate use of psychopharmacology neces- sonal therapy, group therapy, cognitive±behav- sitates a careful consideration of the underlying ioral therapy, hypnosis) that may be applied sin- medical illness, drug interactions, and contrain- gly, in combination, or alternately in different dications. In addition, many medications used in stages of an illness.60±72 Extensive review of the the treatment of medical/surgical illness are as- literature73 reveals the bene®ts of a wide range of sociated with psychiatric syndromes (e.g., hal- psychotherapeutic modalities, especially when lucinations with L-dopa, anxiety with broncho- they are structured for the speci®c illness or con- dilators, psychosis with steroids). Therefore, the dition (e.g., cancer or heart disease) and when the C-L consultant must be knowledgeable about psychiatric consultant is familiar with the prob- the psychiatric effects of medications as well as lems encountered in the speci®c medical/surgical the speci®c indications for psychopharmacol-

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ogical interventions. Pharmacotherapy of the pregnancy); and the potential for drug±drug medically ill often involves modi®cation in dos- interactions; age (e.g., to account for older patients with an 4. Recognition of drug-induced psychiatric increased volume of distribution, a decreased syndromes (e.g., depression, psychosis, de- rate of metabolism, and an increased physiologic lirium); reactivity).80 Furthermore, modi®cations may be 5. The use of psychotropic agents for the treat- necessary because of liver, kidney, or cardiac ment of substance-induced psychiatric dis- disease, or because of potential for multiple orders (e.g., withdrawal syndromes) and drug±drug interactions.81±84 Pregnancy presents substitution algorithms for detoxi®cation another challenge, with concerns regarding po- protocols. Because noncompliance and sub- tential teratogenicity.85±88 therapeutic use of psychotropics are com- The decision to use pharmacological agents mon, the C-L consultant must make addi- follows immediately upon the differential diag- tional efforts to ensure appropriate and nosis, and appropriate agents should be pre- timely compliance with pharmacological scribed when major psychiatric syndromes arise. recommendations arising from inexperience C-L psychiatrists should be familiar with current on the part of the consultee or resistance on reviews and databases in the literature for phar- the part of the patient. Obtaining medication macotherapy of the medically ill.89±93 blood levels should be considered when The C-L psychiatrist must be knowledge- available; and able about electroconvulsive therapy (ECT) and 6. The appropriate indications for ECT. recognize when to introduce it in depressed, cat- atonic, or critically ill patients. Referral, Outpatient Follow-Up, and Signing Off Guideline 1. Referral and Requests for Services of Other Consultants. The C-L consultant should rec- The C-L psychiatrist must be a licensed ommend that other professionals be brought into physician with extensive clinical experience and the case when additional expertise is required. knowledge about the use of pharmacological Such expertise includes neurology, pain, sub- agents. stance abuse, geriatrics, and neuropsychology; it The psychiatric consultant should recom- may be provided by practitioners from a variety mend and prescribe medications whenever a ma- of disciplines (e.g., psychology, social work, oc- jor psychiatric syndrome is diagnosed and when cupational therapy, physical therapy, pastoral the bene®ts of treatment outweigh its risks. care, and psychiatry as in behavioral medicine As an essential skill, the C-L consultant or ECT) or from patient representatives or es- must have additional pharmacological knowl- pecially knowledgeable nonmedical volunteers. edge related to the following: Guideline 1. Variations in diagnoses and the natural pro- gression of psychiatric disorders in the med- Psychiatric consultants should recommend ically/surgically ill; consultation with other physicians and nonphys- 2. Indications for initiation, reduction, and dis- ician specialists, when appropriate. The request continuation of therapy with speci®c psy- for additional consultation(s) should in general chopharmacological agents; be arranged by the physician of record (i.e., the 3. Appropriate adjustments of dosage depend- original consultee). When appropriate, the psy- ing on the patient's age, gender, and medical chiatric consultant may end his/her involvement condition; physiologic abnormality (includ- with the patient when another specialist is pre- ing liver, renal, and cardiac disease or pared to deliver the necessary care to the patient.

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When the consultant recommends psychotropic the patient's medical record with information as medications, he/she should continue to follow to how the C-L consultant can be reached, the patient for the duration of the hospitalization, should the need arise. until psychotropics have been discontinued, or until the consultee no longer requires the con- Constant Observation and Restraints sultant's services. The decision to use constant observation 2. Outpatient Follow-Up and Disposition. It and restraints is extremely serious. Because of is the responsibility of the psychiatric consultant the delicate balance between medical necessity to recommend patients for outpatient psychiatric and individual liberty, the implementation of follow-up when necessary and to discuss the rec- these measures requires documentation of medi- ommendations with both the patient and the con- cal need, follow-up monitoring, and reporting of sultee. The eventual disposition of a patient is consequences. Constant observation and re- determined by the nature of the psychiatric prob- straints should be implemented for the shortest lem and the physical, psychological, economic, possible time with the least restrictive, though and social resources of the patient. The psychi- effective, means available; these interventions atric consultant should work with the primary must not be made solely for the convenience of care physician, the social worker, and the pa- medical staff. Assessment and treatment of un- tient's family to arrange the best disposition for derlying psychiatric conditions that contribute to the patient.37 the patient's need for these measures should be expeditiously undertaken. Guideline 1. Constant Observation. Constant observa- It is the responsibility of the consultant to tion is often necessary to ensure patient safety suggest outpatient psychiatric treatment and to in the medical/surgical setting. It is typically discuss these recommendations with both the provided by nursing staff and at times with the patient and the consultee. assistance of family members.95 Patients who require constant observation typically fall into one 3. Signing Out and Signing Off. Psychiatric of three categories: patients who have attempted consultation for patients in the general medical suicide; patients with an altered mental status setting must be available 24 hours/day, 7 days/ (e.g., secondary to dementia or delirium) who week. A system of coverage should be arranged may inadvertently harm themselves or others; to provide this level of care. Problem patients and patients with psychopathology (e.g., severe who require close follow-up and patients who depression or psychosis) who are at risk for sui- are under observation for suicidal and/or homi- cide or assaultive behaviors.96,97 Other catego- cidal ideation should be formally ªsigned out,º ries of patients who may require constant obser- either in writing or verbally to the person who vation include those with mental retardation and will be responsible for their care. those who are attempting to leave the hospital The decision to terminate involvement with against medical advice. Because patients moni- a patient should be made in concert with the con- tored with constant observation often require in- sultee and discussed with the patient.94 patient psychiatric hospitalization, it is reason- able to request psychiatric consultation on all Guideline patients who require this type of treatment.98

When the decision to stop seeing a patient Guideline has been made, the consultant should discuss the planned termination with the consultee and with Although the initial need for constant ob- the patient. A sign-off note should be placed in servation is generally instituted by the physician

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of record, psychiatric consultation is recom- clinically evaluate the medicolegal elements of mended for these patients to facilitate diagnostic the decision-making capacity of the patient evaluation and to reduce harmful behaviors and within the context of the medical±psychiatric litigious outcomes. presentation.107±111 The psychiatric consultant Policies regarding constant observation should perform a complete diagnostic exami- should be delineated, including the writing of nation with an extended cognitive evaluation. orders to initiate and discontinue observation, The consultant should evaluate the extent and the role of the staff providing constant obser- accuracy of information given to the patient and vation, the requirements of record keeping, and subsequently retained by the patient;112 the pa- the appropriate documentation regarding the dis- tient's understanding of the nature of the illness; continuation of observation. the risks and bene®ts of the proposed treatment; treatment alternatives; and the consequences of 2. Restraints. Restraints should be applied in treatment refusal. Because the incompetent pa- accordance with written institutional policiesthat tient often has underlying cognitive de®cits, the are developed in accordance with local and state consultant needs to be knowledgeable about the laws and the standards of accrediting agencies evaluation and treatment of the cognitively im- (e.g., Consolidated Omnibus Reconciliation Act, paired patient and emergency evaluations.113±115 HCFA, Joint Commission on Accreditation of The consultant must clarify that the patient's ca- Healthcare Organizations); restraints should be pacity or lack thereof is speci®c (e.g., a patient monitored as a special treatment procedure that may be competent to accept treatment without requires speci®c justi®cation. Restraints include being competent to execute a will). soft or leather restraints, wrist or ankle cuffs, jackets, belts, sheets, gerichairs, and mittens. Guideline The C-L consultant should be knowledgeable about the physical and emotional risks of The C-L psychiatrist's role is to evaluate a restraints; the need to implement the least- patient's capacity for medical decision making restrictive alternatives in managing agitation; with regard to a speci®c medical determination. the most conservative level of assessment meth- A patient who clearly demonstrates diminished odology; the highest guidelines of documenta- capacity may be treated over objection in an tion (i.e., doctor's orders and progress notes); emergency (i.e., if as a result of refusal the pa- and the need to frequently reevaluate the patient, tient is likely to suffer serious adverse medical allowing for the earliest, safest release from re- consequences or to die). However, the clinical 99±106 straints possible. determination of capacity is often relative, and it requires a complex medical decision (of bene- Guideline ®ts and risks with regard to which intervention Psychiatric consultants must be knowledge- for what medical illness given possible out- able of all applicable state, local, and institu- comes). Impaired judgment in one area does not tional guidelines with regard to restraints. Re- imply incompetence in all matters. straints should not be used for discipline or as a When the C-L consultatnt has determined convenience for the staff. The C-L service must that the patient has impaired decisional capacity, provide 24-hour, 7-day/week coverage for all the C-L consultant should recommend that a patients who they have evaluated and who re- court order be obtained to treat a patient over the quire restraints. patient's objection. Where no medical emergency exists, this may involve appointment of a Competency Evaluations guardian. Decision-making powers of the guardian differ from state to state. Although psychiatric consultants cannot le- Treatment of an incompetent patient who gally declare a patient incompetent, they can does not object is subject to ethical and legal

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considerations appropriate to the patient, the oc- control. This may be a review of all cases seen casion, and the community standard. over a speci®ed period of time (e.g., a week or a month of a resident's rotation), or reviews may Psychiatric Commitment and target an area of clinical interest. For example, Transfer to Psychiatry a review of attempted suicides in hospitalized patients might reveal environmental risks (e.g., As part of a complete psychiatric evalua- windows that can be opened by patients) that 116 tion, the consultant should consider the appro- could be minimized. priateness of inpatient psychiatric treatment. All untoward events should be reviewed This determination requires familiarity with the thoroughly and problems dealt with by a quality voluntary and involuntary legal statutes of the assurance committee. Areas in need of remedi- state and local mental health acts; an evaluation ation should be identi®ed and addressed appro- of the suitability of the type of intended psychi- priately by staff education, by recommendations atric unit (e.g., locked or open, dual diagnosis, for alterations in protocols and policy, by rec- rehabilitation/detoxi®cation, medical±psychiat- ommendations for alterations in the physical ric, conventional psychiatric or geriatric units) plant, or by changes regarding staf®ng and su- and an evaluation of the capacity of the psychi- pervision. atric unit to provide the necessary medical/surgical care required by the patient. Guideline

Guideline C-L consultants should create a system for regular internal quality review of the service's The psychiatric consultant should be famil- clinical, research, and supervisory activities. Re- iar with the clinical indications for, and potential cords must be properly maintained and safely bene®ts of, inpatient psychiatric admission for stored, yet readily accessible for clinical and re- particular psychiatric conditions. The C-L con- search purposes. Patient con®dentiality must be sultant should be familiar with all appropriate considered and safeguarded. legislation and institutional rules about admission and transfer to psychiatric units. The C-L Supervision of Trainees psychiatrist is also responsible for determining whether the patient is medically stable before The education of psychiatrists and other transfer and in a condition suitable enough to be medical staff has always been an important mis- able to receive appropriate inpatient psychiatric sion of C-L psychiatry. Previously published care, without imminent physical decompensa- guidelines recommended that the C-L experi- tion. ence is best suited for PGY-3 or PGY-4 psychiatric residents, rather than less experienced res- ADMINISTRATIVE ISSUES idents.3 The education of psychiatric residents, nonpsychiatric residents, psychologists, social Data Collection and workers, and nurses is in part provided through Quality Control supervision of clinical activities, with discussion of diagnostic and psychotherapeutic issues. Ap- It is no longer suf®cient merely to do a con- propriate didactic material should be used in the sultation and write a note in the record. Records training of residents and others.117±121 These ma- must be kept for administrative and clinical re- terials should be modi®ed for individuals in dif- view purposes (e.g., as proof of supervisory ser- ferent disciplines. The performance of trainees vices rendered). A review of cases should be should be assessed periodically to maximize the conducted by each C-L service to ensure quality development and re®nement of their skills.122,123

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Guideline mation is put in the patient's chart to protect the patient's con®dentiality.5 A suf®cient number of faculty should be The C-L consultant is exposed to a variety of con¯icting issues that require careful consid- made available so that all new patients consulted 127,128 by a resident can be seen by an attending psy- eration regarding ethical decision making. chiatrist, preferably within 24 hours. The attend- When faced with pressures from consultees, ing supervisor may determine when a case re- hospital utilization review committees, managed quires his/her bedside examination, and case care companies, or a patient's family, the con- supervision may be made initially via telephone sultant must skillfully negotiate numerous chal- lenges to act in the best interests of the pa- if an attending physician is not physically on 129±131 site. The resident should make a notation in the tient. chart that the case was discussed, with whom, Guideline and note any recommendations made by the attending physician. Trainees should receive di- C-L consultants should follow the principles dactic training in the topics outlined in the Rec- of medical ethics in all patient interactions. They ommended Guidelines for Consultation-Liaison should collaborate with the medical staff to re- Psychiatric Training in Psychiatry Residency solve ethical dilemmas that may arise in the care Programs. of a patient. The psychiatric consultant must be prepared to act as an advocate for the patient and Ethical Guidelines clarify the underlying intent and meaning of his/ her overt statements. C-L consultants must also All physicians have a primary duty to con- be knowledgeable of the medicolegal issues(e.g., duct themselves ethically and to examine the capacity to consent to treatment, refusal of treat- ethical dilemmas that arise in the care of their ment, civil commitment, responsibility of a patients. The ethical practice of medicine is out- health care proxy, and conservatorship). It is the lined in the APA and American Medical Asso- responsibility of the consultant to be knowledge- ciation guidelines.124 In addition to knowledge able about the laws and guidelines that are to be of the ethical guidelines, the C-L consultant has considered in ethical and medicolegal determi- a special role in alerting the staff and in explor- nations in the hospital setting. ing the ethical issues that arise in the care of the CHILD AND ADOLESCENT CONSULTS patient. Despite overt statements of intent to the Although the general guidelines for consultation contrary, many requests on the part of the patient regarding children and adolescents are similar to are made for reasons, sometimes hidden, that run those for adults, there are speci®c considerations counter to the true wishes of the patient. It is the that are unique to the pediatric population. Con- responsibility of the C-L consultant to give eth- sultation with children and adolescents requires ical consideration to these issues with regard to specialized clinical experience and knowledge right of treatment refusal, capacity to consent to that goes beyond that of most C-L consultants. treatment, civil commitment, or medical futil- 108,112,125,126 Not all consultants at the present time are re- ity. quired or assumed to have this additional capa- C-L consultants are also entrusted with cer- bility. tain private information from and about patients. At its core, the relationship is based upon trust Quali®cations and both in the physician and in the principles of Role of the Consultant medical ethics. An awareness that the medical record may be read by a variety of staff may lead The role of the C-L consultant includes the the psychiatric consultant to limit what infor- evaluation and treatment of developmental, be-

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havioral, and psychological problems as mani- cial to consider the impact of developmental is- fest in children, adolescents, and families in the sues and regression observed in children medical setting.132 Often this role includes an hospitalized with serious medical illnesses.135 awareness of the special psychiatric needs of this By virtue of their complexity, pediatric consul- population in a pediatric setting, particularly in tations typically take longer than consultations children facing traumatic medical procedures with adults. and hospitalization. In addition to an ability to identify the social, environmental, and cultural Legal and Ethical Issues factors relevant to any psychiatric consultation, the consultant should be able to appreciate de- The consultant should have a thorough velopmental and family issues as they apply to knowledge of the relevant local laws that apply diagnosis and intervention.133 It is essential that to this population. These include the mandatory the consultant have expertise in areas that in- reporting of suspected cases of sexual or physi- clude behavioral effects of medications, non- cal abuse or abandonment; the obligation to re- compliance with treatment, treatment of chronic port suspected maternal use of drugs during the pain, reaction to acute and chronic medical ill- neonatal period; the child's right to treatment ness, disorders of attachment, parent±infant re- (particularly when this con¯icts with the par- lationship dif®culties, speech and language dis- ents' desire to refuse or withhold treatment in orders, learning disabilities, and psychiatric the case of critically ill neonates or due to pa- disorders speci®c to childhood. The C-L con- rental religious beliefs); the legal age for consent sultant should have an in-depth understanding of and the legal de®nition of an emancipated minor, medical illness, as well as a general knowledge which may vary according to state and according of procedures, medications, hospital routines, to the nature of the illness or problem (e.g., in and outcomes for children and adolescent pa- the area of reproductive rights); and the invol- tients. untary medical or psychiatric treatment of mi- C-L consultant quali®cations for this role nors.136 should include board eligibility or board certi- The limits to con®dentiality implicit in a ®cation in child and adolescent psychiatry and psychiatric consultation become even more the ability to perform in a leadership role within complicated when the consultation involves mi- a multidisciplinary team. nors, especially with regard to the issue of sexual behavior, teen pregnancy, criminal behavior, or Clinical Procedure substance abuse. These limitations should be clari®ed with both the family and the child at the Before starting the consultation, the consul- time of the consultation.134 It is important to tant should ascertain that both the child and the safeguard the documentation of sensitive infor- parents or legal guardians have been informed mation in the medical record; this concern ex- about the purpose of the consultation. Given the tends to disclosure of information to contacts importance of the family to the child, the fre- made at schools and other outside agencies. quent contribution of family dynamics to the child's symptoms, and the impact of the child's Interventions medical illness on the family system, it is essential that the consultant obtain information from Knowledge of treatment modalities should family members. An alliance with the family is encompass cognitive and behavioral interven- essential for successful intervention. When rele- tions (including hypnosis); psychotherapy (in- vant, consultation should include contact with cluding individual, family, and group modali- others (e.g., members of the school system, the ties); and expertise in the area of pediatric primary pediatrician, the caseworker, the pro- psychopharmacology.137 In addition, the consul- bation of®cer, or the therapist).134 It is also cru- tant should have familiarity with the local out-

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patient referral resources, support groups for ited by Cassem NH, Stern TA, Rosenbaum JF, parents and children, and special educational re- et al. St. Louis, MO, Mosby-Year Book, 1997 sources. The American Psychiatric Press Textbook of Consultation-Liaison Psychiatry, edited by Run- Future Research and Review dell JR, Wise MG. Washington, DC, American Psychiatric Press, 1996 Given the relative shortage of research in The MGH Guide to Psychiatry in Primary this ®eld, consultants should promote and de- Care, edited by Stern TA, Herman JB, Slavin velop research in the areas of assessment, inter- PL. New York, McGraw-Hill, 1998 vention, and prevention of illness in children and adolescents in a pediatric setting.138 Finally, Reference Database given the complexity of the issues relating to psychiatric consultation in children and adoles- Strain JJ, Hammer JG, Himelein C, et al: cents, a large-scale survey of this ®eld should be Further evaluation of a literature database soft- undertaken with the goal of developing more de- ware and content. Gen Hosp Psychiatry 1996; tailed practice guidelines for this patient popu- 18:294±299 lation. Societies Guideline The Academy of Psychosomatic Medicine The principles of psychiatric consultation The American Psychosomatic Society with children and adolescents are similar to The American Academy of Child and those of adult consultation. However, special Adolescent Psychiatry knowledge and clinical experience related to the Society of Pediatric Psychology pediatric population are required. Association of Medicine and Psychiatry

BIBLIOGRAPHY GUIDELINES DEVELOPMENT

C-L consultants should be familiar with the ex- Next Steps tensive literature and resources that currently ex- ist for support of practitioners in the ®eld. Major The development of guidelines on the na- works and commonly used resources in the ®eld ture of psychiatric consultation and intervention of C-L psychiatry are listed below. is a serious undertaking that must be carefully reviewed. No single report on guidelines can be Journals complete in itself. The Task Force endorses the Institute of Medicine's principles in the process Psychosomatics, Psychosomatic Medicine, of developing guidelines. The practice guide- General Hospital Psychiatry, Psychiatric Ser- lines presented here represent a step along that vices, International Journal of Psychiatry and process. Further efforts should be directed at the Medicine, Journal of Pediatric Psychology following:

Textbooks 1. Establishing the validity, reliability, and re- producibility of the guidelines; Psychiatric Care of the Medical Patient, ed- 2. Re®ning the clinical applicability, ¯exibil- ited by Stoudemire A, Fogel BS. New York, Ox- ity, and clarity of the guidelines; ford University Press, 1993 3. Documenting the development, participant Massachusetts General Hospital Handbook assumptions, and rationale behind creation of General Hospital Psychiatry, 4th Edition, ed- of the guidelines;

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4. Identifying opportunities for collaborative of the Academy of Psychosomatic Medicine endeavors; (1-703-556-9222). 5. Maintaining a viable standing committee The Academy of Psychosomatic Medicine is for guidelines development; and grateful for the generous support of Eli-Lilly, 6. Inviting interested parties to offer review which made publication of this practice guide- and comment through contact of the of®ce line possible.

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