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

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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, pharma- cotherapy), 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 q 1998 The Academy of Psychosomatic tions and actions. Instead, they are meant to Medicine. serve as an outline for the training and knowl- S8 PSYCHOSOMATICS Practice Guidelines 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- VOLUME 39 · NUMBER 4 · JULY±AUGUST 1998 S9 Practice Guidelines 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 con- sultation. 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
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