CONSULTATION LIAISON PSYCHIATRY (CLP)

Meaning of CLP:

Consultation-Liaison Psychiatry is a subspecialty of psychiatry that incorporates clinical

service, teaching, and research at the borderland of psychiatry and medicine. (Lipowski,
1983).

Liaison psychiatry, also known as consultative psychiatry or consultation-liaison psychiatry

(also, psychosomatic medicine) is the branch of psychiatry that specialises in the interface
between other medical specialties and psychiatry, usually taking place in a hospital or
medical setting.

"Consults" are called when the primary care team has questions about a patient's mental
health, or how that patient's mental health is affecting his or her care and treatment. The
psychiatric team works as a "liaison" between the medical team and the patient. Issues that
arise include capacity to consent to treatment, conflicts with the primary care team, and the
intersection of problems in both physical and mental health, as well as patients who may
report physical symptoms as a result of a mental disorder.

Consultation-liaison psychiatrists are an expert at the complex task of managing psychiatric

illness in the context of the general hospital and the emergency department. The
responsibility of the C-L psychiatrist is first to assure that the proper medical evaluation and
management are accomplished for the medical stabilization of patients before providing the
necessary psychiatric treatment in collaboration with the patient’s clinical team. The C-L
psychiatrist then arranges for psychiatric disposition, if and when that is clinically indicated.

History of CLP:

The history of psychosomatic medicine can be traced back to Johann Heinroth

(1773–1843), who coined the term “psychosomatic” in 1818. Few years later in 1922 Felix
Deutsch first gave the concept of “psychosomatic medicine.” Jackson Putnam is considered
to be the first consultation psychiatrist, who worked as a neurologist in Massachusetts
General Hospital in later part of 19th century. However, the clinical aspect of psychosomatic
medicine, that is, CLP made a beginning in the early part of the 20th century, with the
opening of the first viable general hospital psychiatric unit (GHPU) at the Albany Hospital in
1902 by JM Mosher. The basic aim of opening of the GHPU was to bring mental health
professionals into close proximity with other specialists in medicine for the purposes of
training and providing psychiatric care. This is considered as a forerunner of the later
med-psych unit. This beginning led to the development of GHPUs across the world and the
development of CLP as a subspecialty of psychiatry.

The progress in the field of CLP over the last century or more in the United States is divided
into four phases, that is, preliminary phase, organization/pioneering phase, developmental
phase (conceptual-development phase and rapid-growth phase), and
consolidation/retrenchment phase; each phase roughly lasting for 30 years, with the current
consolidation/retrenchment phase, beginning since 1980. The term “liaison psychiatry” was
used for the first time by Billings during the organization/pioneering phase, which also saw
other major developments such as the establishment of CLP services in many hospitals in the
United States, using many different models. During the same phase, the Academy of
Psychosomatic Medicine was established in 1953 in the United States.

Roles and Functions of a Consultation Liaison Psychiatrist:

The roles or functions of a consultation–liaison (CL) psychiatrist encompass clinical work,
teaching, administration, and research.
The clinical work includes facilitation of the medical treatment of the patient. A CL
psychiatrist is expected to be a medical expert, good communicator, good collaborator, a
manager and supervisor, health advocate, professional, and a scholar.

The CL psychiatrist is expected to address the needs of the patients, requesting physicians,
nursing staff, patients’ families and friends, and the health‑care system.

In terms of training, the CL psychiatrist is expected to enhance the knowledge of the

trainees in psychiatry and other specialties and enhance the awareness of members of
medical and surgical team with respect to the mental health issues.

In terms of extending the mental health services at the primary care level, CL psychiatrists
are considered as the most suitable persons who can help the primary care physicians in
recognizing and managing mental disorders. In fact, considering the importance of mental
health issues in overall health of the patients, CL psychiatrists are expected to become the
primary clinical caretakers of the patients.

The role of a CP in a general hospital setting

Consultation-Liaison Psychiatry (CLP) is the part of psychiatry related to the study of

co-morbidities between medical general conditions (located on the third axis in the
international taxonomies) and psychiatric conditions (coded on the first and the second axis).
The role of CLP is that of a link between psychiatry and other medical fields. Thus, the
consultation-liaison psychiatrist is the psychiatry’s ambassador in the general hospital.

Any medical condition has a significant impact on the human psychic life, first because
one is psychologically aware of being ill and he/she is acting as being ill, then because the
impact the general medical condition has on the life’s quality with respect to social, familial
and professional activity. Furthermore, the medical and/or surgical treatment contributes to
the patient’s lack of comfort, due to the medication’s side-effects or post-operatory sequelae
respectively (Hays et al. 1995, Druss et al. 1999).

There is a high correlation between a longer hospitalization and depression or personality

disorders; the same group of patients have greater re-admission rate for the next four years
after the first admission (Saravay, Lavin 1994, Aoki et al. 2003).

On the contrary, if the depression is recognized and adequately treated while patient is in the
hospital, the outcome is significantly better, the hospitalization is shorter, and the
re-admission rate is lower (Strain et al. 1991). CLP is also important in the care of
outpatients with organic co-morbidities, as there is a high rate of unrecognized depression
in the general practice’s diagnosing process (Consoli, 2003).

This fact correlates with the General Practitioner’s (G.P.’s) tendencies to consider they are
skilled in recognizing and treating psychiatric conditions; concomitantly, G.P.s tend to
consider the CLP has the main role in advising on psycho-social issues (Doron et al. 2003).

The role of CP in a primary setting

In more recent years, the potential advantages of consultation liaison in the primary care
setting have been recognised (Harmon 2000; Sved Williams 2006), and the World Health
Organization (WHO 2001; Kohn 2004) identified primary care as essential to improving the
delivery of mental health care because of its greater accessibility. Primary care, such as
general or family physician practices, provides general community‐based health care
which links people to specialist services for specific health needs. In mental health
consultation liaison, the primary care provider maintains a central role in the delivery of
mental health care with the mental health care specialist typically assessing the person with a
mental disorder and providing consultation to the primary care provider. The mental health
specialist may also directly treat and refer consumers. The mental health specialist is often a
psychiatrist, but can also be a mental health nurse, psychologist, social worker, or a team of
mental health care providers. Consultation liaison has the potential to improve the ability of
primary care providers to recognise and treat mental disorders enhance communication
between services , increase effective use of mental health resources and decrease mental
health admissions.

Consultation Liaison also lends itself readily to e‐health technologies such as

videoconferencing to provide mental health support in areas with limited access to resources,
such as rural areas and in resource‐poor settings (Vythilingum 2011).

Models of CLP:
With the recognition of CLP as a subspecialty, various models of CL services have been
developed.
● According to the focus of consultation, the models which are described include
patient‑oriented approach, crisis‑oriented approach, consultee‑oriented approach,
situation‑oriented approach, and expanded psychiatric consultation.
❖ Patient-oriented approach- In this, the patient is the primary focus of the
consultant’s interest. It includes diagnostic interview and assessment of the
patient with respect to patient’s personality and reaction to illness.
❖ Crisis- Oriented approach- It involves a rapid assessment of patient’s
problem and coping styles and immediate therapeutic intervention to address
the problem.
 ❖ Consultee-Oriented approach- In this, the motive of the consultee and his
related difficulties and expectations are the major focus.
❖ Situation-Oriented approach- It focuses on the interpersonal interactions
of all the members of the clinical team involved in the care of the patient for
whom consultation had been sought are taken into consideration to understand
the patient’s behavior and the consultee’s concern about it.
❖ Expanded psychiatric consultation-This model includes an operational
group that involves the patient, the clinical staff, other patients, and the
patient’s family, however the central focus is the patient for whom
consultation has been sought.

● Based on the function, the models of CLP include consultation model, liaison model,
bridge model, hybrid model, and autonomous psychiatric model.
❖ The traditional consultation model has patient as the focus.
❖ The liaison model has the consulting physician as the centre of focus and in
addition to providing consultation for the patient also involves teaching
psychiatric and psychosocial aspects of patient’s problem to the physician and
clinical team.
❖ The bridge model involves the teaching role of a CL psychiatrist for the
primary care physician.
❖ The hybrid model has psychiatrist as a part of multidisciplinary team.
❖ In the autonomous psychiatric model, the CL psychiatrist is not affiliated to
any department but is hired by primary care services.

● As per the focus of work, the various models include critical care model, biological
model, milieu model, and integral model.
❖ In the critical care model, the CL psychiatrist is attached to a critical care unit,
like ICU, CCU who is involved in patient care and redressal of issues of the
staff.
❖ The biological model lays emphasis on neuroscience, psychopharmacology
and psychological management.
 ❖ The milieu model is based on interpersonal theory and involves group aspects
of patient care, reaction and interaction of staff and understanding of ward
environment.
❖ The integral model is usually agency based and involves providing
psychological care as an integral factor of clinical and administrative need.

The various models which have been followed across the world have been influenced
by the available resources and the composition of the teams has varied from single
consultant to multidisciplinary teams.

The scope of CLP has also extended from the medical‑surgical inpatient facility to
providing collaborative care at the outpatient level with physicians and surgeons or at
the primary care level.
In most of the Western countries, CLP services have a multidisciplinary team, which
is led by a consultation–liaison psychiatrist with mental health nurses, clinical
psychologists, occupational therapists, and social workers as other team members.

Characteristics of Psychosomatic Medicine:

1. Studies the correlations of psychological and social phenomena with physiological
functions.
2. Focuses on the interplay of biological and psychosocial factors in the development,
course and outcome of all diseases.
3. Advocates the biopsychosocial approach to patient care.

Reasons for Referral to CP Psychiatrist by Physician:

● Evaluation of a patient with suspected psychiatric disorder, a psychiatric history,
or use of psychotropic medications.
● Evaluation of a patient who is acutely agitated.
● Evaluation of a patient who expresses suicidal or homicidal ideation.
● Evaluation of a patient who is at high risk for psychiatric problems by virtue of
serious medical illness.
● Evaluation of a patient who requests to see a psychiatrist.
 ● Evaluation of a patient with medicolegal situations.
● Evacuation of a patient with known or suspected substance abuse.

Characteristic of effective psychiatric consultation:

1. Talks with the referring physician, nursing and other staff before and after
consultation. Clarifying the reason for the consultation is the initial goal.
2. Establishes the level of urgency (i.e., emergency- immediate-“that should be
completed within an hour time” or routine- :that should be completed withing 24
hours).
3. Reviews the chart and data thoroughly.
4. Performs a complete MSE and relevant portions of a history and physical exam.
5. Gets collateral from family, friends as indicated.
6. Makes notes as brief as appropriate.
7. Arrives at a tentative diagnosis.
8. Formulates a differential diagnosis.
9. Recommends diagnostic tests.
10. Has the knowledge to prescribe psychotropic drugs and be aware of their interactions.
11. Makes specific recommendations that are brief, goal oriented and free of psychiatric
jargon and discusses findings and recommendation with consultee- In person
whenever possible.
12. Follow-ups the patient in hospital, and arranges out-patient care, including help
arranging post discharge referrals.
13. Maintaining absolute doctor-patient confidentiality is not possible for a psychiatric
consultant.
Interventions:
● Psychotherapy-
The modality introduced should be primarily selected in response to the patient’s
needs. No single psychotherapeutic modality will be effective with all patients, at all
times, in the medical setting.
● Pharmacotherapy and other somatic therapies-
35% of psychiatric consultations include recommendations for medications.
About 10-15% of patients require reduction or discontinuation of psychotropic
medications.
Appropriate use of pharmacology necessitates a careful consideration of the
underlying medical illness, drug interactions and contraindications.
Pharmacotherapy of the medically ill often involves modification in dosage because
of liver, kidney or cardiac disease, or because of potential for multiple drug-drug
interactions.
Pregnancy presents another challenge, with concerns regarding potential
teratogenicity.
The CL Psychiatrist must be knowledgeable about ECT.