Consultation – Liaison Psychiatry

Chris P. Alipio, MD, DSBPP

 CL Psychiatry
• Liaison Psychiatry is distinguished from
consultation psychiatry by the nature of an
“ongoing” relationship

• A liaison psychiatrist becomes a member of the

team while the consultant is an “outsider”

• Consultation Psychiatry – Referrals; Interaction of

IM and Psychiatry
 Liaison Psychiatry
• The liaison function is accomplished through
regular weekly group meetings with the team
• The role of the psychiatrist is not that of a leader
but a facilitator, an avuncular role
• Avoid undermining the leadership position
Common Areas which Establish Liaison Psychiatry Programs
Common specialties that refer to Psychiatry?
 Common CL Referrals
• Capacity to Consent
• Agitation / Delirium
• Postoperative Depression / Anxiety
• Insomnia
• Crisis Management Postsuicide
• Brief Interventions - Psychotherapy
 Intensive Care Units
• Copenhagen 1952 (positive pressure ventilation in
Polio)
• ICU mortality is high
• Psychological impact of the ICU environment
piqued interest of researchers
 Intensive Care Unit
• Kornfield 1969 categorized ICU psychiatric
problems into four areas
– Psychiatric reactions to the conditions that lead
to ICU admission
– Psychiatric reations provoked by the unusual
environment of the ICU
– Psychiatric reactions that develop post-discharge
– Psychological welfare of staff working in ICUs
 ICU Consultation-Liaison
• Review aspects of the psychiatric evaluation unique
to patients in the ICU
• Provide a general discussion of treatment
recommendations or critically ill patients
• Review some of the psychiatric and behavioral
problems that commonly lead to request for
psychiatric consultation
• Discuss the stresses frequently encountered by
staff in the ICU
 Psychiatric Evaluation in the ICU
• Apply same principles
• Challenging due to
– pressure of time
– Lack of privacy
– Noise
– Physical or pharmacologic barriers
– Emotionally overwhelmed relatives
– Limited awareness of staff about affect, or
behavior
 Psychiatric Evaluation in the ICU
• The patient’s history is the most helpful guide to
diagnosis
• The chart is unrivaled as a source of information
• Assess level of awareness
• If a definitive diagnosis is difficult to establish, label
it provisional
• Frequent reassessments due to dynamic state of
patients in the ICU
Acute behavior problem noted

Does an acute danger to self or

others exist? Ensure safety
Physical or chemical restraint
+
- 24-hour observation
Psychiatric consultation
Is delirium present?

+ Delirium workup and treatment

-

Is mental retardation present + Psychiatric Evaluation

Is functional psychosis present?


Is functional psychosis present?
-
Is either anxiety or panic
disorder present?
-
Is depression present?
- Identify
Psychiatric Evaluation
+
Antipsychotics
Initial psychiatric evaluation
+ Anxiolytics and reassurance
Consider adding TCA or MAOI
Treat depression
+
(eg, use SSRI, TCA, stimulants)
Character Type
Physician’s Response to Patient
Physician/Patient response to
difficult situation
Asses response to similar
problem on prior admission
Psychiatric Treatment of the Critically Ill Patient
• First step in the mgmt is consideration whether a
changes in the medical mgmt of a disorder would
alleviate or treat the psychiatric symptoms
– Eg. Delirium due to hypoxia or hypoglycemia
should NOT be treated by neuroleptics
• Establish whether a temporal correlation between
onset of mental symptoms and changes in the
surgical-medical mgmt occured
 Life Threatening Causes of Delirium
WWHHHIMP (Tesar & Stern, 1986)
• Wernicke’s Encephalopathy
• Withdrawal States
• Hypertensive Encephalopathy
• Hypoglycemia
• Hypoxia/Hypoperfusion of Brain
• Intracranial Processes (bleeding, tumors, edema)
• Meningitis/Encephalitis or metabolic imbalances
• Poisoning (or drug ADE)
 Psychiatric Treatment of the Critically Ill
• Always check ICU flowchart, laboratory summary
sheet, and medication list
• Make every effort to achieve an accurate diagnosis
before initiation of treatment
• It is unwise to avoid the use of psychotropic drugs
simply because the patient is critically ill especially
if the presence of psychiatric symptoms adds to the
suffering of the patient
 Guidelines for Prescription of Psychotropic
Drugs to the Critically Ill
1. Take a careful psychiatric history
2. Diagnose before initiation of treatment
3. Optimize the patient’s environment
4. Know the pharmacology of the drugs prescribed
5. Use a low dosage initially, advance dosage slowly (if the
situation warrants it)
6. Avoid polypharmacy when possible
7. Monitor drugs and response to target symptoms
8. Observe for ADE
9. Evaluate potential for noncompliance
10. Do not avoid use of psychotropic agents just because
patient is critically ill
 Non Pharmacologic Measures
• Provide calming environment
• Frequent reassurance and reorientation
• More frequent interactions with staff
• Presence of a supportive friend or relative (when
possible)
 Use of Restraints
• Agitated, threatening, at risk for causing injury to
himself or others
• Closely supervise
• It is much easier to defend the using restraints when
indicated than from negligence resulting from failre
to protect the patient or a bystander
• Typically used with sedatives or neuroleptics
• Document your rationale and precautions
Psychiatric Disturbances in the Critically Ill
• Anxiety
• Depression
• Confusion
• Psychosis
• Personality Problems
 Anxiety
• Common
• Frequently unable to describe a cause
• May interrupt sleep or interfere with ability to
comply with treatment
• Differential includes medical and substance-
induced causes
• Fear is differentiated as having identifiable stressor
 Anxiety
• Fear – low dose neuroleptic
• Primary anxiety disorders – treat as guided
• Benzodiazepines generally tx of choice
• Psychoeducation, support, behavioral (relaxation,
hypnosis, imagery)
 Depression
• Apathy, withdrawal, helplessness, tearfullness,
decreased cooperation, suicidal ideation or
behavior
• Discouragement and worry are commonly mistaken
as symptoms of a formal depressive disorder
• Anger, fear, apathetic states and hypoactive
delirium
• May not meet criteria
 Depression
• Interventions that address concerns about comfort,
autonomy, availability of loved ones, abandonment
usually leads to relief
• Draw a person and picture of what the patient thinks
is wrong is useful to access and monitor changes in
self-perception
• Treat with pharmacologic agents (SSRI)
• Psychostimulants
(dextroamphetamine/methylphenidate)
 Confusion
• Most confusional states are secondary to medical or
substance-induced causes
• Confusion with agitation is often misdiagnosed by
the nonpsychiatrist as functional psychosis
• Neuroleptics are first choice in treatment –
Haloperidol
• Pharmacologic treatment for delirium can usually
be discontinued once patient is symptom free for
24-48 hours
 Common Delirium-Inducing Drugs in the ICU
• Antiarrhythmics – Lidocaine, Mexiletine,
Procainamide, Quinidine
• Antibiotics – Pennicilin, Rifampin
• Anticholinergic – Atropine
• Antihistamine – Diphenhydramine, Promethazine,
H2 blockers, Cimetidine, Ranitidine
• B-Blocker – Propanolol
• Narcotic Analgesic – Mepiridine, Morphine,
Pentazocine
 Guidelines in the Treatment of Delirium in the
ICU
1. Monitor patient’s mental state and behavior closely
2. Search for causative problems and correct
3. Use medications to treat agitation and psychotic
symptoms
4. Structure patient’s environment to provide adequate
contact with others without overstimulation
5. Maintain nutrition, fluid and electrolyte balance and
vitamin intake
6. Provide general nursing care aimed at reorienting
patient, provide emotional support
7. Provide supportive psychotherapy
 Psychosis
• Staff require coaching or instructions with
behavioral management of patients with psychosis
• Neuroleptics are mainstay (high-potency)
• Avoid depot preparations
• Benzodiazepines are useful adjuncts
 Personality
• Personalities are exaggerated during stress
• (Tables)
 Clinical Situations Unique to the ICU
• Respirators
• Intraaortic Balloon Pumps and Cardiac Surgery
 Staff Stress
• ICU – aptly named from the perspective of the
caregivers
• Increased risk for burnout
• Group interventions are best for reducing work
stress
 Common Stressors : Physicians
• Sleep-deprivation
• Long on-duty assignments
• Providing high-technology care
• Dealing with chronically or severely ill
• Feeling a responsibility to patient’s families
• Having limited training in ethics
• Being exposed to contagious or deadly diseases
• Performing complex or invasive procedural tasks
• Being overload with information
• Having a large financial debt
• Anxiety about malpractice
 Common Stressors : Nurses
• Excessive workload (high patient-nurse ratio)
• Having too little time to deal with patient or families
emotional needs
• Dealing with deaths
• Dealing with the unnecessary prolongation of life
• Providing high-technology care
• Having unpredictable schedules
• Being subjected to environmental stress
• Administrative conflicts
• Feeling powerless or insecure
 Goals for Group Work with ICU Staff
• Identify subjective reactions to clinical situations
• Learn to use motions in clinical practice
• Learn to minimize possible disruptive effects of
reactions to patients (eg manage angry feelings so
they can be expressed during rounds and not
interfere with patient care)
• Share reactions with each other and thereby learn
that they are not alone in their feelings
 Surgery

Christopher P. Alipio, MD, DSBPP

• Psychological aspect of surgery patients –
important role surgeons play in the patient’s life
(Surman, 1987)
• Two aspects of surgery speak to the reality and the
excess meaning of the experience :
– Surgery represents a decisive approach to the
relief of pain and suffering
– Surgery involves a transference relationship with
the patient in a role of heightenened dependency
and expectation
• Surgical patients typically experiences fear
– Fear of bodily injury
– Fear of death
 Pre-Operative Anxiety
• Reassurance
• Education
• Consultation with a Psychiatrist familiar with the
surgical procedure
• Operative Syndromes – Psychiatric syndromes that
develop during the course of surgical treatment
(Mumford et al)
– Acute psychotic episodes
– Overdependency
– Addiction
– Suicidal depression
– Disruptive ward behavior
 General Principles
• Context of consultation – pre-surgical hospital-
based psychiatric consultations are rare except in
transplant
 Common Concerns in Pre-Surgical Psychiatric
Consultation
Jacobson and Holland (1989)
• When patients experience preoperative panic or are
refusing surgery
• When questions arise about perioperative
management of patients who are taking
psychotropic drugs
• When concern exist about a patient’s capacity to
give informed consent or refusal
 Ingredients of Capacity
(Appelbaum and Grisso 1989; Hall and Ellman 1990)
• The consistent ability to communicate a choice
• The capacity to demonstrate an understanding of
relevant medical information, including risks and
benefits
• The capacity to appreciate the current situation and
its consequences
• The ability to manipulate information in a rational
manner
 Psychiatric Morbidity in Postsurgical Patients
• Mental Disorders secondary to medical treatment of
substances of abuse
– Delirium
– Withdrawal from alcohol and other substances
• Other psychiatric disorders
– Disruptive ward behavior (acting-out)
– New-onset or recurrent depression, mania,
anxiety symptoms, brief psychoses
– Iatrogenic intoxication
– Acute stress disorder and adjustment disorder
 Treatment Considerations
• Formal psychotherapy is difficult to engage because
of :
– Noise
– Interruptions
– postoperative medical regimen
– lack of recognition among staff of important
psychological concerns
 Treatment Considerations
• Brief focused meetings are valuable
• Behavioral interventions :
– Treatment contracts
– Relaxation techniques
– Guided imagery
• Psychopharmacology
– NPO
– Drug interactions
• ECT
 Subspecialty Issues
• Cardiothoracic Surgery
– Preoperative Concerns
• Competency and compliance
• Preoperative anxiety
• Agitation
• Cardiac assist devices
 Subspecialty Issues
• Cardiothoracic Surgery
– Perioperative Concerns
• Confusion and agitation
• Cardiac assist devices
• Substance withdrawal
• Pain control
 Subspecialty Issues
• Cardiothoracic Surgery
– Postoperative Issues
• Neuropsychological changes
• Depression and return to function
• Valve replacement
• Automatic implantable cardiac defibrillation
 Clinician Management of Acute Pain
• Treat patients as individuals
• Provide medication “round the clock” especially during
the immediate postoperative period
• Know the potency and period of action of analgesics
• Assess the patient frequently, especially when initiating
or changing the route of administration
• Recognize and treat side effects
• Observe for the development of tolerance and adjust
dose appropriately
• Be aware of substance abusers
 Subspecialty Issues
• Orthopedic Surgery
– Delirium
– Borderline Personality disorder
• Clear communication
• Understanding patient’s need for constant
attention
• Dealing with patient’s entitlement without
confronting defenses
• Setting firm limits on dependency, manipulative
behavior, rage, self-destructive behavior
 Subspecialty Issues
• Orthopedic Surgery
– Chronic Pain
– Substance Abuse
• Ophthalmology
– Psychosomatic issues
– Black patch psychosis
– Vision loss
 Subspecialty Issues
• Burn Units
– Acute
• Denial and Education
– Reconstructive Phase
• Grief, affective expression, regression
– Long-term adjustment phase
 Approach for Patients with Burn Injuries
• Identify the primary feelings about the burn
experience without making this the exclusive focus
of the therapy
• Define a hierarchy of problems facing the patient
• Define a hierarchy of desired goals and solutions
using a problem-solving/cognitive approach
• Continue to work with flexibility on the above goals
while addressing other issues the worry or concern
the patient
 Subspecialty Issues
• Cosmetic Surgery
Five Stages in the course of elective cosmetic
surgery
– Decision to seek consultation
– The initial consultation
– The preoperative and intraoperative period
– Immediate postoperative period
– Long-term postoperative period
 Subspecialty Issues
• Head and Neck Surgery
– Disfigurement
• Staff Issues