This document describes models and processes in psychosomatic medicine and consultation-liaison psychiatry. It discusses different models including traditional consultation upon request and liaison psychiatry. It outlines the essential tasks of consultation-liaison psychiatrists including assessment, management planning, education, and facilitating understanding between medical teams and patients. The document also reviews the steps in a psychiatric consultation and elements of the written consultation note. Finally, it discusses different methods of integrated mental health care programs within medical settings.

1. MODELS AND PROCESS
OF PSYCHOSOMATIC
MEDICINE
Ehab Elbaz, M.D, MBA
Consultant psychiatrist
Lecturer of psychiatry MMA, AFCM
Certified psychotherapist EACBT
Director of psychiatry hospital, Maadi Military Medical compound

2. Learning Objectives
■ Describe different models of CL Psychiatry and differentiate from traditional
office-based psychiatric care
■ Identify essential tasks of the CL psychiatrist
■ List the steps on a psychiatric consultation and the elements of the consult note
■ Review different methods and structure of integrated mental health care
programs
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3. Introduction
■ “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” +
“Collaborative Care” share core features
■ Goals?
– Assist patients with mental health concerns within a medical context
– Make mental health concerns relatable and understandable for medical colleagues
– Improve patient lives via collaboration with medical colleagues
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4. Psychosomatic Medicine
■ Subspecialty at the interface of Medicine and Psychiatry
– Clinical service
– Research
– Training
■ Consultation Liaison (CL) Psychiatry is the current name of the accredited subspecialty
– Feb 2017: American Board of Psychiatry and Neurology petitioned American Board
of Medical Specialties (on behalf of Academy of Psychosomatic Medicine) to
change the name back to “Consultation-Liaison Psychiatry”- granted
– Nov 2017: APM voted to change its name to ACLP
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5. Traditional Models
■ “Consultation upon request”
– Reactive
– Patient- and consultee-specific
– Primary responsibility for patient remains with consultee
■ Liaison psychiatry components
– Support
■ Service, ward, nursing staff
■ Can be specialty specific (OB, Oncology, Neurology etc.)
– Education
■ Formal and informal education
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6. Types of Patients
■ Complex, co-morbid psychiatric and medical conditions
■ Neurocognitive disorders
■ Somatic symptom and functional disorders
■ Psychiatric disorders secondary to medical conditions or
treatments
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7. Distinctions from Office-Based
Psychiatry
■ Services are requested by consultee
– Rare “self referral” by the patient
– Obligations to consultee as well as patient
■ Patient is often unaware of referral
■ Participation may be limited
– Patient may be ill, uncomfortable, or in pain
– Patient motivation is often compromised
– Privacy issues abound on inpatient med/surg wards
■ Visits are not scheduled nor time based
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8. Function of Psychiatric Consultation
■ Doctor-to-doctor communication designed to address the
mental health needs of the patient and improve patient care
■ The over-riding concern is the patient’s well-being
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9. Essential Tasks
■ Complete a comprehensive psychiatric assessment and develop a reasonable
management plan
■ Remove barriers to medical care
■ Bring a fresh perspective to the clinical dilemma
■ Facilitate a mutual understanding between patient, doctor, and treatment team
■ Educate the consultee about the emotional and neuropsychological needs of the
patient
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10. Steps in the Consultation (1)
■ Review chart and identify consult question
■ Discuss case with consultee
– To help delineate the manifest question and help identify any latent
question(s)
– To help consultee reformulate their question, in a manner which
addresses underlying issues and allows the consultant to be most
helpful
– To help consultee with appropriate expectations of the consultant
(what can/cannot be gained by consultation)
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11. Steps in the Consultation (2)
■ Determine urgency
– Routine versus urgent versus emergent
■ Patient interaction
– Introduce self and sit down
– Share your reason for being there
– Address patient’s surprise at the arrival of a psychiatrist (if present)
and diffuse tension (as needed)
– Attend to any physical discomfort
– Perform thorough interview
– Answer patient questions as able
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12. Steps in the Consultation (3)
■ Mental status exam
– Includes bedside cognitive testing
■ Targeted physical exam (if appropriate)
■ Ancillary history gathering is often appropriate
– Family
– Additional caregivers
– Primary care physician
– Pharmacy
– Other
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13. Steps in the Consultation (4)
■ Written note
■ Verbal communication (feedback) with consultee, regarding
your opinion
■ Follow-up visits as appropriate
– Range from none to daily
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14. The Written Note (1)
■ Formally addressed to the physician requesting the
consultation
■ Designed to be used by other members of the treatment
team(s) who are treating the patient
■ May be read by a variety of hospital personnel
– Consider the audience
– Consider confidentiality
– Consider medico-legal implications
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15. The Written Note (2)
■ Title
– “Psychosomatic Medicine” or “Psychiatry CL Service”
■ Author(s)
– Attending
– Resident/fellow
– Other
■ Nature of the note
– Initial Consultation Note
– Follow-up Consultation Note
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16. The Written Note (3)
■ Date and Time
– Particularly important when dealing with fluctuating mental status
■ Source(s)
– Patient, family, medical record, other
■ Identifying statement
– This lays the groundwork for your formulation and recommendations
in a way that helps the readers to understand your note
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17. The Written Note (4)
■ Reason for consultation
– Why did the primary treatment team request a psychiatric evaluation?
– There is often a difference between what the primary team requests
and what they actually want from the psychiatrist
■ Manifest request: R/O depression
■ Latent request: There is nothing actually wrong with this patient. She is
manipulative and difficult. Please make her behave!
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18. The Written Note (5)
■ Identifying statement
– Important!
– “The patient is a 34 year old male admitted for abdominal pain with a
history of multiple medical complaints and pain unresponsive to usual
interventions. Psychiatry CL team was asked to evaluate him for
possible depression.”
– A reiteration of the manifest question
■ Reminds us to answer the question
■ Respectful to consultee
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19. The Written Note (6)
■ History of present illness (HPI)
– Documents the essential positive and negative aspects of the history
– Provides a historical framework for understanding the patient
■ Must include DSM descriptive characteristics and review of systems relevant to patient
diagnosis
■ Consider the following
– Special events of the patient’s life (e.g., losses, illnesses)
– Precipitants of the current psychological and physical difficulties
– Nature of the patient’s reaction to these precipitants
– Usual coping mechanisms and ability to implement them
– Availability of support systems (e.g., family/friends)
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20. The Written Note (7)
■ Past Medical/Surgical History
– Include menstrual and obstetric as applicable
■ Past Psychiatric History
– Include past diagnoses, treatments, hospitalizations, suicide attempts
■ Medication
– Prior to admission
– At time of consultation
– Recent changes
■ Substance Use History
– Include history of complicated withdrawal
■ Family History
■ Social History
– Include upbringing, abuse, legal, military, violence/legal as applicable
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21. The Written Note (8)
■ Physical Exam (as appropriate)
■ Mental Status Exam
– Is analogous to the physical examination
– Reflects one point in time
– Addresses the question of the consultation and your formulation
within the mental status examination
– Provides an opportunity to teach and to demonstrate how diagnoses
are made
– Helps the clinician gain access to a patient’s mental life
■ Pertinent laboratory and radiologic findings
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22. The Written Note (9)
■ Assessment/Impression
– Other than recommendations, the most likely part of the consult to be
read
– Should have the components of a good biopsychosocial formulation,
but avoid psychiatric jargon whenever possible
■ Know your audience and what you want to accomplish
■ Include stressors and functional status
– Differential diagnosis, including personality disorders and medical
disorders
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23. The Written Note (10)
■ Diagnosis
– DSM-5 is the primary diagnostic framework
– List ICD-9-CM V codes related to psychosocial and environmental
problems
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24. The Written Note (11)
■ Plan/Recommendations
– Most likely part of the consultation to be read!
– Safety elements (e.g., does patient require 1:1 observation)
– Further work-up suggested (e.g., labs, EKG, imaging, EEG)
– Physician management
■ Medication – scheduled and PRNs, with specific indications
■ Behavioral approaches with patient – be clear, avoid jargon
– Nursing management (e.g., restraint initiation/limitations)
– Social service needs
– Legal issues (e.g., legal guardian, involuntary transfer status)
– Aftercare plans
– Consultant follow-up
■ Inform treatment team of your availability, whether/when you will return, and the
purpose of your return
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25. Mental Health Integration (1)
■ “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” +
“Collaborative Care” share core features
■ Goals?
– Assist patients with mental health concerns within a medical context
– Make mental health concerns relatable and understandable for medical colleagues
– Improve patient lives via collaboration with medical colleagues
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26. Mental Health Integration (2)
■ Collaboration within multidisciplinary team framework
– Mental Health (MH) + non-Mental Health (non-MH) providers
– Psychiatrist, other MDs, PhDs, SW, NPs/PAs, RNs, case managers, support staff
■ Elements of integration
– Mission
■ Optimal care for mental health/behavioral issues in non-MH setting
– Target population
■ Patients with co-morbid medical and psychiatric problems
■ Patients with MH problem but no other MH care
– Location
■ Generally involves co-location of MH staff in medical site
– Communication
■ Team meetings, shared medical records, shared treatment plans
– Administration
■ Shared or coordinated efforts between MH and non-MH staff
– Fiscal
■ Integrated budget for MH and medical staff vs. separate
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27. Mental Health Integration (3)
■ General hospital-based
– Tends to be disorder specific
■ E.g., delirium, transplant, or substance use disorder teams in the general
hospital setting
■ Ambulatory
– Primary care clinics
– Medical/Surgical specialty clinics
■ OB, Oncology, Neurology, Transplant etc.
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28. Mental Health Integration (4)
■ Rationale
– Improved access
■ Need for improved access to MH services
■ Patient reluctance to go to MH clinic
– Patient-centered care
■ Prevalence of mental health (MH) issues in medical settings
– Improved medical and psychiatric clinical outcomes
■ Extensive co-morbidity of medical and MH disorders
■ Bidirectional adverse effect of co-morbid disorders
■ Associated morbidity and cost of disorders
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29. Mental Health Integration (5)
■ Method/structure
– Reactive programs
■ Mimic traditional consult services, except perhaps for co-location
– Planned programs
■ Highly structured, oriented toward “Disease Management”
■ Value added
– Delirium prevention programs
– Anxiety, depression, bipolar disorder, schizophrenia, and substance use disorder
management in primary care
– Co-morbid MH and medical disorders
■ Depression, diabetes, cardiac disorders
– Medically Unexplained Physical Symptoms (MUPS)
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30. Mental Health Integration (6)
■ Planned care framework
– Addressing behavioral health disorders in medical clinics
– Derivative of chronic disease management programs
– Over 70 randomized control trials have established value of
collaborative care for patients with mental health issues
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31. Mental Health Integration (7)
■ Methods
– Proactive screening/case identification by designated team members
– Patient-centered care
■ Co-location does not equal collaboration
– Population-based care
■ Create patient registries and tracking methods to monitor progress
– Algorithm- or otherwise evidence-based treatments
– Measurements
■ Based on tracking results, changes are made until treatment is effective
– Team management and case management
– Accountable care
■ Providers are held accountable (and reimbursed) based on quality of patient care and
outcomes, not merely the volume of patients
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32. Mental Health Integration (8)
■ Psychiatrist role as a collaborative care team member?
– Receive referrals and “warm hand-offs” from primary care colleagues
– Consult and provide supervision on a scheduled and PRN basis, for an identified
caseload of patients followed in the medical clinic
– Function as the team expert
■ Support the team as they engage with the patient
■ Give mental health input and suggestions for evidence-based care
– Function as an educator
■ Teach medical colleagues clinically-relevant and evidence-based information, with
relevance for the patient cohort in question
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33. Conclusions
■ “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” +
“Collaborative Care” share core features
■ Goals?
– Assist patients with mental health concerns within a medical context
– Make mental health concerns relatable and understandable for medical
colleagues
– Improve patient lives via collaboration with medical colleagues
THANK YOU!
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