Assessment of Psychiatric Disorders in Consultation-Liaison Setting

INTRODUCTION In the chapter of Overview of Practice of Consultation - Liaison Psychiatry by Gautam et al., we have understood the concept of consultation-liaison-psychiatry (CL-psychiatry)-its need, various models and settings in which they operate. Next, we move on to the assessment in CL-psychiatry settings. The basic structure of psychiatric assessment remains the same with detailed history taking, review of previous treatment documents, and the mental status examination (MSE). However, apart from these, there remains certain uniqueness in the assessment of patients in CL-psychiatry settings. THE UNIQUENESS IN PSYCHIATRIC ASSESSMENT AND COMMUNICATION IN CONSULTATION-LIAISON-SETTINGS[12] The uniqueness remains within the name itself. While in individual clinical practice, it is only “consultation”-that is assessment followed by advice; in CL-psychiatry setting, there remains both “consultation” and “liaison” with the primary treating team to form a collaborative opinion regarding the condition and management of the patient. Thus, in CL-psychiatry assessment, this liaison or communication holds the key which should be followed in its every step. We would discuss these steps of liaison under following headings: THE MODE OF APPOINTMENT OF A PSYCHIATRIST WITH THE PATIENT IN CONSULTATION-LIAISON SETTINGS In individual consultation, a patient comes directly to a consultant of personal choice, while in CL-setting, a patient comes to the contact of only the designated consultants who are either integral part of the treating team or being referred to. THE NEED OF APPOINTMENT OF A PSYCHIATRIST IN CONSULTATION-LIAISON SETTINGS In individual consultation, the need to contact a psychiatrist is a felt-need of the patient or the relative either by themselves or being guided by anybody. However, in CL-setting, the need of appointment of a psychiatrist is felt by the primary treating team who feel that there are certain issues where a psychiatrist would guide them better toward management of the patient. THE FOCUS OF ASSESSMENT BY A PSYCHIATRIST IN CONSULTATION-LIAISON-SETTINGS [CHART 1]Chart 1: Psychiatric assessment in CL-setting in a flow chartIn individual consultation, the focus of assessment of a psychiatrist is diagnosis and management of psychiatric disorders or problems which have caused impairment or difficulties in the personal-socio-occupational functioning of the patient. However, in CL-settings, apart from the above, there can be many other areas of focus of assessment by a psychiatrist: Whether the presenting psychiatric conditions in the medical setting are of primary psychiatric origin or secondary to the existing medical illness or its ongoing treatment Whether ongoing psychotropic medications for patients with diagnosed psychiatric morbidity have impact on management of the ongoing medical illness Whether the abnormal or uncooperative behaviors of the patients in wards are due to some psychiatric disorders or fall out of any bio-psycho-social issues Whether there is any immediate risk of self-harm or harm to others by the patient Whether there is any need to transfer the patient to psychiatric ward Whether there are any issues of privacy or medicolegal issues attached to particular cases (suicidal attempt vs. accidental injury; any homicidal or sexual urge or advances; history of sexual abuse; any use of surreptitious medicines, etc.) Assessment of mental conditions of patients whose sustained treatment compliance is matter of concern, like MDR Tb, ART in HIV Assessment of motivation and eligibility preparedness of patients undergoing any major intervention – e.g., organ transplantation, cross-sex medical-surgical gender-affirmation interventions. THE PREPARATORY PHASE OF ASSESSMENT IN CONSULTATION-LIAISON-SETTING In individual consultation, there is no preparatory phase between appointment and contact with the patient. However, in CL-setting, there should be a compulsory preparatory phase when the psychiatrist should do the following review: Current Medical diagnosis and the ongoing treatment Chart review of all available papers Any past or ongoing history of psychiatric illness and their treatment Direct communication with the treating/referring consultant to understand their conceptualization of the case and their need and focus of psychiatric assessment For admitted patient, observation of the nursing staff or duty doctor in station For admitted patient, sending information to the family member to be present at the time of interview. INTRODUCTION WITH THE PATIENT AND FAMILY During introduction with the patient in CL-psychiatry, disclosure of identity of the interviewer as psychiatrist at the outset may be little tricky. It might often be unexpected for the patient and relative to be interviewed by a psychiatrist and there may be emotional bias or stigma attached to it. Thus, depending on the situation, identity should be gradually revealed following the establishment of rapport and maintaining optimum privacy. RAPPORT BUILDING AND ITS PREDICAMENT During any psychiatric interview, rapport building is the most sensitive and delicate part. In CL-setting, this job may be further difficult as the need for mental health service often remains unexpected here. The psychiatrist should explain the patients with common example that body and mind are inseparable. While anxiety affects our heart rate and respiration in the one hand, changes in body in high-fever affect our mental condition on the other hand. This makes the acceptance of psychiatrist easier for the patient and the family. Certain situations such as paranoia, disorganized behaviors, substance use disorder, personality disorder or problems, dementia, and delirium pose further problems. Delirium being a very commonly encountered condition in CL-psychiatry, it needs special mention. In delirium, since fluctuating consciousness and attention is the main problem, here psychiatrist should talk gently, loudly, slowly-with one question at a time. PSYCHIATRIC INTERVIEW AND HISTORY TAKING[3] Interview should begin with open narrative regarding current health problems and the distress associated with them. Patient’s experience with ongoing medical treatment, particularly any difficulties in adjustment, should be enquired. Unlike individual consultation, in CL-psychiatry, there may not be any spontaneous account on mental and behavioral issues of the patient. Questions in this regard may start with vegetative functions which are common issues for anybody. Then, the internalizing symptoms such as presence of anxiety, somatic distress, and low mood should be inquired. Apart from the ongoing illness, any other recent or ongoing stressor and its impact on the patient not to be missed. Any history of self-injury (suicidal or nonsuicidal) should also be gathered along with any family history of such event. Questions on externalizing symptoms of any agitation, anger, excitement, suspiciousness should follow. Inquiry regarding hallucinatory behavior and disorganization is also important. History of substance intake and their details must not be missed. Patient’s neuro-cognitive functions in daily-life situations particularly in case of elderly should be gathered. A common mnemonic”Memory-LAPSE” – memory-language-attention-perceptuomotor-socialization-executive function may be helpful. For example, any forgetfulness regarding recent events-where things kept–what is to be done–common names, address; any difficulties in finding right words; difficulties to focus and process information when interacting different persons together; any difficulties in usual activities of cooking-shaving; any recent oddities in socializing; difficulties in finance handling, decision-making. Family history of any mental illness should be inquired. Patient’s development history and personality features – particularly stress handling capacity, interpersonal relationship, emotional stability, and impulsivity should be enquired. Any religious and cultural influence on overall behavior or cognition of the patient should also be noted. MENTAL STATUS EXAMINATION In CL-psychiatry setting, since delirium is the most common cause of referral, MSE may start with general inspection of behaviors suggestive of lack of touch with the surroundings, hallucinatory behaviors, agitation-floccillation, hands being tied to prevent picking-and-pulling of ports. It should be followed up with questions on orientation and patient’s open narrative on ongoing distress. During initial interaction, catatonia should be ruled out from motor behavior and speech. Organization of the speech and thought should be noted carefully. Examination of effect is quintessential because depression, anxiety, adjustment difficulties are very common association in medical setting. Complain of somatic distress or “unexplained physical symptoms” being very common in medical setting, signs of depression-anxiety, obsession-hypochondriasis must be looked for. Apart from them, la-belle-indifference in effect, health-care seeking behavior and anything suggestive of secondary gain should also be looked into. Other than internalizing symptoms, if any elevated, expansive, irritable effect is noted, that should be followed with relevant examination of psychomotor activity, thought, and perception – suggestive of mania. Delusion and hallucination should be elicited carefully if the patient is found to be having hallucinatory behavior or showing guarded, evasive, hostile attitude. There must be customary assessment of any suicidal intent in every patient. For patients with paranoid psychopathology, anger, excitement, any thoughts of causing harm to others should be probed. A brief assessment of neuro-cognitive functions particularly in elderly and those having presented with such history. Apart from these issues, assessment must also include patient’s insight regarding the ongoing medical illness and the problems for which psychiatric assessment has been sought. USE OF SCREENING TOOLS FOR ASSESSMENT In CL-setting, there may be a paucity of time for detailed psychiatric assessment. For this purpose, few standardized screening tools have been developed for quick screening of common psychopathology in primary-care or other specialized medical setting. These tools can be used by trained mental health professionals or even primary care personnel before confirmatory diagnosis by psychiatrists. Hence, this training of the primary care personnel about proper use of these screening tools is also an essential part of CL-psychiatry practice. Basic characteristics of the tools should be: Short, easy, and quick to apply Locally developed or adapted and translated versions in local language are more appropriate They should be appropriate for particular age group under examination. Tools may be of two types: Targeting broad psychopathology such as internalizing symptoms of depression, anxiety, panic, somatic symptoms, stress-trauma-all in one tool-PRIME-MD-PHQ (primary care evaluation of mental disorders-patient health questionnaire (PHQ) or its brief version brief-PHQ (BPHQ)[4] Targeting specific psychiatric disorder such as PHQ-9[5] (a 9-item questionnaire for depression), generalized anxiety disorder-7-item (GAD-7)[6] for anxiety, PHQ-15[7] (A 15-item PHQ) for evaluating severity of somatic symptoms. All these self-rated questionnaires are developed from PRIME-MD-PHQ. There are plenty of other screening tools customized for particular symptoms, age group, and situation of assessment, which will be discussed subsequently. Apart from general history taking, MSE and application of screening tools – assessment of certain situations warrants special mention in CL-psychiatry assessment. They are as follows. ASSESSMENT OF IMMEDIATE RISK TO SELF AND OTHERS Agitation, excitement, and violence in a patient always presses a panic button in a medical setting for which referral comes to psychiatrist for assessment of immediate risk to self and others. That can be clinically assessed by: Observation Violent behavior Possession of weapon Self-destruction Extreme agitation or restlessness Bizarre/disorientated behavior. Reporting of Death wish, suicidal urge Thoughts of hopelessness, intolerability, inescapability, and desperation along with marked anxiety, insomnia Verbal commands to do harm to self or others, that the person is unable to resist (command hallucinations) Trait impulsivity and recent violent behavior. ASSESSMENT OF UNCOOPERATIVE BEHAVIORS CAUSING MANAGEMENT PROBLEM Another issue of major concern is uncooperative behavior in the ward in apparent clear consciousness-like not following ward norms or treatment advice, pressing for early discharge, giving suicidal threats, complaining against treating staffs, etc. Apart from ruling out underlying depression and psychosis, here, the assessment should focus more on the psycho-social aspects of the patient. Patients’ understanding of the medical and ward advice communicated to them and their apprehension regarding those issue Any miscommunication or mistrust with the treating team Degree of discrepancy in the background milieu of the patient and that of the hospital Personality – negative affectivity, impulsivity, ability to adjust to a new situation and new persons Perceived role deficits of the patient when away from home, for example, a patient living alone with pets in home may become anxious and press for discharge to look after them. REQUEST FOR TRANSFER OF PATIENT TO PSYCHIATRY WARD This request usually comes for patients with apparent immediate risk to self or others as mentioned above. First thing to rule out is delirium because in delirium patients may turn violent in a state of confusion. The behavioral presentation of delirium may become the major concern for the treating team, but the principal concern for the patient is the underlying medical cause. Another issue is substance intoxication and withdrawal where the apparent behavior abnormality often may have serious medical underpinning and an expression of delirium. Management of delirium should continue in medical ward with regular psychiatric observation. Substance use disorder patients may be shifted to psychiatry ward after initial stabilization of medical complications. Patients with depression, suicidality, or psychosis with serious medical morbidity where chance of medical emergency may emerge at any time should also be managed in medical ward with regular psychiatric supervision. In stable medical conditions – like not being put on any ports or requiring oxygen therapy, patient may be shifted to psychiatry ward with provision of regular observation by the medical team. FORMULATION OF THE DIAGNOSIS AND RELATED NOTES IN CONSULTATION-LIAISON-PSYCHIATRY Provisional or differential diagnoses of psychiatric disorders or problems as per current nosology of DSM or ICD Probable etiology of the psychiatric condition in the background of medical illness– any mutual causative role, or comorbidity, or any coincidence Probable interaction of the required psychiatric treatment with ongoing medical treatment and the treatment milieu There should be also some comment on biopsychosocial background of the patient which may be relevant regarding overall management of the case, like developmental issues (low intelligence, intellectual disability, autism), any ongoing stressor in personal life, personality, etc. Any evidence of immediate risk to self and others and need or decision regarding transfer to psychiatry ward Any adjustment needed on the part of the treating team to manage uncooperative behavior of the patient. MODE OF COMMUNICATION TO THE REFERRING TEAM In CL psychiatry, apart from putting down notes on papers, certain additional things are advisable. Psychiatrist should communicate directly to the treating consultant at least through telephonic conversation. Mitigate all the doubts regarding the case from mental health perspective and overall formulation and give suggestion regarding a comprehensive treatment plan. COMMUNICATION TO THE PATIENT AND FAMILY In liaison practice, the referred consultant usually does not give any direct therapeutic advice to the patient or family, but there must be some transparent and supportive communication with them regarding the following issues: Explanation regarding how mental health issues are pertinent in this case Why the primary treating team has sought for psychiatric assessment and opinion Impression of CL-psychiatrist regarding presence of any psychiatric morbidity and current severity If any risk of immediate self-harm or harm to others or any ongoing strain to treatment milieu Role of family members to help the patient adjust to the treatment milieu, for example, if there is any obligation of the patient back home– that should be taken care properly by relatives How provision of mental health support or treatment along with the primary treatment services would improve the overall outcome One very important issue in liaison-practice is to ensure that there is no discrepancy in communication between the primary treating team and the liaison specialist. PLAN FOR FOLLOW-UP In cases of confirmed major psychiatric diagnoses where pharmacological treatment needs to be started, follow-up should be there at least within a week. For those patients, regular follow-up at psychiatry outpatient department (OPD) after discharge is also must. Their treatment response can be evaluated by serial MSE or with different rating scales as in case of individual consultation. In cases where definitive psychiatric diagnosis could not be reached, regular follow-up is necessary with need for psychometric evaluation and symptomatic management. Now we proceed further to. ASSESSMENT OF PSYCHIATRIC CONDITIONS IN INDIVIDUAL CONSULTATION-LIAISON-PSYCHIATRY SETTINGS AS PER THEIR NEED [CHART 2]Chart 2: Flowchart of customized assessment in particular settingsHere, discussion would not be done as a psychiatric or medical diagnosis but as a clinical-problem as perceived by the primary treating team in liaison services. We would divide this section under five groups: Psychiatric assessment at emergency resuscitation (ER) units Psychiatric assessment at intensive care units (ICU) Assessment at nonemergency and chronic care units of different specialties Assessment of need for medical-work-up in patients undergoing treatment in psychiatry units Multidisciplinary assessment at medical boards. Psychiatric assessment at emergency resuscitation In emergency setting, referral is the usual model of CL- psychiatry practice. For quick assessment of urgency of psychiatric attention, the primary care personnel in the ER may be trained with a screening tool named Mental Health Triage Scale (MHTS)[8]. In MHTS, the behavioral problems are arranged in five categories of urgency for psychiatric assessment Immediate (red) – Immediate need of mental health response along with referral to security or police-due to violent aggression/possessing weapon/self-destruction attempt Emergency (orange) – Very urgent need of mental health response (usually within 4 h) – clear-cut intent, plan and arrangement for committing harm to self or others;-very high-risk behavior associated with confusion and disorganized behavior Urgent (yellow) – need of mental health response within 24 h – expression of suicidal intent (no clear-cut plan yet); rapidly increasing confusion, psychotic behavior (delusion, hallucination, disorganization) Semi-urgent (green)– need within 72 h – major psychiatric disorders of mood or apparent psychosis without any suicidal intent; uncooperative behaviors in ward like wandering, refusing medicines, and other ward norms Nonurgent (blue) – need within 4 weeks – known psychiatric disorders stable on medication which need regular follow-up A recent Indian study[9] on emergency psychiatry referral in a tertiary care hospital using MHTS found that the degree of urgency corroborated with the severity of scoring in Brief Psychiatric Rating Scale (BPRS)[10] and yellow was the most common zone of referral. Now, we discuss some of those conditions according to commonality of their presentation and urgency of assessment in ER: CONFUSION WITH BEHAVIORAL ABNORMALITIES These are the most common cause for referral in Indian liaison settings.[911] Such referral raises the possibilities of either a neurocognitive disorder (delirium) where the consciousness, attention, orientation are the primary deficits with psycho-motor and thought-perceptual disturbances; or it may be another primary psychiatric condition with behavioral disorganization where there is inattention and difficulty in assessing consciousness and orientation. ASSESSMENT FOR DELIRIUM Delirium is an acute (onset within 2 weeks) neurocognitive syndrome which at times may be prolonged up to 6 months. There may be a plethora of presentation- Variable psycho-motor disturbances (hyperactive, hypoactive, or mixed) Perceptual disturbances (hallucination, illusion) Thought abnormalities (disorganization or delusions). Thus, the hyperactive variety is often mistaken for psychosis and hypoactive for depression. The hyperactive variety is the more common presentation in ER.[11] However, the primary deficit areas are attention, consciousness, and comprehension leading to disturbed orientation, memory, and other cognitive dysfunctions. Very important feature of delirium is fleeting and fluctuating presentation with time – particularly worsening after evening or “Sun-downing phenomena.” Another characteristic behavior feature of delirium is floccillation-picking and pulling of objects around Since primary impairment is inattention, during assessment, one has to talk slowly, clearly and loudly and not many questions at a time. For early recognition of delirium and to prevent being misdiagnosed as psychosis or depression, health-care personnel at medical setting may be trained with some screening tools.[12] Among them, NEECHAM[13] (Neelon and Champagne) Confusion Scale is one of the most suitable screening instruments in medical and surgical wards. Delirium always occurs secondary to some medical condition or existing dementia (particularly Lewy body and fronto-temporal dementia). Thus, after clinical confirmation of delirium, causes of delirium should be searched for by history, examination, and investigation. Metabolic, autoimmune, and infective are the three main etiologies behind delirium which would require relevant investigations in blood and cerebrospinal fluid. Neuroimaging should also be done to rule out any cerebral lesion. Delirium may also occur due to acute intoxication and withdrawal of addictive substances, psychotropic drugs, and exposure or overdose to certain drugs Anticholinergics (commonly referred as atropine psychosis) Antimalarials (commonly referred as chloroquine psychosis) Diuretics and other hyponatremic drugs, Corticosteroids and other immunosuppressant drugs like azathioprine Dopaminergic antiparkinsonian drugs like levodopa Antitubercular (particularly isoniazid, cycloserine, ethambutol) Antibiotics particularly fluoroquinolones, Antiretroviral (particularly efavirenz, zidovudine), Antimetabolite (particularly 5-fluorouracil) etc. Another important condition is postictal state in epilepsy or nonconvulsive status epilepticus or NCSE, which can only be established by prolonged electroencephalography (EEG) recording with the help expert epileptologists. ASSESSMENT OF OTHER PRIMARY PSYCHIATRIC CONDITIONS WITH CONFUSION LIKE PRESENTATIONS[14] Presentation with acute disorganized behavior may appear as confusion. It may be a symptom of psychosis particularly acute psychotic conditions such as acute and transient psychotic disorders with apparent confusion and polymorphic features of psychomotor and thought-perceptual disturbances. Puerperal psychosis very commonly presents like this. However, with increasing knowledge, we are gradually coming to know that many of these acute psychotic conditions are auto-immune origin-particularly NMDA-encephalitis. Thus, in acute onset (few weeks), disorganized behaviors predominantly in young females (age <45 years) with confusion and particularly convulsion – autoimmune encephalitis must be ruled out. At times, psychotic conditions such as schizophrenia and mania may also present in a grossly nongoal directed excitatory condition with marked hallucinatory behaviors – which may be considered as catatonic excitement historically described as delirious mania by Kraepelin. In these cases, influence of psychoactive substances must also be ruled out. At times dissociative conditions with anxiety and agitation may also present with experiences of Deja phenomenon and depersonalization-derealization which may appear as confusion-historically described as hysterical psychosis. These often happen in trans-cultural background or may follow acute stressor or trauma. These diagnoses should come only after exclusion of delirium. INTOXICATION AND WITHDRAWAL OF ADDICTIVE SUBSTANCES[14] Substance use-related disorders come second to delirium regarding overall cause of referral to psychiatry.[11] For these patients, the need for psychiatric service is because the patients often remain confused, aggressive with immediate threat to self and others. Physicians may need psychiatrists’ knowledge about medical complications of intoxication and withdrawal of different substances and their interactions. After immediate stabilization of patients, psychiatrists’ role would be important for subsequent detoxification. Long-term management plan would depend on assessment of degree of severity of the substance use disorder– like isolated or established harmful use or dependence. This can be done with the help of diagnostic guidelines of ICD/DSM or screening tool like Alcohol Use Disorder Identification Test[15] for the most commonly used substance alcohol. SELF-INJURIOUS (SI) ATTEMPTS[1416] Any self-injurious (SI) attempts outside the hospital premises are always brought to the ER first and after initial medical stabilization of the patient, referral to a psychiatrist is obligatory. In the preparatory phase of assessment, the psychiatrists should enquire about the following: Observation of any aggressive behavior in ward Any evidence of substance intoxication or withdrawal Any records of ongoing or previous mental illnesses and their treatment Any history of ongoing chronic debilitating or fatal medical illness and their treatment. With this available information, psychiatrist would further proceed toward interview of relative: Any history of past and family history of SI If any previous SI attempts-nature, lethality, and expressed intent in that attempt Regarding current SI-in what circumstances and time-that occurred How the patient was recovered Any suicide note was recovered or not Any history of psycho-social stressors such as bereavement, financial loss, or acute incident of shame-guilt or anger-altercation or temper-tantrum Any recent discussion regarding hopelessness, death, or warison Patient’s family structure, social support Usual sleep pattern and any recent insomnia Any behaviors suggestive of impulsivity, emotional dysregulation, aggression in personality Personality pattern regarding stress handling, adjustment to a new situation, and inter-personal relationship Any history of developmental delay or diversity. After talking to the informant, a customary MSE must include examination of: Affect – any sadness, emptiness, or despondency Cognition of worthlessness, inescapability, intolerability, desperation Any persecutory thoughts or hallucinatory experiences (particularly commanding voice) Detailed interview regarding SI attempt: Intent of the SI – an attempt to die/or a sudden expression of anger, frustration, protest/or an attempt to relieve anxiety In case of death wish – reason for that – to get relief from an inescapable, intolerable situation (temporary shame-guilt/or ongoing worthlessness, hopelessness/or helplessness out of fear of harm)/or an attempt to meet a beloved dead person Whether the commission of the act – at the heat of the moment/or with any prior plan/or any activities as a part of a group/or reaction to some commanding voices from air If prior plan, or command – how long those were happening If any previous attempt – what happened in those attempts – either self-restrained due to some reason or aborted by others – how the life was saved. Apart from MSE, there can be application of standardized tools to determine chance of recurrence of suicide attempt based on the current severity of intent Beck’s scale for suicidal ideation (SSI)[17] – most commonly applied tool particularly in research – but the tool is not available for free use. Columbia Suicide Severity Rating scale (C-SSRS)[18]-another increasingly used tool which is free to use and has more extended dimensions. Apart from screening the current suicidal intent and rating of its intensity, it also screens for previous suicidal behavior or attempts which also include nonsuicidal self-injury (NSSI). There is also rating for degree of lethality of previous suicidal attempt. With all these cross-sectional assessment – formulation should be done as follows: NSSI Any influence of substance – intoxication or withdrawal Any habitual NSSI – related to developmental diversity or personality (borderline) factors In suicidal SI – ascertain the possibility of grief, acute stress reaction, mood disorders and psychosis, associated anxiety, substance use disorder, personality disorder Risk of recurrence of suicidal SI – based on previous attempts, persisting thoughts of intolerance-inescapability-desperation and personality features of impulsivity, anxiety, aggression, scores in tools like SSI or C-SSRS Acceptance of need for hospitalization and adjustment to its milieu subsequent pl