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Understanding the Breadth and Depth of Consultation-Liaison Psychiatry: Pediatric Care

• Haniya Raza , D.O., M.P.H. ,
• Maryland Pao , M.D.

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This article is one of a series coordinated by APA’s Council on Consultation-Liaison Psychiatry and the Academy of Consultation-Liaison Psychiatry.

Pediatric consultation-liaison (C-L) psychiatry is a well-established subspecialty that seeks to understand, assess, and treat emotional and behavioral distress in medically ill children and adolescents. The pediatric C-L psychiatrist provides expertise in medical and pharmacological principles, child and adolescent development, and presentations of abnormal psychological and behavioral responses in the pediatric patient. When assessing patients, it is crucial for the pediatric C-L psychiatrist to consider the family’s values, beliefs, and functioning while advocating for the patient.

Liaison work, including psychoeducation, participation in multidisciplinary treatment teams, and partnering with outside agencies as appropriate, can be particularly important when working with children with medical illnesses and emotional, behavioral, or cognitive problems. The pediatric C-L psychiatrists’ circle of care can also extend beyond the patient; sometimes they are asked to alleviate the distress and anxiety of parents, siblings, and even the medical team.

The following case illustrates the complex and multidimensional nature of pediatric C-L psychiatry.

DB is a 15-year-old ninth grader with severe aplastic anemia (SAA)—a rare and serious condition in which the bone marrow stops producing blood cell lines (causing fatigue, infections, and uncontrolled bleeding)—who was admitted to the hospital for immune suppression therapy. He was referred for psychiatric evaluation after the primary treatment team observed symptoms of anxiety prior to procedures and treatments, episodes of irritability and anger leading to conflicts with others, and insomnia.

DB, otherwise healthy, was diagnosed with SAA approximately one month earlier after a visit to the emergency department for two months of recurring nose bleeds and easy bruising. Initially he and his family were told he had leukemia; however, after a bone marrow biopsy and additional testing over the next week, he was diagnosed with SAA.

DB has a history of depression and anxiety. He was treated with the selective serotonin reuptake inhibitor (SSRI) escitalopram and psychotherapy, but after two years, he stopped all treatments. Eventually he began “treating” symptoms of anxiety with marijuana, which he smoked several times a week.

When DB was age 7, he and his three siblings were placed with their maternal grandmother and her husband by the foster care system. They were removed from his biological mother’s care for neglect because of her chronic substance abuse. Since then, DB has lived in a stable and nurturing environment, where he attends school regularly, has friends, and enjoys basketball and boxing; however, he had to stop both activities abruptly once he was diagnosed with SAA.

After thorough assessment, the pediatric C-L service diagnosed DB with generalized anxiety disorder and adjustment disorder. When assessing DB’s mood and anxiety levels, the team considered the potential effects of the immune suppression therapy for his SAA, as well as the abrupt discontinuation of marijuana when he was admitted.

Given DB’s severe low blood-cell counts, the team decided against restarting an SSRI (SSRIs are associated with an increased risk for platelet dysfunction and low platelet counts, or thrombocytopenia). Instead, they prescribed a low dose of the benzodiazepine lorazepam, which significantly improved DB’s anxiety and insomnia symptoms. In addition, the team provided bedside cognitive-behavioral therapy (CBT) to treat his pre-procedure anxiety and address the longer-term goal of marijuana cessation.

Importantly, the pediatric C-L service established rapport with DB using supportive psychotherapy, sometimes while working on a puzzle or playing video games together. This eventually led to more detailed and insightful conversations, during which DB shared his fears about his illness and whether he would die from it, his anxiety about having been told for one week that he had cancer, and his sadness and anger about not being able to play sports or box anymore. A trusting relationship ensued.

Using psychoeducation, the treatment team and DB’s grandmother were taught how to identify, understand, and manage DB’s anxiety, which typically manifested as irritability and “treatment refusal.” The pediatric C-L service also provided emotional support to DB’s grandmother, who was clearly overwhelmed.

Once discharged, DB re-engaged in CBT with his outside therapist, and the pediatric C-L service continued to follow up with DB monthly in the outpatient setting. He continued to improve over time, becoming well-adjusted to his clinic visits and subsequent hospitalizations. Lorazepam was eventually used only prior to certain procedures, such as a bone marrow biopsy.

Pediatric C-L psychiatrists are integral members of the medical treatment team, providing invaluable psychiatric expertise during the medical care of children and adolescents in a developmentally sensitive manner. They must be particularly flexible and astute as they establish rapport with the patient and the family; understand and formulate the nature of the psychological difficulties and the medical context from which they emerge; and develop a multimodal treatment strategy, ultimately advocating for the emotional well-being of the child and adolescent. ■

The opinions expressed here are those of the author and do not necessarily reflect the official policy or position of the National Institutes of Health or the Department of Health and Human Services. Funding for this work is provided by the NIMH Intramural Research Program, Office of the Clinical Director.

Haniya Raza, D.O., M.P.H., is a child, adolescent, and adult psychiatrist; chief of the Psychiatry Consultation-Liaison Service at the National Institutes of Health Hatfield Clinical Research Center; and faculty member of the Consultation-Liaison Psychiatry Fellowship Program at Georgetown University Hospital. Maryland Pao, M.D., is a child, adolescent, and adult psychiatrist; clinical and deputy scientific director of the National Institute of Mental Health Intramural Research Program; and an attending on the Psychiatry Consultation-Liaison Service at the NIH Hatfield Clinical Research Center.

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Consultation-Liaison Psychiatry: A Longitudinal and Integrated Approach

• Eva M. Szigethy , M.D., Ph.D. ,
• Pedro Ruiz , M.D. ,
• David Ray DeMaso , M.D. ,
• Federic Shapiro , M.D. , and
• William R. Beardslee , M.D.

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Historically, psychiatrists and other mental health professionals have played an important role as consultants in medical-surgical inpatient services and to a lesser extent in outpatient services. However, with the advent of managed care, this situation has changed radically. As a result of the carving out of psychiatric benefits from general medical-surgical benefits, consultation-liaison psychiatric services have not been routinely covered. Consequently, the coordination and integration of psychiatric and medical-surgical services in ambulatory care settings are not only more difficult to achieve but often lead to discontinuity in longitudinal and integrated health services.

Several factors illustrate the scope and magnitude of this problem:

1. Patients with concomitant medical-surgical and psychiatric conditions represent a significant number of the patients currently treated by the health services system in this country (1) .

2. The presence of comorbid medical-surgical and psychiatric conditions leads to higher morbidity and mortality, as well as an increase in the health care costs of such patients (2 , 3) .

3. Evidence exists that comorbid medical-surgical and psychiatric disorders tend to improve, if not be cured, when psychiatric interventions, such as psychopharmacotherapy and psychotherapy, are applied (4) .

4. It has been demonstrated that primary care practitioners quite often fail to appropriately diagnose and treat psychiatric disorders and conditions (5 , 6) .

It is within this context that we present and discuss the story of a patient with comorbid medical-surgical and psychiatric conditions who demonstrated a reduction in both her psychiatric and physical morbidities after treatment with an integrated, longitudinal psychiatric and medical-surgical approach. We hope that our description of this case will serve to improve and/or call attention to the deficiencies that are present in this country’s health care system, insofar as psychiatric consultation-liaison services are concerned.

Case Presentation

Angela (not her real name) was a 13-year-old girl who had been hospitalized for assessment and treatment of severe neck dystonia of 8 months’ duration. The dystonia had developed acutely after she had been hit in the neck by a soccer ball. After the seemingly minor injury, she had developed extreme neck hyperextension to the point at which her occiput was in contact with her back. This position became fixed such that neither active nor passive forward flexion was possible. Cervical spine X-rays and head and neck magnetic resonance imaging and bone scans were unremarkable except for the extreme hyperextension. These symptoms persisted over several months, despite the use of various pain medications, muscle relaxants, superficial neck muscle botulotoxin injections, intensive physical therapy, and hypnotherapy. Angela stopped attending school and no longer participated in any social activities.

Given the lack of any improvement in Angela’s neck mobility or pain, she was referred to and admitted to an inpatient orthopedic unit for consideration of more aggressive orthopedic treatment, such as botulotoxin injections into deeper neck musculature and/or surgical release of the contracted cervical extensor muscles. Her admission work-up was consistent with neck dystonia secondary to traumatic injury. The severe intensity of her pain, the lack of any symptom resolution with conventional medical interventions, and the high risk of longer-term complications with invasive interventions resulted in a psychiatric consultation to assess the role of psychological factors in her clinical presentation.

Initial Assessment

During her psychiatric examination, Angela was lying in bed with her neck hyperextended; she appeared to be much younger than her age. She alternated between loud moaning and speaking in a quiet voice. She was withdrawn and angry, often refusing to answer questions, stating, “I hate doctors.” Angela’s complete history was obtained slowly by returns to her bedside for small intervals over several consecutive days. Angela reported feeling apathetic, hopeless about any improvement, worthless, and guilty about subjecting her family to her medical ordeal. She reported symptoms of insomnia, decreased concentration, fatigue, and decreased appetite, along with “constant pain.” Angela progressively developed extreme anticipatory anxiety regarding medical procedures, along with hypervigilance and defensiveness during attempts to move her neck. She reported no suicidal ideation or nightmares or flashbacks related to the injury. Angela expressed anger because her neck pain had not disappeared; however, she had a nonchalant attitude about missing school, her peers, and participation in sports. She had not yet reached menarche and reported being happy about it, since she dreaded becoming “a grown-up.”

Angela met full criteria for a DSM-IV major depressive episode after the injury. At that time, there were significant ongoing interpersonal stressors related to heightened self and family expectations regarding both academic and athletic achievement, which occurred in the context of developmentally normative separation-individuation issues. The diagnosis of depression was further supported by a family history of depression, a history of subsyndromal depressive symptoms, social isolation, and the presence of a disabling physical illness (7 , 8) . Angela also manifested symptoms (e.g., anticipatory anxiety, hypervigilance, and avoidance) of a subthreshold anxiety disorder.

Given the predominance of depressive symptoms, the demonstrable pathophysiological evidence for her dystonia, and the absence of an individual or familial pattern of somatization, Angela did not meet DSM-IV criteria for either conversion or somatization disorders. Although her physical symptoms overlapped with the neurovegetative symptoms of depression (e.g., insomnia, lessened appetite, fatigue), her psychological symptoms of depression (e.g., guilt, indecision, low self-esteem, diminished social interest, feelings of worthlessness and hopelessness) were highly specific for the diagnosis of major depressive disorder (9) .

In addition to diagnostic considerations, a good strategy, determined by use of a biopsychosocial model, was essential in planning a flexible, developmentally appropriate treatment algorithm for this complicated clinical presentation of physical pain and disability, as well as depression and anxiety.

Course of Treatment

Treatment began with head halter traction designed to relax the contracted extensor muscles of the neck and allow flexion to resume gradually, also gentle physical therapy to strengthen the stretched anterior cervical muscles. During the second week, Angela was given paroxetine, 10 mg/day, for her depressive symptoms and lorazepam, 0.5 mg as necessary, for anticipatory anxiety related to the physical therapy. Trazodone, 50 mg at bedtime, was added to her regimen for several days to provide relief from insomnia.

Psychotherapy consisted of a blend of supportive, psychodynamic, cognitive behavior, and family therapy and focused on building a therapeutic alliance, educating Angela and her family about depression, addressing the stigma of having a mental illness, and decreasing the anxiety related to physical therapy. During psychotherapy, the treating psychiatrist (E.M.S.) listened to Angela’s account of her distress, while allowing her to verbalize her anger at her doctors for “not helping [her] more” and at her parents for “being too demanding.” The psychiatrist also spoke with both parents to address their concerns about their daughter’s failure to attain their “expected” performance goals, to help them accept a diagnosis of depression in the context of the physical injury, and to develop behavioral strategies to reduce their inadvertent reinforcement of the sick role in Angela. They were encouraged to express their feelings of helplessness to Angela without additionally blaming her. During this treatment phase, Angela showed improved motivation for physical therapy, an increase in neck mobility, better tolerance of pain, an elevated mood, an improvement in sleep and appetite, and better social interactions. However, her hopelessness about regaining full neck mobility and her lack of interest in interacting with her peers persisted.

Her orthopedic management (performed by F.S.) consisted of continuing head halter traction and frequent but gentle physical therapy. Since traction could only be performed while Angela was in bed, a brace was made to incorporate support for the back of her head, neck, and trunk. Angela was placed under general anesthesia on two occasions for passive manipulation of her head to a more upright position and for neck brace adjustments that moved her head into more neutral postures. This allowed for demonstration of the fact that the contracture into hyperextension was not rigidly fixed. To allow Angela to practice relaxation techniques without the distraction of pain, the psychiatrist worked with the orthopedic surgeon and the pain treatment staff to medicate Angela with intravenous methohexital before changing the position of her head and neck. This premedication was titrated to produce a light-drowsy but alert state, which facilitated the use of relaxation techniques. With verbal encouragement from the psychiatrist, Angela was able to move her neck with nearly full range of motion. Her second head adjustment session was videotaped with her family’s permission and later reviewed with Angela and her parents to help reinforce the fact that she had the ability to move her neck. Although her neck was able to tolerate more upright positions, it returned to its initial hyperextension when Angela was not sedated or in a neck brace.

Angela remained depressed and had significant ruminations about her pain. The psychiatrist reframed her mood symptoms and pain into her lexicon as a “biochemical reaction to the injury.” Angela spontaneously shared thoughts about the meaning of her symptoms (e.g., understanding her physical impairment as a vehicle for coping with fears about growing up and maturing into a woman, her ensuing inability to continue to compete successfully with her twin brother, and separation from her parents). Relaxation and distraction techniques were presented to help her “cope better” with her “ordeal”; her paroxetine dose was increased to 20 mg/day without producing side effects. Over the next several weeks, both her physical symptoms and depression improved.

Upon discharge, after 6 weeks in the hospital, Angela was able to hold her neck in the neutral position with a brace and at 45° of extension of the cervical spine without a brace. Her depression remitted, but stress-induced dysphoria, fatigue, and low self-esteem were evident. She wore her brace during waking hours and continued daily physical therapy. Paroxetine, 20 mg/day, was continued; the lorazepam was tapered before discharge.

After discharge from the hospital, twice-a-week outpatient therapy with the psychiatrist was arranged to continue treatment of the depression and to maintain continuity. A behavioral plan was constructed to provide daily structure and to pave the way for a return to school and extracurricular activities. Discharge planning with Angela’s parents centered on reinforcement of the behavioral plan, education about relapse of depression, and anticipation of a possible temporary worsening of mood, behavioral, and pain symptoms.

Angela participated in daily physical therapy and gradually reduced her need for the neck brace. By the end of this treatment phase, Angela was able to hold her head upright without a brace and no longer complained of pain. She was increasingly able to constructively express anger at her parents for “expecting perfection,” and at the same time she was able to recognize that her feelings also represented her own fear of failure. She was able to talk about her neck injury as a way of “preventing me from viewing my whole body;” thus, she did not have to see her pubertal body changes. She was also able to talk more directly about how the illness helped her differentiate from her brother. While identifying these issues, Angela had a concomitant improvement in her neck symptoms. After this improvement, her sessions were reduced to once a week, with emphasis on a behavioral plan for a gradual return to school and contact with peers. Angela no longer reported depressive symptoms upon standard clinical questioning; her episode of major depression had remitted. Work with her parents consisted of helping them reinforce the behavioral plan. Given the family’s vacation plans, a 3-hour drive to therapy, and her improvement, psychiatric care was discontinued for the summer.

Angela was seen by the psychiatrist again after a nearly 3-month absence from psychiatric treatment. Her history of the interval found her free of depressive and neck symptoms. However, the family had made a decision to stop psychotherapy as well as discontinue paroxetine therapy, stating that the depressive symptoms were a reaction to the illness and “a chapter in our lives we now want to forget about.” Angela was to return to school, although she expressed ambivalence about discontinuing psychiatric care in light of the “anniversary date” of her injury being just a few months away. Her neck dystonia was found to be in full remission at a follow-up orthopedic visit.

Angela did well in the first 6 weeks of school with no relapse of symptoms. She settled into a full academic schedule, started socializing with same-sex peers, and began participating in nonathletic extracurricular activities. Nevertheless, at the anniversary of her injury and onset of her menses, Angela developed fatigue, hypersomnia, spontaneous crying episodes, anhedonia, decreased concentration, social withdrawal, and academic decline. Angela also complained of neck pain but retained normal neck posture and mobility. She was immediately seen for reassessment by the psychiatrist, after a 5-month absence from psychiatric treatment, at which time she again met the DSM-IV criteria for a recurrent major depressive disorder. On the Children’s Depressive Inventory (10) , her score of 20 was consistent with moderately severe depression. On the Children’s Global Assessment Scale (11) , her score was 50, which is consistent with a serious impairment in functioning.

Psychiatric treatment was reinitiated on a weekly basis, with the same combination of supportive, psychodynamic, cognitive behavior, and family therapy, and paroxetine was reinitiated. This treatment approach was supplemented by exploration of both Angela’s and the family’s illness narratives (12 – 14) ; that is, the use of narratives applied cognitive skills to the family’s experiences and helped target the coping skills needed to appropriate areas of functional difficulty. Angela’s negative attributional style, particularly her fear of failure and feeling of hopelessness, was targeted with cognitive reframing exercises. A family meeting was held to reeducate her parents on the patterns of depressive relapse and to gently confront their denial about Angela having a major depressive disorder that was beyond an adjustment reaction to the injury. Angela’s parents were taught ways in which they could support her developmentally normal attempts to individuate from them.

After completing a 14-session course of this enhanced cognitive behavior therapy along with family therapy, Angela reported a remission of her depressive symptoms (Children’s Depressive Inventory: score=10, Children’s Global Assessment Scale: score=70), had a remarkable improvement in her academic performance, and began socializing with peers. After 1 month of sustained remission, the therapy sessions were tapered to monthly intervals for 4 months then discontinued given her sustained remission. The final sessions focused on the feelings surrounding the termination of therapy. The family decided to continue to give Angela paroxetine through their local pediatrician.

One year after her relapse, Angela, who is now nearly 16 years old, has been free of paroxetine for 6 months. Her depression is still in remission, as are her physical symptoms. She made the honor roll in school and has begun to play and enjoy competitive hockey.

This case illustrates the critical importance of how an accurate diagnosis of major depressive disorder in an adolescent girl with a physical disorder and an appropriate multimodal treatment over time resulted in a reduction of both psychiatric and physical morbidities. It further outlines the crucial importance of coordinating medical-surgical and psychiatric services into an integrated treatment approach by using the same therapist over time. The recognition of depression and its appropriate treatment likely prevented more expensive and invasive medical-surgical interventions (e.g., cervical muscle resection and/or deep muscle injection of botulotoxin), as well as protracted physical and functional disability. The integrated treatment involved the use of psychotherapeutic strategies supplemented by narratives of the physical illness and family psychoeducational approaches, along with psychopharmacotherapy.

In this case, the manual-based cognitive behavior therapy approach developed by Weisz et al. (15) was used. This approach is based on a two-process model of control and coping (16 , 17) . The model holds that depression may be addressed in part by learning to apply primary-control coping strategies (making objective conditions conform to one’s wishes) to distressing conditions that are modifiable (e.g., relaxation to decrease pain and social skills training to overcome isolation from peers) and secondary-control strategies (adjusting one’s interpretation of events to fit reality) to conditions that are not modifiable (e.g., cognitively reframing negative distortions). In Angela’s case, linking the expression of her depressive symptoms to changes in her processing of anxiety (18 , 19) and to learned helplessness (20) provided a theoretical framework within which to better target the coping strategies taught.

Enhancing cognitive behavior therapy with a narrative framework appeared critical in Angela’s treatment, since it allowed integration of cognitive-based learning with her life circumstances. Narrative therapy emphasizes the construction of meaning as a central goal by helping to reconstruct life experiences that have become too restrictive or too negative into more adaptive ones; it can be useful as a bridge across different therapy modalities (12 , 21) . Some researchers have had good results applying narrative approaches to the treatment of children (22) and adults (23) with chronic physical illness. These data suggest that for an intervention to optimize resilience in patients with chronic physical illness, it should include a focus on self-understanding in a developmentally appropriate context. Self-understanding has proven to be an important component of resiliency in two studies (24 , 25) . In this case, it was important to frame Angela’s injury and associated depression as a vehicle with which to remove her from her peer group, an important component in successful separation from parental figures during adolescence.

Psychoeducation of adolescents and their families about depression is an important step in treatment (25 , 26) . Psychoeducation can help adolescents and their parents identify affect, deal with stigmatization, modulate shame and guilt, decrease noncompliance and resistance to the concept of illness, and create a more hopeful perspective (14) . Cognitive approaches in family therapy have been shown to be quite effective in educating families about childhood depression, increasing family understanding, and decreasing the risk factors associated with depression (26 , 27) . Angela’s intervention targeted psychoeducation about depression and family communication about the illness and linked psychoeducational material to her narratives about life experiences. Given the developmental tasks of adolescence, the added burden of comorbid depression and physical illness had far-reaching functional implications for this family.

There is considerable evidence that families with comorbid pediatric depression and physical illnesses deserve special attention: families with depressed children are much more likely to have parents who are also depressed (27) , and families with children who suffer from chronic physical illness have higher rates of psychological distress and poorer communication than other families (28 , 29) . In this case, the psychoeducational material presented to the family framed depression as a medical as well as an emotional illness, with definable physical and psychological manifestations. In this way, the family was able to link its own conceptualization of the illness to a framework of understanding based on factual information about pain and depression and thus begin to communicate better and to mitigate confusion, guilt, and shame. This case report supports the premise that an efficacious psychosocial treatment for depression in an adolescent with physical illness needs to target negative attributional style and learned helplessness, while simultaneously providing family psychoeducation and taking into account illness narratives.

Angela’s neurovegetative symptoms at her initial psychiatric assessment supported the use of antidepressants in addition to psychotherapy. Selective serotonin reuptake inhibitors have become a common treatment for uncomplicated adolescent depression, given their efficacy, their relatively benign side effect profile, and their low lethality in overdose (30) . However, we are aware of no controlled studies exploring the efficacy of antidepressants in treating depression among adolescents with physical illnesses, although there are studies of adult patients with comorbid depression and physical illness and who have shown improved functioning after antidepressant treatment (31 , 32) . Keller et al. (33) reported that in a group of eight adults with chronic depression, the combined use of cognitive behavior therapy and antidepressants was found to be more effective that either modality alone. Clinical experience has supported the premise that major depressive disorders respond to a combination of psychotherapy and pharmacotherapy, even when somatization complicates the clinical picture (34) . This case report outlines the successful multimodal use of psychotherapy, family psychoeducation, narratives of physical illness, and psychopharmacology appropriately integrated over time with orthopedic care in an adolescent with a physical illness.

Depression is a recurrent condition, even after successful remission of the acute phase, with many individuals having ongoing subsyndromal depressive symptoms and difficulty functioning (35) . For this reason, longitudinal follow-up is key. In this case, the 3-year perspective of continuous psychiatric care allowed for the integration of Angela’s developmental, biological, psychological, and social domains into a responsive multimodal treatment program. Despite a full remission, Angela had a relapse of depression as well as neck pain 5 months after her family’s decision to terminate treatment. This is consistent with the literature, which shows that depression is recurrent (32) . As many as 60% of all adolescents experience a second depressive episode within 2 years and nearly 75% within 5 years of their initial episode (36) . Several reasons can be hypothesized for the patient’s relapse, including

1. Noncompliance with treatment after remission was first obtained.

2. Increased psychosocial stressors (e.g., academic and social demands).

3. Reemergence of the family’s high achievement demands and their denial of the existence of mental illness.

4. The discontinuance of antidepressant medication (paroxetine).

Regardless of the reason for relapse, this case report demonstrates the importance of treatment continuity as a vital part of relapse prevention, particularly with continuous psychiatric care across time and across different modalities of treatment, and especially in patients with complex conditions and co-occurring physical and emotional illnesses.

Between 10 and 20 million American youth have a chronic physical illness (37) . This population has a disproportionate burden of psychiatric comorbidities, particularly depression (9) . Although the definition of chronic physical illness usually refers to conditions such as diabetes, asthma, or inflammatory bowel disease, which persist for long periods of time, given that Angela’s neck symptoms appeared after an acute injury, persisted for almost 1 year, and were associated with physical disability, her physical symptoms were labeled as “chronic.” In this regard, the case formulation and multimodal treatment approach outlined in this case report can be extended to more prototypical chronic physical illnesses. It was likely that none of these approaches would have been successful in lessening physical or psychiatric symptoms, but their application in a staged, sequential manner appeared most instrumental in the treatment’s success.

Although our single-case study cannot allow us to make definitive causal conclusions about the relationship between treatment and behavioral outcome, in this case there was a strong suggestion that treatment did lead to symptomatic and functional improvement. First, when psychiatric treatment was most intense, Angela had the greatest improvement in psychiatric and physical symptoms. Continuous assessment of her depressive symptoms with clinical observation and use of the Children’s Depressive Inventory and of her global functioning with use of the Children’s Global Assessment Scale provided a way to follow trends for change. Second, the family’s termination of integrated treatment after the remission of depressive and neck symptoms and the subsequent relapse of depression after a resolution of depressive symptoms followed the reversal design (ABAB) advocated by Kazdin (38) and suggests that it was treatment that accounted for the behavioral changes, rather than any other influence. Studies with a larger group and with therapists who are blind to outcome assessments would certainly strengthen the validity of these findings.

Conclusions

This case report demonstrates the potential for positive treatment outcome, which is achievable with a multimodal treatment approach based on psychiatric consultations across medical specialties and across time. This case also offers a rich source of clinical observations and intervention strategies that can be tested in larger comparative trials. These include the following:

1. Supportive, psychodynamic, and cognitive behavior therapy approaches appear to be most useful if developmental considerations and physical illness narratives are considered within a biopsychosocial model.

2. Cognitive behavior therapy techniques seemed to help this patient cope better with her physical illness, particularly in terms of fatigue and pain.

3. Combined psychotherapy and antidepressant treatment appears to have been most beneficial to this patient in terms of initial recovery and sustaining remission from pain and depression.

4. Family involvement seemed to be an essential component in this case in that it helped the family navigate the stresses of dealing with a comorbid disorder, while still reinforcing developmentally appropriate autonomy in social realms.

5. The continuity of psychiatric care appeared to be critical in this case.

6. Supportive, psychodynamic, cognitive behavioral, and family therapy were logistically and conceptually integrated with pharmacotherapy in a highly complicated consultation-liaison case.

It is obvious, however, that this case is not representative of the majority of children with physical and psychological conditions. Actually, the treatment in this case required much effort and length. Without question, continuing advances in the treatment and understanding of psychosomatic illness interfaces will result in even more effective treatments geared toward decreasing illness-related morbidity and mortality in this patient population.

Received July 11, 2001; revision received Aug. 19, 2001; accepted Sept. 5, 2001. From Harvard University Medical School, Boston; Children’s Hospital, Boston; and the University of Texas Medical School, Houston. Address reprint requests to Dr. Ruiz, 1300 Moursund St., Houston, TX 77030; [email protected] (e-mail).

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• An examination of the services provided by Psychiatric Consultation Liaison Nurses in a general hospital 8 July 2008 | Journal of Psychiatric and Mental Health Nursing, Vol. 15, No. 6
• Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 43, No. 12
• YA-MEI BAI , M.D. ,
• HSIEN-JANE CIU , M.D. , and
• ZHAO-ZHAN GUO , M.D. ,
• FELIX ROSENOW , M.D. ,
• SUSANNE KNAKE , M.D. , and
• JOHANNES HEBEBRAND , M.D. ,
• MAREK WYSTANSKI , M.D., F.R.C.P.(C.) ,

• Open access
• Published: 29 April 2021

Deployment of the consultation-liaison model in adult and child-adolescent psychiatry and its impact on improving mental health treatment

• M.-J. Fleury 1 , 2 ,
• G. Grenier 2 ,
• L. Gentil 2 &
• P. Roberge 3  

BMC Family Practice volume  22 , Article number:  82 ( 2021 ) Cite this article

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Metrics details

Little information exists on the perceptions of psychiatrists regarding the implementation and various impacts of the consultation-liaison model. This model has been used in Quebec (Canada) through the function of specialist respondent-psychiatrists (SRP) since 2009. This study assessed the main activities, barriers or facilitators, and impact of SRP in adult and child-adolescent psychiatry on the capacity of service providers in primary care and youth centers to treat patients with mental health disorders (MHD).

Data included 126 self-administered questionnaires from SRP and semi-structured interviews from 48 SRP managers. Mixed methods were used, with qualitative findings from managers complementing the SRP survey. Comparative analyses of SRP responses in adult versus child-adolescent psychiatry were also conducted.

Psychiatrists dedicated a median 24.12 h/month to the SRP function, mainly involving case discussions with primary care teams or youth centers. They were confident about the level of support they provided and satisfied with their influence in clinical decision-making, but less satisfied with the support provided by their organizations. SRP evaluated their impacts on clinical practice as moderate, particularly among general practitioners (GP). SRP working in child-adolescent psychiatry were more comfortable, motivated, and positive about their overall performance and impact than in adult psychiatry. Organizational barriers (e.g. team instability) were most prevalent, followed by system-level factors (e.g. network size and complexity, lack of resources, model inflexibility) and individual factors (e.g. GP reluctance to treat patients with MHD). Organizational facilitators included support from family medicine group directors, collaboration with university family medicine groups and coordination by liaison nurses; at the system level, pre-existing relationships and working in the same institution; while individual-level facilitators included SRP personality and strong organizational support.

Quebec SRP were implemented sparingly in family medicine groups and youth centers, while SRP viewed their overall impact as moderate. Results were more positive in child-adolescent psychiatry than in adult psychiatry. Increased support for the SRP function, adapting the model to GP in need of more direct support, and resolving key system issues may improve SRP effectiveness in terms of team stability, coordination among providers, access to MH services and readiness to implement innovations.

Peer Review reports

Most individuals affected by mental health disorders (MHD) use primary care services as the point of entry to the mental health (MH) care system. Primary care is the gatekeepers to specialized MH services in Quebec (Canada), as in many countries [ 1 , 2 ]. General practitioners (GP) are the main primary care providers, evaluating and treating in their clinics from 20 to 40% of patients with MHD annually [ 3 , 4 , 5 , 6 ]. Primary care services are less costly and stigmatizing, and more accessible than specialized MH services [ 7 , 8 ]. Yet studies have reported limited capacity among primary care clinicians, especially GP, to diagnose and treat MH conditions, particularly severe or co-occurring MHD [ 5 , 9 , 10 , 11 , 12 ] and substance-related disorders [ 13 ]. Better integration of specialized MH services into primary care has thus been strongly recommended and is at the heart of current international [ 14 , 15 ] and Canadian [ 16 ] MH reforms.

Several models for integrating MH and primary care services have been developed in the past decades, including collaborative care [ 17 ], shared care [ 9 ] and the consultation-liaison model [ 18 ]. Collaborative and shared care originated with the Wagner chronic care model [ 19 ]. In shared care, psychiatrists work closely with GP [ 20 ], whereas collaborative care involves nurses, psychologists, social workers and other clinicians [ 21 , 22 ], integrating three core work components: use of systematic psychiatric assessments; longitudinal patient monitoring and care management usually performed by nurses; and stepped-care recommendations by psychiatrists or other MH specialists [ 23 ]. Both collaborative and shared care may target specific populations (e.g. elderly, children and adolescents) and include clinician collaboration of varying intensity [ 22 ]. In the consultation-liaison model, psychiatrists hold regular case discussions with GP or other primary care clinicians, providing care management, clinician support and referrals without seeing patients directly [ 24 , 25 , 26 ]. The psychiatrist function is focused essentially on improving clinician skills [ 27 ]. Compared with the collaborative and shared care models, the consultation-liaison model implies fewer changes for primary care clinicians, as consultation-liaison essentially targets improvements to MH expertise, without reorganizing other areas of interdisciplinary group practice. Hybrid models also exist that blend characteristics of the three generic models [ 28 , 29 ].

Randomized controlled trials have assessed the impacts of MH service integration in primary care on patient health outcomes [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ] and determined that these models reduced psychiatric symptoms among patients with depression [ 29 , 38 , 39 , 41 , 42 , 43 ], anxiety disorders [ 29 , 40 , 44 ], bipolar disorders [ 45 ] and multiple MHD [ 31 ]. Other studies focused on health service use found that integrated MH services increased access to MH services [ 20 , 21 ] and reduced psychiatric hospitalizations [ 46 , 47 ]. Other studies evaluated the impacts of MH service integration in primary care on clinical practice revealed improved MH screening [ 48 , 49 , 50 ] and prescribing practices [ 48 ].

Concerning the consultation-liaison model, patient outcome research found that the model improved MH conditions in the first 3 months of treatment while improvements in co-occurring MHD, alcohol and cannabis use appeared after 4 months [ 35 ]; depressive symptoms diminished as effectively with the consultation-liaison model as with collaborative care at 9-month follow-up [ 32 ]. Concerning heath service use, the consultation-liaison model improved treatment adherence and satisfaction with services between 3 and 12 months post-treatment [ 30 ], promoting efficiency in specialized MH service use [ 18 , 27 ]. Finally, clinical practice improved in terms of GP knowledge and skills in diagnosing and treating patients with MHD [ 30 , 51 ], medication prescribing [ 51 ], inter-professional communication [ 51 , 52 ] and less stigmatizing attitudes [ 53 ].

Qualitative studies have assessed barriers and facilitators in implementing integrated MH services into primary care around multiple issues. At the system-level these included supportive legislative/policy environment [ 25 , 54 ], availability of appropriate resources [ 55 ], preexisting relationships between specialized MH services and primary care [ 22 , 56 ], and adequate incentives [ 25 , 57 , 58 , 59 ]. Organizational-level issues included clinician acceptance of the model [ 60 , 61 ], team stability [ 55 ], organizational support [ 1 , 62 , 63 ], leadership [ 55 , 62 ], and feedback on model effectiveness [ 59 ]. Finally, individual-level concerns included interest among GP in MHD [ 1 , 25 , 59 , 63 ], and individual qualities of psychiatrists [ 58 , 60 ].

As implementation of the consultation-liaison model was not expected to involve sweeping changes, this model was selected in Quebec with the aim of improving MH expertise among providers in primary care, and youth centers which are specialized services treating patients under 18 years old, a majority of whom with MHD [ 64 ]. Moreover, this MH reform only aimed at changing practices in the public MH sector, which excludes the majority of GP who work in private practices under the direction of another Quebec ministry. The Quebec consultation-liaison model was based on the deployment of a specialist respondent-psychiatrist (SRP) function, launched as part of the 2005 Quebec MH Action Plan to help consolidate MH expertise outside of specialized psychiatric care [ 65 ]. Yet even the introduction of this “simplified” model of integrated specialized MH care was strongly contested by the Quebec Association of Psychiatric Physicians. An agreement was finally signed in 2009 between the Association and the Quebec government, establishing a high hourly fee for psychiatrists willing to serve as SRP in their health networks as a strong incentive for them to integrate this function into their professional activities. Under the 2009 agreement [ 66 ], one or two SRP were allocated either per 50,000 inhabitant in adult psychiatry or per 50,000 patients under age 18 in child-adolescent psychiatry. SRP had to be present on-site for 3.5 h/weekly to train clinicians working in MH primary care teams (MH-PCT), one-stop MH service teams, family medicine groups or youth centers, and provide on-call telephone availability during office hours between on-site visits.

MH-PCT and one-stop MH services were also mandated under the 2005 MH Action Plan [ 65 ]. MH-PCT located in local community health centers, the main public primary care organizations in Quebec, were projected to include 20 interdisciplinary psychosocial professionals and two GP. However, these original objectives have yet to be completed [ 67 , 68 ]. One MH-PCT was allocated per 100,000 inhabitants among the health networks. MH-PCT offered individual and group therapies for patients with MHD. For networks with a minimum of 50,000 inhabitants, one-stop MH service teams were also established in local community health service centers as the point of entry for accessing MH services from either MH-PCT or psychiatric care. The one-stop MH service teams provide assessments for self-referred patients or those referred by GP, community organizations (voluntary sector) or by inter-sectorial resources (e.g. addiction rehabilitation centers). At the time they were created, one-stop MH service teams and MH-PCT were mainly staffed by MH professionals transferred from specialized MH services to primary care [ 67 , 68 ]. Established in 2002 [ 69 ], family medicine groups brought together GP working in private practices and integrated secretarial support, as well as multidisciplinary teams that mainly included nurses and in some cases other psychosocial clinicians like social workers. Financed by the government, the enhanced family medicine groups ensured patient registration, and better continuity of care and access to care as they offered more days and hours of medical coverage including work-in clinics [ 70 ]. By 2015, more than 60% of GP in Quebec worked in family medicine groups [ 69 ]. Created in the 1970s [ 71 ], youth centers remain key partners in child-adolescent psychiatry offering specialized regional public services for children and adolescents in difficulty as well as psychosocial, rehabilitation, social integration and placement services [ 72 ]. In the consultation-liaison model, the SRP function included close working relationship with these four types of health care providers to reinforce their MH expertise with the aim of improving MHD treatment and increasing numbers of patients with MHD that these clinicians can overall treat.

While research has assessed impacts of the consultation-liaison and other integrated models on patients and GP or other psychosocial clinicians, few studies have explored the perspectives of psychiatrists working as SRP or their managers [ 25 , 58 , 73 , 74 ]. Moreover, impacts of the consultation-liaison model and related barriers/facilitators have rarely been considered [ 25 , 58 ], nor to our knowledge have studies compared implementation of the consultation-liaison model in adult versus child-adolescent psychiatry. A better understanding of SRP perspectives on the consultation-liaison model may help improve future implementation and adaptation of the model leading to better outcomes, while providing guidance to decision-makers involved with future MH reforms, whether in Quebec or elsewhere, especially considering that primary care MH consolidation is a key issue for service improvement. This study may also identify previously unknown barriers or facilitators regarding the implementation of integrated models such as consultation-liaison. Accordingly, this study assessed the main activities of SRP and barriers or facilitators affecting the SRP function from the perspectives of SRP and managers and compared the impacts of SRP in adult and child-adolescent psychiatry in terms of the capacity of Quebec GP, MH-PCT, one-stop MH service teams and youth centers to care for patients with MHD.

Study context

In Canada, health and social services are under provincial jurisdiction and are covered by a universal health insurance system [ 75 ]. The Canadian and Quebec health and MH systems have been criticized over the years for inadequate access and continuity of care [ 76 , 77 ] and for less than optimal consolidation of services within primary care [ 76 , 78 ]. In the province of Quebec, which accounts for 23% of the Canadian population [ 79 ], some 25% of inhabitants are without a “family doctor”, and instead use walk-in clinics as a regular source of care [ 80 , 81 ]. Wait times to access MH-PCT and psychiatric care are also quite long, varying from several months to more than a year especially for psychiatric care in some Quebec territories [ 67 , 82 ]. Benchmarks originally set for access to treatment were 1-month for MH-PCT and evaluations within 7-days were promoted for the one-stop MH service teams [ 65 ], yet these standards have to be met due to organizational issues and high patient demand [ 67 , 68 , 83 ].

In this context, major recent reforms have been ordered aimed at decreasing the overall number of Quebec health providers while integrating network services; a more recent focus is on the implementation of clinical best practices. In particular, the 2015 health reform [ 84 ] created 22 integrated health and social service centers in Quebec, nine of them university-affiliated, merging all public health and social service organizations like hospitals, local community health service centers (including MH-PCT and one-stop MH services) and youth centers into 22 networks (except for 12 university hospitals). Each MH network includes specialized services offered in psychiatric departments of general hospitals or psychiatric hospitals staffed by approximately 1,200 psychiatrists, most (± 90%) working in hospitals [ 85 ] and about 44% located in metropolitan Montreal or Quebec, the capital city [ 86 ]. Of a total 37 psychiatric departments, 23 serve both adults and children or adolescents through multidisciplinary teams consisting mainly of nurses, psychologists, occupational therapists and social workers. These public MH networks also work in conjunction with GP employed in private family medicine groups on fee-for-service payment schemes to further consolidate MH expertise and better serve patients with MHD.

Study design

The study used a sequential explanatory mixed-method design [ 87 , 88 ], with qualitative findings from psychiatric department heads (hereafter: “managers”) on deployment of the consultation-liaison model used to explain and complement the quantitative data from a survey of SRP on their activities and impacts. Mixed methods are particularly useful for understanding the implementation of new programs or reforms [ 87 ]. The study was also designed in collaboration with an advisory committee, consisting of representatives from the Quebec Health and Social Services Ministry, the Quebec Association of Psychiatric Physicians, chiefs of psychiatry at MH university institutes and SRP leaders.

Data collection and instruments

SRP survey data were collected using a self-administered questionnaire and quantitative information from managers using semi-structured interviews. Data collection took place from June 2019 to February 2020 (see Supplementary materials ). The questionnaire and interview guide were validated by the advisory committee, and pre-tested by three SRP and three managers. Interviews were conducted by a senior research agent trained and closely monitored by the study researchers. Questionnaire responses were reviewed by the project coordinator to verify that all questions were fully addressed and ensure data quality. The SRP questionnaire required 30 min to complete, while interviews with managers lasted 60 min on average.

The SRP questionnaire included: (1) socio-demographic and professional data (e.g. age, years as SRP); (2) professional activities (e.g. hours per month dedicated to case discussions, telephone availability); (3) profiles of patients discussed or seen (e.g. diagnoses, service use); and (4) perceived impacts of SRP function (e.g. on GP or in MH teams). Manager interviews addressed the organization of SRP (e.g. work integration with MH-PCT or GP) and barriers or facilitators to SRP effectiveness. Manager socio-demographic and professional data (e.g. age, seniority) were also collected through a brief questionnaire (3 min) administered prior to the interviews.

Recruitment process

First, all departmental managers were contacted to obtain a list of SRP in their respective territories and invited to participate in a semi-structured telephone interview. Invitations to complete the questionnaire were then sent to SRP by email, fax or through departmental secretaries. Up to 12 automatic reminders or emails were sent to non-responders after 2 weeks, or follow-up telephone calls made. Help with recruitment was also sought from the project advisory committee members (December 2019, January 2020). Managers were solicited as often as four times to maximize participation in the study. All participants provided informed consent. The research ethics board of the Douglas MH university institute approved the study protocol.

Regarding quantitative data from SRP questionnaires, the very few missing data found (< 5%) were replaced by the means. First, descriptive statistics including percentages for categorical variables and median or mean values for continuous variables were produced. Second, comparative analyses were conducted to test differences in responses among SRP in adult and child-adolescent psychiatry using the Mann–Whitney U test and Anova. Quantitative data from managers were analyzed using content analysis based on a four-step process [ 89 ]: 1) audio-recording of interviews and verbatim transcription; 2) preliminary readings and selection of classification units based on 10% of the verbatim by two research team members working independently, and verification of their high inter-rater reliability by researchers; 3) separation of content of the entire verbatim into units of meaning framed by the interview guide and more broadly, by system, organizational and individual-level barriers or facilitators to deployment of the SRP function; and 4) quantification of qualitative data for weighing the importance of issues discussed by managers. The triangulation process involved: a) summarizing the quantitative data in tables, b) synthesizing the quantitative data in a document, c) validating agreement between results of the SRP survey with information provided by manager, d) and using data from the qualitative investigation to further describe the quantitative results.

Sample description (data from questionnaires)

Of 214 SRP identified by managers, 126 participated (response rate = 59%). SRP were mainly female (69%) and 48 years old on average, had worked 16 years as a psychiatrist and six as SRP. Nearly all (90%) were active SRP, 75% working in adult psychiatry, 25% in child-adolescent psychiatry, 65% in general hospital settings versus 35% in psychiatric hospitals, while 42% were in university health regions versus 24%, 19% and 15% in peripheral, remote and intermediary regions, respectively. Of 55 managers invited to the study, 48 participated (response rate = 87%). Managers were mainly female (59%), mean 50 years old with an average of 18 years as a psychiatrist and eight as manager. Moreover, 90% previously or currently worked as SRP, 60% in adult psychiatry and 40% in child-adolescent psychiatry.

SRP activities (data from the SRP questionnaire and manager interviews)

Table 1 presents the main SRP activities based on the questionnaire. SRP devoted 24.12 h/month on average to their functions, mainly including case discussion meetings, followed by patient consultations with/without clinicians, telephone/video consultations and other. Most SRP (88–96%) performed all these activities, except for patient consultations reported by 56%. Specifically, they provided consultations to one-stop MH service teams (21%), MH-PCT (20%), GP (16%) and youth center patients (10%). Total hours/month reported by SRP and the number of telephone/video consultations with GP and one-stop MH service teams were significantly higher in adult versus child-adolescent psychiatry, whereas the number of SRP consultations with MH-PCT patients was significantly higher in child-adolescent psychiatry than in adult psychiatry.

Table 2 shows the distribution of specific clinical activities per month among SRP. Their time was mainly allocated to GP for pharmaceutical recommendations, to MH-PCT and youth centers for psychosocial and psychotherapeutic recommendations, and to one stop MH service teams for referrals within health service networks. SRP in child-adolescent psychiatry devoted significantly more time toward information sharing on MHD in MH-PCT than those in adult psychiatry.

According to 40% of managers, the total hours covered by SRP was below their cap for 2009, while 10% stated that SRP offered more time than required; the remaining 50% reported rates of SRP coverage in line with government regulations. Questionnaire results indicate that SRP reached 22.0 GP on average, 11.6 clinicians from MH-PCT, 6.2 from one stop MH service teams, and 3.8 from youth centers. SRP in adult psychiatry reached significantly more GP than those in child-adolescent psychiatry (mean 25.6 vs 11.3) and relatively fewer clinicians from adult vs. child-adolescent MH-PCT (9.4 vs 18.0). Managers identified that most network psychiatrists were registered as SRP and provided rotating telephone coverage for brief patient consultations with GP during office hours. However, GP used this service sparingly (median 3 h/month: Table 1 ).

Managers reported that SRP usually divided their work between sub-networks or MH-PCT and one stop MH service teams or GP family medicine groups. SRP worked with all or most network MH-PCT and one stop MH service teams, whereas half or fewer networks developed partnerships between SRP and GP. MH-PCT consultations were carefully prepared, with psychosocial clinicians sending patient case discussions to SRP in advance; GP were generally not involved in MH-PCT. A maximum of six cases difficult to manage in MH-PCT and requiring SRP assistance were usually discussed per session. SRP provided guidance and recommended treatment based on patient profiles. In one stop MH service teams, SRP mainly supported nurses in evaluating MH demands and orienting patients to appropriate services: whether a return to GP with clinical guidance, referral to the MH-PCT, community services or specialized care to the network hospital link evaluation modules (“module d’évaluation/liaison”). In some networks, SRP or liaison-nurses occasionally met patients for more extended evaluation or provided brief treatment during the wait period for transfer. GP were updated concerning patient profiles and treatments. Regarding family medicine groups in the networks, roughly half of managers noted that the SRP function had not been promoted; only 20% had presented this function to GP through memos, presentations at clinics or to clinic representatives. SRP services had higher priority in larger family medicine groups and those in closer proximity to hospitals employing SRP, in clinics with greater interest in MH and in those where SRP had affiliations or had previously collaborated. Overall, GP were viewed as having little interest in SRP consultation, preferring that SRP consult directly with their patients and providing them with brief orientation. SRP were more successful when targeting “university” family medicine groups, whose training objectives involving medical residents coincided with SRP case discussions. Regarding youth centers, there was usually close collaboration with child-adolescent psychiatry departments, although few managers mentioned that SRP had much contact with them. SRP targeted specialized psychosocial clinicians in youth centers working with patients whose MH conditions were more serious and complex.

Comfort, motivation, and satisfaction among SRP (questionnaire data, 5-point scales)

SRP comfort and motivation related to their function and capacity to support primary care or youth centers were evaluated as good (3.7/5) (Table 3 ). SRP evaluated the complexity of their interventions as medium (3.3). They were very satisfied with their degree of influence in decision-making regarding patient referrals and choice of therapeutic interventions (4 +), but less so regarding the clarity of their civil responsibility (3.4). They rated the relevance of their collaboration/consultations as high (4 +), except for GP consultations which were less satisfying (3.6). Satisfaction among SRP regarding the support offered by their organizations was low (2.8) in terms of training activities, feedback on SRP effectiveness or help forthcoming for administrative and logistical tasks. SRP working in child-adolescent psychiatry were significantly more comfortable and motivated around their overall functions than their counterparts in adult psychiatry (3.9 vs 3.6), including the clarity of their role/mandate (4.0 vs 3.7), civil responsibility (3.8 vs 3.3) and their margin of maneuver for accomplishing tasks adequately (4.0 vs 3.5). SRP in child-adolescent psychiatry were also significantly more satisfied with both the administrative and logistical support provided by their organizations (3.4 vs 2.7) and with requests from MH-PCT for their services (4.4 vs 3.5).

Profiles of patients discussed or seen in the context of SRP functions (questionnaire data)

Overall, SRP patients were 18–30 years old, single, widowed or divorced and with low income (Table 4 ). They were mainly affected by common MHD (e.g. depressive disorders), followed by personality and substance-related disorders. Regarding service use, SRP estimated that 67% had a family doctor, and few used MH community organizations, addiction rehabilitation centers or private psychologists. Patient referral to specialized services was justified by severity or complexity of MHD and need for direct and regular psychiatrist intervention.

Compared with patients consulted in primary care or youth centers by SRP in child-adolescent psychiatry, those consulted by SRP in adult psychiatry were generally older, living with a spouse/common-law partner and with low income. They were significantly more affected by depressive, bipolar, psychotic, personality or substance-related disorders, or had experienced a second MHD episode, while less affected by adjustment or attention deficit disorders with/without hyperactivity or other MHD. Work or housing problems, chronic physical illnesses and social isolation were also prevalent, but risk of aggressivity was lower. Moreover, adult patients received more services from addiction rehabilitation centers and were less likely to be followed by MH-PCT or youth centers. SRP in adult psychiatry also referred significantly more patients to specialized services for co-occurring MHD-substance-related disorders, but also encountered more patients who refused referral to specialized services.

Barriers or facilitators to effectiveness of the SRP function based on manager interviews

Verbatim from the qualitative findings illustrates the main system-level, organizational, and individual barriers/facilitators to the deployment of the SRP function (see Additional file 2 ). Managers identified slightly more barriers than facilitators, mostly organization-related, followed closely by system-level, then individual factors. Major organizational barriers included instability or frequent MH-PCT staff turnover, but to a lesser degree in one-stop MH service teams (barrier identified by 40% of mangers – hereafter: “% only”); lack of clinician involvement in MH-PCT meetings (30%); insufficient SRP support from hospitals (25%); insufficient coordination mechanisms between one-stop MH service teams, specialized care and SRP (25%); and difficulty managing patients without family doctors in one-stop MH service teams (25%). These patients could have been treated by GP in MH-PCT, had these teams recruited GP or by SRP directly. For more rapid access to specialized care, patients often had to go through emergency departments. Many youth centers were also not prepared organizationally to accommodate SRP (20%). Important organizational facilitators to the SRP function were: having a medical director supportive of SRP in family medicine groups, and interest in MH among psychosocial clinicians in those family medicine groups (30%); working in university family medicine groups with teaching mandates aligned with SRP functions (30%); networks with liaison nurses for care coordination between one-stop MH service teams and specialized care (25%); adequate preparation of case discussions with SRP in MH-PCT (25%); the possibility of referrals to specialized care and direct treatment by the SRP for patients not known to hospitals, optimizing the evaluation process (10%); and in one-stop MH service teams, the provision of brief MH interventions to patients waiting for transfer to either MH-PCT or specialized care (10%).

The main system-level barriers reported were network size and complexity, as when SRP had to travel long distances for team meetings (Web training was not allowed), when the SRP function covered two networks in “borderline” areas or included networks with a large volume of underprivileged patients with complex conditions (60%). Another issue was lack of human resources, especially for psychiatrists working outside the Montreal and Quebec City networks, or where SRP networks were not viewed as a priority but as “icing on the cake” (50%). The inflexibility of the consultation-liaison model particularly in relation to GP needs and modes of remuneration was evaluated as another key barrier (45%). As SRP consultations were organized at regular intervals (e.g. the first Monday of each month), certain GP working at multiple settings were never able to attend. Office space for SRP working in clinics was sometimes problematic. As well, GP paid on a fee-for-service basis generally declined to spend several hours consulting with SRP on “other cases”, preferring brief and immediate responses to their urgent patient needs. Other reported barriers were difficulties distinguishing between MHD appropriate to MH-PCT teams, GP only or specialized care (25%), criteria that could vary according to network expertise and resource availability. Evaluations suggested that SRP spent too much time on MH-PCT consultations (10%) relative to other providers, mostly GP; and that SRP were being highly paid for a service that would otherwise be integrated in their regular practice (10%). Findings identified as main system-level facilitators were: pre-existing relationships with PCT (60%); working in the same hospital as the SRP, more often the case for pediatricians and some MH-PCT (35%); sharing the same electronic medical patient records, which was more characteristic in network hospitals and local community health service centers where MH-PCT and one-stop MH service teams were situated than in family medicine groups that had a separate electronic system (20%); and the optimization of patient treatment (10%). It was thought that the SRP could discuss four cases in the time required by a psychiatrist to complete one patient consultation.

Individual-level barriers related to the reluctance of many GP to treat patients with MHD (40%); discomfort among SRP toward evaluating patients with whom they had not consulted directly, impacting on their civil responsibility (30%); and the delay between GP calls to SRP and their responses which tended to come in the same day, whereas GP often wanted an immediate response (15%). The individual qualities of SRP, their accessibility, sympathetic approach, openness to different practices, knowledge of network resources, and ability to work collaboratively and deal with crises were major facilitators (50%). The ideal SRP would need to be a psychiatrist “champion” to ensure success of this function. Other facilitators were the leadership ability of the head network psychiatrist in supporting the SRP function or ensuring that the SRP function aligned well with main departmental service orientations (30%), and awareness that MH-PCT and one-stop MH service teams consisted of highly respected, senior clinicians.

Perceived impacts of the SRP function according to SRP self-evaluation (questionnaire data, 5-point scale)

Overall, SRP rated the impacts of their function as moderate (Table 5 ). They ascribed high impact (4.0 +) only in terms of their ability to perform patient evaluations, particularly through MH-PCT, as well as their coordination and orientation of patients with specialized services, notably for MH-PCT and for one-stop MH services in child-adolescent psychiatry. SRP evaluated their impacts as low (2.0–2.9) on improving the ability of GP to establish a diagnosis, prescribe and orient patients with substance-related disorders toward counseling and psychotherapy. SRP also acknowledged their lack of impacts on the quantity of patients treated by GP or MH-PCT, on timeliness and effectiveness in treating patients referred by youth centers, and on their capacity to increase the supply of MH services in the networks.

SRP in child-adolescent psychiatry were significantly more positive than those in adult psychiatry concerning the overall impacts of their function (3.2 vs 2.8) in improving patient health and well-being (3.6 vs 3.1), integrating and promoting fluidity between primary care and specialized services (3.7 vs 3.2), and responding adequately to patient needs for service (3.8 vs 3.4). They were also significantly more confident that their function had improved the capacity of MH-PCT to evaluate (4.0 vs 3.4) and treat (3.9 vs 3.4) patients, the capacity of MH-PCT and one-stop MH service teams to coordinate with primary care (3.9 vs 3.3; 4.1 vs 3.4) and specialized care (4.2 vs 3.4; 4.2 vs 3.6), and coordination between MH-PCT and addiction rehabilitation centers (3.9 vs 3.3). They also viewed themselves as having significantly improved the capacity of one-stop MH service teams to orienting patients toward appropriate services (4.0 vs 3.3). GP improvement in pharmacological treatment was the only area where SRP working in adult psychiatry rated their impact as significantly more positive than that of their colleagues in child-adolescent psychiatry (3.5 vs 3.1).

This study was original in focusing on the main activities of Quebec SRP and their impacts on the capacity of primary care providers (MH-PCT, one-stop MH service and GP) and youth centers to treat and orient patients with MHD. Little has been published on the perceptions of psychiatrists regarding the consultation-liaison model or on the SRP function, specifically in Quebec. Results showed that SRP were implemented sparingly in family medicine groups, while they viewed their overall impacts on the consolidation of primary care and youth centers as moderate. This was also the first study to compare the activities and impacts of SRP working in adult versus child-adolescent psychiatry, with more positive results for the SRP function in the latter.

While previous research estimated the total number of Quebec SRP at 446 [ 90 ], roughly half were not active in 2019–20. Our study response rate suggests that fewer than 25% of Quebec psychiatrists worked as active SRP for roughly 1 day a week. Their work focused on supporting either MH-PCT and one-stop MH services, or GP in family medicine groups. Few SRP services were developed in youth centers, and fewer still with GP as compared to MH-PCT and one-stop MH services. Overall, SRP have reached few GP, and the SRP function has not responded as well to their needs as other potential models of integrated MH services. For instance, the use of systematic psychiatric assessment, longitudinal monitoring and care management, as in the collaborative care model, may have better met the needs of GP and patients with MHD, yet these strategies were not included in the consultation-liaison model. As the main providers of MH services for common MHD and gatekeepers to other MH and social services [ 91 , 92 ], GP might benefit more from the SRP function if they adhered more closely to the collaborative care model. Moreover, the SRP function focused more on consolidating services provided by one-stop MH service teams as crucial for promoting service coordination between MH-PCT and specialized care and for reducing wait time for these services. Developed after 2007 in each Quebec network [ 67 , 93 ], one-stop MH service teams with the assistance of SRP also aimed to help GP with treatment of patients with MHD, ensuring that only severe and complex cases were transferred to psychiatric care.

Regarding the main activities of SRP, the finding that patient consultation was the second-highest activity reported in terms of median hours per month for over half of SRP suggests that some SRP had incorporated this characteristic of the collaborative care model into their practices [ 60 ]. As the 2009 agreement stipulated that SRP could meet patients only exceptionally [ 66 ], this change seems to correlate with frequent GP requests that SRP assess their patients directly, bypassing lengthy wait times for accessing one-stop MH service teams or specialized care. The higher total hours per month provided by SRP in adult psychiatry compared with child-adolescent psychiatry can be easily explained by the higher number of primary care clinicians targeting adults for adequate coverage in each network. Both the SRP questionnaire and manager interviews outlined the underutilization of telephone/video availability by SRP between consultations with primary care clinicians or youth centers, and particularly in child-adolescent psychiatry where this service was nonexistent in most networks, mainly due to lack of psychiatrists or the inability of youth centers to coordinate with SRP. In terms of the main SRP activities delivered, the fact that SRP essentially provided GP with medication-related recommendations, MH-PCT and youth centers with recommendations on psychosocial and psychotherapeutic treatments, and one-stop MH service teams with advice on service network orientation was not surprising, as SRP recommendations corresponded to key elements of the mandates under which these service providers operated.

Concerning the comfort level and motivation of SRP, dissatisfaction with the organizational support offered was invoked by both SRP and managers. Formal SRP meetings were rarely held, nor was training or feedback on their activities provided, which may explain the lack of uniformity in their practice. Regarding relationships between SRP and the various teams, their great comfort level with primary care teams but not GP suggests that their specialized expertise was viewed overall as complementary to that offered by psychosocial professionals. Moreover, MH-PCT and one-stop MH service teams consisted largely when created of former MH professionals from specialized services [ 67 ], whose positive collaboration with SRP was likely due to previous shared work experiences. Moreover, the greater motivation and comfort of SRP in child-adolescent psychiatry compared with adult SRP may be explained by their longstanding history of consultations in the community, a highly valued aspect of their practice as previously reported [ 2 , 94 ].

Regarding the profiles of patients met or discussed by SRP, it was not surprising to find a preponderance of patients with low incomes and using few health services, much like patients overall seen in local community health service centers [ 95 , 96 ]. Moreover, the percentage with a family doctor (67%) reported in the study was slightly inferior to that of the general Quebec population (~ 75%) [ 97 ]. SRP patients were also mainly affected by common MHD, corresponding to the profile usually targeted by shared care or collaborative care [ 29 , 38 ]. As well, the proportion of study patients with personality disorders or substance-related disorders was relatively high. GP and other primary care clinicians usually have limited time to treat and follow up such patients whose relationships with health services are often conflicted [ 98 , 99 ]. Finally, diagnoses found mainly in child-adolescent psychiatry (adjustment disorders, attention deficit disorders with or without hyperactivity) were those that affected academic performance, social relationship and the safety of children and adolescents [ 100 , 100 , 101 , 103 ].

Regarding identified barriers/facilitators to the effectiveness of SRP activities, most concerned organizational-level issues. Team instability and frequent staff turnover led to the loss of skills and knowledge hard-won over time [ 55 ]. Lack of involvement in some teams may have reflected little interest in the model or doubts about its capacity to improve skills [ 61 ]. Regarding the difficulty of managing patients without family doctors, the 2005–2010 Quebec MH Action Plan [ 65 ] had recommended two GP per 100,000 inhabitants in MH-PCT, but this target had not been reached. Concerning system-related barriers/facilitators, the availability of appropriate resources [ 55 ], payments or incentives [ 57 , 58 , 59 ], and preexisting relationships between specialized MH services and other care providers [ 56 ] were reported in previous research as key to implementation of the model. Successful deployment of the consultation-liaison model is also impossible without adequate and sufficient human resources, including psychiatrists and GP working in MH-PCT throughout the networks [ 56 , 104 ]. Not least, preexisting relationships are key to the intensity of collaboration necessary for successful implementation of this model [ 22 ]. Regarding individual-level barriers, the reluctance of some GP to embrace the SRP function was reported previously [ 25 ]. Discomfort among SRP in assuming joint liability with clinicians for patients not consulted directly by them was another source of discomfort previously reported in a Canadian study [ 22 ].

Regarding impacts of the SRP function, the perceived moderate impacts of SRP in this study on the ability of GP to establish a diagnosis, prescribe and orient patients with MHD toward counseling and psychotherapy as well as the quantity of patients treated ran counter to previous results [ 30 , 51 ]. Considering that the SRP model had little flexibility and seemed mostly unresponsive to GP needs, SRP continued to have difficulty appealing to GP, who too often showed little interest in treating patients with MHD in their current practices, had little time to discuss treatments with SRP and complained that SRP responses to their urgent questions came too late. By contrast, the longer history of collaboration with primary care and youth centers in child-adolescent psychiatry may account for the more positive impacts of SRP there [ 94 ]. Another possible explanation is that MH primary care services for children and adolescents in Quebec were less developed than adult services, where better results were attained. Some studies suggest that resource scarcity may encourage interorganizational and inter-professional collaboration [ 105 , 106 ].

Limitations

Certain limitations in this study should be noted. First, the study did not investigate the impacts of SRP on patient outcomes. Second, the perspectives of GP and other primary care or youth center clinicians were not investigated. Third, the SRP response rate, while adequate for this type of research with medical doctors, could have been higher. Finally, the results may not be generalizable to other models of integrated MH services in primary care or to diverse MH systems.

Results suggested that the consultation-liaison model as implemented in Quebec since 2009 differed to some extent from what was initially planned, as evidenced in the time SRP dedicated to direct consultations with patients with or without other clinicians. Results also showed that SRP were generally motivated and comfortable in their function, notwithstanding lack of support from their organizations. Support for SRP needs to be increased in terms of integrating training programs, monitoring meetings, and sharing patient data among providers. Forums for regular professional support among SRP, tailored to their specific needs, are recommended, allowing them to exchange experiences and challenges, increase their comfort/motivation with the SRP function, and feel less isolated in their work. Such meetings could be organized with SRP in adult and child-adolescent psychiatry. Virtual SRP meetings should be encouraged particularly in isolated regions or in geographically extensive areas to promote more efficient collaboration. A standardized provincial guide on best practices for SRP, with particular focus on treating cases of MHD in primary care or specialized services, could be produced. More flexibility toward implementation of the model may also be advisable, as well as better adaptation of the model to territorial characteristics. SRP had a less positive impact on GP in family medicine groups, suggesting the need for increased adaptation of the model to meet GP needs. Perhaps the Quebec model may be more closely aligned with the collaborative care model, based on the generic Wager chronic care model, including the stepped-care approach. Other than modifying GP payment schemes to increase their motivation to collaborate with SRP, the orientations supported by MH reforms need to be better integrated with government directives regarding the consolidation of primary care. Lack of access to a family doctor for all citizens is another major issue that hampers the SRP function. Systemic problems, mainly professional instability, particularly in MH-PCT, long wait times for access to MH-PCT and psychiatric care and the implementation of innovations especially for GP and youth centers should be tackled without delay. Better working conditions including incentives for personnel retention and adaptation of best practices are greatly needed. As well, wider deployment of liaison nurses working closely with SRP and their partners may improve coordination between primary care and specialized MH services. Regarding future research, it would be interesting to compare the perspectives of primary care clinicians with those of SRP and further investigate differences among SRP in terms of their profiles, work characteristics and impacts on primary care MH consolidation.

Availability of data and materials

The datasets generated and analysed during the current are not publically available, signed confidentiality agreements preventing us from sharing the data, but are available from the corresponding author on reasonable request.

Abbreviations

General practitioners

Mental health

Mental health disorders

Mental health primary care teams

Specialist respondent-psychiatrists

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Acknowledgments

We thank the individuals who participated in the research especially the specialist respondent-psychiatrists, the psychiatrist department heads or other clinician-managers interviewed, as well as the research team including our advisory committee made of key decision-makers who help with the study data collection. We would like to thank Armelle Imboua who coordinated this research project, and Judith Sabetti for editorial assistance.

This study was funded by the Canadian Institutes of Health Research (CIHR), grant number 8736. The funding agency had no further role in the study design, data analysis and interpretation, the dating of the manuscript or the decision to submit this article for publication.

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MJF designed the overall research project and was responsible for the data collection. MJF, LG and GG designed analytical plan for the article. LG, GG and MJF wrote the article. LG produced the quantitative analyses and tables. PR revised the final version of the article. All authors read and approved the final manuscript.

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Sample quotations for specialist respondent-psychiatrist (SRP) managers: Main barriers (--) and facilitators (++) to implementation of the SRP function.

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Fleury, MJ., Grenier, G., Gentil, L. et al. Deployment of the consultation-liaison model in adult and child-adolescent psychiatry and its impact on improving mental health treatment. BMC Fam Pract 22 , 82 (2021). https://doi.org/10.1186/s12875-021-01437-5

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Certificate of Advanced Training in Consultation–liaison psychiatry

Overview of the certificate.

When you specialise in consultation–liaison psychiatry you will:

• gain clinical work experience in psychiatry training posts
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See the entry requirements for this certificate

Duration, study and training load

It takes at least 24 months to complete this certificate. You have up to six years to complete all of the requirements.  

During this time you will complete:

• 24 months of full-time equivalent training in consultation-liaison psychiatry posts 
• eight EPAs, two per 6-month rotation
• regular workplace-based assessments
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• case summaries
• study requirements based on your formal or self-directed learning.

Clinical work experience

You must undertake 24 months of full-time training in consultation-liaison psychiatry training posts, covering the following experiences:

General hospital liaison including emergency

Complete 12 months FTE in a consultation-liaison service consulting across an entire general hospital, including emergency work.

Medical or surgical unit 

Complete one or more liaison-style attachments to a unit providing medical or surgical treatment (at least one day per week of FTE for at least 12 months)

Outpatient service including chronic physical illness

Complete an outpatient experience, including longitudinal follow-up of patients with chronic physical illness of at least one half-day per week FTE for at least 12 months.

Subject to approval, up to 12 months of FTE can be spent in another area of clinical practice, in research or in medical administration.

Trainees must not spend more than 30 per cent of their time during standard work hours in an emergency department. ‘Standard work hours’ does not include after-hours or on-call work.

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Consultation-Liaison Psychiatry—from theory to clinical practice: an observational study in a general hospital

Giuseppina de giorgio.

Functional Homogeneous Area, Local Health Authority 3, Umbria, Italy

Roberto Quartesan

Section of Psychiatry, Clinical Psychology and Psychiatric Rehabilitation, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy

Tiziana Sciarma

Martina giulietti.

Department of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy

Angela Piazzoli

Laura scarponi, silvia ferrari, laura ferranti, patrizia moretti, massimiliano piselli.

Psychiatry School, University of Perugia, Perugia, Italy

To investigate significant association between various clinical and extra-clinical factors brought out the activities of Consultation-Liaison Service.

Data from all psychiatric consultations for patients admitted to the Perugia General Hospital and carried out over a 1-year period (from July the 1st 2009 to June the 30th 2010) were collected by a structured clinical report including: socio-demographic features, features of referrals, features of back-referrals. T-test, Mann–Whitney U-test, χ 2 -test and Fischer’s were statistically used.

1098 consultations were performed. The consultations carried out the Emergency Unit were excluded from the study. The type and the reasons for the referrals were discussed such as the ICD-10 diagnosis and the liaison interventions too. Significant associations emerged between gender and: social status and occupation ( p  < 0.05 and p  < 0.01 respectively). Clinical sector related with reason for referral ( p  < 0.01), type of consultation ( p  < 0.01), liaison investigations ( p  < 0.01) and long-term treatment plan after hospital discharge ( p  < 0.01). The ICD-10 psychiatric diagnosis (Schizophrenia, Affective Syndrome and Neurotic-StressSomatoform Syndrome) was associated with social status ( p  < 0.01), social condition ( p  < 0.01), consultation type ( p  < 0.01), advice ( p  < 0.01) and reason for consultation ( p  < 0.01).

Conclusions

The need for better physical and psychological investigation is confirmed in order to promote not only disease remission but overall wellbeing.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1375-6) contains supplementary material, which is available to authorized users.

Over the past two decades research in psychiatry has identified Consultation-Liaison Psychiatry (CLP) as “The guardian of holistic approach to the patient” [ 1 ], underlining its pre-eminent role in management of patients who are admitted to a general hospital. The CLP objectives and operating procedures have evolved in recent years from administration of psychiatric treatment [ 2 ] to integrating therapy [ 3 ] into the bio-psyo-social model along the lines of the recommendation from an editorial in the Lancet “No health without mental health” [ 4 ]. Hospital staff are confronted daily by physical/psychiatric multimorbidity [ 5 ] with its extensive costs of suffering for patient and consumption of medical and economic resources [ 3 ]. It is worth noting that psychiatric disorders, even when sub-clinical [ 6 ], worsen outcome, lengthen hospital stays and are associated with increased mortality and use of health service resources [ 7 , 8 ].

Although early detection and treatment of psychological distress and psychiatric disorders in comorbidity are known to reduce health care costs significantly [ 9 ], in Italy no shared systematic schema of CLP interventions has, as yet, been drawn up. Whereas CLP was token systematically, various limits appeared, underlying the need to apply new method both inside and outside of general hospital [ 10 , 11 ].

Moreover, awareness of how interdependent the psychological and physical features of disease are, appears to have widened the gap between research and clinical practice. The former measures outcome efficacy using parameters of little relevance to medicine overall [ 12 ], and the latter cannot intervene without taking into account social and health service organization and the network of family and social assistance that obtain [ 13 ].

All over the medicine understand that psycho-social features influence aetiopathogenesis and prognosis of many chronic disease such as ischemic heart disease, diabetes, cancer [ 14 ]. All over the medicine understand that psycho-social variables are crucial to management of the patient with multi-morbidity and “unexplained medical symptoms”, to the doctor–patient relationship, response to therapy, maintenance of illness behaviour and the onset of psychiatric complications in medical illness [ 15 ]. However this awareness has not yet brought significant change in research and particularly in clinical practice, with its two-pronged interventions directed towards patients (in consultation) and towards physicians and surgeons in other hospital units (in liasion). This raises the question of creating multi-disciplinary teams with the psychiatrist mediating CLP integration and system [ 16 ]. Furthermore, the unique features of CLP and the difficulties in implementing it are due to patients lacking both awareness of their own psychiatric disturbances and not personally requesting intervention [ 16 ].

Regarding research, few reports are available on long-term follow-ups and outcomes. Most studies are retrospective and descriptive [ 17 , 18 ], and often cannot be compared because of structural and methodological differences [ 17 ].

The success of CLP intervention depends on variables such as how the service is organised, the team experience and uniformity of intervention and ability to establish good lines of communication with specialists in internal medicine [ 19 ]. The consultant psychiatrist, when called upon to coordinate, inform and educate [ 16 ], needs standard procedures, guidelines and quality indicators [ 20 ]. This observational study describes CLP activity as conducted in Perugia General Hospital, Italy, with the aims of assessing

• which hospital unit most requested psychiatric consultation;
• what factors were most closely associated with the request (medical and psychiatric diagnosis, drug and psychological therapy) and
• the role bio-psycho-social variables played in determining the above factors.

CLP activity was performed by the Psychiatry, Clinical Psychology and Psychiatric Rehabilitation Unit, University of Perugia at Perugia General Hospital, Italy. The hospital has 740 beds for inpatients and Day Hospital/Surgery Services and treats about 43,500 patients per year.

The Psychiatry, Clinical Psychology and Psychiatric Rehabilitation Unit receives requests for urgent or planned consultations, via intranet, from all hospital units (in- and out-patients) and the Accident and Emergency Unit. Urgent requests are prioritized and all consultations are carried out within 24 h of request. Written comments and diagnosis according to Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-IV TR) [ 21 ] are provided. For present study purposes DSM-IV TR diagnoses were transformed into ICD-10 diagnoses. Upon patient discharge, the Psychiatry Unit contacts local health services, general practitioners (GPs) and, when required, organises patient transfer to other psychiatric institutes. All these activities are conducted in accordance with ECLW proposals for standardized data collection and training (1996), using a data collection form derived from the Patient Registration Form [ 22 ] and full-team participation in weekly supervision sessions [ 23 ].

In the present study consultations were carried out between 1st July 2009 and 30th June 2010, 6 days a week from 8.00 a.m. to 8.00 p.m. A pool of psychiatrists from Local Health Board No 2 in Umbria was on call for consultations at other times. All patients were over 18 years of age. To group data, Hospital Units requesting consultation were assigned to one of three sectors: medical, surgical or specialist 1 (Additional file 1 : Table S1).

The data were scheduled into:

• socio-demographic features;
• referrals features (urgency, referrals reason, referring ward, medical co-morbidity);
• referrals result (psychiatric history, psychiatric diagnosis, therapy, pharmacologic prescription).

Statistical analysis

Continuous variables were analysed by T-test and non-parametric variables by the Mann–Whitney U-Test. Categorical variables were analysed by the χ 2 -tests and Fischer’s exact test. Significance was set at p  < 0.05. The SPSS programme (version 12.0) was used for data analysis.

In the mentioned time 1098 psychiatric consultations were carried out (932 first examinations and 166 check-ups).

First examinations: 275/932 (29.5 %) were requested by the Accident and Emergency Unit (A&E) and the other 657 (70.5 %) from other Hospital Units. Excluding A&E requested from the present data analysis because the Unit did not have in-patients, a total of 811 patients were examined in psychiatric consultations. They constituted 1.8 % of the total number of in-patients. 657/811 patients (81 %) received only one examination and 154 (19 %) more than one. Additional file 1 : Table S1 reports the socio-demographic characteristics of patients who received psychiatric assessment through consultation.

Almost all the inpatients were from Europe, the mean age was 57.9 (SD ± 19.4); the female were 60.8 %; married people were 47.5 %; in most cases (39.5 %) the inpatients were pensioner.

Details of consultations: 24.7 % of requests were flagged as urgent and 84.6 % of patients had been informed of the request. Medical units provided 53.1 % of requests for psychiatric consultation, surgical units 8.8 % and specialist units 38.1 %. The most common reasons for requesting consultation were anxiety (18.9 %), symptoms of depression (18.2 %), confusion (13.4 %), unexplained somatic symptoms (11.2 %), suicide attempt/risk (11.2 %), psychomotor agitation (10.9 %) and history of psychiatric illness (14.4 %). Reasons from medical units focused on anxiety (22.3 %) and depression (16.9 %) (Additional file 1 : Table S2).

The main reasons for consultation from surgical units were suicide attempt/risk (31 %) and agitation (21.1 %) (Additional file 1 : Table S2). The specialist units motivated requests on the grounds of depression (21.7 %), unexplained somatic symptoms (17.8 %) and anxiety (159 %) (Additional file 1 : Table S2).

Referrals result: A history of psychiatric illness was present in 41.3 % of patients and 60.8 % used psychoactive drugs (usually benzodiazepine and/or antidepressant agents). Only 17.5 % of patients was being treated by the health service when hospitalised. The most common ICD-10 diagnoses (International Classification of Disease) were Somatic–Neurotic–Stress Syndrome (28.7 %) and Affective Syndromes (26.6 %).

The psychiatric consultation was the only diagnostic intervention in 83.3 % of cases. Liason interventions were mainly directed towards medical and nursing staff of the Unit requesting consultation (66.2 %). Therapeutic interventions included patient interviews (47.5 %) and prescription of psychoactive drugs (60.3 %). Benzodiazepine and antidepressant were the most prescribed drugs. However, use of BDZ as monotherapy was reduced from 14.5 % at admission to 8.1 % and monotherapy with neuroleptic agents was increased from 6.2 % at admission to 8.2 %. The discharge plan of care included referral to the CSM (24.8 %), to the Psychiatric Unit day service (20.1 %) or to the patient’s GP (17.1 %).

Associations between variables

Significant associations emerged between gender, the two options for marital status ( p  < 0.05), occupational status ( p  < 0.01) and information about the consultation ( p  < 0.05). Males were more frequently single and in work than females (Additional file 1 : Table S3).

Sources of requests for consultation correlated significantly reasons for requests ( p  < 0.01), the type of consultation ( p  < 0.01), interventions for diagnosis ( p  < 0.01), liason ( p  < 0.01) and discharge programme (<0.01).

Patients who had attempted or were at risk of suicide were more often admitted to surgical units which most frequently requested urgent consultations (Additional file 1 : Table S4).

The main ICD-10 psychiatric diagnoses (schizophrenia, affective or neurotic-stress-somatoform syndromes) were significantly associated with marital status ( p  < 0.01), socio-environmental status ( p  < 0.01), type of consultation ( p  < 0.01), patient information ( p  < 0.01) and reason for request ( p  < 0.01).

Post hoc analysis showed that patients with schizophrenia lived with their original families, were single, pensioners or invalids, assessed in urgent consultations, less informed than others and directed to the CSM when discharged, after having been put in contact with the CSM during the consultation (Additional file 1 : Table S5).

For patients with affective syndromes, suicide attempt or risk and depression were the reasons for requesting consultation. They were directed to their GP upon discharge from hospital (Additional file 1 : Table S5). Patients with neurotic-stress-somatoform syndromes had jobs and were assessed because of anxiety and unexplained medical symptoms. The main liason intervention was raising awareness among medical and nursing staff in the unit where they were being treated. Upon discharge they were directed to their GP or to the Psychiatry Unit Out-patient Service (Additional file 1 : Table S5).

The present study used a CLP service that was structured according to setting and codified assessment procedures [ 24 ]. As features satisfied some recommendations that have been reported in other papers the service may thus be considered valid for implementing compliance with CPL interventions and evaluating their effectiveness [ 19 ].

In particular referring to description of population and clinical variables the authors close:

• sending requests by intranet ensured the request is clearly stated, and facilitated identifying the most appropriate form of intervention and measurement tools [ 16 ];
• performing consultation within 24 h of request improved treatment compliance [ 19 ];
• adopting the “clinimetric” [ 25 ] rather than the “psychometric” approach led to detection of sub-clinical symptoms and of deficits in some functional areas that persisted after treatment [ 26 ];
• applying qualitative rather than quantitative parameters provided a more accurate definition of outcomes [ 27 ];
• writing down consultation findings encouraged communication within the multidisciplinary team [ 16 ];
• finally, as one feature of the CLP service was a link with the community health and social services, information could be provided about treatment plans after discharge from hospital [ 14 ].

Details of consultations: Consultations were requested for 1.8 % of all hospital admissions, which was in line with reports over the years of 1–2 % requests [ 28 ]. As observed elsewhere, most patients received only one consultation examination and required psychiatric treatment while in hospital [ 29 ].

Social backgrounds and demographic data from patients in the present study were also in line with other reports [ 30 ].

Adequate information was imparted to 80 % of patients during the consultation, which is a rise in the 66 % reported in an earlier Italian study by Gala [ 31 ]. The improvement may be due to World Health Organization (WHO) campaign which emphasizes that Mental Health is a crucial part of psycho-physical well-being [ 32 ]. The present study showed that schizophrenia was the only factor impacting upon lack of patient information, unlike a previous study of ours which had correlated male gender with poor patient information [ 33 ]. Provision of information to the patient with schizophrenia may be hampered not only by the patient’s psychopatology such as limited insight and sometimes bizarre behaviour studio [ 34 ], but also by the urgent status of consultation requests because of the patient’s agitation or distorted perception of, and contact with, reality [ 35 ]. The stigma arisen from referring area is to be confirmed.

The high prevalence of patients with affective and neurotic-stress somatoform syndromes in medical and specialist units focuses attention on physical/psychiatric multi-morbidity and the difficulties in medical and psychiatric managing patients with somatisation or with somatic expression of psychological pain [ 36 ]. In the surgical sector only about 20 % of requests were motivated by agitation due to physical distress [ 37 ], which illustrates the need for flexible, personalised interventions that not only satisfy the demands of patients and medical staff but which can also be adjusted to fit diverse clinical situations [ 38 ].

Findings in the present study show the usage rate of an in-depth diagnostic flow chart with psychometric and laboratory tests overlaps with Italian [ 31 ] and European [ 30 ] reports. Although more drugs were prescribed in interventions than is the trend in Europe, the drug prescription rate was still below what Gala reported in 1999. In any case drug treatment was the most common form of intervention [ 39 ], followed by staff support. In general, the most frequently prescribed drugs were anti-depressive agents and BDZ [ 31 ].

It is hard to compare the 38 % rate of expressive/supportive interventions which emerged in the present study with other reports because parameters vary greatly [ 40 ]. Even though reports demonstrate that in the hospital setting this form of intervention is more effective than interventions directed towards personal or family support or focal psycho- education or therapy, few data are available on the prevalence of expressive/supportive interventions probably because the use of such techniques in CLP has not been standardized. Hunter et al. [ 40 ] suggested developing a multi-focal setting to identify pre-morbidity and stressor factors that interfere with patient acceptance of illness and hospitalization and which are the focus of therapy.

Finally, a much lower rate of patient transfer to psychiatric units than reported elsewhere [ 41 ], and promotion of treatment plans after discharge from hospital provide evidence of the success the present approach, which aimed at reducing staff anxiety and promoting total care of the patient.

Hospitalization in itself is a stressful event which may disturb balance of mind in some cases and worsen the clinical condition of patients who are suffering from psychiatric co-morbities [ 42 ]. Without specialized training medical and nursing staff may not recognize psychological distress and consequently delay early intervention [ 43 ]. A CLP service is able to raise awareness among health service personnel and improve detection of psychological problems in patients, both of which have beneficial repercussions on the length of hospital stays and the well-being of patients. CLP, however, still needs to develop clinical and research standards that are in line with the trend towards Evidence Based Medicine. Innovative methodological tools are required to establish qualitative parameters [ 44 ].

A systemic schema of interventions will censure psychiatrists confront the full complexity of diagnosis and therapy, promote all round care of the individual patient and use liason interventions to foster multidisciplinary teamwork.

Authors’ contributions

DGG have made contribution to conception and design of the study, was involved in acquisition and interpretation of data, written the preliminary version of the manuscript and collaborate to the final draft. QR encouraged the study, provided to the supervision of the research group, revised the manuscript for intellectual content and gived the final approval to the version to be pubblished; ST: have made contribution to the conception and design of the study, and cooperated to write and to revise the manuscript; GM: have made contribution to acquisition the data; PA: have made contribution to acquisition the data; SL: have made contribution to conception and design, acquisition and interpretation of data; FS: have made contribution to conception and design; FL: have made contribution to acquisition the data; MP was involved to revised the manuscript. PM: have made contribution to conception and design, analyzed the data and cooperated to revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We thank Geraldine Boyd who provided medical English translation on benhalf “Centro Linguistico d’ Ateneo”-University Language Center-Perugia University, funding by Division of Psyvhiatry-University of Perugia.

Compliance with ethical guidelines

Competing interests The authors declare that they have no competing interests.

Ethical approval This study was aproved from Comitato Etico Aziende Sanitarie dell’ Umbria–Umbria Health Service Ethic Committee with license number 2176/13.

Additional file

Additional file 1. Data analysis of clinical investigation. (246K, pdf)

1 MEDICAL SECTOR: internal medicine and endocrine science; occupational medicine; internal medicine, angiology and atherosclerosis; internal medicine and oncologic ward; internal and vascular medicine ward. SURGICAL SECTOR: intensive care; heart surgery; general surgery; thoracic surgery; vascular surgery; orthopedics; neurosurgery. SPECIALISTIC SECTOR: cardiology; dermatology; hematology; gastroenterology; geriatric ward; infectious medicine; nephrology; ophthalmology; oncologic ward; otorhinolaryngology; obstetrics and gynecology; neurology; lung ward; urology; spinal unit.

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The role of a psychiatric consultation liaison nurse in a general hospital: a case study approach

Affiliation.

• 1 The Centre for Psychiatric Nursing Research and Practice, The University of Melbourne, Australia.
• PMID: 12405282

Growing support for the role of the psychiatric consultation-liaison nurse in assisting general nurses in caring for patients experiencing mental health problems in the general hospital environment is evident from the relevant literature. However, there remains a paucity of research which examines the process of this nursing role or its impact on outcomes for nurses and patients. This paper seeks to contribute to the literature in articulating the role of the psychiatric consultation-liaison nurse using a case study approach to describe the role of the nurse in assessing the needs of, and, planning and providing care to two general hospital patients experiencing mental health problems, and the general nurses caring for them.

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The role of a psychiatric consultation liaison nurse in a general hospital: a case study approach

The Australian journal of advanced nursing: a quarterly publication of the Royal Australian Nursing Federation

Growing support for the role of the psychiatric consultation-liaison nurse in assisting general nurses in caring for patients experiencing mental health problems in the general hospital environment is evident from the relevant literature. However, there remains a paucity of research which examines the process of this nursing role or its impact on outcomes for nurses and patients. This paper seeks to contribute to the literature in articulating the role of the psychiatric consultation-liaison nurse using a case study approach to describe the role of the nurse in assessing the needs of, and, planning and providing care to two general hospital patients experiencing mental health problems, and the general nurses caring for them.

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Julie Sharrock

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Terence McCann

Journal of medicine and life

This article reviews some of the recent data concerning Consultation-Liaison Psychiatry in a general hospital. As the organic medical conditions have a major impact on the one&#39;s quality of life and self-awareness as an ill-person, very often a psychiatric disorder appears as co-morbidity. It is the responsibility of the psychiatrist to recognize and to treat these psychiatric conditions, and also to develop good work-relationships with the patients and the clinical team.

BMC Health Services Research

Matt Fossey

Background To describe the clinical activity patterns and nature of interventions of hospital-based liaison psychiatry services in England. Methods Multi-site, cross-sectional survey. 18 acute hospitals across England with a liaison psychiatry service. All liaison staff members, at each hospital site, recorded data on each patient they had face to face contact with, over a 7 day period. Data included location of referral, source of referral, main clinical problem, type of liaison intervention employed, staff professional group and grade, referral onto other services, and standard assessment measures. Results A total of 1475 face to face contacts from 18 hospitals were included in the analysis, of which approximately half were follow-up reviews. There was considerable variation across sites, related to the volume of Emergency Department (ED) attendances, number of hospital admissions, and work hours of the team but not to the size of the hospital (number of beds). The most common cli...

International Journal of Mental Health Nursing

BMC research notes

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To investigate significant association between various clinical and extra-clinical factors brought out the activities of Consultation-Liaison Service. Data from all psychiatric consultations for patients admitted to the Perugia General Hospital and carried out over a 1-year period (from July the 1st 2009 to June the 30th 2010) were collected by a structured clinical report including: socio-demographic features, features of referrals, features of back-referrals. T-test, Mann-Whitney U-test, χ(2)-test and Fischer&#39;s were statistically used. 1098 consultations were performed. The consultations carried out the Emergency Unit were excluded from the study. The type and the reasons for the referrals were discussed such as the ICD-10 diagnosis and the liaison interventions too. Significant associations emerged between gender and: social status and occupation (p &lt; 0.05 and p &lt; 0.01 respectively). Clinical sector related with reason for referral (p &lt; 0.01), type of consultation (p...

Makombo Ganga-Limando

Since 2002, all health establishments in South Africa including district hospitals are compelled by the Mental Health Care Act No. 17 of 2002 to admit acute psychiatric patients for 72 hours without consent for assessment and observation. The admission of psychiatric patients and those with medical conditions in the same units came with new challenges for the healthcare team. With the shortage of psychiatric trained nurses in most settings, non-psychiatric nurses are expected to work with psychiatric patients. The purpose of the study was to explore and describe the concerns of non-trained psychiatric nurses who work with acute psychiatric patients. Indepth interviews with 15 general nurses were carried out between January and March 2013 in a Government Hospital in South Africa. Data collection and analysis were carried out simultaneously and a modified Tesch method of data analysis was used. Two themes emerged from the analysis ( safety related concerns and psychiatric nursing rela...

Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association

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Hospitals and emergency departments (EDs) are caring for increasing numbers of patients who present with underlying mental health issues. Managing these patients can be challenging for clinical staff who often lack the specialist knowledge and skills required to provide appropriate care. This article, part two of two on the evaluation of a newly formed mental health liaison team (MHLT) working in a general hospital, focuses on the perceptions and experiences of the MHLT participants, and explores three sub-themes derived from the interview data. The article considers the effect of these themes on practice, and the relationship between MHLT members and staff in EDs and the wider hospital.

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Pediatric Consultation-Liaison: Models and Roles in Pediatric Psychology

• First Online: 21 March 2020

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• Bryan D. Carter 5 , 6 ,
• Kevin K. Tsang 7 ,
• Christine E. Brady 5 , 6 &
• Kristin A. Kullgren 8  

Part of the book series: Issues in Clinical Child Psychology ((ICCP))

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Ever since the establishment of the subspecialty of pediatric psychology, psychologists have been called upon to provide consultation to their pediatrician colleagues in ever-expanding roles and in a variety of medical settings. In response, a number of models have been created to address how psychologists fit into the overall health-care system in order to address those psychosocial factors that can have a major impact on prevention/early intervention in pediatric illness and injury and overall adjustment and quality of life. This chapter addresses both theoretical and pragmatic issues in establishing and maintaining a viable consultation-liaison service while avoiding personal and professional burnout.

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Carter, B.D., Tsang, K.K., Brady, C.E., Kullgren, K.A. (2020). Pediatric Consultation-Liaison: Models and Roles in Pediatric Psychology. In: Carter, B.D., Kullgren, K.A. (eds) Clinical Handbook of Psychological Consultation in Pediatric Medical Settings. Issues in Clinical Child Psychology. Springer, Cham. https://doi.org/10.1007/978-3-030-35598-2_2

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Consultation-Liaison Case Conference: Assessment and Management of a Physician with Thoughts of Suicide.

• M. Schimpf , Liliya Gershengoren , +2 authors Scott A Simpson
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