Consultation Liaison Psychiatry ( C-L-P )

Prof. DR. Dr. M Syamsulhadi, SpKJ (K)

S. SOCIAL

BIOPSYCHOSOCIAL

S. PSYCHOLOGY

GEORGE L ENGEL

S. BIOLOGY

CLP
MEDICAL ASPECS + PSYCHIATRY QOL, BRIEF, EFFICIEN, FRIENDLY MEDICAL SERVIS

Dotted lines: negative regulatory Solid llines: positive regulatory

Andrea H Marques, Giovanni Cizza, Esther Sternberg. Brain-immune interactions and implications in psychiatric disorders. Rev Bras Psiquiatr. 2007;29(Supl I):S27-32

Dennis H. Novack, M.D., Oliver Cameron, M.D., Ph.D. Elissa Epel, Ph.D., Robert Ader, Ph.D., Shari R. Waldstein, Ph.D. Susan Levenstein, M.D., Michael H. Antoni, Ph.D. Alicia Rojas Wainer, M.D.Psychosomatic Medicine: The Scientific Foundation of the Biopsychosocial ModelAcademic Psychiatry, 31:5, September-October 2007

DEFINITION
Definition at Indonesia Based on meaning of CLP term it self : Consultation - clinical references for examination and management suggestion. Liaison - connector. Liaison Psychiatry knowledge that develop for that purpose. Liaison Psychiatrist - conector psychiatrist that do the task psychiatry liaison. Consultation-Liaison Psychiatry term based on practice clinical need (companion).

DEFINITION
Based on opinion of Pasnau and Lipowski than define CLP as: Subspecialist psychiatry knowledge root that intense psychiatric aspect from another medical condition, including evaluation, diagnosis, therapy, prevention, study and education.

C-L-P
Development of psychiatry in relations with another general medical field/another connected field.
Connect medical knowledge with psychosocial/behavioral aspect. Point at final purpose therapy: recover good quality of life (not only cure from symptom/disease).

CLP
Not only psychiatric consultation
Cant learn it in short time. Important to start with concept understanding. Prepare and intent from psychiatry field. Understanding and preparation of another medical field. Make a collaboration.

CLP GENERAL MANAGEMENT

1. Liaison psychiatry working consept
Primary, secondary, tertiary prevention Detection & Diagnosing (CLP vs. Consults Psi) Health services evaluation (group responsible) Giving authority to non psychiatry staff Develop new knowledge Change health service structure ( Modern Service )

 2. CL preparation and aplication (at Indo)?

a. Consultant psychiatry
CP quality and effectively and competency (Abel?Leader) Another physician hope (Dx, Gx, Tx, Help)

b. Approximation in consultation
Examination models (Psychoanalytic?, > cog) Helping aid and skill Consultation process

 3. Organization Structure CLP Service

General organization field Group practice CLP with another specialist

Required skills for the evaluation and treatment of patients with psychiatric disorders in the general medical setting
1. Ability to take a medical-psychiatric history 2. Ability to recognize and categorize symptoms 3. Ability to assess neurological dysfunction 4. Ability to assess the risk of suicide 5. Ability to assess medication effects and drugdrug interactions 6. Ability to know when to order and how to interpret psychological testing 7. Ability to assess interpersonal and family issues 8. Ability to recognize and manage hospital stressors 9. Ability to place the course of hospitalization and treatment in perspective 10. Ability to formulate multiaxial diagnoses 11. Ability to perform psychotherapy 12. Ability to prescribe and manage psychopharmacological agents 13. Ability to assess and manage agitation 14. Ability to assess and manage pain 15. Ability to administer drug detoxification protocols 16. Ability to make medicolegal determinations 17. Ability to apply ethical decisions 18. Ability to apply systems theory and resolve conflicts 19. Ability to initiate transfers to a psychiatry service 20. Ability to assist with disposition planning

Health services as system

EXT

DISORDER

SICK,

Health services

QOL

INT

CASE FINDING APPROACH

Liaison approach direct to medical staff sensitivity increasing, so that its can product more effective budget management and early detection at patient services.

Approach Method
1. Non structure interview 2. Structure interview 3. Self-report

MANAGEMENT SYSTEM CASE FINDING

OPERATIONAL PROCEDURE HEALTH SERVICES

QUALITY OF LIFE PATIENT

MEDICAL SERVICES EFFECTIVITY

Criteria for Identification of an Emergency by Consultation-Liaison Psychiatrists

1. Psychiatric antecedents 2. Agitation 3. Suicidal thoughts and attempted suicide 4. Confusional state 5. Other symptoms indicating a serious psychiatric state (depression, anxiety, state of shock, borderline state, or catatonic state) 6. Substitute treatment (methadone) for a drug-dependent patient 7. Forensic problem 8. Transfer to a psychiatric ward 9. Psychiatric symptoms linked to the perspective of somatic treatment 10. Patient should be seen before the weekend

Categories of Psychiatric Differential Diagnoses in the General Hospital

Psychiatric presentations of medical conditions Psychiatric complications of medical conditions or treatments Psychological reactions to medical conditions or treatments Medical presentations of psychiatric conditions Medical complications of psychiatric conditions or treatments Comorbid medical and psychiatric conditions
Source: Adapted from Lipowski 1967

Procedural Approach to Psychiatric Consultation

Speak directly with the referring clinician. Review the current records and pertinent past records. Review the patients medications. Gather collateral data. Interview and examine the patient. Formulate diagnostic and therapeutic strategies. Write a note. Provide periodic follow-up.

Case Finding Role

Active Pasive Team work Service system

DIAGNOSIS

DIAGNOSIS

Case finding
Examination back up Fx ( MRI, CT-Scan, EEG ) Ability for evaluate and manage Chemical examination (drugs level, estrogen, thyroid, ureum, creatinin ) Psychometri ( MMPI, MMSE, structure interviewed)

Anamneses
Screenings Filling list -sociodemografic background -somatic complain -emotion change -history of illness -history of drugs abuse Laboratory Another examinations

Medical condition etiologically related to depression

Neurologycal disorders Stroke Parkinsons disease Multiple sclerosis Epilepsy Hutingtons disease Dementia Endocrine disorders Hyperthyroidism Hypothyroidism Cushings syndrome Addisons disease Hyperpharathyroids m Hyperprolactinemia

Cancer

Medications

Medications and Psychoactive substances assosiated with depression

Antihypertensive Reserpin Metyldopa -Blockers Cancer chemotherapeutic agents Vincristin Vinblastin Procarbazine Amphotericin B Interferon

Streroids
Oral contrasceptives

Histamine resceptor antagonists Cimetidine Ranitidine

Psychoactive substance Alcohol Opiate Amphetamine/ cocaine

INTERVENTION
Step between diagnosis and treatment Preparing patient for treatment

Communic ation with patient

Communica tions skills

Patient recieved therapy

FRAMES
F = Feedback on the patients risk or impairment R = Responsibility for change belongs to the patient A = Advice to change should be specific and nonambiguous M = Menu of alternative strategies E = Empathetic rather than confrontational counseling style S = Self-efficacy : a positive view of patients ability to change and the treatments efficacy

A. MIND AND BODY INTERACTION

Sex

Constitution
Strength resources & other support Life experience

PERSON

Age
Life phase

Religion
Culture Believe
(Wibisono, 2007)

B. CLP TREATMENT GUIDELINES

The site of psychiatric treatment and the use of psychiatric consultants is currently a matter of : 1. preference, 2. the patient's acuteness, 3. risk factors, 4. availability of local resources. C-L psychiatrists usually use biological and psychotherapeutic treatments that have demonstrated efficacy.
(Westphal J.R dan Freeman A.M, 2000)

a.BIOLOGICAL/PHARMACHOTHERAP Y TREATMENT
Treatment principle in CLP : 1. Remember that discontinue treatment sometimes is a beneficial action 2. If possible, need to avoid recipe if needed treatment 3. If there is a require to give if needed treatment dose, observe using frequency to decide precise dose level 4. That is important to use minimum dose in maintenance the targets response 5. Change one drug in one time

Treatment principle in CLP cont

6. If possible, used only one drug to treat patient disorders

or symptom 7. Keep to make simple mixed drug 8. Dont give prophylaxis drugs except there is a rational reason 9. Use drugs with proved efficacy 10. Remember that serum drugs levels only one indicator of effect, not evidence for efficacy or toxicity 11. Need to know that generic drugs more cheap but the bioavailability may low 12. Consider that each patient show a new experience

(Jachana, Lane, dan Gelenberg, 1996)

Principle in choosing drugs

1. 2. 3. 4. 5. 6. 7. Effect on clinical problems. Effect on basis desease. Implication side effect figure. Interaction with somatic drugs. Oral or parenteral drugs. Lever or kidney function and dose. Biological matching?
(Malt, 2006)

FACTORS THAT INFLUENCE ADHERENCE

Insight into illness Perception of severity of illness Perception of tendency to relapse Acceptance of illness Type / symptoms of illness Degree of support Stability of family Doctor-patient relationship Type of administration Method of prescription Psycho-education Therapy supports: symptom diary, text messages to a mobile phone Side effects Primarily critical attitude Lack of symptom control Complex therapy regimen Type of therapy

Changes in lifestyle
Substance abuse Stigmatisation Package insert

Fenton et al 1997; Lacro et al 2002

b. Psychotherapy
Prime form psychotherapy
1. Dynamic psychotherapy. 2. Humanistic-experience psychotherapy. 3. Cognitive-behavior psychotherapy. 4. Ecletic and integration psychotherapy.
(Nash, 2000)

There is some adaptation for psychotherapy technique at patient with medical illness
1. Focus on supportive than conflict, built therapeutic relations that give safe felling. 2. Strengthen resources that patient have. 3. Facilitate patient emotion flooding. 4. More structure in make safety therapeutic schema. 5. Focus on brief time (short time perspective). 6. Strengthen social support (that give benefit). 7. Involve people that have strong influence for the patient. 8. Give support on medical treatment. In psychotherapy, must consider the patient adaptation to the illness. (Sollner, 2006)

Adjustment to illness
Recognition, professional support, treatment

Life event(s) Illness

Personality features, previous experiences, psychiatric disturbance

Stress

Adjustment disorder Successful adjustment

Vulnerability
Recurrent/chronic life events

Adaptation of cognitions, behaviour

Coping

Interpersonal relationships, social support

W. Sllner, Lausanne 2006

Stage psychosocial care for medical illness

Pharmacology therapy
Psychotherapy, konseling Emotional support from physician & paramedic

Emotional support from patien social environment

W. Sllner, Lausanne 2006

c. Relation between psychopharmaca and psychotherapy

Psychopharmaca have different effect and pathway compare with psychotherapy. Psychotherapy and psychopharmaca effective but the effect that give is not amazing (there is no panacea).

(Malt, 2006)

INTRODUCTIONS
PATIENT

SIGNIFICANT PEOPLE

CARE TEAM

FOUNDATION
SOCIAL

BIO PSYCHO

PSYCHIATRIC COMMUNICATION

COMPETENCE

EFFECTIVENESS

ANOTHER DEPARTMENT

CLP

COMMUNICATION
EXAMINATION MODEL

ANOTHER DEPARTMENT

COM MUNI CATION

SKILL AID

GROUP PRACTICE

CONSULTATI ON PROCESS

CONCLUSION
Treatment integration

Collaboration between department

PATIENT

Inter discipline collaboration

Intra discipline collaboration