Experiences and Perspectives of a Fellowship Course in Consultation-Liaison Psychiatry

Consultation-Liaison psychiatry (CLP) is a domain of psychiatry that comprises the clinical and academic activities of psychiatrists and other mental health professionals in the nonpsychiatric branches of a general hospital setting. ¹

CLP has evolved through four distinct phases. ²

1. From around 1900 to 1930, it was the Preliminary phase propelled by the establishment of psychiatric departments in general hospitals.

2. In the pioneering phase, specialized educational programs were introduced in university hospitals from the 1930s to the late 1950s.

3. Until about 1980, resulting from a confluence of varied interests, traditions, and needs, there was an expansion of consultation liaison programs, research endeavors, and medical training initiatives in the Developmental phase.

4. Currently, CLP is in a phase of consolidation or retrenchment.

CLP complements the advancements in scientific medicine, addressing its limitations and Rosenberg’s fundamental question regarding the organization of healthcare to balance technical and human needs.

The synergetic relationship between mind and body (psyche and soma) has been talked about for ages and remains uncontested. Subclinical psychiatric symptoms in hospitalized patients have negative outcomes, including longer stays and increased healthcare use. The duration of hospital stay is reduced considerably if patients with physical and mental health problems are referred early to CLP. ³ Early referral also reduces the number of readmissions after discharge. ⁴ It is also equally important to recognize and handle subclinical mental health issues such as distress, which improves outcomes. The quality of life and experience of patients and their families during hospital stays subjectively improves with CLP interventions.

Components of CLP include consultation, which is the expert advice provided for diagnosing and managing mental and behavioral disorders upon referral from other medical/surgical departments, and liaison, which is the collaboration between different specialties to facilitate effective, comprehensive healthcare. These components can be facilitative, consensus-seeking, and interpretative. ⁵

Academic Scope and Extent—CLP Fellowship Courses Across India

In recent years, CLP has evolved into a significant subspecialty of psychiatry, with a strong basis in the biopsychosocial model. This approach values the interconnectedness of physiological, psychological, and sociological aspects of human illness (physical/mental health-related). Despite its importance, little prominence is given to this branch during training in India.

An online survey conducted in various institutes providing postgraduate training in psychiatry revealed significant differences in the organization of CLP services across training centers in India. ⁶ The findings reinforce the previous observation that there needs to be a specific philosophy or context for CLP practice in India. This further highlights the need for more well-designed training programs aimed at shaping a complete and competent psychiatrist equipped to deliver care efficiently in both academic and non-academic settings.

Currently, in India, there are one-year postdoctoral fellowship courses at the National Institute of Mental Health and Neurosciences (NIMHANS, Bengaluru) and PGIMER, Chandigarh. ⁷ I completed my one-year fellowship course in CLP from St John’s Medical College in 2021–2022, which has an interview-based selection process.

Personal Narrative

A keen interest in general hospital psychiatry pushed me to choose to do this fellowship course. Five months of postings in CLP during my postgraduate training, consisting of reviewing the referred patients with a consultant, liaising with the primary treating team, and following up regularly until discharge, played a key role in developing an interest and acumen for this particular branch of psychiatry.

Expectations from the course included honing the skills concerned with both the consultation and liaison parts of the branch:

In terms of the consultation aspect, the aspirations focused on enhancing diagnostic capabilities and honing the ability to detect sub-syndromal psychological distress, which is often more prevalent than full-blown syndromal mental illness in individuals with chronic medical and surgical conditions. Additionally, on expanding knowledge about the efficacy and safety profiles of psychiatric medications that can be administered to patients with both acute and chronic medical or surgical illnesses, including understanding potential drug interactions.

For the liaison component, the expectations centered on improving communication skills and mastering the subtle nuances of working collaboratively with other specialties. This included navigating the complexities of professionalism and patient care, ensuring seamless coordination and integration of services to provide comprehensive and holistic treatment plans.

The one-year CLP fellowship was comprehensive and enriching, with professional fulfillment. The complexities of the human mind, with theories colliding with practice, gave birth to insights that progressed beyond the boundaries of textbooks.

The academic programs, which included case conferences, journal clubs, and seminars with topics concerning psychosomatic medicine, were challenging and intellectually stimulating. With intriguing themes ranging from capacity assessment to triaging of suicide to setting up a geriatric psychiatry unit in a general hospital, the seminar topics gave plentiful food for thought and evoked creative thinking as well. The wide variety of cases discussed during case conferences broadened our horizons to collateral thinking when coming up with differential diagnoses and management plans. The different types of studies deliberated upon in the journal clubs enhanced our statistical knowledge in a different realm post-PG. The profound comments and discussion points provided by the seasoned faculty of psychiatry, as well as other specialties, were an added and invaluable bonus.

The external postings where we attended OPD and in-patient rounds in other departments such as neurology, immunology, endocrinology, neurosurgery, pain and palliative medicine, general medicine, nephrology, physical medicine, and rehabilitation, oncology, and cardiology truly brought the lessons to life, infusing theory with the hues of reality. Each patient I encountered in settings other than psychiatry made me look at their clinical profiles through a completely new lens, with psychological issues quite intricately woven with their physical issues. This experience, along with learning about the physicians’ points of view, made me more mindful about looking at the patient as a whole, irrespective of the ward to which he/she is admitted.

A database of referrals handled by the fellowship students, with details of physical and psychiatric conditions and management, was developed to expand knowledge and research opportunities.

Assessments in the course included—Formative assessments—case-based discussions and feedback during academic presentations, and Summative assessments (at the end of the course)—a theory exam and a practical exam.

During the course, some key areas in the practice of clinical psychiatry were given enhanced emphasis, such as

Drug interactions

Precautions before, during, and after surgical procedures

Choice of psychotropics in the presence of medical and surgical comorbidities

Psychotherapeutic interventions in a patient with medical/surgical conditions, including cancer and terminal illnesses

Although these topics are taught in the postgraduate period during rounds and academic sessions, when it comes to making independent decisions, the knowledge that gets updated periodically through discussions with senior faculty members and reading the latest literature and guidelines becomes invaluable. The fellowship paved the way for this by nudging us in the right direction to approach a patient with these specific conditions.

Our skill sets in handling a patient with deliberate self-harm (DSH) and suicidal ideation also saw an upgrade as quite a large number of these patients were referred to the psychiatry department regularly. Collaborating with the primary treating team (depending on the nature of the DSH), triage of the patients, risk assessment in a general hospital setting, crisis intervention, providing supportive psychotherapy and psychosocial interventions, and educating and sensitizing the ward staff were carried out systematically with frequent reviews and by the involvement of a multidisciplinary approach. Various nuances and sensitivities entailed in managing a patient with DSH were strengthened through this process.

Handling CLP cases enhanced my skills in keeping a personal touch of psychiatry in physically ill patients as I could explain their mental health issues to them from a biological standpoint as well as spell out the implications of their medical/surgical conditions from a psychological viewpoint which gave a new sense of satisfaction of being in such a position to be able to do so.

Intriguing Experiences and Challenges

A few of the many consultations remain- memorable for particular reasons. Either they were diagnostic puzzles such as a young male patient with a one-day history of behavioral changes—hallucinations and suspiciousness, with no past history who turned out to have viral encephalitis or an elderly female with depression and significantly reduced oral intake who was diagnosed to have hypokalemic periodic paralysis causing laryngeal weakness and difficulty in swallowing.

There were also a few cases in which handling families took as much if not more importance, such as a patient with long-term COVID-19, staying in an ICU for more than 6 months whose brother had burnout and adjustment disorder, or a mother whose 20-year-old daughter had schizophrenia and spinal tuberculosis with paraplegia requiring round the clock care.

Supportive psychotherapy sessions taken regularly during the admission played an important role in managing such families.

Experiences with the transplant team included conducting capacity assessments for organ donors and recipients to ensure they understood the entire process of transplantation. There were a few instances in which the primary treating team was asked to provide a more comprehensive explanation of the post-surgical care, including chances of rejection and immunosuppressant therapy, which was later assessed in the patients before providing clearance for surgery.

The palliative care experience was enriching in terms of the varied dimensions in which the care is provided, which was learned during daily rounds with the team. The insights by the pain and palliative physicians about how they handle their emotions while dealing regularly with terminal patients and death were eye-opening.

These experiences shaped my thinking in terms of

Making a list of possible diagnoses and systematically figuring out the possibility of each one, even if they are rare

Advocating for a patient—for giving each complaint equal importance, either physical or psychological

Nuances of dealing with family members when a patient has both medical and psychiatric diagnoses and how it affects the prognosis of both the patient’s condition and the family’s

Challenges faced in terms of consulting include diagnostic dilemmas for camouflaging and co-occurring symptoms in physical and psychological disorders, posed difficulties in making an axis one psychiatric diagnosis, and in management in terms of limited pharmacological options due to comorbidities and drug interactions, especially in using benzodiazepines for withdrawal in the presence of respiratory depression, choice of antipsychotics to manage delirium in the presence of compromised cardiac/renal status, etc.

Challenges in collaborating with other departments included scheduling timely reviews while keeping in mind the regular clinical and academic duties and communicating with the primary treating team about certain decisions regarding medication choices when a change of a particular drug was required to avoid complications and interactions.

Navigating a team in CLP involves dealing with role incertitude when making an integrated care plan. Assertiveness in advocating for patients while ensuring that medical/surgical territories are not encroached upon is a skill that is honed through practice.

There can also be significant stigma regarding mental health issues both among the patients and their families in accepting psychiatric care, which needs to be addressed.

The willingness of primary treating team members to accept CLP inputs varied based on their psychiatric knowledge and interest in collaboration as well as stigma and dubiety about a psychiatric diagnosis, which was tackled tactfully to ensure a strong therapeutic alliance.

Fortunately, only a few instances of having to deal with difficult physicians were handled by direct communication explaining the purpose of a particular planned intervention and its expected and proven benefits.

The positives of a CLP team approach comprise better treatment outcomes, including early detection of psychiatric complications and safe medication choices. It also provides a wide array of learning opportunities among various experts, both in terms of exchange of treatment and disease-related knowledge and techniques of patient care, including soft skills while communicating bedside.

Future Directions and Recommendations

A few recommendations for the future include streamlining human resources in a consultation-liaison service with trained personnel and creating effective communication channels between psychiatry and other departments to ensure comprehensive patient treatment and facilitate continuity of care.

A consultation-liaison psychiatrist should be involved in interdepartmental policy making, which clinches a component of mental health in protocols and procedures related to physical health.

General Hospital Psychiatry Units (GHPUs) can incorporate an organized C-L system where the daily referrals are discussed and seen by a consultant. Proper management and a follow-up plan can be in place, which can be documented in the in-patient chart as well as in the discharge summary. This ensures the completion of the loop and comprehensive care for the patients.

The training of psychiatry postgraduates can include daily reviewing of the consultations seen by them and discussing them with a consultant, training in general hospital psychopharmacology, and proper guidance on conducting therapy sessions for patients with mental health issues admitted in different departments. This will enable the postgraduates to understand the nuances of general hospital psychiatry practice and to become well-rounded psychiatrists.

Some challenges in practicing CLP in central institutions can be the high patient load with multiple comorbidities and possible treatment-resistant conditions, as these are usually tertiary care centers. There can also be difficulties in coordinating with other large teams, especially with changing staff members of different professional backgrounds and mindsets. Having a robust CLP system with frequent interdepartmental meetings to ensure all the departments are on the same page concerning patient care can be a possible solution.

Additionally, increasing the number of fellowship opportunities in CLP within general hospitals that have robust clinical departments is crucial. This would promote academic and research interest in the field, fostering the development of skilled professionals dedicated to advancing the integration of psychiatric and medical care.

Conclusion

When it comes to providing holistic care to a patient with co-existing physical and mental health conditions and making treatments more economically feasible and accessible, expertise in CLP garners prime importance.

Choosing to do a fellowship course after post-graduation in a branch like psychiatry comes with its own unique set of nuances. Personal interest, specialized skill set, and a good learning environment play an important role in this regard.