Year : 2019  |  Volume : 61  |  Issue : 2  |  Page : 117--124

Consultation–liaison psychiatry in India: Where to go from here?


Sandeep Grover, Ajit Avasthi 
 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India

Abstract

Consultation–liaison psychiatry (CLP) is a young and upcoming subspecialty of psychiatry. When one looks at the history of CLP in India, the progress in the area of CLP paralleled that seen in various developed countries. However, over the years, compared to developed countries, CLP started lagging behind in India. In India, CLP services are mostly been provided as per the consultation model and true liaison model practice is missing. There has been meager research in the area of CLP in India, and there is marked heterogeneity in training across different centers. There is lack of specialized training programs in this country. Considering the increasing emphasis on providing person-centered care, there is a need to shift the focus of training from identifying and managing only primary psychiatric disorders to interphase of psychiatry and other disciplines.



How to cite this article:
Grover S, Avasthi A. Consultation–liaison psychiatry in India: Where to go from here?.Indian J Psychiatry 2019;61:117-124


How to cite this URL:
Grover S, Avasthi A. Consultation–liaison psychiatry in India: Where to go from here?. Indian J Psychiatry [serial online] 2019 [cited 2019 Mar 24 ];61:117-124
Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/2/117/253825


Full Text



 Introduction



Consultation–liaison psychiatry (CLP) is a relatively young but vibrant and upcoming subspecialty of psychiatry. The term CLP is often used interchangeably with “psychosomatic medicine,” which is understood as a discipline which deals with the understanding of “the interplay of biological and psychosocial factors in the development, course, and outcome of all disease (s).” The basic premise of CLP is to integrate all information available from all the sources to provide optimal health care. The care provided should be sensitive to the needs of patients and other specialists, mindful of prevention, and economically sound.[1],[2],[3],[4]

The history of psychosomatic medicine can be traced back to Johann Heinroth (1773–1843), who coined the term “psychosomatic” in 1818.[5] Few years later in 1922, Felix Deutsch first gave the concept of “psychosomatic medicine.”[6] Jackson Putnam is considered to be the first consultation psychiatrist, who worked as a neurologist in Massachusetts General Hospital in later part of 19th century.[7] However, the clinical aspect of psychosomatic medicine, that is, CLP made a beginning in the early part of the 20th century, with the opening of the first viable general hospital psychiatric unit (GHPU) at the Albany Hospital in 1902 by JM Mosher. The basic aim of opening of the GHPU was to bring mental health professionals into close proximity with other specialists in medicine for the purposes of training and providing psychiatric care. This is considered as a forerunner of the later med-psych unit.[6] This beginning led to the development of GHPUs across the world and the development of CLP as a subspecialty of psychiatry. The progress in the field of CLP over the last century or more in the United States is divided into four phases, that is, preliminary phase, organization/pioneering phase, developmental phase (conceptual-development phase and rapid-growth phase), and consolidation/retrenchment phase; each phase roughly lasting for 30 years, with the current consolidation/retrenchment phase, beginning since 1980.[8] The term “liaison psychiatry” was used for the first time by Billings during the organization/pioneering phase, which also saw other major developments such as the establishment of CLP services in many hospitals in the United States, using many different models. During the same phase, the Academy of Psychosomatic Medicine was established in 1953 in the United States.[8]

 Roles and Functions of a Consultation–liaison Psychiatrist



The roles or functions of a consultation–liaison (CL) psychiatrist encompass clinical work, teaching, administration, and research. The clinical work includes facilitation of the medical treatment of the patient. A CL psychiatrist is expected to be a medical expert, good communicator, good collaborator, a manager and supervisor, health advocate, professional, and a scholar.[9] The CL psychiatrist is expected to address the needs of the patients, requesting physicians, nursing staff, patients' families and friends, and the health-care system.[10] In terms of training, the CL psychiatrist is expected to enhance the knowledge of the trainees in psychiatry and other specialties and enhance the awareness of members of medical and surgical team with respect to the mental health issues.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] In terms of extending the mental health services at the primary care level, CL psychiatrists are considered as the most suitable persons who can help the primary care physicians in recognizing and managing mental disorders. In fact, considering the importance of mental health issues in overall health of the patients, CL psychiatrists are expected to become the primary clinical caretakers of the patients.[9],[10],[11]

 Models of Consultation–liaison Psychiatry



With the recognition of CLP as a subspecialty, various models of CL services have been developed. According to the focus of consultation, the models which are described include patient-oriented approach, crisis-oriented approach, consultee-oriented approach, situation-oriented approach, and expanded psychiatric consultation. Based on the function, the models of CLP include consultation model, liaison model, bridge model, hybrid model, and autonomous psychiatric model. As per the focus of work, the various models include critical care model, biological model, milieu model, and integral model. The various models which have been followed across the world have been influenced by the available resources and the composition of the teams has varied from single consultant to multidisciplinary teams. The scope of CLP has also extended from the medical-surgical inpatient facility to providing collaborative care at the outpatient level with physicians and surgeons or at the primary care level.[11],[12] In most of the Western countries, CLP services have a multidisciplinary team, which is led by a consultation–liaison psychiatrist with mental health nurses, clinical psychologists, occupational therapists, and social workers as other team members. In the recent times, depending on the scope of CLP, Royal College of Psychiatrists has described Core, Core 24, Enhanced 24, and Comprehensive CL psychiatry services. The core CLP services have low and variable demand across the week, whereas Core 24 teams are supposed to have 24-h response. Enhanced 24 services are supposed to have additional specialists from other subspecialties of psychiatry. The comprehensive services are considered as true multidisciplinary services with psychologists, mental health nursing, occupational therapists, and physiotherapists as a part of the team. These comprehensive services are expected to provide services for 24 h, 7 days a week along with liaison inpatient beds.[13],[14]

 Why Focus on Consultation–liaison Psychiatry is Important



In recent times, there has been an increased focus on the physical health of mentally ill participants. Data from different surveys show that about half of the mentally ill participants have some form of physical illness.[15] Further, with the increase in lifespan, there is an increase in geriatric patients who present to psychiatrists with primary psychiatric illnesses.[16] These patients invariably have some form of physical illnesses as well. These changing trends suggest that it is the need of the hour for the psychiatrists to have good knowledge about physical aspects of mentally ill patients and also have better understanding about managing psychiatric disorders in patients with concomitant physical illnesses. Further, CLP services and practices cut across ages and can help in improving mental health care for children, women, and elderly, thereby complementing the development of these subspecialties. Majority of the patients who present to primary care and to various physicians come with medically unexplained physical symptoms.[17] A high proportion of them have underlying psychiatric disorders. The role of CL psychiatrist in providing care to patients in the primary care and training of primary care physicians is well documented in Western countries. Accordingly, focus on CLP can also help in bridging the mental health gap in terms of improving the mental health care at the primary care setting. Over the last decade or so, there is a rapid growth of technology with development of telepsychiatry services at various centers. CL psychiatrists can be considered as the most appropriate person to lead the telepsychiatry services, as they can provide mental health inputs to physicians at the remote places. Considering the role of CL psychiatrists in addressing the ethical and legal issues encountered in medical practice, encompassing issues such as euthanasia, organ transplant, and gender reassignment surgeries, CLP can also help in enhancing the knowledge of mental health professionals in terms of forensic issues. Hence, it can be said that focus on CLP can actually help in the development of other subspecialties of psychiatry too. Last decade has also seen a rise in focus on noncommunicable diseases (NCDs) and 5 NCDs have come under one umbrella. Although the impact of psychiatric disorders on the onset, course, and outcome of NCDs is well acknowledged, somehow, mental health professionals have been kept out of the rubric of NCDs. There is a need for continued efforts to emphasize the role which mental health professionals can play in prevention and management of NCDs. Here too, CL psychiatrists can help in bridging this gap, by showing the importance of psychological factors and mind-body interaction.

 Contributions of Consultation–liaison Psychiatry to Growth of Psychiatry



GHPUs have facilitated the mental health care, by being accessible and have also possibly helped in reducing the stigma associated with mental illnesses. CLP has also helped in establishing psychiatry as a medical discipline in the mainstream of medicine. CLP has influenced the practice of medicine by showing the importance of humanism, communication skills, competency, and beneficence in medicine. Research in the field of CLP has shown the importance of recognizing mental illnesses among medically ill patients, and their role in causation and outcome of chronic medical illnesses such as coronary artery disease, cancer, and stroke. CLP practice, training, and research have highlighted the role of mental health professionals in various disciplines of medicine and surgery, and over the years, there is evolution of terms such as psychooncology, transplant psychiatry, psychonephrology, and cardiac psychiatry.[11] Proper identification and management of delirium by mental health professionals in various treatment settings have helped in reduction of hospital morbidity, reduction in health-care costs,[11] restructuring of the designs of intensive care units (ICUs), and procedural changes in the management of patients admitted to the ICU (providing more periods of uninterrupted sleep, reorientation of patients from time to time, and transfer of patients to a non-ICU setting as soon as possible).[11] Role of depression as a contributory risk factor in the development of coronary artery disease and the impact of depression on the rehabilitation of patients with myocardial infarction has now been well recognized. CLP has also helped medical professionals by highlighting the impact of sleep deprivation on medical errors, which led to the change in policies for training and posting of trainees. CLP has shown the importance of telling the truth to patients, especially in relation to diagnoses such as cancer. In fact, CLP has influenced the practice and policy of “truth-telling” in medicine and individualization of information. The role of mental health professionals in organ transplant is now well recognized. CL psychiatrists also have a role in addressing end-of-life issues.[11]

 Emergence of General Hospital Psychiatric Units in India



In India, mental health services were limited to the confines of mental hospitals up till the1930s. The first GHPU was started by Dr. Girindra Shekhar at R. G. Kar Medical College and Hospital, Calcutta, in 1933.[18] This also marked the beginning of CLP in this country. When one looks at this initiative, it can be said that India was not far behind the United States in establishment of GHPUs. However, due to initial resistance, GHPUs did not take off in India till the 1950s. A major rise of GHPUs was seen in India during the 1960s and by late 60s–early 70s, there were 90 GHPUs.[19] With the opening of more and more GHPUs, psychiatry training also started to shift to the GHPUs. All India Institute of Medical Sciences, New Delhi, and Postgraduate Institute of Medical Education and Research started postgraduate training in psychiatry in 1962 and 1963, respectively.[12] Over the next 50 years, almost all the psychiatry training shifted to the GHPUs. A survey of postgraduate training centers in India done in the mid-80s reported that 75% of the postgraduate training centers were in the GHPUs setting.[20] According to the information available on the website of the Medical Council of India, at present, 184 centers are providing postgraduate training in MD psychiatry and 59 institutes are providing training in the Diploma of Psychological Medicine (DPM). These institutes have 599 seats for MD course and 135 seats for the DPM.[21] In addition, the National Board of Examinations awards Diploma of National Board in psychiatry.

 Progress in the Subspecialty of Consultation–liaison Psychiatry in India



With the establishment of GHPUs, most of the departments of psychiatry are providing CLP services to various disciplines. This has also led to training in CLP during the junior residency. In addition, specialists from multidisciplinary private hospitals seek the opinion of the psychiatrists for their inpatients and outpatients. With the increase in the number of training seats for psychiatrists, more and more psychiatrists are entering into the private practice. This has enhanced the collaboration between the mental health professionals and other specialists.

 Current Status of Consultation–liaison Psychiatry in India



Till recently, no information was available with regard to the CLP services in India. In terms of practice of CLP, the service models practiced in India have not been well described. As per the available data, the CLP services at various centers have focused on inpatients and outpatients. Published data from most of the centers are silent on the functioning of the CLP services. In general, it is evident that CLP services across various centers follow the consultation model for both inpatients and outpatients, in which on the request of the physician/surgeon, the psychiatrist evaluates the patient and provides psychiatric inputs. For outpatients too, a consultation model is followed at various centers and a true liaison model is not evident from the available studies.[11] There is no information in terms of academic activities held at different institutes which involve multidisciplinary discussions.

A recent online survey collected information from 90 training centers with regard to the practice of CLP. In three-fourths of the institutes in India, the CLP services are provided as “on-call services.” Although faculty members are a part of the CLP team in majority of the centers, a three-tier system involving a faculty member, a senior resident, and a junior resident is present in only about one-third of the institutes. Other mental health professionals such as psychiatric nurse, psychiatric social workers, and clinical psychologists are a part of CLP team in very few centers. Junior resident is the first-line respondent in majority (60%) of the CLP teams. The most common diagnostic categories which are encountered in the CLP practice across different centers include delirium, substance use disorders, self-harm, and depression. At most of the centers, there is no specific CLP posting for junior and senior residents and joint academic activities involving other specialties are conducted in less than half of the centers. Very few research projects are carried out with psychiatrist being the principal investigator. When asked about the importance to be given to CLP, majority of the participants expressed that CLP should be given equal importance or more importance than other subspecialties such as child psychiatry, addiction psychiatry, and geriatric psychiatry in postgraduate training programs. All the participants expressed that improving focus on CLP will help in reducing stigma attached with mental illnesses and improve the training of postgraduates and the undergraduates. It was also felt that having good knowledge of CLP can help in managing psychiatric patients in a better way too. In most of the centers, which provide exposure to psychiatry at undergraduate level, psychiatry training is mostly done at the psychiatry inpatient setting or psychiatry outpatient setting with only occasional institute providing psychiatry training to undergraduates in the CLP setting. When the participants were asked about the sensitivity of the specialists from other specialties toward psychological aspects of medically ill patients, about half of the participants rated it as average and one-third rated as good. About half of the participants also rated acceptance of advice given by CLP teams to be good. In terms of rating the CLP services at their institute, majority of the participants rated it as average. When suggestions were sought as to how the CLP services can be improved at their center, majority of the participants suggested that there is a need to have a dedicated CLP team.[22]

It can be said that although almost all psychiatry departments in India practice consultations from other departments, these are at best rudimentary. The reasons for this range from fewer staff to nonexistent staff in many medical colleges and the expectation to run all special clinics with limited number of professionals. Resultantly, the professionals are burdened with clinical, teaching, and administrative duties. However, there are few places with adequate staffing run more structured CL psychiatry models.

At present, in this country, there is no specific training program in CLP, except for a postdoctoral fellowship program of 1 year at the National Institute of Mental Health and Neurosciences. PGIMER, Chandigarh, is going to start the postdoctoral fellowship program from the year 2019. This is in contrast to the United States and some European countries where CLP has been given accredited subspecialty status with well-established structured CLP training guidelines.[23],[24]

 Problems in the Progress in the Subspecialty of Consultation–liaison Psychiatry in India



Although in the last 50 years, psychiatry training has shifted to the GHPUs, CLP has not been the major focus of training. A National workshop on general hospital psychiatry held at Chandigarh in 1984, with regard to the postgraduate training recommended that ”A workable knowledge of psychiatry subspecialties like Child psychiatry, mental retardation, psychotherapy, alcoholism, drug dependence, and psychogeriatric is advisable. Familiarity with psychosomatic medicine and liaison psychiatry is advisable.”[20] This clearly shows that CLP was never recognized as the major subspecialty in India. A review article, which looked at the progress of CLP services in India, concluded that ”there is no specific philosophy or particular clinical context being identified in liaison psychiatry in India.”[18] The national organization, Indian Psychiatric Society (IPS), has recognized many subspecialty sections such as child psychiatry, geriatric psychiatry, forensic psychiatry, and biological psychiatry but has never focused on CLP as a subspecialty. There are very few continuing medical education programs and conferences with the theme focusing on CLP. There have been no major efforts at the organizational levels to enhance the awareness of specialists from other disciplines with respect to the importance of mental health issues in providing holistic and comprehensive care to medically ill patients.

Researchers from India have also not focused much on the psychiatric and psychological aspects of medically ill patients. A review of data from India, published in the “Indian Journal of Psychiatry” during the period of 1950–2010, showed that there were only 117 studies on psychiatric aspects of various physical illnesses.[11] In the last few years, the focus on research among medically ill patients has increased, with many studies focusing on patients with delirium, psychiatry morbidity in patients with various medical illnesses.[25] Researchers have not been able to impress the funding agencies with respect to carrying out multidisciplinary projects, to show the role of mental illnesses in altering the course and outcome of physical disorders.

Undergraduate medical training in this country also does not focus much on the psychiatry. Lack of knowledge about psychiatry is widely acknowledged by professionals from other specialties. A survey of physicians and surgeons showed that 87% of them acknowledged that they had poor knowledge about psychiatry and 91% of them opined that the development of CLP units would definitely help in improving the care of the patients with psychiatric problems in nonpsychiatric units in general hospitals.[26] Another survey of general practitioners showed that general practitioners felt deficient in the psychiatric skills provided to them during their training and were eager to learn more about the management of their psychiatric cases.[27] Data also suggest that specialists from other disciplines have negative perception about psychiatric ailments such as drug addiction, eating disorders, depression, dementia, and schizophrenia.[28]

Despite repeated attempts, psychiatry has still not received the status of a separate subject in the undergraduate curriculum. The lack of knowledge about psychiatric disorders at the undergraduate level is never rectified and specialist from other specialties continues to grope in the dark when they encounter patients with psychiatric comorbidities.

 What Can Be Done for Better Consultation–liaison Psychiatry Training in Future?



Over the last few decades, a significant growth has been seen in the subspecialty of CLP in India. However, there is a long way to go further [Table 1]. There is a need to sensitize and educate psychiatrists about their role in the practice of medicine, beyond managing the primary psychiatric disorders. The focus of psychiatry training should move from the primary psychiatric disorders to providing holistic and personalized care. Psychiatrists should know that they can play an important role in pre- and postorgan transplant evaluation, pain management, prevention, diagnosis and treatment of delirium in the ICUs, gender reassignment surgeries, cosmetic surgeries, addressing the issues of patients with cancer, in palliative care, etc.{Table 1}

As CLP has never been a focus at most of the centers in the country, at first, there is a need to develop more experts in the area of CLP. For this, centers with well-established CLP setup should take up lead and start providing CLP training to mental health professionals in practice and working in teaching institutes. This will enhance the workforce and dissemination of the expertise across the country. At the postgraduate training level, depending on the availability of workforce, all the institutes must strive to have dedicated faculty for CLP, and there should be full-time posting for trainees in the CLP setting, which will enhance skills in the practice of CLP [Table 2] and [Table 3]. During the clinical posting, the postgraduate trainees must be given adequate opportunities to see and manage psychiatric ailments and psychological issues in medically ill patients. In addition, the postgraduate trainees must also be posted in the emergency medical and surgical emergency setting to expose them to both psychiatric emergencies and medical emergencies with psychiatric comorbidity and overlap of symptoms. The duration of CLP training must be of at least 3 months for junior and senior residents. The CLP posting must preferably be three tiers, with involvement of junior resident, senior resident, and a faculty. The CLP team must also include other mental health professionals such as nurses, clinical psychologists, and social workers so that they can provide some of the basic inputs to improve the mental health and care of medically ill participants. During the CLP posting, the postgraduate trainees must be supervised adequately to learn skills to make proper diagnosis, how to communicate with the specialists in other disciplines, documentation from medicolegal point of view, periodic review of the cases, providing psychological interventions in nonpsychiatric setup, and use of psychotropic medications in medically ill participants. At the postgraduate training level, joint academics with participation of faculty from the Department of Psychiatry and other specialties must be made mandatory. Considering that, the most common psychiatric ailments seen in CLP setting include delirium, substance use disorders, depression, self-harm, and adequate competencies to assess and manage these disorders at the end of CLP posting must be evaluated. Establishing a credible-reliable and good quality CLP services can increase the referral rates. The quality of CLP services can be improved by having quick response with least lag time in the receipt of the call and attending to the patient, discussing the clinical issues with the consultee after seeing the patients and following up the patients regularly, informing the family about the clinical status of the patient, and addressing their issues. The consultee should also be informed, if on evaluation, it is seen that there are issues of lack of communication between patient/family and the primary team. The CLP teams also must maintain their separate records and registries which must be audited from time to time to improve the services.{Table 2}{Table 3}

Besides this, it is very important to impress upon the health administrators and specialists from other disciplines that focusing on mental health issues can improve the outcome of various physical illnesses and all the health indices.

At most of the GHPUs, which are situated in the medical college setting with undergraduate courses, psychiatry posting must be given due importance. The clinical exposure to psychiatry to undergraduates must not be limited to teaching at the psychiatry inpatient or outpatient setting but must actually extend to CLP setting. This will help in emphasizing the role of psychological factors in manifestation and management of medical illnesses and also sensitize the budding physicians about psychiatry. The training programs at different institutes which have postgraduate trainees from other specialties, posted in psychiatry must also be sensitized to the psychological aspects of medical illnesses. Besides this, all professionals such as nurses and paramedical staff must be sensitized about the mental health issues, communication skills, and screening for mental disorders.

Centers with established consultation models should strive further to establish true CL model with few medicosurgical specialties to start with. Already some of the centers, which are providing specialized care to certain group of patients, for example, malignancies have full-time mental health professionals focusing on the psychosocial issues of these patients only. Development of liaison model can involve having mental health professionals attached to various medical-surgical wards, who not only provide inputs in the patient care but also teach professionals from other specialties and carry out research.

At the organization level, societies such as IPS should have CLP subspecialty section, which must organize different scientific activities across the country. Although in recent times, IPS has a task force on general hospital psychiatry, it is not sufficient to address all the issues related to training to research in the area of CLP. Organizations such as IPS should also have more scientific programs focused on CLP. Efforts should also be made to collaborate with other medical organizations for having joint conferences to enhance the skills of specialists of either specialty. Alternatively, having few talks focusing on mental health issues in conferences of other specialties can enhance skills of specialists from other disciplines. These all can help in having attitudinal change toward psychiatry and mental health issues and can have long-term beneficial implications.

Centers with telepsychiatry facilities must not focus only on extending the services to their fellow psychiatrists but also must focus on primary care physicians and other specialists. If the telepsychiatry services are not available, then with the availability of high-speed internet, video calling facilities, and smartphones in the hand of everyone, the CLP services can be extended to all the professionals with minimum of economic inputs. Ready accessibility at their own work place can also reduce the inertia for seeking opinion of the psychiatrists and improve sensitivity about the mental health issues. Telepsychiatry services can also be used for teaching and training purposes. Centers which do not have expertise in CLP can seek help of experts from other centers in teaching and training purposes.

Besides this, it is very important to impress on the health administrators and specialists from other disciplines that focusing on mental health issues can improve the outcome of various physical illnesses and all the health indices. Psychiatrists should also move out of the bounds of mental illnesses only and should talk about mental health rather than only mental illnesses.

The need for carrying out further research cannot be underscored. The research should focus on developing indigenous instruments, models of practice, and intervention to improve overall outcome of patients. The research should move forward from small sample single-center studies to multicentric studies. Although there is need to have epidemiological research on detection of psychiatric morbidity in various medical illnesses, the research should move toward intervention studies, evaluating both pharmacological and nonpharmacological measures in CLP setting.

 Conclusions



Over the last few decades, CLP as a subspecialty has made major strides across the globe, including India. However, although when one considers the beginning of development of CLP services and training, India was not far behind the developed countries like the United States in starting GHPUs. However, over the years, the CLP services and training in India have lagged behind the developed countries. Research in the area of CLP has never been the focus in India, except for one or two centers. Considering the increasing emphasis on providing person-centered care, there is a need to broaden the frontiers of training from identifying and managing only psychiatric disorders at the interphase of psychiatry and other disciplines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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