Assessment and Management of Psychiatric Disorders in Medically Ill In-patients

1. The Field: Consultation-Liaison (C-L) Psychiatry

2. Categories of Clinical Problems

3. Assessment (Evaluation Process)

3a. Standard Approach

• Full psychiatric history: past history, family history, developmental history, review of systems
• Medical history and current treatments: reviewed and documented thoroughly
• Full mental status examination (MSE): level of consciousness, attention, concentration, memory, executive function, language, praxis, mood, affect, perception, judgment, and insight
• Cognitive screening: The Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) provides a baseline score for serial retesting, especially when delirium or dementia is a concern
• Targeted neurologic and physical examinations as indicated
• Laboratory work: Basic chemistry, hematology, cardiovascular workup, thyroid function, liver function, vitamin B12, folate, toxicology, syphilis serology, and HIV testing
• Neuroimaging/other: CT or MRI brain, EEG, or lumbar puncture when clinically indicated

3b. Special Steps in the Medical Setting

1. Communicate with the referring clinician first - The reason for consultation is often unclear; understanding the team's concerns can reveal the patient's behavior (e.g., over- or under-use of pain medication), frustration with a difficult patient, or specific concerns not captured in the referral note.
2. Obtain collateral information - From family members and other healthcare providers (including existing mental health professionals) to establish prior psychiatric history and inform discharge planning.
3. Adapt the interview to the patient's medical status - Patients may be experiencing pain, discomfort, distraction from medical problems, or cognitive compromise. The interview should be focused on the consultation question when needed.
4. Understand the patient's illness experience - Developmental and personal history, key dynamic conflicts, personality traits, coping strategies, and defense mechanisms help make the patient's response to illness comprehensible and guide both psychotherapy and advice to the primary team.
5. Write a synthesizing report - Include specific recommendations for additional evaluation and intervention, limited to what is medically necessary. Accompany with a discussion with the referring physician. - Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 6791-6792

4. Common Psychiatric Disorders and Their Management

4a. Delirium

• Treat the underlying medical cause (infection, metabolic disturbance, medication toxicity, withdrawal)
• Reorientation, sleep-wake cycle restoration, minimizing sedating medications, removing unnecessary catheters/restraints, ensuring adequate hydration and nutrition
• Involve family members for reorientation

• Benzodiazepines are avoided (except in alcohol or sedative-hypnotic withdrawal) because they can exacerbate delirium and increase fall risk. The exception: alcohol withdrawal delirium (delirium tremens) is treated with benzodiazepines (e.g., lorazepam infusion/bolus, tapered slowly).
• Antipsychotics are the most studied class. Review evidence in non-ICU patients shows unclear efficacy on delirium severity/duration/mortality; however, expert consensus supports a limited role for patients with severe distress, agitation, or psychotic symptoms.
• Haloperidol remains the agent of choice for behavioral/psychotic symptoms in delirium due to:
  • Availability (oral and IV routes)
  • Minimal hypotension
  • Not anticholinergic
  • Does not depress respiration
  • Does not impair glucose regulation
  • QTc monitoring required: Obtain baseline QTc before starting; do not use IV haloperidol if QTc ≥450 ms (male) or ≥470 ms (female); discontinue if QTc increases >25% above baseline
  • Dosing in older adults: 0.25-0.5 mg IV every 8 hours scheduled + 0.25-0.5 mg IV every 6 hours as needed; oral doses are higher (0.5-1 mg). Continue for 2-3 days then taper over 2-3 days once agitation resolves
• Atypical antipsychotics (risperidone, olanzapine, quetiapine) are equally effective to haloperidol for agitation/psychosis in delirium and are generally well tolerated
• Dexmedetomidine (alpha-2 agonist) in mechanically ventilated ICU patients: shown to produce more delirium/coma-free days than lorazepam (7 vs. 3 days, p=0.01)
• Limited evidence for melatonin, ramelteon, or cholinesterase inhibitors - Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 12887-12888

• Antipsychotic alone or combined with a benzodiazepine is used
• Classic IM combination: haloperidol 5 mg + lorazepam 2 mg
• Monotherapy with lorazepam, midazolam, droperidol, or haloperidol is recommended first; add benzodiazepine-antipsychotic combination if monotherapy fails - Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 9820

4b. Depression in the Medically Ill

• Highly prevalent (10-40%) in medical in-patients; often underdiagnosed because somatic symptoms of depression overlap with those of physical illness
• Screening tools validated for medically ill patients: Hospital Anxiety and Depression Scale (HADS) is preferred because it de-emphasizes somatic items
• Studies using HADS have identified 10-15% of medical in-patients who would qualify for prophylactic treatment
• Management:
  • Psychotherapy: Cognitive-behavioral therapy (CBT), supportive therapy, and problem-solving therapies are effective; goals are adapted to the illness (e.g., addressing barriers to treatment adherence in diabetes, loss of role/function in arthritis, existential concerns in terminal illness)
  • Pharmacotherapy: SSRIs are first-line (consider drug-drug interactions, hepatic function, risk of serotonin syndrome). Must consider side effect profiles specific to the medical condition (e.g., weight gain, cardiac risk, QTc prolongation)
  • ECT: May be treatment of choice for severely depressed, suicidal, or pregnant patients who cannot take medications, or in geriatric/medically ill patients where rapid response is needed
  • Interventions for depression in diabetic patients have shown both reduced depressive symptoms and reduction in medical costs of care

4c. Anxiety in the Medically Ill

• Anxiety is often a reaction to the medical condition or its treatments (e.g., chemotherapy-related anticipatory anxiety)
• Must be distinguished from anxiety secondary to a medical cause (e.g., hyperthyroidism, pheochromocytoma, cardiac arrhythmia, respiratory disease, medication side effects)
• Management:
  • Treat underlying medical cause first
  • Psychosocial interventions: CBT, relaxation techniques, mindfulness-based approaches, supportive therapy
  • Pharmacotherapy: Short-term benzodiazepines (use with caution in respiratory disease, elderly, or delirium-prone patients); SSRIs/SNRIs for persistent anxiety; buspirone
  • Education of the patient and family about the medical condition reduces anxiety significantly

4d. Somatic Symptom and Related Disorders

• Psychological factors that contribute to or worsen medical symptoms
• Management involves avoiding unnecessary investigations (while ensuring adequate evaluation), consistent communication with a single treating physician, psychotherapy (particularly CBT), and judicious use of antidepressants for comorbid depression/anxiety

4e. Primary Psychiatric Disorders Managed in the Medical Setting

• Continue effective psychiatric medications where medically feasible
• Adjust for organ dysfunction (renal, hepatic)
• Watch for drug-drug interactions with medical treatments (e.g., lithium toxicity with NSAIDs or diuretics; antipsychotic effects on QTc, metabolic syndrome, or tardive dyskinesia with prolonged use)
• Increased awareness of antipsychotic risks in patients with dementia (increased mortality)

5. Psychopharmacology in the Medically Ill: Special Considerations

6. Psychosocial Interventions

• Dynamic/insight-oriented therapy: Addressing illness meaning, coping with disability
• Supportive therapy: Providing emotional support, normalizing distress
• Cognitive-behavioral therapy (CBT): Challenging maladaptive illness beliefs, behavioral activation
• Family and group therapy: Addressing caregiver burden, peer support for chronic illness
• Goals vary by disease stage:
  • Addressing changes in role and function (all chronic conditions)
  • Coping with pain and physical changes (arthritis, chronic pain)
  • Addressing death and dying (terminal cancer, advanced heart failure)
  • Improving treatment adherence (diabetes, HIV, transplant)

7. Capacity Assessment and Special Evaluations

• Decision-making capacity: Does the patient understand, appreciate, reason, and communicate a choice? Capacity is decision-specific and fluctuates (unlike competence, which is a legal determination)
• Pre-transplantation psychological evaluation: Assessing psychiatric stability, substance use, adherence potential, social support
• Quality of life and end-of-life symptom management in terminally ill patients

8. Service Models

Key Takeaway

• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Chapter 27.1: The Clinical Practice and Evaluation Process and Treatments in C-L Psychiatry (pp. 6790-6795)
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Chapter 55.3g: Delirium pharmacotherapy (pp. 12887-12888)
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Chapter on Agitation in Medically Ill Patients (pp. 9820-9821)
• Kaplan and Sadock's Synopsis of Psychiatry - Section 25.1: Consultation-Liaison Psychiatry (p. 2445)