Assessment and Management of Psychiatric Disorders in Medically Ill In-patients “The good physician treats the disease; the great physician treats the patient who has the disease.” — Sir William Osler 1. INTRODUCTION A medically ill patient is an individual with an acute or chronic physical illness requiring medical or surgical care, in whom psychological, behavioural, or psychiatric factors may influence the presentation, course, treatment adherence, recovery, and outcome. The relationship between physical and mental illness is bidirectional. (1) Consultation-Liaison (C-L) Psychiatry is the branch of psychiatry concerned with the assessment and management of psychological and psychiatric problems in patients receiving care in non-psychiatric medical settings. Lipowski described C-L Psychiatry. (2) Consultation (patient-centered) refers primarily to psychiatric assessment and advice requested by another healthcare professional, whereas liaison (system-centered) emphasizes continuing collaboration, communication, education, and support between psychiatry and medical or surgical teams. (1,2) Historical Perspective The roots of C-L Psychiatry lie in psychosomatic medicine and general-hospital psychiatry units. The development of George Engel’s biopsychosocial model and the pioneering work of Lipowski established the specialty as functioning at the “borderland of psychiatry and medicine.” In India, a major milestone occurred in 1933, when Dr. Girindra Shekhar Bose established the first General Hospital Psychiatric Unit (GHPU) at R.G. Kar Medical College and Hospital, Calcutta. (2) During the twentieth century, psychiatric practice progressively evolved from consultation-based services towards a broader liaison model incorporating clinical care, education, research, and multidisciplinary collaboration. (2) Epidemiology Psychiatric morbidity among medically ill in-patients is common but substantially underrecognized, undertreated, and under-referred. An Indian systematic review of 33 studies found inpatient psychiatric referral rates ranging from 0.01% to 3.6%, with depression, delirium and other organic disorders, substance-use disorders, intentional self-harm, and anxiety disorders among the commonly identified diagnoses. (3) The discrepancy between the burden of psychiatric morbidity and the low rate of psychiatric referral highlights the recognition–referral gap and the need for systematic psychiatric assessment in medical settings. (3) Scope & Clinical Functions • Clinical Settings: Emergency departments, intensive care units (ICUs), perioperative care, medical/surgical wards, neurology, oncology, cardiology, transplantation services, pain and palliative care, rehabilitation, and chronic disease clinics. • Core Functions: Diagnostic and risk assessment, psychotherapeutic and pharmacological management, behavioral interventions, family education and support, interdisciplinary communication, prevention, rehabilitation, teaching, and clinical research.¹,² Clinical Spectrum The clinical spectrum ranges from normal psychological responses and adjustment difficulties to: These presentations may occur independently or in combination with the underlying medical illness. Therefore, the central task of C-L Psychiatry is to understand the psychiatric syndrome in the context of the whole patient and the underlying medical illness. 2. WHY PSYCHIATRIC ASSESSMENT IS IMPORTANT Psychiatric manifestation in medically ill patients may be due to: Prmary psychiatric disorder, psychological response to illness, medical or neurologival disorder, medications, substance use and multipfactorial interaction. Unaddressed psychiatric morbidity in medically ill patients negatively impacts: • Treatment adherence • Recovery and rehabilitation • Length of hospitalization • Patient safety • Quality of life • Healthcare utilization • Family functioning • Medical outcomes An underlying medical cause should always be actively investigated when psychiatric symptoms are new, atypical, acute, fluctuating, or accompanied by neurological or systemic abnormalities. “In a medically ill patient, the psychiatric symptom is not the diagnosis; it is the starting point for a comprehensive biopsychosocial and medical assessment.”

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