The Geezer’s Dirty Dozen on Introduction to Consult Psychiatry

This is yet another Dirty Dozen, this time an introduction to consultation-liaison psychiatry–which, arguably, should have been first in the series, but what the heck; better late than never. One additional reference is for the large U.S. survey showing depression is overdiagnosed and overtreated:

Rajaraman, M. (2013). U.S. survey shows depression overdiagnosed, overtreated. Clinical Psychiatry News, IMNG Medical Media. 41.

Slide 3: The links are:

http://cambridgemedicine.wordpress.com/2011/01/10/core-competencies-and-the-psychosomatic-medicine-%E2%80%9Csupraspecialty%E2%80%9D/

Slide 4: It’s worth pointing out that a recent study of a liaison approach to teaching critical care unit physicians and nurses about the importance of delirium prevention and management was not very effective, see my post, Educational
Impact on Delirium in the Medical Intensive Care Unit by a Psychiatric Liaison? – The Practical Psychosomaticist
.
Slide 5: Here I’m saying that small psychiatric consultation services can have a positive impact as well as the more ambitious integrated services, although meeting the daily challenge is necessarily more difficult. Communication amongst stakeholders is critical, regardless of the model used.
Slide 6: In general, when reaching for the sky of excellence, academic departments need to consider investing in the psychiatry consultation service by remembering that, in fact, just like liaison arrangements, they need “money, manpower, and motivation.”
Slide 7: The enormous cost added to hospital budgets by psychiatric illness cannot be ignored. And we must acknowledge the human cost in suffering.
Slide 8: I can’t emphasize enough the incalculable waste of many unnecessary psychiatric consultations. The infamous “day-of-discharge”, “clear-for-takeoff”, “clear-for-competence”, empty consultation requests plus the inevitable emergencies will always provide the busy consultant with a disincentive to implement proactive case finding. Why ask for more trouble?
Slide 9: Haldol is not the treatment for delirium. Delirium is a medical emergency. Antipsychotics have their limitations. While they can reduce agitation that interferes with managing the medical problems causing the delirium, they can cause potentially deadly cardiac rhythm problems such as torsades de pointes, and neuroleptic malignant syndrome (NMS).
Slide 10: If the psychiatric consultant is not in a position to provide close follow-up of the patient who is being discharged with a new prescription for antidepressant from the hospital, then it’s irresponsible to do so. This is probably one of the major reasons why patients are not started on antidepressant while in the hospital. Moreover, depression tends to be overdiagnosed and overtreated, as noted above.
Slide 11: Psychiatry consultation services can, indeed, add value when they are properly funded and staffed.
Slide 12: References and Resources
1.  Zaubler, T.S., et al., Quality Improvement and Cost Savings with Multicomponent Delirium Interventions: Replication of the Hospital Elder Life Program in a Community Hospital. Psychosomatics, 2013. 54(3): p. 219-226.
2.  Kunkel, E.J.S., et al., Physician Staffing for the Practice of Psychosomatic Medicine in General Hospitals: A Pilot Study. Psychosomatics, 2010. 51(6): p. 520-527.
APM Practice Guidelines for PM, http://www.apm.org/prac-gui/psy39-s8.shtml

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