1. Models and Process of Psychosomatic Medicine
APM Resident Education Curriculum
Robert C Joseph, MD, MS, FAPM
Director Consultation-Liaison and Primary Care
Behavioral Health Service
Program Director, Psychosomatic Medicine Fellowship
Cambridge Health Alliance, Cambridge MA
Assistant Professor, Harvard Medical School
Updated
Summer 2011
Robert Joseph, MD, MS
Fall 2013
R. Brett Lloyd, MD, PhD

2. Psychosomatic Medicine
Subspecialty at the interface of Medicine and Psychiatry
Clinical Service
Research
Training
Psychosomatic Medicine is the name of the accredited subspecialty
The terms ‘Consultation-Liaison Psychiatry (C-L) and ‘Psychosomatic Medicine’ (PM) have had a variety of connotations historically.
The 2 terms are increasingly used interchangeably
One can think of PM as the background body of knowledge and C-L as the clinical service

3. Models of Psychosomatic Medicine Psychiatry
Traditional/Conventional
Hospital or Ambulatory Based
Consultation Upon Request (reactive)
Liaison Psychiatry
Mental Health Integration
Case Finding/Screening
Proactive/Systemic Mental Health Involvement
Population Based Programs
Disorder Specific Programs
Hybrid Models
Traditional Models: Classic, hospital based C-L service; Conventional; Common
Integration Model: Integration occurs along a spectrum. The degree of integration varies from something that may closely resemble a traditional (reactive) service to a highly structured, multidisciplinary disorder specific management program.
Increasingly common
More often seen in ambulatory settings
Consistent with many aspects of health care reform proposals.
Most common inpatient version is seen with delirium prevention and management programs
Hybrid Models: Elements of both

4. Traditional Models Consultation Upon Request
Reactive
Patient and consultee specific
Primary responsibility for patient remains with consutee
Liaison Psychiatry Components
Education
Formal and informal education
Support
Service, Ward, Nursing Staff
Can be Sub-Specialty Specific
OB, Oncology, Neurology etc.
Consults usually funded by FFS system.
Liaison work not supported in FFS system.

5. Types of Patients
Complex, co-morbid psychiatric and medical conditions
Neurocognitive disorders
Somatic symptom and functional disorders
Psychiatric disorders secondary to medical conditions or treatments
Disorders above are most commonly seen but range of disorders include all DSM Dx
The range of disorders seen can present significant challenges to residents early in their training
Most common reasons for consult request: Depression, Mental Status Change, Capacity, Safety, Dementia

6. Distinction from Office Based Psychiatry
Services requested by consultee
No “self referral”
Obligations to consultee as well as patient
Patient often unaware of referral
Usually ill, uncomfortable or in pain
Patient motivation often compromised
Limited privacy
Visits not scheduled nor time based
The working environment presents challenges not generally encountered in the rest of psychiatry.
Pt is often less motivated to willingly participate
These factors add to the challenge for trainees.

7. Function of Psychiatric Consultation
Doctor-to-doctor communication designed to address the mental health needs of the patient and improve patient care
the over-riding concern is the patient’s well-being
The primary function cannot be ignored.
Addressing any conflict (when present) is difficult but critical to a successful consultation

8. Essential Tasks
Complete a comprehensive psychiatric assessment and develop a management plan
Remove impediments to medical care
Bring a fresh perspective to the clinical dilemma
Facilitate a mutual understanding between patient, doctor and treatment team
Educate about the emotional and neuropsychological needs of the patient
Multiple agendas are present in most consultations.

9. Steps in the Consultation (1)
Review chart and consult question
Discuss case with consultee
To help delineate the manifest question and help identify any latent question(s)
To help consultee reformulate the question, in a manner which addresses underlying issues and allows the consultant to be helpful
Review all staff notes. Notes from nursing, PT etc often contain valuable information on pt.
The stated reason for the consultation often does not reflect the nature of the problem.
Discussing the problem with the consultee before seeing the patient is critical to the consultation.
The consultant can often help reformulate the question in a way that better describes the nature of the problem and allows one to be the most helpful.
For Example “Rule out depression” might be a reflection of other, less defined concerns…. “I have been unable to explain this patients symptoms….it must be something psychological…”

10. Steps in the Consultation (2)
Patient Interview
Introduce self
Sit down
Address patient’s surprise at the arrival of a psychiatrist (if present)
Attend to any physical discomfort
Identifying oneself as the Psychiatric Consultant is usual but must be weighed against the possibility of premature termination of the interview.
Be active in your approach, clarify distortions and misconceptions aggressively (“No one thinks you are crazy”)
Personally attend to the patients physical discomfort or obtain nursing assistance if needed.
Adjust bed, patient position, obtain drink etc.
Conversation should be conversational, polite and respectful
Pay attention to personal items, visitors etc
Observe personality traits, coping styles without digging
Support defenses. The tone should generally be conversational and supportive.
‘Uncovering’ is usually to be avoided

11. Steps in the Consultation (3)
Mental status exam
Includes bedside cognitive testing
Targeted physical exam (if appropriate)
Ancillary history gathering often appropriate
Family
PCP
Other care givers
Other
MS exam is tailored to the clinical situation.
Serial MSE’s are often useful to make diagnosis and document response to treatment
Cognitive exams are common and facility with bedside neuropsychological assessment is necessary.
Must be comfortable either doing a targeted PE or suggesting that one is necessary.
Ancillary informants are often critical and should be considered a routing part of the process.

12. Steps in the Consultation (4)
Written note
Verbal communication (feedback) with consultee, regarding your opinion
Follow-up visits as appropriate
Range can be none to daily
The written note largely follows the standard medical write up.
Verbal communication with the consultee is critical to confirm that your assessment was understood and to address any remaining question.
At least one follow up visit is often important to verify that your recommendations were understood and followed, or, if not, ascertain why not
Multiple fu visits are sometimes necessary (persistent suicidal ideation, behavioral disruption, fluctuating MS).

13. Designed to be used by other members of the treatment team
The Written Note (1)
Document formally addressed to the physician requesting the consultation
Designed to be used by other members of the treatment team
May be read by a variety of hospital personnel
Consider confidentiality
The document is addressed to the consultee but the audience is usually varied. The note should be written with this in mind.
Depending on the nature of the problem the target audience could be nursing staff, social workers, lawyers etc…

14. The Written Note (2) TITLE: Psychosomatic Medicine Service
Attending
Resident
Other
NATURE OF THE NOTE
Initial Consultation Note
Follow-up Consultation Note
Given the variety of MD notes in the chart it is important to clearly identify who you are and your role.

15. The Written Note (3) DATE AND TIME: SOURCE IDENTIFYING STATEMENT
Essential when dealing with a fluctuating mental status
SOURCE
Patient, family, medical record, other
IDENTIFYING STATEMENT
This lays the groundwork for your formulation and recommendations in a way that helps the readers to understand your note
Distinguish the time of the exam from the time the note was written if discrepant
Collateral information is often critical and obtaining such is more the norm than an exception.
It is also worthwhile to document the total time spent on consultation.
May help for reimbursement and demonstrates the amount of effort involved in consultation

16. The Written Note (4) Reason for Consultation
Why did the primary treatment team request a psychiatric evaluation?
There is often a difference between what the primary team requests and what they actually want from the psychiatrist
Manifest request: R/O depression
Latent request: There is nothing wrong with this patient. She is drug seeking and manipulative. Make her stop complaining and behave!
The consultant’s understanding of the reason for the consultation evolves in the process of reviewing the chart and talking to the consultee, nurses etc.

17. The Written Note (5) Identifying Statement Important
“The patient is a 34 year old female admitted for abdominal pain with a history of multiple medical complaints and pain unresponsive to usual interventions. We are asked to evaluate her for possible depression”
A reiteration of the manifest question
Reminds us to answer the question
Respectful to consultee
This statement sets the tone for the consultation and frames the objectives of the consultation
Remains nonjudgmental and respectful of affect behind the consultant’s original request
Tactfully reformulates original question into one that allows the consultant to address the underlying issue and thus, be more helpful

18. The Written Note (6) HISTORY OF PRESENT ILLNESS
A place to document the essential positive and negative aspects of the history
Provides a historical framework for understanding the patient
Must include DSM descriptive characteristics and review of systems relevant to diagnosis
Consider:
The special events of the patient’s life, e.g., losses, illnesses.
The precipitant to the current psychological and physical difficulties.
The nature of the patient’s reaction to these precipitants.
Usual coping mechanisms
The written history illustrates what information we judge as being important.
This data plus other data should substantiate the ultimate formulation and differential diagnosis.

19. The Written Note (7) Past Medical/Surgical History
Include menstrual and obstetric
Past Psychiatric History
Medication
Prior to admission
At time of consultation
Recent changes
Substance Use History
Family History
Social History
Medication documentation should also distinguish what medications are ordered from what meds are taken

20. The Written Note (8) Physical Exam (as appropriate) Mental Status Exam
Analogous to the physical examination.
Reflects a point in time
Address the question of the consultation and your formulation within the mental status examination
It is an opportunity to teach and to demonstrate how diagnoses are made
A tool to gain access to a patients mental life
Pertinent Laboratory and Radiologic Findings
Should document signs that substantiate one’s diagnostic impression and changes over time

21. The Written Note (9) Impression
Other than recommendation, the most likely part of the consult to be read
Should have the components of a good biopsychosocial formulation, but avoid psychiatric jargon whenever possible
Include stressors and functional status
Know your audience and what you want to accomplish
Differential diagnosis, including personality and medical disorders
Consider the audience and remember ‘essential tasks’ of consultation in composing this
An opportunity to educate the medical community about the patient

22. The Written Note (10) DIAGNOSIS DSM-V DSM IV-TR Multi-axial assessment
Axis III – including disorders relevant to the psychiatric disorder(s)
Axis IV – Psychosocial/ environmental problems
Axis V – global assessment of functioning
DSM-V
Axis I-III combined: list relevant diagnoses to consultation
List ICD-9-CM V codes related to psychosocial and environmental problems
WHODAS – may be used to demonstrate disability
Axis I – III merged. Relevant diagnoses that impact case formulation are listed.
Consider using ICD-9-CM V codes for factors that may further influence or impact diagnosis.
WHODAS may be performed as indicator of overall disability.

23. WHODAS: World Health Organization Disability Assessment Schedule 2.0
The Written Note (10)
WHODAS: World Health Organization Disability Assessment Schedule 2.0
Axis V (GAF) was dropped from DSM-V
WHODAS is included for further study as an assessment tool for functioning
36-item, self-administered measure used to assess disability in adults (age 18 and older
Included in Section III of the DSM-V
Domains include: Communication, getting around, self-care, relationships, household activities, school and work activities, participation in society
Global Assessment of Functioning (GAF) was dropped in the DSM-V. Lack of conceptual clarity, questionable psychometrics.
WHODAS may be performed instead as indicator of overall disability.
WHODAS has been included for further study (placed in section III of the DSM-V)

24. The Written Note (11) Recommendation/Plan
Most likely part of the consultation to be read
Further work-up suggested
Physician management
Medication
Behavioral approaches with patient
Be specific, avoid jargon
Nursing management
Legal issues
Social service needs
Aftercare plans
Consultant follow-up
Inform treatment team of your availability, whether/when you will return and the purpose of your return
Tone should be confident, informative and respectful
Content should be evidenced based and practical
Example “This is not the best time to confront the patient on the possibility of their overuse of prescription drugs. This can wait till the medical crisis passes.”

25. Mental Health Integration (1)
Collaboration with Multidisciplinary Team
Mental Health (MH) and non-Mental Health (non-MH) providers
Psychiatrist, other MD’s, Psychologists, Social Workers, Nurses, Case Managers, Support Staff
Elements of Integration
Mission
Optimal care for behavioral problems in non-MH setting
Target Population
Patients with co-morbid medical and psychiatric problems
Patients with MH problem but no other MH care
Location
Generally involves co-location of MH staff in medical site
Communication
Team meetings, shared, medical record and treatment plans
Administrative
Shared or coordinated between MH and non-MH staff
Fiscal
Integrated budget for MH and medical staff vs. separate
No one definition or model for integrated care
Tends to involve teamwork and multiple providers at various levels
Seen most often in primary care but also done in specialty clinics (OB, Oncology etc)
Responsibility for care is usually shared between MH and non MH providers
Shared Record and Co-location tend to be minimal elements of integration
Many models are easily adaptable to proposals for health care reorganizaion including the “medical home”

26. Mental Health Integration (2)
General Hospital Based
Tends to be disorder specific
E.g., delirium, transplant or substance use disorders
Ambulatory
Primary care
Medical/Surgical Specialty clinics
OB, Oncology, Neurology, Transplant etc
General Hospital based tend to have screening or structured case finding, assessment and management program
Ambulatory Integration runs from co-location of fairly traditional reactive consultation to full service MH care thoroughly integrated into medical clinic
Planned Care: AKA ‘Collaborative Care’, ‘Stepped Care’, other

27. Mental Health Integration (3)
Rationale
Prevalence of mental health (MH) issues in medical setting
Lack of access to conventional MH services
Patient’s reluctance to go to MH clinic
Extensive co-morbidity of medical and MH disorders
Bidirectional adverse effect of co-morbid disorders
Associated morbidity and cost of disorders
Method/Structure
Wide range
Reactive Programs
Mimic traditional consult services except, perhaps for co-location
Planned Programs
Highly Structured, oriented toward “Disease Management”
Prevalence, co morbidity, cost, documented in many studies
Access to MH services especially problematic in rural areas and with lower SES and immigrant populations
Many patients are willing to be seen in medical clinic but not willing to go to MH clinic
Stigma less for MH care received within medical clinic
Growing evidence of affect of mental disorders on medical outcomes and vice versa

28. Mental Health Integration (4)
Value added
Delirium prevention programs
Depression, Anxiety and Substance Abuse Management in primary care
Co-morbid MH and medical disorders
depression, diabetes, cardiac disorders
Medically Unexplained Physical Symptoms (MUPS)
Evidence exists for the efficacy and cost efficiency for programs for each of these disorders

29. Mental Health Integration (5)
Planned Care for Behavioral Health Disorders in Medical Clinics
Derivative of chronic disease management programs
Proven efficacy in multiple studies
AKA Collaborative Care, Stepped Care
Methods
Proactive Screening/Case Finding, Registry, Team Management, Algorithm directed, Consultation and Supervision, Case Management, Teamwork
Recognition that many Behavioral Disorders are chronic/intermittent and require long tem management similar to many medical illnesses
Proven outcome benefits in many studies
Improved outcomes generally correlate with the number of interventions. Case Management and Psychiatric Consultation/Supervision seem to be most critical elements

30. REFERENCES
Garrick TR, & Stotland NL. How to write a Psychiatric Consultation. Am J Psychiatry 139:7, 1982.
Meyer F, Joseph RC, Peteet JR. Models of Care for Co-occurring Mental and Medical Disorders. Harvard Review of Psychiatry, In press.
Gilbody S et al; Collaborative Care for Depression, Accumulative Meta-analysis and Review of Longer-term Outcomes. Arch Intern Med. 2006;166:
Williams J et al; Systematic Review of Multifaceted Interventions to Improve Depression Care. General Hospital Psychiatry 29 (2007)
Kathol R et al; Psychiatrists for Medically Complex Patients: Bringing Value at the Physical Health and Mental Health/Substance-Use Disorder Interface. Psychosomatics 50:2, March-April 2009.
Kontos N; Querques J. Psychiatric Consultation to Medical and Surgical Patients. In: Stern TA, Rosenbaum JF, Fava M, et al. eds: Massachusetts General Hospital Comprehensive Clinical Psychiatry. Philadelphia: Mosby-Elsevier. 2008; p
Smith G; Clarke D. Assessing the Effectiveness of Integrated Interventions: Terminology and Approach. Med Clin N Am 90 (2006)
Katon W et al. Collaborative Care for Patients with Depression and Chronic Illnesses. N Engl J Med 2010; 363: