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CONSULTATION-LIAISON PSYCHIATRY

CONSULTATION-LIAISON PSYCHIATRY AT AN ACADEMIC MEDICAL CENTRE COMPARED WITH A LITERATURE REVIEW

Susmita Hazarika*,Subhashish Nath**,Atmesh Kumar***,Pranjal Sharma****, Debjit Roy*****,Shyamanta Das******,Kamal Nath*******

*,**,***,****Postgraduate Trainee, Department of Psychiatry, Silchar Medical College and Hospital ******,*******Assistant Professor, Department of Psychiatry, Silchar Medical College and Hospital

Abstract

Background Consultation-liaison psychiatry is an important component of a multidisciplinary hospital yet often being overlooked and underused in our set up. There is also a dearth of study in the region.AimThe study of clinical and sociodemographic variables of psychiatric consultations among patients attended outdoor patients department (OPD) as well as admitted in indoor departments of various other specialties. Settings and Design Cross sectional study design in the setting of a tertiary care teaching hospital.  Methods and Material Sample consisted of indoor as well as outdoor patients referred from various departments and attending psychiatry OPD and ‘out-of-hours’ for consultation, over a period of four months. Psychiatric diagnoses were carried out according to ICD-10. Sociodemographic data were collected using a standard proforma prepared for the study. Statistical analysis used Descriptive statistical analysis. Results out of 218 referrals, 75.6% had only psychiatric diagnoses and 15.6% had psychiatric disorders with co morbidities. 68.8% patients were referred from department of medicine. 25.11% patients were referred just for psychiatric opinion, whereas 21.5% with conversion reaction, 18.3% with abnormal behavior. 30.9% patients were diagnosed as having dissociative [conversion] disorders, 18.18% mood [affective] disorders, 12.7% substance related disorders. Mean age of the patients was 31.97 years, 51.9% were males, and 82.5% belonged to rural locality, Hindus constituted 51.9% and Muslims 48.1%. Conclusions Considering the high prevalence of psychiatric disorders and their negative effects on physical condition, turning the faces of other medical professionals towards detecting psychiatric co-morbidities can result in the promotion of patients' health and quality of life.

Key words Consultation-liaison psychiatry, Clinical variables, Sociodemographic variables.

Introduction

Historically, psychosomatic medicine was known as consultation-liaison psychiatry (CLP), and it represented the care delivered by psychiatrists to patients with co-occurring medical and psychiatric problems who were treated primarily in medical settings. The term psychosomatic is derived from the Greek words psyche (soul) and soma (body). The term literally refers to how the mind affects the body.1 

In India, the interplay of mind and body is known since antiquity.2 An ancient Indian medical text, Sushruta Samhita3 describes a type of insanity borne out of grief, Shokaja, which ‘…… occurs in a person who is frightened by a thief, a king’s officer, or his own enemy; or due to the loss of wealth; or bereavement; or disappointment in love …’ Another text4 describes four types of insanity which manifest when mind is afflicted ‘… by passion, anger, greed, excitement, fear, attachment, exertion, anxiety or grief’ and also caused by ‘fierceful battles, destruction of countries, communities and towns …’  

The department of psychiatry in a general hospital setting has a multidimensional role, providing inpatient care, maintaining strong interaction with community psychiatric services and offering specialist services to the general hospital wards either as part of the multidisciplinary approach to patient management or by offering specialist inpatient care to patients already hospitalized in other departments by transferring certain patients to the psychiatry department.5,6

The CLP service is the link between any general hospital ward and the department of psychiatry.7 The consultation-liaison psychiatrist is called upon to evaluate and treat a wide variety of psychiatric disorders in patients with general medical disorders.8 CLP bridges nonpsychiatric and psychiatric wards in general hospitals.9 At least 30-60 % of inpatients in general hospitals seem to be involved in one or more psychiatric disorders simultaneously.8 This co-morbidity worsens the course and prognosis of medical illnesses10 and also makes hospitalisation period longer.11

Since mid-20th century, research in psychosomatic medicine and consultation-liaison has taken two interconnected paths. Psychosomatic medicine research has generally focused on understanding psycho physiologic mechanisms underlying mind-body relationships. Consultation-liaison research, on the other hand, has largely been directed at understanding psychiatric problems among clinical population with medical illnesses.1

This study aims to find out:

1. The clinical variables of the patients being referred for psychiatric consultation from other specialties i.e. Source of referral, reason for referral, other medical and/or surgical illness, psychiatric diagnosis;

2. The sociodemographic variables of the patients referred for psychiatric consultation from other specialties e.g. Age, gender, religion, locality. 

Methods and materials

The study prospectively included a series of 218 patients consecutively referred between February and May 2010 to the psychiatric consultation-liaison service of a tertiary care teaching hospital. The consecutive consultations were performed by a team including a consultant psychiatrist and psychiatric residents and diagnosis was according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10): Clinical descriptions and diagnostic guidelines for mental and behavioral disorders.12

In a descriptive analytic cross-sectional study, all the consultations requested were evaluated with regard to referring department, reason for referral as given by the physician making the referral, other medical and/or surgical illness, psychiatric diagnosis according to ICD-10 based on the consultation interview and sociodemographic characteristics (age, gender, religion and locality).

Results

Out of a total sample size of 218, 165 (75.6%) patients had only psychiatric diagnoses, 34 (15.6%) patients had psychiatric disorders with other comorbidities, and 17 (7.8%) patients had only medical/surgical illness; in 2 (0.91%) patients, the psychiatric diagnoses were deferred (figure 1).

Figure 1 Disorders.

Clinical characteristics 

Referring departments One hundred and fifty (68.8%) patients were referred from medicine followed by 15 (6.8%) from surgery, 15 (6.8%) from otorhinolaryngology, 11 (5.1%) from obstetrics and gynecology, 11 (5.1%) from orthopedics, 9 (4.1%) from dermatology, 3 (1.3%) from cardiology, 3 (1.3%) from pediatrics, and 1 (0.4%) from tuberculosis and chest department (figure 2).

Figure 2 Referring departments.

Reason for referral (as given by the physician making the referral) Fifty six (25.11%) patients were referred for psychiatric opinion, 48 (21.5%) for conversion reaction, 41 (18.3%) for abnormal behaviour, 20 (8.9%) for somatic complains, 14 (6.2%) for substance use, 10 (4.48%) for suicidal behaviour, 4 (1.79%) for confessional state, 4 (1.79%) for depressed mood; there were no diagnosis in 8 (3.58%) and others included 18 (8.07%) (figure 3).

                       

Psychiatric diagnosis (according to ICD-10) Fifty one (30.9%) patients were diagnosed with dissociative [conversion] disorders, 30 (18.18%) with mood [affective] disorders, 21 (12.7%) with substance related disorders, 13 (7.8%) with anxiety disorders, 10 (6.06%) with intentional self harm, 9 (5.45%) with organic mental disorders, 9 (5.45%) with schizophrenia, schizotypal and delusional disorders, 7 (4.24%) with acute stress reaction, 6 (3.63%) with somatoform disorders, 4 (2.42%) with sexual dysfunction, 2 (1.21%) with sleep disorders, and others constituted 3 (1.81%) patients (figure 4).

Figure 4 Psychiatric diagnoses.

Sociodemographic characteristics

Mean age of the patients was 31.97 years with 46 (21.1%) in the age group of 11 to 20 years, 70 (32.1%) in 21 to 30 years, 53 (24.3%) in 31 to 40 years, 26 (11.9%) in 41 to 50 years, 19 (8.7%) in 51 to 60 years, and 4 (1.8%) in 61 to 70 years. One hundred and thirteen (51.9%) were males and 105 (48.1%) were females. Hindus constituted 113 (51.9%) and Islam was 105 (48.1%). One hundred and eighty (82.5%) patients belonged to rural while 38 (17.5%) to urban locality (table 1).

Table 1 Sociodemographic characteristics

Age (in years)

                         Mean: 31.97

                         Standard Deviation: 13.036

                         95% Confidence Interval: 30.247-33.708

                         Minimum: 11

                         Maximum: 70

Gender, n (%)

                         Male: 113 (51.9)

                         Female: 105 (48.1)

Religion, n (%)

                          Hindu: 113 (51.9)

                          Islam: 105 (48.1)

Locality, n (%)

                          Rural: 180 (82.5)

                          Urban: 38 (17.5)

 

Discussion

Psychiatrists reportedly believe that psychopathology in the hospitalised population at any moment, even with conservative estimations, exceed 30% and ranges from 30 to 50%.13 Psychiatric units have been said to be reluctant to receive patients transferred from the general hospital and this has been an important issue. Their 'preference' to patients with psychiatric diagnoses only is based not only on the pressure from the community for such admissions, but also on the argument that patients with somatic illnesses may exert a 'negative' influence on the therapeutic environment or are difficult to take care of.14,15

The term 'difficult to take care of' usually refers to those patients who present with a variety of, mainly behavioral, problems in addition to their somatic illness, which actually makes them 'not wanted' in any ward.16-18 Some of these problems may have been the reason that led their physicians to refer them for a psychiatric consultation or even discuss a transfer to psychiatry ward in the first place.19

Psychiatric symptoms and disorders are serious problems absorbing high health service provision capacities.10 Kisely et al.20 claims that 30-60 % of admitted patients in general hospitals suffer from one major psychiatric disorder. Meanwhile, somatoform, mood and anxiety disorders are among the most prevalent diagnosed disorders.21 The management of co-morbid psychiatric and physical illness is an important issue for health services.22 It seems that co-morbid psychiatric disorders, negatively affect the course and prognosis of the medical diseases due to changes and irregularities in autonomous nervous, endocrine and immune systems.23

There have already been numerous studies about the effect of CLP on the quality of life in hospitalised patients, indicating a noticeable association between the diagnosis and treatment of psychiatric disorders in physical patients and their faster cure, shorter hospitalisation period, less recurrence of disease and lower costs of treatment.24 For example, Chadda25 showed that spending just two million dollars on CLP can save sixteen million dollars in return.

Present study detected 165 (75.6%) patients with psychiatric diagnoses, 34 (15.6%) having psychiatric disorders with comorbidities, and 17 (7.8%) patients with medical/surgical illnesses. The psychiatric disorders most commonly associated with comorbid medical/surgical illness were found to be dissociative disorders, mood disorders, and anxiety disorders.

Maroufi et al.26 found 156 (42.7%) of the evaluated subjects had psychiatric co-morbidities and the most prevalent psychiatric symptoms determined in this group were depression, somatisation and anxiety.

Altogether, there were 37 cases of delirium out of 968 referrals reviewed by Ku et al.27 Nearly all cases had significant physical illness, except 2 cases for whom organic etiology were not certain. Out of these 37 patients, 4 were found to have underlying dementia.

There were 229 referrals given schizophrenia or related psychotic disorders as the primary diagnosis in the total sample reported by Ku et al.27 One hundred and three (45.0%) were suffering from significant physical illness, which might be the main reason for hospitalisation.

Clinical characteristics

Referring departments Ozkan28 observed that between the years 1989 and 1991, the distributions of consultations made by various referring clinics were as follows: Internal Medicine (48.99 %), Surgery (21.21 %), and Neurology (9.43 %). In the years 1995 and 1996, the distribution was: Internal Medicine (41.8 %), Surgery (31.8 %), Physical Therapy and Rehabilitation (7.6 %). In the years 1997 and 1998, the highest number of consultations was requested by Internal Medicine (38.8 %). This was followed by Surgery (24.1 %). In 2003, the distribution was: Internal Medicine (50.1 %), Surgery (26.6 %), and Physical Therapy and Rehabilitation (10.0 %).

In most of the studies13,29-31, the highest proportion of referrals was from the department of internal medicine. In a review study32, a percentage of 47.7 % - 90 % was reported. The range of percentages fell between 10 % - 90 %.32,33 The proportion of referrals from the department of surgery generally ranks second in general hospital consultations. In a review carried out in the 1980s, Hengeveld et al.32 reported a range of 7 % - 34.7 %. A more recent study reported a percentage of 25.5.34 Grant et al.35 reported that the Intensive Care Unit provided for the second greatest number of requests for consultations. Rothenhausler et al.36 reported that internal medicine accounted for one-half of all referrals.

In our study, Medicine was found to be the most common referring department (68.8%) followed by Surgery (6.8%). Similar observations were seen in the study done by Singh et al.37 where 49.8% referrals were from Medicine followed by 11.2% Surgery. Christodoulou et al.19 reported that the majority of the transferred patients to the psychiatry ward came from medicine (73.1%) and the remainder (26.8%) from surgery. Forty-five percent of consultations in the study by Alhuthail38 were from medicine followed by surgery (25.3%). Seventy seven percent of the total sample reviewed by Ku et al.27 was from the department of medicine. 

Physicians and surgeons are increasingly becoming aware that one third to two thirds of their patients have significant psychiatric symptomatology which is amenable to treatment by psychiatrists.39,40  The fact, that psychiatric patients can also present to the medical or surgical units due to antecedent physical illnesses and may need additional care by psychiatrists is being recognised.2

Reasons for referral According to Ozkan28 an overall assessment of the patterns of reasons for referral over 14 years revealed that;

• During the first years, consultation requests for differential diagnoses (organic-psychogenic) (25%) were predominant.

• Consultation requests for anxiety (14.4% in 1989-1991; 17.7% in 2003) and depressive state (14% in 1989-1991; 21.8% in 2003) associated with or accompanying physical illness have meaningfully increased in 14 years.

• Confusional state (10.3% in 1997-1998; 11.8% in 2003) has become the third most-occurring reason for consultation in the last 6 years.

• Past psychiatric history has always been regarded as a routine reason for psychiatric consultation.

One of the main objectives and consequences of the CLP service is that psychiatry in medicine is not limited to “functional cases or suicide attempts” and psychiatric disorders of various kinds occur in medical patients (comorbidity). As the CLP service developed, not only was there an increase in the number of requests for psychiatric consultation, reasons for psychiatric consultations also grew in kind such that psychiatric cooperation was indicated for all kinds of psycho-situational conditions (e.g. Organic mental, psychosocial, behavioural, adaptive disturbance) associated with or accompanying physical disorders. The fact that the presence of a confusional state has become the third most prevalent reason for consultation requests implies that physicians have become able to recognize cases of delirium better.28

Altogether, the data of 14 years imply that the understanding that physical and psychiatric disorders can co-exist has improved.28 Diefenbacher and Strain41 reported that the primary reasons for referral remained constant, with “depression and behavioural management/agitation” being the most frequent.

We found 25.11% referrals for psychiatric opinion, 21.5% for conversion reaction, 18.3% for abnormal behaviour, 8.9% for somatic complains, 6.2% for substance use, 4.48% for suicidal behaviour, 1.79% for confusional state, 1.79% for depressed mood; there were no diagnosis in 3.58% and others included 8.07%.

Grant et al.35 reported that in a study covering a ten year period, depression and chemical dependency assessment appeared to be the main reasons for referral. A study from Italy indicated the distribution of reasons for psychiatric consultation as defined by the referring physician as: psychological symptoms (63.9 %), unexplained physical symptoms (9.3 %), suicide attempts (5.9 %), history of psychiatric illness (3.1 %).42 Evaluation of depression was the reason for referral in one-third of the total number of consultations, whereas suspected substance abuse represented only 1.1% (the least).38

Ku et al.27 found that suicide assessment was the commonest reason of psychiatric consultation and accounted for about one-third of referrals from medical, surgical and orthopedic units. Altogether, there were 58 (6.0%) out of 968 cases referred for the reason of depressed mood. Neurotic and somatic symptoms were infrequently quoted as the main reason for psychiatric consultation, and only accounted for 25 (2.6%) and 16 (1.7%) cases respectively. Revision of psychiatric drugs was asked for in 23 cases (2.4%) and most were concerned with side effects of antipsychotic or tricyclic antidepressants.27

Some referring doctors requested psychiatric consultation by giving unclear or non-specific reasons, such as “routine assessment”, “psychiatric assessment” or “past history of psychiatric problem” etc. It gave rise to about 20% of all referrals.27

According to Ku et al.27 there was still little emphasis in the interface between physical and mental health, concerning the current practice of CLP. In the year, they found only 16 referrals quoted with somatic symptoms as the main reason of psychiatric consultation. Some patients with significant physical illness might had adjustment problem or depression, but they were usually not referred until gross depression or having suicidal intent. It might reflect the physician’s low awareness of psychiatric morbidity among physically ill patients.  

Psychiatric diagnosis Ozkan28, in all four studies, found the distribution of psychiatric diagnoses to follow a similar trend with depressive disorder, adjustment disorder, and delirium comprising the first three psychiatric states, though in differing degrees of frequency. Adjustment disorder had become the most prevalent psychiatric diagnosis in recent years.

Psychiatric disorders are reported to occur in nearly two-thirds of hospitalised patients. The majority of hospital psychiatry studies indicated that depression of various kinds and subtypes constitute the most prevalent psychiatric diagnosis in inpatient psychiatric referrals.5,43 Prevalence of depression in the medically ill ranges between 10.8 and 27 % (with the median being 22 %), depending on the populations included.35,44,45

The distribution of the most frequent diagnostic characteristics of patients in Europe and American studies indicated depressive disorder, adjustment disorder, delirium, somatoform disorder, anxiety disorder and alcohol and substance disorder, in differing ranks.34-36,46

Rothenhausler et al.36 reported significant changes in diagnostic characteristics in their study of comparison of two 1-year surveys done 8 years apart. This study reported an increase in the category of delirium and a decrease in the category of “no psychiatric diagnosis.” Brown and Waterhouse47 reported a significant decrease in the frequency of personality disorders and an increase in organic states. A study of changes in psychiatric consultation over a ten-year period reported meaningful changes over time. For instance, mood disorders, anxiety disorders and delirium were replaced by mood disorders, alcohol problems, and other substance use disorders.35 In a more recent study covering a 10-year period, Diefenbacher and Strain41 reported that organic mental disorders (e.g. Delirium, dementia and substance-induced organic mental disorders) accounted for the majority of cases, followed by depressive disorders (including adjustment disorders), and thirdly by substance use disorders.

The label “no psychiatric diagnosis” was applied to a patient who has been referred for consultation, for whom no diagnosis has been established. This is a reflection of the understanding that cooperation with psychiatry is not limited to “functional” or “severe” psychiatric disorders and that there are various emotional, behavioural, situational or crisis areas that cannot be classified within classical nosology but will benefit from psychiatric consultation. Restricting ourselves to assisting in the diagnosis of classical psychiatric disorders will only go to limit our development as a discipline.28

Most common psychiatric diagnosis in our study was dissociative [conversion] disorder (30.9%) followed by mood [affective] disorders (18.18%), substance related disorders (12.7%), anxiety disorders (7.8%), intentional self harm(6.06%) , organic mental disorders (5.45%), schizophrenia, schizotypal and delusional disorders (5.45%),  acute stress reaction (4.24%),  somatoform disorders (3.63%), sexual dysfunction (2.42%), sleep disorders (1.21%), and others constituted 1.81%.

Singh et al.37 found that depression constituted 26.9% followed by anxiety disorder (15.5%). Alhuthail38 reported that mood disorders were diagnosed in 27.6%, whereas 20.6% of the referred patients were not diagnosed with any psychiatric disorder.

In the study by Ku et al.,27 altogether, 99 (10.2%) patients were given organic mental disorders as the main diagnosis including 46 dementia and 37 delirium. Eighty-one (8.3%) were suffering from mental disorders due to psychoactive substance use. Among them, 42 were related to alcohol use. There were 241 (24.9%) patients suffering from functional psychosis other than mood disorders, including 169 schizophrenia, 38 acute schizophrenia-like psychotic disorders and 22 delusional disorder. One hundred and two (10.5%) patients had mood disorders, including 50 depressive episode and 29 manic episode or bipolar disorder. Forty-one (4.2%) patients suffered from neurotic disorders, such as phobic and anxiety disorders (10 cases) and dissociative disorders (10 cases). Besides, there were 205 (21.2%) patients having diagnosis of reaction to stress, adjustment disorder or problems due to psychosocial circumstances. Thirty-eight (3.9%) patients were given no psychiatric diagnosis after seen and 112 (11.6%) could not be given any definite diagnosis as most of them were discharged before seen by psychiatrist.

The transferees were more likely to have been diagnosed with a mood disorder (including bipolar disorder types I and II, unipolar depression, dysthymic disorder) or a personality disorder, whereas the non-transferred were more likely to have been diagnosed with adjustment disorder as well as having ‘no psychopathology’.19 Depression has always been the most prevalent psychiatric disorder. Recently, however, adjustment disorder has replaced depression as the most common diagnostic category.28

Christodoulou et al.19 found that suicide attempts represented 49.6% of transfers, 70.5% of them being related to drug overdose (self-poisoning), whereas the rest were not drug related. According to Ku et al.27 suicide attempt was the commonest reason of referral, accounting for one-third of all referrals. 

In our study, suicidal behaviour represented 4.5% of the referrals from various departments; 5.9% received a psychiatric diagnosis of intentional self harm. Although many suicidal attempts are usually regarded as having minor emotional turmoil and low risk of suicide, the attempts should not be simply regarded as not genuine and of low suicidal risk.27

In our study, more than one psychiatric diagnosis was given in consultations. The observation of multiple psychiatric diagnoses leads to consideration of an as yet little-defined phenomenon: multiple psychiatric co morbidity that complicates the management of medical/surgical illness. In studies that considered only single or major psychiatric diagnoses, the detail offered by consideration of multiple diagnoses is not provided.8

Out of 968 patients studied by Ku et al.27 68 were given more than one psychiatric diagnosis. Concerning the second psychiatric diagnosis, personality disorder (21 cases) and mental retardation (10 cases) were the commonest two.

Bourgeois et al.8 reviewed the diagnoses from all inpatient psychiatric consultations conducted by, faculty psychiatrists during calendar year 2001 (N=901) at an academic medical center. In about 25% of the consultations, multiple psychiatric diagnoses were made. The most frequent diagnosis groups were mood (40.7%), cognitive (32.0%), and substance use disorders (18.6%). Among 671 consultations in which only one diagnosis was made, the rates of these diagnosis groups were 35.4%, 20.1 %, and 10.2%, respectively. Mood, cognitive, and substance use disorders remain major, foci of consultation-liaison practice in the managed care era, although the rate of cognitive disorder diagnoses has increased.

Demographic characteristics

Mean age was found to be 31.97 years. Most of the patients were in the age group of 21-30 years. The possible reason might be that dissociative disorder was the most common psychiatric diagnosis in our study and this disorder generally presents in younger age. Our study comprised of 113 (51.9%) males and 105 (48.1%) females.

According to Bourgeois et al.,8 the group of patients seen by the consultation-liaison service was 52% male and had a mean age of 48.59 years. Approximately 64.8% of the patients were females, as reported by Alhuthail.38

Ozkan28 observed that the demographic profile of the referred patients in terms of gender and age has changed over the years. Demographically, two major findings stood out. First, the ratio of males to females has increased e.g. the number of males referred compared to females has increased, with the number of females relatively declining over the years. Secondly, the mean age of referred patients has steadily increased.

Generally, it was reported that more female patients are referred for psychiatric care in general and in an acute care general hospital setting as well.32,35,36,42,48-50 The findings of our study contradict this general tendency. We believe it is because psychiatry has gradually lost the stigma attached to it, reflecting a general transformation in the value system of the society. This has resulted in men being less reluctant to seek psychological help. Thus, in examining this phenomenon, the changes in the value system of the society need to be taken into consideration.28 Gender differences in consultations have been reported in three different settings in which men were referred more often.51-3

In general, these results confirm some results of other studies and contradict others. Nevertheless, other studies do not come up with a consensus about factors affecting referral. Rather, those studies investigated the impact of such factors in different settings with different methodologies. Thus, one has to consider all these issues, including the cultural aspects and different patterns of practice before one generalizes the results.38

Study Limitations There are some methodological limitations in this study. First, standardized psychiatric scales and structured clinical interviews were not used in this study.38 Most of the cases were not admitted and diagnosis was done on OPD basis. Therefore there is a thin possibility of error in diagnosis. As our study was done in a tertiary care set up it might not represent the actual picture prevailing in the community. 

Conclusion

In conclusion, providing simultaneous and ongoing psychiatric service within the medical-surgical departments has been a very functional and rewarding platform through which communication and collaboration between physicians has been possible. This has also enabled the stigma associated with psychiatric disorders in the minds of physicians, patients and the families to be altered, lessened, thus allowing for the integration of psychiatry with medicine.28

Limiting general hospital psychiatry to requested consultations are insufficient to reach the people who are in need of service. Consultation-liaison connections have played a major role in the training of non-psychiatric physicians and in the recognition of psychiatric problems in the medical setting. In time this has increased both the quantity and quality of psychiatric consultations and has made possible early recognition of psychopathology, which has thus led to early collaboration. The liaison model advances the concept of coexistence of psychiatric morbidity in medical settings.28

The larger multidisciplinary CLP service, the training of nonpsychiatric physicians, and liaison work will contribute to the improvement of psychiatric referrals and increase the quality of service given.28 Establishing communal scientific meetings and paying more attention to CLP in different levels of medical education seem essential.26

Besides suicidal assessment and management of adjustment disorder or related problems, the consultation-liaison team’s major workload was the care of patients with major psychoses admitted to general hospitals. These two major areas of job would remain consultation-liaison services’ bread and butter.27 the data revealed the demand from the general hospital and might disclose the deficiency of the consultation services. In other words, it would be a reference for the future development of CLP in the region.27 Further studies are also needed in this line of research

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