The guideline “consultation psychiatry” of the Netherlands Psychiatric Association

Research questions 

The guideline intends to provide an evidence based answer to three questions: (1) Is psychiatric consultation in general practice and in general hospital effective, and if so, which forms are effective? (2) How should a psychiatric consultation be carried out? (3) Which factors are associated with an improved efficacy of consultation and increased compliance with the recommendations of the consultation psychiatrist? In addition to these three core questions, the guideline explains the context and models of consultation and discusses a number of legal and organizational issues that are largely specific to the Dutch situation and will not be discussed here.

Is psychiatric consultation effective? 

In general practice, the efficacy of psychiatric consultation has almost exclusively been studied in the context of collaborative care and in patients with somatoform disorders or depressive disorder. Collaborative care is a complex intervention, in which psychiatric consultation is embedded, making it difficult to measure the specific contribution of the psychiatric consultation in this intervention. A number of meta-analyses and randomized controlled trials show that collaborative care as such is effective in improving several outcomes. In patients with somatoform disorder, general functioning improves, the use of health care facilities is reduced, and physical as well as psychological symptoms improve; in patients with depression, there is a slight improvement in psychological symptoms [5], [6], [7], [8], [9], [10]. In only one study involving depressed patients, psychiatric consultation was the only intervention and appeared to increased treatment compliance and the use of antidepressants [6].

Psychiatric consultation in general hospital and nursing home setting is also effective in improving clinical outcome [11], [12]. However, many studies are limited to efficacy in terms of a decrease of the length of hospital stay and/or cost savings as study end points. Although there is no evidence for the efficacy of single visit psychiatric evaluations based on the results of a screening procedure [13], [14], screening for psychopathology in selected populations, followed by consultation and liaison activities, is probably more effective than providing consultation only on request [12], [15], [16]. There are indications that carrying out liaison activities has a positive effect on consultees and leads to more and better referrals, a greater compliance with advice as to medication, and more satisfaction on the part of the consultee [17], [18], [19], [20].

How should a psychiatric consultation be carried out? 

As a general rule, the same standards apply to a psychiatric consultation as to a regular psychiatric assessment. In the Netherlands, these rules are laid down in the “Guideline psychiatric evaluation of the adult patient” of the NPA [21]. However, there are some characteristics in the assessment of patients in the setting of psychiatric consultation that require special attention. In general practice, the psychiatrist is working before the “referral filter” with consequently less clear presentations of complaints and possibly a lesser motivation for psychiatric assessment compared to working with patients already referred to psychiatric services. In the general hospital, it is the somatic comorbidity that complicates the assessment, as well as the fact that psychiatric assessment is often not requested by the patient but by the treating physician.

In both general practice and in the hospital setting, it is important that there is agreement about what may be expected from the psychiatric consultant.

Before the actual assessment, there must be clarity regarding the questions that are to be answered. The limited psychiatric expertise of the consultee brings with it that the consultation request will sometimes be unclear or incorrect. Also, the consultee may have implicit and clearly unrealistic expectations regarding the consultation. Making the request for help more explicit clarifies these mutual expectations and helps prevent disappointments.

Before seeing the patient, the psychiatrist must inform himself thoroughly with regard to the context of the request for a consultation and hence the somatic diagnosis, the results of laboratory tests and any other supplemental diagnostics, the nature and stage of the treatment, and the prognosis. This contextual orientation is essential in order to gain the patient's confidence and to make it possible to assess the value of the information that is obtained during the consultation, as well as the patients' emotional reaction, if any [22].

The conversation with the patient should preferably take place in a separate room that guarantees sufficient privacy so that talking about symptoms that are embarrassing for the patient, or intimate details, can freely be discussed. A fundamentally empathic attitude in which the psychiatrist displays sympathy for the circumstances in which the patient finds himself contributes to confidence and treatment compliance [23].

The interview technique must also be adjusted to the patient. Most of these patients have had no experience with psychiatry. Psychoanalytic techniques that leave a great deal of room for free association and periods of silence are seldom suitable in a psychiatric consultation [24]. Psychodynamic interpretations of observed cognitions and behavior can of course play a useful role [25]. In general, a less open interview over a relatively short time should yield the information that is necessary to answer the questions posed. The impact that the somatic disease has on the patient is part of the areas to cover in the interview. Questions as to how the patient experienced his hospitalization, and whether or not he has confidence in the treatment can yield important information and provide clear evidence of possible conflicts with the attending physician or the medical system in an early stage. There are other factors that should not be discussed in too much detail. A single assessment, and certainly one during a stay in hospital, is not a suitable context for an extensive exploration of emotionally laden subjects. A detailed exploration of recalled sexual abuse, for example, can lead to too much unease during a hospital stay and hence actually impede recovery. The collection of general information should be aimed for, not the building up of a therapeutic relationship. In these cases it is better to give the patient a signal that his problem has been understood and to create the perspective of treatment following recovery or discharge. At the end of the consultation, the patient must also be told the conclusions and advice. In general practice, the role of the GP as treating physician is mentioned and underlined.

After the consultation has been completed, a report and advice must be given to the consultee. The latter usually has little knowledge or experience with psychiatry. This should be taken into consideration in the report so that essential information is correctly transmitted. Both form and content of the assessment and advice must be understandable for the consultee. The style of the report should be dictated by pragmatic considerations for the purpose of giving therapeutic advice that is as specific as possible, in the hope that this will increase the compliance with the recommendations given.

If an initial assessment leads to recommendations for further diagnostics or treatment, then the psychiatrist's role in this must be clear to the consultee. When a consultant limits himself to giving advice, then the referring physician is responsible for its implementation; if there is to be cotreatment, then the psychiatrist is responsible for his part of the treatment. Diagnosis and treatment should be carried out as much as possible according to the evidence-based guidelines that have been adopted by the professional society.

Depending on the local customs in the institution, a letter regarding every consultation may be written or not. In case of consultation in general practice, this is to be recommended. In the hospital this is, in principle, unnecessary since the attending physician is supposed to include any relevant therapeutic information in his discharge letter. However, practice shows that this is only the case in 50% of the discharge letters [26] so that many consultation services have decided to report their findings in a letter anyway. For complex patients, and especially when they are referred to a different institution for follow-up, the indication and the proposed treatment can often be put into words better by the consultant, so that in these cases, in order to prevent misunderstanding, it is recommended that a letter be written to both the somatic therapist and the future psychiatric therapist.

What increases adherence with consultees' advice? 

Interdisciplinary consultation can only be effective if the recommendations given by the consultant are actually followed up. It is therefore important to know which factors are associated with improved adherence to given advice, especially those factors that are of interest and can be influenced by the consultant himself, because they can contribute to a more effective consultation.

In general practice, psychiatric consultation seems to be more effective when given regularly at fixed times and by professionals with good psychiatric expertise [5]. Compliance with treatment advice may be increased by the use of a so-called consultation letter [7], [8], [27].

In the general hospital, advice given by the consultation psychiatrist is better complied with when given earlier during the hospital stay or during the period of cotreatment [28], [29], [30]. In case of diagnostic or therapeutic advice, single consultations should be followed by follow-up contacts [28]. Adherence with medication advice rises to 100% when the consultation psychiatrist writes medication orders himself to the nursing staff of the department that requested the consultation [31]. However, this also increases the responsibility of the consultant. When psychiatrists prescribe medication themselves, they are also responsible for checking potential interactions or complications and for good communication with the attending physician who must always retain an overview of the overall treatment of the patient. Compliance is better when the professional level of the consultant is higher [19]. The organization of “liaison activities” on the wards also increases adherence [32]