Psychiatrists offer tips about when, and how, hospitalists should seek mental health care for their patients
by Susan Kreimer
Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.
That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.
“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”
The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”
So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?
“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”
“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.
Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.
Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.
The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”
“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”
So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.
It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”
These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.
Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”
Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.
For those in complete remission from a past addiction to alcohol, benzodiazepines, opiates, or a combination thereof, beware that prescribing certain medications puts them at substantially increased risk for relapse. Use alternative treatments whenever possible; if clinically indicated, be certain that these patients have a safety net to prevent relapse. Patients with severe pain need effective relief.
“If a patient has been exposed to significant dosages of pain medications in the past, their neurotransmitters will have physically adapted,” says Dr. Worley, president-elect of the Academy of Psychosomatic Medicine. “They will require higher doses than normal for effective pain relief.”
“Patients in withdrawal from physiologically addictive medications may have forgotten to tell you that they were taking these medications,” Dr. Worley says. “Abrupt discontinuation can cause incapacitating anxiety and life-threatening delirium.”
Put on your thick skin. Don’t take insults or slights personally. And resist the urge to flee or counterattack. Instead, Dr. Worley suggests hospitalists stay calm and focused on providing the best medical care that they can. “Chronically noncompliant patients can be excruciatingly frustrating to care for when they don’t follow through on what they are repeatedly advised to do, but lecturing more vigorously at them won’t help,” she says. “It only makes them shut down more and feel more helpless and you more exhausted. Shift to more of a listening mode and inquire about what they hope to accomplish by coming to you for help.”
After your explanation, ask them, “Do me a favor and explain back to me in your words what I said. I want to be sure I got across what I wanted to say.” Then ask whether they have any questions. Also know that all too often patients are so anxious and upset that they are “emotionally flooded” and unable to hear much of what you communicated. You can save a lot of time if they understand you in the first place.
A majority of communication is nonverbal, and your facial expressions, gestures, and body posture speak volumes to patients and family members. “The innocent tilt of a chin upwards while peering through bifocals can be misperceived as arrogance,” Dr. Worley says. “The thoughtful furled brow of contemplation may be misconstrued as irritability or disapproval.”
It’s better to call a psychiatrist unnecessarily than to overlook a patient at risk for suicide. Benzodiazepines, alcohol, or a combination of the two might reduce inhibition and increase the likelihood of a suicide attempt. Be sure to assess suicidal ideation, intent, and lethality of suicide attempt.
“Hopelessness about the future correlates with completed suicide,” says Gregory Ruhnke, MD, assistant professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. “Additionally, it is helpful to ask about the four H’s: Hate, humiliation, hostility, handguns.”
“The patient may become angry and engage in splitting, whereby he or she emphatically expresses the view that certain caregivers are all good or all bad. This may reflect such [a] patient’s desire to divide the caregivers into opposing factions. It’s a maladaptive way of coping,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the Pritzker School of Medicine. This can be very time-consuming, and it can breed hostility among colleagues. “Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”
Fortunately, she says, “even though these situations can arise, they are the exception rather than the rule.”
For example, Dr. Ruhnke says, if a patient complains of hemoptysis and hematochezia with negative endoscopies, talk to the nurse about the patient’s diet, and be suspicious if it includes only red foods and liquids. The most common symptoms among patients who come to medical attention because of factitious disorders are diarrhea, fever of unknown origin, gastrointestinal bleeding, hematuria, seizures, and hypoglycemia.
A patient with schizophrenia or bipolar disorder could experience a severe psychiatric episode without psychiatric medication. An appropriate alternative, perhaps administered intravenously if necessary, “can make all the difference in the world,” says Christopher Dobbelstein, MD, assistant professor of psychiatry at the University of Pittsburgh School of Medicine.
Medical teams can handle many psychiatric issues. Straightforward delirium is a good example. The bigger question, which takes experience and confidence, is to recognize when a line has been crossed. “The decision to consult psychiatry is not formulaic,” Dr. Dobbelstein says.
Sometimes a patient is acting strangely, and the team can’t explain why a psychiatrist could offer sound advice. “That’s when they should trust their instincts and consult us,” he says, “because the patient likely does have something more complex going on.”
Sometimes psychiatric medications are started without good oversight. Suicide risk is highest during the weeks following an inpatient psychiatric admission, so a patient should see an outpatient mental health provider within seven days after hospital discharge, says NAMI’s Dr. Duckworth.
“This is the secret to achieving a lifelong rewarding career in medicine,” Dr. Worley says, “and is the most important ingredient in positive outcomes.”
Susan Kreimer is a freelance writer in New York.
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.