Consultation-liaison (CL) psychiatry is often thought of as an inpatient clinical - specialty. However, outpatient services have been available in the United Kingdom and the United States since the first half of the 20th century (Dolinar, 1993; Mayou, 1989). Advances in medical science and changes in health policy are now shifting patient care from hospitals into the community; inpatient stays are shorter, and an increasing number of investigations and procedures are carried out on an outpatient basis. Consequently, the majority of patients, including those who have serious and chronic medical illnesses, are now treated in primary care or seen by specialists in their outpatient clinics.
Just as brief admissions have become routine in general hospitals, the way we provide psychiatric care has also changed, with a focus on treatment at home whenever possible. These changes challenge the traditional model of CL psychiatry
18
Consultation-Liaison Psychiatry in the Outpatient Setting
Jane Walker and Michael Sharpe
CONTENTS
18.1 Psychiatric Disorders in Medical Outpatients . . . 193
18.1.1 Depressive Disorders . . . 193
18.1.2 Somatoform Disorders . . . 194
18.2 Treating Medical Outpatients . . . 194
18.3 Consultation-Liaison Psychiatry in Primary Care . . . 194
18.4 Collaboration and Communication in Outpatient Liaison Psychiatry . . . 195
18.5 Advantages of Outpatient Consultation-Liaison Psychiatry . . . 195
18.6 Disadvantages and Potential Difficulties . . . 196
18.7 Medical Education and Outpatient Consultation-Liaison Psychiatry . . . 196
18.8 Methods of Working in Outpatient Liaison Psychiatry . . . 196
18.8.1 The Specialist Consultation-Liaison Clinic . . . 197
18.8.2 Urgent Consultations. . . 198
18.8.3 Joint Medical–Psychiatric Clinics . . . 198
18.8.4 Screening of Outpatients for Psychiatric Disorder . . . 199
18.8.5 Liaison. . . 199
18.9 Examples of Outpatient Consultation-Liaison Psychiatry . . . 199
18.9.1 Clinic Example: A Service for Neurology Outpatients . . . 199
18.9.2 Case Example: Somatoform Disorders in Neurology. . . 200
18.9.3 Clinic Example: A Service for Cancer Outpatients . . . 201
18.9.4 Case Example: Cancer and Depression . . . 202
18.10 Conclusion . . . 203
192
and demand a shift away from an inpatient focus and toward outpatient and primary care services.
18.1 Psychiatric Disorders in Medical Outpatients
The spectrum of psychiatric disorders in the outpatient population differs con- siderably from that in hospital inpatients. The inpatient CL psychiatrist typically is called upon to assess patients with delirium and those admitted following an overdose or self-harming behavior, whereas among outpatients the most common problems are mood disturbance and somatoform disorders.
18.1.1 Depressive Disorders
It is now well recognized that patients who have chronic medical conditions are at increased risk of depressive disorder (Wells et al. 1988) and are also more likely to experience suicidal thoughts (Druss and Pincus, 2000). Depressive dis- order is associated with increased disability, reduced compliance with medical treatment, and worse outcome (Katon, 1996). Despite its impact, depression is often neglected in this population; for example, it has been reported that only a minority of cancer outpatients with major depressive disorder currently receive adequate treatment (Sharpe et al., 2004). There are a number of reasons for this failure (Table 18.1). First, a diagnosis of depression may not be made because
Table 18.1 Untreated depression in medical outpatients
Stage Problem Possible causes
Diagnosis Depression is not diagnosed Clinician is inexperienced in diagnosing psychiatric disorders
Symptoms of depression are attributed to medical illness
Clinician or patient view depression as a natural consequence of medical illness
Treatment Treatment is not commenced Treatment is not deemed necessary
Treatment is not viewed as effective
Treatment is unavailable Worries regarding drug interactions and side effects
Treatment is subtherapeutic Worries regarding drug interactions and side effects Ambivalence regarding diagnosis
Treatment effect is not Time constraints of
monitored consultations
Prominence given to medical illness
Patient does not feel able to question treatment approach
the clinicians attribute the patient’s symptoms to his or her medical condition or because they consider depression to be an obvious consequence of having a chronic illness. Second, treatment is not initiated either as a result of this misat- tribution of symptoms or because the clinicians judge antidepressant treatment to be ineffective or too bothersome to the patient in terms of side effects and interactions. Third, even if treatment is administered it is done so in subthera- peutic doses. Finally, treatment response is not systematically monitored, leav- ing patients with ongoing depressive symptoms. There is therefore an important role for outpatient CL services in assessing medical outpatients for depression, providing advice regarding pharmacologic and psychological treatments and educating clinicians and patients on the impact of mood on medical conditions.
18.1.2 Somatoform Disorders
Symptoms and syndromes that are not explained by pathology or disease have been given various names: in the psychiatric classification they are referred to as somatoform disorders, whereas among medical specialties the same symptom clusters may be referred to as functional syndromes. These conditions occur in 30% of outpatients attending clinics such as neurology and rheumatology (Carson et al., 2000; Maiden et al., 2003). Such somatoform disorders are an important cause of chronic disability and use of health resources (Carson et al., 2003; Reid et al., 2003). Furthermore, nonpsychiatric physicians typically find it difficult to manage these patients (Chew-Graham and May, 1999) and may unwittingly make symptoms worse by repeatedly proposing medication, investigation, or referral for possible medical disease. The outpatient CL service, therefore, has an important role both in assessing patients with somatoform disorders for comorbid psychi- atric conditions such as depression and panic disorder, and in contributing to their long-term management, usually in collaboration with the primary care physician.
18.2 Treating Medical Outpatients
Shorter inpatient stays mean that there is less time to deliver psychiatric treatment.
Consequently it may be limited to merely starting medication or recommending psychological treatment, with the actual delivery of treatment occurring after discharge. An outpatient CL service can provide a broader range of management options and a possibility for follow-up; patients who are prescribed antidepres- sants, for example, can be reviewed at an appropriate time and any necessary changes made. Psychological interventions, such as cognitive-behavioral therapy, problem-solving therapy, and assisted self-help, can also be delivered by the psychiatrist or other members of the CL team. The outpatient service can also offer support and supervision for members of the medical outpatient service, such as nurses, in delivering simple psychological interventions for their patients in medical clinics (Strong et al., 2004).
18.3 Consultation-Liaison Psychiatry in Primary Care
Attempts to reduce the costs and waiting times in specialty services have led to an increasing number of conditions being managed in primary care. A collabo- ration between the primary care physician and CL psychiatrist offers a further
extension of outpatient CL services and is of well-established effectiveness, especially for the management of depressive disorder comorbid with chronic medical conditions (Katon et al., 1995).
The gap between the hospital service and primary care can be narrowed further if the CL psychiatrist spends time in the primary care clinic. There are many advantages to this model of working. For the patient, consultations in this environment are familiar and convenient and avoid the stigma of attending a separate psychiatric clinic. For the clinicians there are increased opportunities for face-to-face discussions; these discussions not only facilitate the manage- ment and follow-up of shared patients but also allow the primary care provider to seek advice regarding patients who then do not need a psychiatric consulta- tion. The psychiatrist can also gain from working in primary care, achieving a better understanding of the prevalence and nature of disorders seen in that set- ting and of the feasibility of delivering treatment in primary care. However, the main disadvantage is potential inefficiency, as primary care practices are typi- cally geographically scattered and necessitate the psychiatrist spending time traveling. A possible compromise is to offer only a limited service to primary care, focusing on joint assessment of especially problematic cases.
18.4 Collaboration and Communication in Outpatient Liaison Psychiatry
Collaboration and communication are essential elements of outpatient CL psy- chiatry. Whether they are referred, identified by screening, or seen in a joint clinic of a CL psychiatry service, patients are in contact with at least one other health professional and usually several. Patients may have ongoing follow-up with one or more hospital specialists, a primary care provider, and a psychiatrist, as well as other professionals involved in their treatment.
In the U.K. health system, the primary care physician is regarded as the clini- cian with overall responsibility for the patients’ care, unless they are admitted to hospital. While this may not always be the case in other health services, it is important that the clinical role each party is expected to play in the patient’s care is made clear. This need for coordination can be illustrated by the example of a patient with somatization disorder; there is little point in the psychiatrist mak- ing this diagnosis and monitoring the patient’s symptoms without communicat- ing with the relevant hospital specialists, who may unwittingly perpetuate the problem by arranging invasive investigations or with the primary care physician who may otherwise continue to refer the patient to medical services.
18.5 Advantages of Outpatient Consultation-Liaison Psychiatry
Beyond matching the service to the changing pattern of delivery of medical care, outpatient CL psychiatry offers several advantages. First, patients who are referred for nonurgent consultation may be more accurately assessed following their discharge from the hospital; for example, symptoms such as sleep disrup- tion, low mood, and anorexia can easily be attributed to hospitalization and the depressive disorder thus remains undiagnosed and untreated. Second, an out- patient consultation provides the opportunity to assess the long-term ways in which patients cope with their chronic illness, their illness behaviors, and their
support systems. Third, consultation in the clinic allows for a more private discussion than at the bedside in a busy ward, encouraging the formation of a therapeutic alliance and promoting the patient’s personal disclosures, which may be relevant both in diagnosis and treatment. Fourth, patients referred to CL services often have no previous experience of mental health professionals, have little desire to see a psychiatrist, and may find the prospect of an interview daunting. Seeing patients in an outpatient clinic, especially if this is based in the medical outpatient department, provides a more familiar environment. Patients feel they have more control in this setting and perceive the consultation as less stigmatizing. Finally, outpatient and inpatient services are usually delivered by the same CL psychiatry team. This means that the same psychiatrist who sees a patient during his hospital admission can monitor his or her progress in a follow-up appointment, providing continuity of care, which can be especially important when treatment regimes have been started or changed. Familiarity with members of the CL psychiatry team through their input into inpatient care is also helpful for physicians, who will be more likely to refer to an outpatient service staffed by colleagues.
18.6 Disadvantages and Potential Difficulties
The advantages of practicing outpatient CL psychiatry must be balanced against the potential difficulties. Patients who are referred for consultation as inpatients may find the idea of a psychiatric interview unpleasant, but only a small minor- ity will refuse to be seen. In contrast, patients referred to the outpatient clinic have the option of simply not attending. Coordinating medical and psychiatric care can be a greater undertaking when patients are seen in clinics; notes are often kept separately, letters take time to arrive, and delays in treatment initiation are more common. A further potential difficulty is the size of the outpatient and primary care population. This has the potential to overwhelm a service and may require that referrals are limited, for example to specific hospital specialists.
18.7 Medical Education and Outpatient Consultation-Liaison Psychiatry
Can medical education be improved using outpatient CL psychiatry? This way of working is an opportunity for joint medical and psychiatric teaching and can be used to encourage students to take an integrated approach to patient assess- ment and care. The outpatient clinic also offers a wealth of experience for psy- chiatric trainees who are exposed to a wider range of medical and psychiatric problems than they would encounter in an inpatient environment.
18.8 Methods of Working in Outpatient Liaison Psychiatry
How should CL services be organized for outpatient work? At the planning stage a number of considerations may be taken into account (Table 18.2): How will the service be staffed? This is dependent on the structure of existing services and the resources available. It is likely that there will be an overlap between inpa- tient and outpatient staffing, and there are many advantages of working in a
multidisciplinary team if this is possible. What will be the focus of outpatient work? It may be that defined patient groups or specific psychiatric disorders are selected, depending on the interests of the team and the practicalities of the hospital system. How will patients be identified? Referrals can be taken from a variety of sources but rely on the knowledge and enthusiasm of other clini- cians, whereas a screening model may identify large numbers of patients who require input and overstretch the service. A variety of outpatient models exist (Table 18.3), and each has advantages and disadvantages. It may be that a hybrid model is most appropriate depending on the service to be delivered.
18.8.1 The Specialist Consultation-Liaison Clinic
In many ways the specialist CL clinic is the simplest model for the delivery of outpatient care. The psychiatrist sees patients in an outpatient clinic in the same Table 18.2 Setting up an outpatient consultation-liaison service
Considerations for service delivery Possible options
Staffing Psychiatry
Psychology Social work
Occupational therapy Specialist nurses
Target population Specific patient groups, e.g., those with cancer Specific psychiatric issues, e.g., depression, alcohol misuse
Identifying patients Referrals from hospital doctors Referrals from primary care providers Referrals from other disciplines Self-referral
Screening Joint clinics
Table 18.3 Models of outpatient consultation-liaison psychiatry
Model Advantages Disadvantages
Specialist clinic Easy to organize Relies on referrals
Concentration of resources Stigma of psychiatric clinic
in one clinic Lack of integration
Useful training opportunities
Urgent consultations Acceptable to specialists Need to be available Lack of integration
Joint clinics Integrated assessment Expensive
Teaching opportunity Challenges traditional Education for physician model of dualistic thinking and psychiatrist
Not reliant on referrals
Liaison service Ongoing input Inefficient
Education of nonpsychiatric Limited facilities for
staff treatment
Screening Large numbers of patients Difficult to set up Not referral dependent Needs a lot of resources Data for research
way as any other hospital specialist and may accept referrals from other specialists, from primary care providers, or from other health care providers.
The clinic, therefore, relies on the appropriate identification of patients by other professionals. This model is by no means new to hospitals and as such is easily organized. However, the situation of the clinic is important; a clinic sited in the main medical outpatient department is less threatening and more acceptable to patients than rooms in a psychiatry department or ward. This type of clinic ensures that resources are concentrated where they are required, and can provide useful training opportunities for medical students and psychiatry trainees.
However, the existence of a psychiatric clinic, wherever it is situated, perpetuates the false dichotomy of mental and physical symptoms and their treatments; this may be exemplified in the organization of patient records, in which medical and psychiatric notes are often filed separately. This lack of integrated care means that communication between professionals who work in specialist clinics is espe- cially important. Patients should have an idea of what to expect when they are referred to a CL psychiatrist and should be made aware of the usual procedures regarding shared information.
18.8.2 Urgent Consultations
Urgent consultations are a simple extension of the traditional CL psychiatry model. In the same way that inpatient care is organized, a physician will request an urgent consultation when he has a specific concern regarding his patient’s mental state. The patient is assessed during the visit to the outpatient clinic, and suggestions are made for management. Although this model is now well known and therefore acceptable to hospital doctors, it again relies on their identification of patients in need of consultation and lacks any attempt to integrate mental and physical care. A further disadvantage is the potential waste of resources, which is incurred when staff must be kept available to deal with urgent requests.
18.8.3 Joint Medical–Psychiatric Clinics
Joint clinics provide a fully integrated assessment and management plan. The patient is seen in the outpatient clinic by a CL psychiatrist and an appropriate specialist, for example a neurologist or cardiologist, and presenting symptoms are placed in the context of psychiatric disorder, psychological background, and social circumstances, as well as the disease pathology. In this way a treatment package can be achieved that encompasses each of these dimensions of ill- ness. The stigma associated with a psychiatric consultation is ameliorated by the presence of the physician. Clinics that are labeled as “psychiatric” or “psycho- somatic” are likely to be less acceptable to patients than those integrated with the medical specialty (Stone et al., 2002; Sullivan, 1993). Joint clinics challenge the model of dualistic thinking that has evolved in modern medicine, and although some physicians and psychiatrists will welcome this approach, others may feel it is too much of a threat to their traditional views. Although the clinic itself may be simple to organize, the practicalities of arranging a regular time when two busy specialists are available may require a great deal of administra- tion. For this reason joint clinics are also expensive, and a decision must be made about which clinics should be organized this way. If all regular medical outpatient clinics were run jointly with a psychiatrist, the cost would be unjusti- fied. Rather, clinics that address specific medical conditions that are known to be associated with increased mental health problems should be targeted.
18.8.4 Screening of Outpatients for Psychiatric Disorder
An outpatient service based on a referral system relies heavily on physicians’
being able to accurately identify those with psychiatric symptoms. Even when training is used to improve this system, detection rates remain low (Merckaert et al., 2005). Screening, therefore, is important if we are to identify all patients who require further psychiatric assessment and not merely the small sample who are referred. Screening works by asking patients to take standard tests that are related to emotional and psychological symptoms when they attend the outpa- tient clinic. The first stage is usually a validated self-report questionnaire, com- pleted on paper or using a computer, which is followed by the second stage of a standardized diagnostic interview for high-scoring patients. Patients who receive a psychiatric diagnosis go on to receive appropriate treatment. The advantages of screening all medical outpatients are not confined to accurate diagnosis; large numbers of patients can be assessed relatively easily, and data on the prevalence of psychiatric conditions in particular clinics can be used to target services.
However, the implementation of large-scale screening can be a daunting prospect; the resources required to screen large numbers of patients can be sub- stantial, patients may need assistance completing questionnaires, trained staff are needed to carry out diagnostic interviews, and screening inevitably leads to false positives in the first stage, placing increased burden on both staff and patients.
The value of screening for depression in medical outpatients is currently a widely debated topic. Some reviewers have concluded that screening improves patients’
outcomes (Pignone et al., 2002), whereas others have disagreed (Gilbody et al., 2005). More recently it has been argued that screening is worthwhile but only if linked to an effective system of management (Gilbody et al., 2006).
18.8.5 Liaison
Providing an outpatient service in a large hospital with limited resources can be a difficult task. One method of dealing with this is for the CL psychiatry team to act in a purely advisory role, in which each psychiatrist is responsible for liaison with specific outpatient medical teams, for example the neurology department or diabetic clinic. By discussing patients and giving treatment sug- gestions, the psychiatrist can deal with many more cases than he would if he arranged consultations for each referral. However, this arrangement relies on accurate assessment by the medical team members and their willingness to be responsible for the patient’s psychological care. Consequently, the success of liaison requires that the psychiatrist participate in the education and supervision of the medical outpatient team.
18.9 Examples of Outpatient Consultation-Liaison Psychiatry
18.9.1 Clinic Example: A Service for Neurology Outpatients
The Department of Clinical Neurosciences in Edinburgh, Scotland, treats patients from across the southeast of Scotland and provides inpatient and outpatient services for the management of acute and chronic neurologic disorders. There are strong links between this department and the CL psychiatry service, which have led to the development of a collaborative model of care, incorporating a specialist clinic, a joint clinic, and effective liaison.
Patients can be referred to a specialist neuropsychiatry clinic for assessment and treatment, either following discharge from hospital or from the neurology outpatient clinic. The role of the clinic is to provide a psychiatric opinion for patients who are considered by their neurologist to have psychiatric or psychological symptoms.
Neurologists often see patients with symptoms that are not easily or fully explained by organic disease. Having recognized that such symptoms are com- mon and associated with significant disability, a joint clinic has been established that is run by a neurologist and a psychiatrist specifically for patients with these problems. Patients receive an integrated consultation, in which the potentially important biologic, psychological, and social issues are assessed.
Both of these clinics rely on the expertise of the neurologists in identifying patients who require psychiatric assessment. However, the liaison psychiatrists who offer these consultations are readily available for informal discussion of patients as well as regularly taking part in educational meetings. In this way they have become as much a part of the neurology service as of the psychiatry department, encouraging a fully integrated and collaborative model of care.
18.9.2 Case Example: Somatoform Disorders in Neurology 18.9.2.1 Background
Mr. A., 52 years old, presented to his primary care doctor complaining of weak- ness and numbness down his left side. He had a family history of cerebrovascu- lar disease and he was a smoker. He was referred to a neurologist for further investigation.
18.9.2.2 Symptoms
Mr. A. described a 2-year history of weakness in his left arm, which he had initially attributed to a sports injury. However, for the last 6 months he had also experienced left leg weakness. He had intermittent numbness and tingling in his left hand and down the outer aspect of his left leg. He also had episodes during which he felt his heart racing, he could not breathe normally, and he was afraid he might die. Cardiology and neurology evaluations revealed no objective findings.
18.9.2.3 Diagnosis
The diagnosis was somatoform (functional) neurologic symptoms and panic disorder.
18.9.2.4 Treatment
Mr. A. was treated using a modular self-help workbook, specifically designed for patients with medically unexplained neurologic symptoms and based on cognitive-behavioral techniques, and had regular sessions with a nurse trained in their delivery. Through this treatment program he was able to understand the functional model of unexplained symptoms and to identify possible triggers for his problems.
18.9.2.5 Discussion Points
1. Should Mr. A. have been referred for a brain scan to reassure him that his symptoms were not life-threatening?
2. How should medically unexplained symptoms be explained to patients?
3. Should Mr. A. have been referred for separate psychiatric treatment of his panic disorder?
18.9.3 Clinic Example: A Service for Cancer Outpatients
The Edinburgh Cancer Centre is a regional tertiary cancer center in Scotland.
The outpatient department has approximately 4000 new patients and 12,000 patient visits annually. A screening service has been developed to collect data on patients’ symptoms and is used to identify cancer patients who have major depressive disorder. The screening service has been established over a number of years and is now a part of routine care. Patients attending the outpatient depart- ment are given an information sheet describing the screening when they arrive at the clinic reception. They are then asked to complete the first stage of screen- ing in a special screening suite using touch-screen computers (Fig. 18.1).
This first stage entails administering a number of questionnaires to patients, including the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) and the Patient Health Questionnaire–9 (Kroenke et al., 2001). A nurse is present in case patients require help, and the results of each screening are pro- vided to the patient’s oncologist prior to their consultation. All patients are asked to take part in this stage of screening unless they are attending the Cancer Centre for the first time; new patients are met by their oncologist prior to screening.
Patients who score above a recommended cutoff on the Hospital Anxiety and Depression Scale are regarded as probable cases of major depressive disorder and go on to the second stage of screening, as do patients who endorse the final question of the Patient Health Questionnaire–9, which focuses on suicidal thoughts (Fig. 18.2). The second stage is delivered by telephone; patients are called at home by a trained nurse who carries out a structured diagnostic inter- view (First et al., 1996) to determine whether patients have major depressive
Fig. 18.1 Touch screens for outpatient screening.
disorder. The results of this interview are then communicated by letter to the patient’s oncologist and primary care provider so that appropriate treatment can be commenced. During the screening procedure nurses receive regular supervi- sion from a CL psychiatrist, who is also available for urgent discussions. This is especially important when patients disclose suicidal thoughts, and a protocol has been devised for these instances.
As well as providing a diagnostic assessment for large numbers of patients (more than 7000 patients are screened per year), the system is a valuable research tool. It allows the evaluation of screening measures and provides epidemiologic data and a representative sample of patients for recruitment into treatment trials.
18.9.4 Case Example: Cancer and Depression 18.9.4.1 Background
Mrs. B., 46 years old, presented to her primary care physician complaining of heavy menstrual bleeding and was referred to a gynecologist, who recommended she have a hysterectomy. During the operation she was found to have a uterine tumor and was referred to her oncologist for further treatment. She had a com- bination of chemotherapy and radiotherapy and returned to her oncologist for a follow-up appointment 3 months later.
18.9.4.2 Screening
18.9.4.2.1 Stage 1: Mrs. B. took part in a screening program when she attended her follow-up appointment in the clinic and completed the Hospital Anxiety and Depression Scale.
18.9.4.2.2 Stage 2: She had a high score, indicating probable major depression and was therefore telephoned for a diagnostic interview.
Stage 1
All return clinic attenders invited to complete questions (HAD and EORTC) on touch screen computers prior to their consultation. Output goes to
consultant.
If total HAD score more than 14, they go to stage 2.
Stage 2
Patient telephoned at home and given SCID interview to diagnose MDD.
If MDD diagnosed, Primary Care Provider and Oncologist informed.
Fig. 18.2 Stages of screening for major depressive disorder (MDD). EORTC, European Organization for Research and Treatment of Cancer; HAD, Hospital Anxiety and Depression Scale; SCID, Structured Clinical Interview for DSM-IV Axis I Disorders.
(From Psychological Medicine and Symptoms Research Group, School of Molecular and Clinical Medicine, University of Edinburgh, United Kingdom.)
18.9.4.3 Symptoms
Mrs. B. described feeling low and miserable most of the time and had stopped enjoying her usual interests. She found it difficult to get to sleep and was wak- ing in the early hours of the morning. Her appetite had diminished and she had lost weight. She was unable to concentrate when reading a book, had very little energy and felt that she was worthless and a burden to her family. She said that she wished she had “died on the operating table.” Mrs. B. thought it was normal to feel this way because of her diagnosis of cancer.
18.9.4.4 Diagnosis
The diagnosis was major depressive disorder.
18.9.4.5 Treatment
Mrs. B. took part in a treatment trial for cancer patients with depression and was randomized to receive a nurse-delivered intervention. This complex inter- vention involved three components: first, Mrs. B. was given information about antidepressant medication and encouraged to discuss a prescription with her primary care provider; second, she received weekly sessions of problem-solving therapy with her specialist cancer nurse; third, the cancer nurse treating Mrs. B.
liaised with her oncologist and primary care physician to coordinate her care.
18.9.4.6 Discussion Points
1. Mrs. B. had a number of clinicians involved in her care. How could her care be optimally coordinated?
2. What are the possible barriers preventing treatment of Mrs. B.’s depression?
3. Should all cancer patients be screened for depression?
18.10 Conclusion
As patient care increasingly shifts away from the inpatient setting, the tradi- tional role of CL psychiatry must change. Outpatient work and liaison with primary care has become increasingly important. These changes present chal- lenges but also offer advantages both for patients and for clinicians. Our own experience is that outpatient CL psychiatry provides a unique opportunity to integrate medical and psychiatric aspects of care and provides a model for truly integrated patient care.
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