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Corresponding author
Gregory Fricchione, MD
Associate Chief of Psychiatry, Massachusetts General Hospital,
Warren 605, 55 Fruit Street, Boston, MA 02114, USA.
E-mail: gfricchione@partners.org
Current Psychiatry Reports 2006, 8:215 222
Current Science Inc. ISSN 1523-3812
Copyright 2006 by Current Science Inc.
This article takes stock of how far the eld of consultation-liaison psychiatry has come since its inception in the
20th century. In order to do this, we review its past in
terms of its knowledge base in psychosomatic medicine
and in terms of its practice at the bedside in the general
hospital setting. We also offer a contemporary account
of the eld and nish with a subjective view of the
opportunities and pitfalls faced during the next phase of
consultation-liaison psychiatry in the 21st century.
Introduction
Consultation-liaison (CL) psychiatry is the practical arm
of the eld called psychosomatic medicine. It has gone
through several phases in its existence and enters the 21st
century with a recognized place in the world of subspecialty medicine, with a list of accomplishments behind it,
and with a series of challenges ahead. This article reviews
where CL psychiatry came from, where it is now, and
where it is going.
216
Medicopsychiatric Disorders
Phases
Key events
Pre-1900
to 1930
1930s to
late 1950s
Late 1950s
to 1980
19601975
19751980s
1980 to
present
Consolidation/
Retrenchment [5]
Consultation-Liaison Psychiatry
Ali et al.
217
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Medicopsychiatric Disorders
American Board of Medical Subspecialties for accreditation, a proposal also supported by Accreditation Council
for Graduate Medical Education (ACGME), making it the
seventh accredited subspecialty in the eld of psychiatry.
CL psychiatry is currently served by three national subspecialty organizations and supports at least three major
subspecialty journals. Fellowship examinations are now
a requirement for certication as a specialist in psychosomatic medicine. Adding this subspecialty certication
opportunity to fellowship training and the formal
2-month requirement with outlined objectives for CL
psychiatry in psychiatry residency training programs certainly reects the strides that the subspecialty has made
in securing its place as a separate entity encompassing a
signicant area of specialized knowledge and research.
Research in CL psychiatry has made major contributions in the eld of medicine, drawing attention to the
psychiatric sequelae of many medical disorders, the
treatment of psychiatric disorders in comorbid medical
illnesses, drug interactions with psychotropics, and the
effect of nonpsychotropic medications on psychiatric
symptoms. In many instances, studies have identied
signicant clinical implications of stress and allostatic
loading and issues of the prognostic value and symptom burden of psychiatric illness in those with medical
illnesses. These have included several landmark studies
in diabetes, HIV/AIDS, coronary artery disease, cancer,
and stroke. The eld has become so vast that focused
areas in burn, intensive care, and transplant psychiatry
and psycho-oncology have evolved as the signicance of
psychiatric disorders in the various medical disciplines is
increasingly recognized.
Depression after myocardial infarction (MI), for
example, represents a rich area of research in psychosomatic medicine and CL psychiatry. There is now good
evidence for signicantly greater risk for all-cause mortality at 5 years post-MI in patients who have depressive
symptoms at the time of hospitalization for acute coronary
syndrome with or without conrmed MI [13]. Depression
has also been found to be associated with increased risk
of mortality and morbidity in patients with acute MI complicated by heart failure; in fact, depression was a stronger
predictor for all-cause mortality than left ventricular ejection fraction [14]. These ndings have raised the issue of
the effects of depression on cardiovascular physiology.
There is now good evidence for pathogenic mechanisms
in depression, such as increased platelet reactivity [15] and
decreased heart rate variability [16].
The possible effects of selective serotonin reuptake
inhibitors (SSRIs) on the above biologic factors and on
cardiac outcomes remain in question. Some frequently
cited trials, including SADHART [17], ENRICHD [18],
and MIND-IT [19], have investigated the effect on cardiovascular outcomes of treating depression. Although
the ENRICHD study did not demonstrate change in
cardiovascular outcome from using cognitive-behavioral
Consultation-Liaison Psychiatry
Ali et al.
219
220
Medicopsychiatric Disorders
Consultation-Liaison Psychiatry
Conclusions
Psychosomatic medicine has a rich tradition, as evidenced by its accumulated knowledge base and by the
role its practical armCL psychiatryhas traditionally
played in the general hospital and in outpatient settings.
Medicine in the 21st century will present a host of new
clinical challenges, many of which will open up opportunities for CL involvement and contribution. Recent
accomplishments such as ABPN recognition as a subspecialty and ACGME accreditation status for fellowships
have brought new energy, if not resources, to the eld.
These developments may be viewed as maturation in the
process of training these subspecialists. Nevertheless,
we will need to track the outcomes of these changes to
ensure that they are actually improving the ability of CL
psychiatry to provide the best care possible for patients
and the best education possible for trainees.
Research advances in our understanding of stress and
allostasis will enable us to contribute to public health
efforts, but our clinical research efforts will need to be
bolstered by commitment to improved research skills, by
research career trajectories for junior faculty members,
and by changes in the way research in clinical psychosomatic medicine is assessed and supported.
Ali et al.
221
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