About Consultation-Liaison (C-L) Psychiatry

C-L Psychiatry is the discipline encompassing the study and practice of psychiatric disorders in patients with medical, surgical, obstetrical and neurological conditions, particularly for patients with complex and/or chronic conditions.

Role of the C-L Psychiatrist

C-L Psychiatry stands at the interface of psychiatry with all other medical specialties. C-L fellows will conduct comprehensive psychiatric assessments on a diverse range of individuals with varying psychiatric presentations occurring co-morbid with other general medical conditions. They will serve as consultants advising on best practices for treating psychiatric illness and psychological distress in patients with other medical conditions, both inpatient and outpatient. They will advise and counsel on potential serious side effects of psychiatric medications requiring medical hospitalization (e.g. lithium toxicity, serotonin syndrome, etc), and risk/benefit assessments of prescribing psychiatric medications in the context of other medical conditions, for example, heart disease, liver disease, and renal disease, as well as in pregnant patients. Fellows will also counsel on the appropriate work-up for potential neurological and medical diagnoses that may present with neuropsychiatric symptoms. The fellows will also guide medical teams on decisional capacity evaluations for medically ill patients, and will advise regarding how and when to pursue involuntary medical interventions, with the support of our ethics colleagues and legal department.

C-L psychiatrists provide education and expertise on mental health issues to our colleagues in other fields. Areas included in this liaison role include education and advice on the appropriate diagnosis and treatment of psychiatric illness, behavioral management of “difficult” patients in primary care or inpatient medical settings, the management of emergent agitation, and the assessment of decisional capacity, among other issues. There are shortages of mental health care providers throughout the nation, which are expected to continue. C-L psychiatrists trained and experienced in the provision of care through collaborative care and integrated behavioral health models, will also help to address the ongoing need for the psychiatric consultant to oversee and advise on the psychiatric care of larger numbers of patients than he or she would be able to see independently, by reviewing cases and collaborating with primary care providers and embedding in other subspecialty medical clinics in high need of psychiatric expertise (e.g. HIV clinics, oncology clinics, etc).

Positions

Two positions are available on a competitive basis each year.

How to Apply

The application and all supporting documentation must be submitted by Oct. 1st of the year preceding the program start date. However, please note that we strongly encourage applications prior to September 1, as this is when we begin offering interview slots.

There are two ways to apply:

You may apply using the Academy of Consultation-Liaison Psychiatry (ACLP) common application or via ERAS.

1. Visit https://www.clpsychiatry.org//to download the Common Application for CL Psychiatry Fellowship Position. All applications must include complete application materials. In addition to the materials requested on the common application, we require a photo, official USMLE transcripts, official medical school transcripts, and scanned copy of your medical school diploma.
2. Visit the ERAS for Fellowships website.

Complete the application form and send with the required application materials to DVMadrid@mednet.ucla.edu,  C-L Psychiatry Fellowship program administrator.

We invite applications from holders of J-1 visas.

1. Appointments are made through the Psychiatry Fellowship Match, which is sponsored by the National Resident Matching Program (NRMP). You must register for the match in addition to applying through ACLP.
2. Applicants considered for an appointment will be invited to visit UCLA for a personal interview with the program director and selected faculty. Interviews are conducted between September and early December each year.

Fellows will have experiences evaluating patients where the intersection of psychiatric symptoms and medical or surgical conditions is a central issue. They will have opportunities to embed themselves in established primary care clinics at the West Los Angeles VA, where they will consult and advise on patients for whom psychiatric symptoms may be interfering with the ability to appropriately care for their medical conditions (e.g. diabetes mellitus) or where the treatment of a medical condition may be having adverse psychiatric consequences (e.g. corticosteroid-induced psychiatric symptoms). Fellows will also be embedded in medical subspecialty clinics, including the HIV clinic at the West Los Angeles VA, and the oncology clinic at Cedars Sinai, where they will learn consultation and liaison skills in collaborative care models that serve the patient from both a mental health and general medical perspective, and will build skills in these nuanced sub-specialties of psychosomatic medicine (e.g. HIV psychiatry, Psycho-Oncology, Transplantation Psychiatry, etc). They will have longitudinal experiences in behavioral neurology, with neurobehavior expert Dr. Mario Mendez, to learn the nuances of assessing complex neurologic disorders and their overlapping behavioral symptoms, and the management of such conditions. Further, fellows will have longitudinal training in perinatal psychiatry through a year-long experience providing supervised consultations for women with psychiatric conditions who are considering pregnancy, who are pregnant, or who are in the post-partum period, in order to build expertise in weighing the risks and benefits of different psychiatric treatment options and providing appropriate treatment recommendations during the perinatal period. This expertise is desperately needed and desperately lacking in the general community of practicing psychiatrists and physicians. Further, inpatient consultation-liaison psychiatry rotations at UCLA, the West Los Angeles VA, and Cedars Sinai will provide broad exposure to the wide variety of cases that present to a typical psychiatry consultation service, ranging from assessing side effects of psychotropic medications and providing recommendations going forward (e.g. lithium toxicity, serotonin syndrome, SIADH), assessing psychiatric side effects of treatments for medical conditions (e.g. tacrolimus neurotoxicity), assessing for broad differential diagnoses underlying new onset psychiatric symptoms in different age groups, completing capacity evaluations, pre-transplantation evaluations, assessment and recommendations for medical patients with co-morbid substance use disorders, and training in the overlap between medical conditions, chronic pain and opiate dependency. Fellows will assist with the need for assessment of depression, anxiety, or delirium in medically ill patients, with careful consideration of appropriate pharmacotherapy, given the often complex backdrop of organ dysfunction and the inherent potential for multiple drug-drug interactions encountered in complex medically ill patients.

There will be regular individual and group supervision of the fellows on their ongoing work. Supervision will consist of direct (i.e. the faculty directly observe the encounter with the patient/examinee) and indirect supervision (i.e. the faculty do not directly observe the encounter but discuss relevant facets to determine joint assessment and evaluation) performed by faculty. Learning how to formulate an appropriate differential diagnosis from which recommendations and appropriate psychotherapeutic interventions can then flow is central to any good C-L fellowship program. Fellows strengthen this ability through synthesizing behavioral data and findings on mental status examination with medical/neurological data and findings. As such, supervision at all sites as well as all aspects of the didactic program will have as their main teaching focus best practices in developing the skills required to address these complex aspects of diagnosis and treatment. Fellows will, of course, have learned how to perform clinical assessments and provide treatment in their general psychiatry residency programs. The value added by subspecialty training in C-L Psychiatry is to become expert in the complex overlay of behavioral and psychiatric issues with medical illness, including broad differentials for neuropsychiatric symptoms, and expertise in drug-drug interactions and drug-illness interactions.

Formal didactics are held once weekly. Further, each longitudinal clinical experience will have embedded teaching, including the Women’s Life Clinic at UCLA, the Neurobehavior Clinic, HIV clinic, and Primary Care Mental Health Integration Clinic at the WLA VA, the Psychosocial Oncology Clinic at Cedars Sinai Medical Center. In addition, there is a C-L Psychiatry Case Conference at UCLA approximately once monthly. Grand rounds occurs weekly at UCLA. There is an ethics lecture series at UCLA approximately once monthly. There are thus extensive educational activities built into the program. In addition, all clinical service will be supervised and thus simultaneously educational, with case-based teaching and faculty supervision built into all components of the fellowship rotations.

Didactic topics for core C-L Psychiatry lecture series:

• Delirium
• Decisional Capacity
• Legal and Ethical Issues in Consultation-Liaison Psychiatry
• Biomedical Ethics
• End of Life Decision Making and Advance Care planning
• End of Life Options Act/Palliative Care and Psychiatry
• Agitation in the Medical Hospital
• Transplantation Psychiatry
• Intro to the Assessment and Treatment of Substance Use Disorders
• Stimulant Use Disorder
• Pain, Opioids, and Opioid Use Disorders
• Smoking Cessation
• SBIRT Techniques and Bedside Motivational Interviewing
• Stigma and Shame: Communicating with Patients Who Have Substance Use
• Disorders
• Withdrawal Syndromes and Their Management
• Cannabis and Cannabis Use Disorder
• Cannabinoids and Pain
• Pain and Analgesic Properties of Psychotropics
• Treatment Approach to Chronic Pain/Somatization
• Ketamine Use for Depression + Pain
• Depression in Advanced Medical Illness
• Inflammatory Biology of Depression: Translation
• Emotional Responses to Medical Illness
• Relaxation Skills Training in the CL Setting
• Borderline personality and maladaptive coping in medical setting
• Suicide in the Medical Setting
• Depression and Heart Disease
• Post-stroke depression
• Psychiatric Management of Inflammatory Bowel Disease
• Anxiety Disorders and Medical Illness
• Transplantation Psychiatry
• Catatonia
• QT Prolongation and Psychotropic Medication
• Drug-Drug/Drug-Disease Interactions
• Insomnia and Behavioral Treatments
• Functional Neurological Disorders
• Factitious Disorders and Malingering
• HIV Associated Neurocognitive Impairment
• HIV and Substance Use Disorder
• Common Psychiatric and Medical Co-Morbidities Associated with HIV
• New Trends in the Management of HIV Infection
• Autoimmune Encephalopathy
• CL Zebras
• Quality Improvement
• Proactive Consultations in C/L
• Collaborative Care/Integrated Care
• NMS/Serotonin Syndrome/Anticholinergic Toxidromes
• Physician Wellness

This is a one-year fellowship. Fellows will spend time evaluating patients at all three sites: UCLA, West Los Angeles VA, and Cedars Sinai Medical Center.

 Rotations:

 Outpatient Clinics

There will be longitudinal clinics at each of the three sites (UCLA, West Los Angeles VA, and Cedars Sinai Medical Center).

1. Primary Care-Mental Health Integration. Location: West Los Angeles VA. This clinical experience is embedded within veterans’ primary care clinics, and provides exposure and training in a co-located, collaborative care approach to mental health, within the primary care setting. Problem-focused evaluations by mental health care providers, embedded within the primary care clinic, help to address common mental health conditions within the primary care setting, without requiring patients to consult with mental health providers outside of their primary care clinic. Given the increasing importance of integrated behavioral health models in meeting the needs of patients nationwide (in the context of a shortage of mental health care providers) it is essential that C-L fellows gain exposure to integrated behavioral health models. The field of C-L Psychiatry has been at the forefront of research and implementation of collaborative care models, and C-L trainees are poised to become leaders in this area.
2. Psychosocial Oncology Clinic. Location: Cedars Sinai Medical Center. Fellows will gain longitudinal experience and exposure to the subspecialty of psycho-oncology and palliative medicine, through a half day per week clinic serving patients with cancer diagnoses. Psychiatric services focus on helping cancer patients and their families cope with the stresses of cancer and its treatment, including management of anxiety, cancer-related distress, depression, insomnia, delirium, treatment adherence, medical decision-making, and end-of-life issues. In addition to traditional psychiatric services, fellows will gain experience and exposure to palliative medicine throughout this clinical experience, with an additional focus on pain and symptom management associated with cancer and its treatment, as well as advanced care planning, including goals of care discussions and medical decision-making.
3. Women’s Life Center (for elective fellowship track in women’s health/perinatal psychiatry). Location: UCLA. This outpatient program is devoted to assessing and treating women with psychiatric conditions associated with hormonal challenges and reproductive life events. The clinic provides pre-pregnancy consultations for women with psychiatric conditions requiring psychiatric treatment, consultations for psychiatric conditions associated with pregnancy and postpartum, psychiatric consultations surrounding miscarriage, pregnancy loss, and infertility, premenstrual dysphoric disorder, and perimenopausal mood and anxiety disorders. UCLA has one of the premier programs in reproductive/perinatal psychiatry, with an embedded weekly seminar and multiple expert supervising faculty in perinatal and women’s psychiatry. There is a shortage of psychiatrists competently trained to appropriately assess risks and benefits of psychiatric treatment in the perinatal period, and many women suffer due to lack of experienced providers who can confidently make balanced recommendations about treatment in the context of co-occurring pregnancy (or desire for pregnancy) and mental health conditions.
4. HIV Psychiatry. Location: West Los Angeles VA. This clinic provides integrated, collaborative care for veterans with HIV. Medicine and mental health (psychiatry, psychology and social work) services collaborate to provide optimal care for veterans with multiple comorbidities, such as HIV, hepatitis C, metabolic disorders, cognitive impairment, major depression, psychosis, substance abuse, and PTSD. Neuropsychiatric assessment and treatment have become an increasingly important focus of this rotation due to the aging of the HIV positive population. The fellows will study current HIV psychiatric and neuropsychiatric literature and integrate this knowledge into practice. The fellows will be guided on the biopsychosocial treatment of HIV patients in the context of the interdisciplinary clinic. The fellows will also be guided on differential diagnosis, psychotropic selection, drug-drug interactions, cognitive impairment in HIV, psychodynamic formulation and psychotherapeutic modalities and multi-focal approaches to treating psychiatric conditions. The fellows will participate as part of the interdisciplinary team.
5. Multidisciplinary Integrated Behavioral Neurology and Geriatric Psychiatry Clinic. Location: West Los Angeles VA. The UCLA/VA Behavioral Neurology and Neuropsychiatry Program has combined strengths in the areas of clinical cognitive disorders, dementia, and neurological neuropsychiatry. Bedside mental status assessment and cognitive evaluations are major aspects of this clinical rotation. Given the large overlap between the specialties of consultation-liaison psychiatry and behavioral neurology, this clinical exposure with expert mentorship and supervision is a great strength, providing C-L fellows more in-depth knowledge and expertise in assessing mental status as well as evaluating and treating neurodegenerative and other neurologic conditions with accompanying behavioral symptoms. In addition, multiple didactic opportunities are associated with this clinical experience.

Inpatient Consultation-Liaison Psychiatry 

 In addition to a number of outpatient clinical experiences, fellows will rotate on the inpatient consultation-liaison psychiatry services at all three sites. This will allow exposure to a variety of patient populations, as well as a variety of clinical supervisors with various areas of niche expertise. Through these inpatient experiences, there will be robust exposure to a diverse array of consultation questions. With rotations at 3 large medical facilities, fellows will receive ample and repeated exposure to all routine consultation-liaison psychiatry questions, providing the opportunity to develop expertise in addressing such questions, while combining the nuance of the individual patient’s clinical circumstances, under supervision. Further, Cedars Sinai and UCLA Medical Centers both provide tertiary care for highly complex medically ill patients. There is thus a clinical need for complex assessments of aspects potentially contributing to mental status alterations and behavioral symptoms, including broad differential diagnoses related to medical and neurological conditions and potential drug toxicities. Nuanced recommendations are required regarding appropriate psychotropic drug selection given high likelihood of drug-drug and drug-illness interactions in these complex patients. Further, both UCLA and Cedars Sinai Medical Center also perform a high volume of transplants. Thus, both psychiatric pre-transplantation evaluations as well as psychiatric care of the post-transplantation patient will be important aspects of the training at these two sites. At all sites there are patients with complex diseases (cardiac, pulmonary, renal, liver) that impact their ability to tolerate or metabolize certain psychotropic medications. Common consultation questions at all sites include assessment of altered mental status, assessment of co-morbid mood disorders, anxiety disorders, psychotic disorders, and substance use disorders in medically ill patients, assessment and management of difficult and/or agitated behavior, and evaluation of decisional capacity.

Fellows will be supervised on all assessments by consultation-liaison psychiatry faculty at UCLA, the West Los Angeles VA, and Cedars Sinai.Fellows, if they choose, will also have the opportunity to perform some ethics consults and participate in the multidisciplinary ethics committee meetings.

There will be no call responsibilities. The typical work week is Monday through Friday from 8 AM to 5 PM. The Director will ensure that all activities, including moonlighting activities, do not exceed allowable duty hours.

Fellows will be expected to participate in a scholarly project and produce at least one scholarly abstract or paper to be submitted for publication in an academic peer-reviewed journal or presented at a professional meeting.

Many of the faculty are involved in scholarly activities, including publishing papers, writing book chapters, and presenting at national meetings. For example, Dr. Kruse (program director) has received NIH and other private grant funding to study the role of inflammation in mood disorders and depression treatment response, presents her work at national meetings, and has published review articles, book chapters, and original research.

Dr. John Brooks is the director of Consultation-Liaison psychiatry at the UCLA Ronald Reagan Medical Center. Dr. Brooks’ research focuses on mechanisms of brain activity, cognition, and personalization of treatment in mood disorders.

Dr. Thomas Strouse is the Vice Chair for Clinical Affairs for the Department of Psychiatry and Biobehavioral Sciences, holds the Maddie Katz Chair in Palliative Care Research and Education, and is board-certified in consultation-liaison psychiatry, as well as hospice and palliative medicine. Dr. Strouse’s clinical expertise is in psychiatric aspects of medical illness as well as cancer pain management.  Dr. Strouse is a Fellow of the Academy of Psychosomatic Medicine and a Distinguished Fellow of the American Psychiatric Association.  He has published and lectured widely. 

Dr. Mario Mendez is a behavioral neurologist with extensive publications in the area of cognition and neurodegenerative disease. Dr. Mendez is the Director of Neurobehavior at the VA Greater Los Angeles and also directs the UCLA Frontotemporal Dementia & Neurobehavior Clinic. Dr. Mendez is trained and licensed in the areas of internal medicine, neurology, neurobehavior, and experimental psychology. His area of research revolves around the clinical aspects of frontotemporal dementia, progressive aphasia, posterior cortical atrophy, and other focal cortical degenerative conditions. He is a well published author with over 200 publications which include peer review articles, books and chapters, and is a highly respected clinician educator.

Dr. Vivien Burt has more than 20 years of experience in adult and reproductive psychiatry. She is Founder and Co-Director of The Women’s Life Center of the Resnick UCLA Neuropsychiatric Hospital. She has authored numerous articles and book chapters in the field of women’s psychiatry and has lectured both nationally and internationally on the subjects of mood disorders and women’s mental health and has provided expert testimony in the area of women’s mental health. She is a recipient of the Outstanding House Staff Teaching Award from the UCLA Neuropsychiatric Institute, and she has devoted her career to training psychiatrists in reproductive psychiatry. Her scholarly activities include projects in women’s mental health with a particular focus on psychiatric illnesses associated with reproductive transitions.

Dr. Scott Irwin is board-certified in psychosomatic medicine, and is the Director of Supportive Care Services at Cedars-Sinai Medical Center. He strives to improve outcomes for those with cancer or other progressive, potentially life-limiting illnesses, and their families, through leading-edge clinical services, ongoing research, and program development, improvement and implementation. Dr. Irwin has received research funding from the NCI, NIMH, the National Palliative Care Research Center, the Archstone Foundation, the John A. Hartford Center of Excellence in Geriatric Psychiatry at UC San Diego, and industry. He is the author/co-author of over 100 articles, chapters and abstracts, is frequently quoted in the media, and has been recognized at many levels for his innovative research, teaching and clinical endeavors.

This just a sampling of our faculty and their accomplishments. We have an extraordinary number of faculty with national and international reputations. The program director will facilitate introductions to faculty with whom the fellow has shared scholarly interests.