Psychiatry and
Behavioral Sciences–

Psychosomatic Medicine Service at Stanford University Medical Center

MISSION STATEMENT

We strive to improve physical and mental health through better understanding and bridging of the mind-body connection. We intend to reach this goal through the following tasks:


CLINICAL PROGRAMS

Psychosomatic Medicine (PM) is the area of Psychiatry concerned with the psychobiological care of the medically ill. This patient population includes persons of all ages and those cared for in specialized settings such as internal medicine, surgery, organ transplantation, and many others. Psychosomatic Medicine specialists, in addition to providing expert formal psychiatric consultation to medical and surgical patients in the general hospital, specialized hospitals and outpatient clinic settings, also train psychiatrists and non-psychiatrist healthcare providers (e.g., internists, neurologists, surgeons, nurses, physician assistants) in the recognition of normal and abnormal reactions to illness and appropriate psychological care of patients with such reactions.

Thus the Psychosomatic Medicine Service (PMS) functions both as a consultant and as part of the primary medical/surgical treatment team. Via conjoint rounds and teaching conferences (primary intervention), formal consultations (secondary intervention), and involvement in inpatient treatment and discharge planning (tertiary intervention), the PMS provides a comprehensive approach to the emotional, cognitive, and behavioral needs of the patient.

Consultation/Liaison Service: Inpatient Program
       
The Inpatient Psychiatric Consult -Liaison (C/L) Service provides a critical service to Stanford Hospital & Clinics (SHC) by enhancing the quality of patient care and offering medical colleagues consultation in all psychiatric aspects of patient management. The C/L Service provides consultation in all 16 medico-surgical units at SHC, providing an average of 1200 new consults per year. The services provided include:

Psychosomatic Medicine Clinic: Outpatient Program
       
The outpatient Psychosomatic Medicine Clinic (PMC) offers a number of services for patients usually referred by physicians in other medical specialties. These services include: evaluative sessions to assess for the presence of psychiatric disorders arising as a consequence of medical disorders or their treatment; psychological assessment for the appropriateness for transplantation and other surgical procedures (e.g., deep-brain stimulator for the treatment of Parkinson’s Disease; bariatric surgery, cosmetic surgery and others); psychopharmacological consultations; psychotherapy; and hypnosis training.

We have ongoing subspecialty clinics to provide specialized services to the following medico-surgical specialties: Internal Medicine & specialty services; General Surgery & specialty services; Neuropsychiatry; Solid Organ & Bone Marrow Transplantation; Composite Tissue Allotransplantation; the Positive Care Clinic (HIV/AIDS); and the Comprehensive Cancer Center.


DIDACTIC PROGRAM

Post-Graduate Medical Training
       
Psychiatry Residents

The Psychosomatic Medicine Team is dedicated to post-graduate medical education, while they are rotating through our service and during their general psychiatry residency education.

- Psychosomatic Medicine In-Patient Rotation: Psychiatry Consultation/Liaison Service (C/L)

During this busy rotation, the CL team strives to provide residents with the best education. The teaching combines formal didactics and presentations by Attendings, Fellow, and Trainees, Quiz aimed at encouraging self-directed learning, rigorous bedside teaching, and discussion of relevant and recent literature. Please see the attached tables for CL residents’ schedule and 8-week teaching curriculum.

The core program for the training of residents (i.e., psychiatry, neurology, internal medicine) and medical students consists of an 8-week curriculum which includes the basic aspects of Psychosomatic Medicine. In addition to the core lecture series resident receive additional training in many aspects of PM, including: neurobiology & psychopathology of head injury; identification and management of neuropsychiatric masquerades (i.e., medical, infectious, metabolic, autoimmune and neurological conditions that present with primary psychiatric symptoms); somatoform disorders, primarily conversion disorder; organic psychosis; identification and management of substance abuse, intoxication and withdrawal states; management of death & dying issues; and training on the use of hypnosis for the management of medical and psychosomatic conditions.

For detailed information about the Consultation/Liaison Psychiatry Formal Teaching Curriculum please open the attached PDF document (PDF of article PDF file)

- Emergency Psychiatry Course

Part of the C/L Service experience at Stanford includes providing psychiatric consultation to the Emergency Department and selected out-patient medico-surgical clinics. As such, residents are exposed to a full range of emergency psychiatry experience. This often serves as gateway to the medicine/surgery units, allowing for follow-up and continuation of care during the patient’s medico-surgical stay and treatment.

The Psychosomatic Medicine Physician Team provides an 11-week course in Emergency Psychiatry to Psychiatry Interns at the beginning of their residency training.

The scheduled series includes:

  1. Emergency Psychiatry Survival Guide: Practical Tips to Surviving the ED.
  2. Medico-Legal Aspects in the ED: LPS Law; Competency Assessment.
  3. ED & Community Resources ; CPS/APS/Mandatory reporting
  4. Assessment and Management of Suicidal Patient
  5. Management of Substance Intoxication & Withdrawal- Part I
  6. Management of Substance Intoxication & Withdrawal- Part II
  7. Delirium Assessment & Management
  8. Acute Management of Demented Patients
  9. Dreadful Rx side effects: akathisia, serotonin syndrome, EPS, NMS, QTc prolongation, TCA side effects.
  10. Assessment & Management of Agitation in the ED
  11. Malingering in the ED

- Training Liaison with the Internal Medicine Program

The Psychosomatic Medicine Team delivers a yearly, 8-lecture module to the Internal Medicine Residency Program directed at teaching basic psychiatric concepts, including diagnosis and treatment in various psychiatric problems commonly found in the general medicine practice. The regularly scheduled lecture series include:

  1. Depression in the medically ill: Recognition, Differential Diagnosis & Management
  2. Anxiety in the medically ill: Recognition, Differential Diagnosis & Management
  3. Delirium: Diagnosis, Prevention & Treatment
  4. Dementia: Assessment and Management
  5. Alcohol abuse & withdrawal
  6. Somatoform disorders (including conversion)
  7. Psychosis: Recognition, Differential Diagnosis and Management
  8. Factitious disorder and malingering

In addition, our team members regularly attends Internal Medicine didactic lectures, M&M Conference an Grand Rounds as discussants of psychiatric factors affecting care, or the psychiatric/behavioral manifestations of medical illness or side effects. On a regular basis, our physicians conduct impromptu teaching sessions, family and interdisciplinary meetings with the medicine residents, or participates in nursing and residents teaching sessions in the clinical units- or at the bedside. Finally, most medicine residents regularly interact with, and many receive direct training from him as part of their formal Medicine training as they rotate through the Psychiatry Consultation Program. During that experience they have hands-on experience in managing psychiatric consequences of medical illness during the direct supervision of our psychiatrists.

- Training Liaison with Neurology Program

The Psychosomatic Service co-organizes Neurology-Psychiatry Conference on monthly/bi-monthly basis. This conference takes place during Neurology Residents didactics. During this conference, we discuss patients that have neuropsychiatric conditions or have co-morbid psychiatric and neurological problems. Each conference consists of case presentations, relevant didactics portion, and discussion by members of both programs (i.e., neurology and psychiatry).

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Medical Student Experience

- Basic & Advanced Psychiatry Rotations

Medical students from Stanford School of Medicine and other medical centers are welcomed to participate in the rich didactic experience our program has to offer. Even though students can fulfill their basic psychiatry experience requirement during this practicum, we feel this rotation is better suited as an advanced clinical experience.

- HIV-Fellowship

We are now a selected training site for the APA-sponsored HIV-Fellowship rotation. The fellowship provides for HIV/AIDS training in Washington D.C., and 1 month of multidisciplinary HIV/AIDS clinical experience at Stanford. The selected students (who compete nationally for the positions) will see patients at both Stanford and Valley Medical Center’s HIV outpatient clinics. They will gain experience in HIV psychopharmacology, HIV and Hepatitis C management, drug-drug interactions, substance abuse, nutrition, health care economics, and gain cultural competency in working with a diverse population. The model will be used to develop a Stanford University School of Medicine course to be offered as an elective for Stanford medical students.

- Stanford Medical Scholar Program

Stanford students may choose to do research in the PMS as part of the Medical Scholars Research Program. Students carry out clinical research under the direction and supervision of one of the PMS faculty members who will serve as their faculty research advisor. In the recent past, such efforts have helped advanced research in the areas of organ transplantation, alcohol withdrawal management, and delirium.

Peer & Community Training

  1. Our educational program includes the Psychosomatic Medicine Interest Group designed to provide ongoing education to SHC faculty members and community mental health professionals interested in Psychosomatic Medicine. The PMIG takes place the 2nd Wednesday of every month. CE credits are available to interested faculty.

  2. Members of our full time faculty are constantly engaged in various professional and community (i.e., patient driven) educational venues and groups, providing education and training to fellow mental health professionals, other medical colleagues, and the community.

      • San Jose AIDS Education and Training Center (SJAETC) – Dr. McGlynn serves as Medical Director for the SJAETC faculty, a multidisciplinary team representing Stanford and other institutions focusing on providing HIV/AIDS education to community physicians and other healthcare workers.  
      • Stanford Methamphetamine Task Force – A research and community consortium under the direction of Dr. McGlynn, with the mission of reducing methamphetamine use and new HIV infections.
      • APM-Education & Annual Meeting Committees – Dr Maldonado serves as a standing member of both committees.
      • Dr Maldonado conducts educational teaching sessions for the following residency programs: psychiatry, internal medicine, surgery, emergency medicine, neurology, and anesthesia.

Psychosomatic Medicine Fellowship

The one-year Stanford Psychosomatic Medicine Fellowship Program, developed and directed by José R. Maldonado MD, offers advanced training in the field of Psychosomatic Medicine and Consultation-Liaison Psychiatry in both hospital and ambulatory settings with abundant clinical, educational, and cutting-edge research opportunities.

For more information about this program please visit the Psychosomatic Fellowship website:

https://psychiatry.stanford.edu/education/pmfp.html

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RESEARCH & SCHOLARLY ACTIVITIES

The attending physician members of the Psychosomatic Medicine team have been involved in a number of research projects throughout the years including:

1992 – 1993           Psychiatric Profiles of Patients with Spinal Disorders.
1994 – 1995           Psycho-Neurophysiology of Conversion Disorders.
1994 – 1995           The Psychophysiology of Conversion Disorder.
1994 – 1995           Effect of Single-Session Hypnosis on Smoking.
1995 – 1996           Research Network on Mind-Body Interactions.
1995 – 1996           Hypnotic Analgesia in Cancer Patients.
1997                       Incidence of Extra-Pyramidal Symptoms (EPS) Associated with the Use of IV vs.
                                 PO/IM Haloperidol in Agitated, Non-Psych Inpatients in the General Hospital.
1997 – 1998           Recognition, Diagnosis and Management of Delirium in ICU and Critical Care
                                  Unit Patients.
1997 – 1999           An Evaluation of Group Psychotherapy for People with HIV.
1998 – 1999           Psychiatric Sequelae of Bone Marrow Transplantation.
1999 – 2001           Difficult to Extubate Patients: Organic Vs. Functional Disorder: Natural History
                                 and Pharmacological Protocols.
2000 – 2001            Extra-pyramidal Symptoms: A New Diagnostic Scale.
2002 – 2003            A Comparison of Lorazepam Versus Diazepam in the Treatment of
                                  Alcohol Withdrawal.
2001 – 2006            ICU Delirium: Can Dexmedetomidine Reduce Its Incidence?
2006 – 2008            Methamphetamine and HIV Prevention in Santa Clara County.
2007 – 2009            Development of the Stanford Integrated Psychosocial Assessment for
                                  Transplantation (SIPAT) - A New Tool for the Assessment of Solid Organ
;                                 Transplant Candidates
2008 – 2009            Validity and Inter-rater Reliability of the Stanford Integrated Psychosocial
                                  Assessment for Solid-Organ Transplantation (SIPAT)
2009 – 2010            The Pharmaco-economics of Dexmedetomidine for Postoperative sedation
                                  Following Cardiac Surgery.

Current research projects include:

2010 – 2012             Melatonin for Delirium Prevention Study in Elderly Orthopedic Patients
2010 – 2011             Prevalence and Factors Associated with Delirium in BMT patients.
2010 – 2012             Trial of Aromatase Inhibition in Lymphangioleiomyomatosis (LAM) Role:
                                   Neuropsychiatric Consultant, for the SHC site.
2011 – 2014             SAWS: The Stanford Alcohol Withdrawal Scale – A new tool for the prediction
                                   of moderate to severe alcohol withdrawal.
2011 – 2014             SIPAT as predictor of Medical and Psychosocial Functioning
                                  after Transplantation.
2011 – 2014             Novel Methods for the Prevention & Treatment of Alcohol Withdrawal
                                   Syndromes: Beyond Benzodiazepines.

Fellows and residents are welcomed to participate in any ongoing projects and are mentored if they choose to start new projects. In fact, many residents become active members of our research team and many others collaborate in writing scientific papers and/or poster presentations at local and national meetings. Recent examples include (names of trainees in bold):

What follows is a partial list of our faculty’s selected publications:

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THE STANFORD INTEGRATED PSYCHOSOCIAL ASSESSMENT FOR TRANSPLANTATION (SIPAT): A New Tool for the Psychosocial Evaluation of Pre-Transplant Candidates (Maldonado et al. 2012)  (PDF of article PDF file)

A review of the psychosocial evaluation process of the various organ transplant programs within our institution revealed we were assessing dozens of psychological and social factors (i.e., a comprehensive psychiatric examination, plus various pieces of social demographical information). Yet it was unclear whether the current process was useful (i.e., predictive of transplant outcome) and whether there was a better way to do it. So we began to scrutinize what we were doing and looked into the published literature for those psychosocial variables that are supported by evidence-based data for treatment adherence, quality of life, and graft survival. We concluded that in order to minimize potential selection bias a tool that attempted to objectively assess complex psychosocial data would be desirable. We started with our own old screening questionnaire and added and deleted items based on our extensive review of the literature. The result was a new comprehensive pre-transplant organ evaluation instrument: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT). The SIPAT intends to assess psychosocial factors that appear to better predict patient’s adherence and graft survival. We divided the 18 identified risk factors into four domains including patient’s readiness, social support, psychological stability and substance abuse.

Based on the assessment of these factors, the SIPAT provides an overall risk severity score for psychosocial variables important in predicting post-transplant behavior, psychosocial support viability and effectiveness, treatment adherence, substance abuse & recidivism and mental health. Studies have shown that the psychosocial and behavioral characteristics were comparable among solid organ, pre-transplant candidates. Thus instead of performing the pre-transplant psychosocial screening in an organ-specific fashion, we recommend a more general screening protocol. In fact, studies have confirmed that the transplant psychiatrist's global rating of risk for post-transplant psychosocial problems that affect management (a measure that among other items incorporated ratings of coping and social support) was strongly associated with post-transplant non-adherence and the number of rejection episodes.

Our review of the evidence suggested that some of the measured factors are more predictive of treatment non-adherence and clinical outcomes than others. Therefore, the SIPAT items scoring system is weighted more heavily to compensate for this reality. When administering the SIPAT it is important that, whenever possible, psychosocial consultants utilize sources of collateral information to verify the facts provided, particularly in patients suffering from end-stage organ failure or encephalopathy. Also, developing good collaborative relationship with the patient’s medical providers and family members can provide a wealth of useful and corroborating (or conflicting) information which may be beneficial for the evaluation process.

The data available to date confirms that, in addition to typical medical factors, psychosocial and behavioral issues may affect the ultimate success of the transplantation process. Accordingly, most guidelines suggest that the pre-transplant screening process must include both a comprehensive medical evaluation and a thorough psychological assessment. Furthermore, there is data to suggest that pre-transplant psychiatric history can predict psychological outcomes after transplant, and that post-transplant psychosocial outcomes may predict physical morbidity and mortality.
In our study, SIPAT scores were highly predictive of transplant psychosocial outcome. These findings are consistent with a previous prospective study assessing patients before and 6, 12 and 24 months after transplantation and demonstrating that the mental health of patients with poor pre-transplant mental health continues to deteriorate after transplantation.

One of the strengths of the SIPAT is that it standardizes the psychosocial assessment evaluation process so all transplant candidates undergo the same rigorous psychosocial scrutiny helping identify areas of strength that can be built upon, and areas of weakness needing assistance or further consultation and treatment. This process helps transplant teams know as much as they need about the factors that may influence transplant outcomes. The function of psychosocial consultants should not be to make a determination regarding the patient’s worthiness as a candidate, but to assist the transplant selection committee in making the best clinical decision based on current available data. The use of assessment tools, such as the SIPAT, not only assists clinicians in eliminating the emotional factor from the decision making process, but also in presenting the facts during the selection process.

We believe the SIPAT compares favorably to the PACT, but it has some significant advantages including detailed descriptions regarding social support, substance abuse use and recidivism risk, knowledge regarding illness and transplantation process, and the effects of psychopathology and other cognitive organic factors. Our study was able to demonstrate excellent inter-rater reliability and a robust association between SIPAT scores and post-transplant psychosocial problems. SIPAT scores appear to be more reproducible than PACT scores between different raters. Moreover, SIPAT scores appear to be consistent between novice and expert raters.

The SIPAT may not only help to improve the selection process of transplant candidates, but it may also serve to identify patient’s level of social, neuropsychiatric and cognitive functioning. Clinicians may use the SIPAT to complement and standardize the psychosocial evaluation process, although it should not be used as the sole determinant of eligibility for transplantation. Instead, the content items of the SIPAT may enhance the selection process by identifying risk factors that may be amenable to clinical intervention before the transplant, or that may require extra attention after transplantation. This will assist in developing a comprehensive psychosocial treatment plan for each individual patient with the ultimate goal of minimizing preventable problems, mitigating risk, and optimizing graft survival and patient’s functioning and quality of life. In fact, we believe the major strength of the tool is not only its accuracy in identifying and predicting those patients that may do poorly after transplantation, but its ability to screen for areas of candidate’s weaknesses in order to allow for the development of interventions directed at improving the patient’s candidacy, thus turning marginal patients into acceptable transplant recipients. Although we recognize that many factors go into determining eventual transplant success (e.g., even with perfect adherence some organs will be rejected), we predict that enhanced psychosocial selection criteria will translate into lower morbidity, lower rejection rates, enhanced graft survival and better quality of life for transplanted patients.

The SIPAT is a comprehensive screening tool designed to enhance the psychosocial assessment of organ transplant candidates. Its strengths include the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient’s candidacy. SIPAT scores were found to be highly predictive of the transplant psychosocial outcome. The instrument has excellent inter-rater reliability, even among novice raters, and is highly correlated with PACT scores. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used along organ specific medical listing criteria in order to establish standardized criteria for the selection of solid organ transplant recipients in a way that promotes fairness, allows for the identification and timely management of potential problems, and maximizes graft survival and quality of life.

The SIPAT Long-Form Questionnaire
For a copy of the SIPAT Long Form Questionnaire for the Psychosocial Assessment of Organ Transplant Candidates click here.(PDF of article PDF file)

The SIPAT Tool
For a copy of the SIPAT Tool for the Psychosocial Assessment of Organ Transplant Candidates click here. (PDF of article PDF file)

Stanford’s Minimal Psychosocial Listing Criteria - Risk Factors for Poor Outcome (PDF of article PDF file)

- Absolute Contraindications:

A. Inadequate social support system
B. Active illicit substance use
C. Active alcohol dependence
D. Active nicotine abuse
E. Active psychotic sx’s that may impair adherence with Tx
F. Dementia
G. A history of multiple suicidal attempts
H. Non-adherence with treatment
I. History of recidivism of substance abuse after previous organ transplantation

- Relative Contraindications

A. High Risk:

• Active alcohol abuse
• Active abuse of prescribed substances
• Non-adherence with treatment
• Deceptive behavior
• Current suicidal ideation (in a patient with no prior Hx of multiple suicidal attempts)
• High degree of denial or ambivalence regarding transplantation
• Personality disorders

– Cluster A (i.e., Paranoid, Schizotypal)
– Cluster B (i.e., Antisocial, Borderline, Narcissistic)

B. Moderate Risk:

• Alcohol use (not directly causative of medical problem)
• Prescribed (“medical”) marijuana use
• Inability to understand relevant information and poor receptiveness to education
• Reluctance to relocate
• Absence of adequate living environment
• Limited or restricted access to resources
• Controlled major psychiatric disorder

– History of suicidal attempts
– Mood disorders
– Psychotic disorders
– Severe anxiety disorders
– Mental retardation

C. Lower Risk:

• Obesity: BMI > 30 – 40kg/m2
• Limited literacy
• Cognitive disorders

Stanford Guidelines for Deferment from Transplant List <Link to PDF here>

A. Patients who meet ONE SEVERE risk factor
- OR -
B. A SIPAT score ≥ 40 – 69, plus any of the following:

- Questionable psychiatric history - until clarified; or a well-documented history of currently unstable psychiatric
symptoms in need of active treatment
- Patient having ≥2 high risk factors
- Patient having ≥3 moderate / low risk factors
- Failure to meet substance use and/or behavioral contract

Stanford Guidelines for Recommending Declining Listing/Removal from Transplant List <Link to PDF here>

A. Patients who meet ONE ABSOLUTE risk factor
OR
B. A SIPAT score ≥ 69, plus any of the following:

- Patient meeting multiple risk factors (≥2 High Risk; ≥3 Moderate & Low Risk).
- Failure to meet abstinence contract terms within the prescribed deferment period.
- Listed patient with a positive toxicology screening test for any substance of abuse, alcohol, or nicotine.
- Listed patient who is not fully adherent with:

- Clinic visit
- 12-step program or Chemical Dependency Treatment Program
- Psychiatric care
- Development of adequate support team


Remediation:

- Patient will receive an intervention, and be given 2 months to modify his/her behavior or correct deficiencies.
- Above step may be repeated once, but on second reassessment (3rd talk) if behavior is still problematic or conditions are still suboptimal a recommendation may be made for the patient to be removed from the transplant list.
- A patient who has been previously declined or removed from the list: After 1 year, during which time must have followed with previous recommendations or corrective measures, must undergo a comprehensive psychosocial evaluation prior to representation to selection committee.

FACULTY

José Maldonado, M.D., FAPM, FACFE  (Program Director)
https://med.stanford.edu/profiles/Jose_Maldonado/
Maldonado

José Maldonado, MD joined the Stanford faculty in 1993 and became Medical Director of the Psychosomatic Medicine Service in 1995. He received his medical degree at Ponce School of Medicine and his psychiatric training at Temple University, in Philadelphia. He completed additional training in Forensic Psychiatry at Temple University, and a fellowship in Consultation-Liaison/Neuropsychiatry at New England Medical Center/Tufts University, in Boston.

For more information about Dr. Maldonado and all other faculty members involved with this program please visit the faculty website:

https://psychiatry.stanford.edu/education/Faculty-pmfp.html

Contact Us

Mailing address:
Psychosomatic Medicine Service
Department of Psychiatry
Stanford University
401 Quarry Road, Suite 2317 
Stanford, CA 94305

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