Critical Care Psychiatry

“Call me back when they are extubated” is a refrain many intensivists hear. Whereas many specialties have integrated directly into the intensive care unit (ICU), psychiatry’s involvement is often limited and delayed until patients are more medically stable or communicative. These delays miss key opportunities to improve care and facilitate ICU liberation, but this longstanding paradigm is beginning to shift toward earlier involvement and integrated models of care.

Psychiatry’s role in the ICU has long lagged behind its role in other hospital settings, shaped by culture as much as by logistical constraints. Intensivists are accustomed to managing common psychiatric emergencies (e.g., overdoses, agitation, serotonin syndrome) without psychiatric input. Psychiatrists, in turn, may hesitate to engage with critically ill patients due to their own unfamiliarity with the ICU environment or concerns that mechanical ventilation will limit meaningful communication. The result has been mutual distance; psychiatry is called late, if at all, and ICU teams dutifully shoulder the psychiatric burden themselves.

Delays in psychiatric care place patients at greater risk for worsened outcomes, prolonging neuropsychiatric symptoms and hindering both medical and functional recovery. Nearly one in three ICU patients has a preexisting psychiatric illness, and one in four has a substance use disorder, although higher rates of psychiatric comorbidities among hospitalized patients suggest that these disorders may be underdiagnosed in the ICU.^1,2 Up to 80% of critically ill patients have delirium, 34% show evidence of catatonia, and 68% of mechanically ventilated patients endure delusional memories.^3-5 Nearly every ICU patient has at least one psychiatric target of intervention, yet psychiatric consultations originating in the ICU comprise only 3% of consultation-liaison service volume.⁶ Closing this gap requires systems-level solutions rather than isolated efforts. Fortunately, evidence now supports proactive and integrated psychiatric consultation, aligning with frameworks for ICU liberation and value-based care.

Historically, psychiatry’s role in the ICU has been reactive, dependent on case-by-case requests. However, recent developments in proactive psychiatric consultation have exposed how the reactive approach misses crucial opportunities to optimize population health and recovery. By embedding a psychiatric consultant directly into the ICU team or by utilizing a systematic approach to screening and early psychiatric consultation for patients who meet predetermined criteria, psychiatrists have demonstrated improved patient outcomes and reduced costs of care.^7,8

In a 2019 study comparing an embedded model of psychiatric consultation with usual care, the integrated psychiatric cohort demonstrated significantly reduced hospital length of stay (LOS) for patients with respiratory failure (median 9.46 days, IQR 4.95–17.56 vs. 12.29 days, IQR 6.58–21.10, P = 0.011).⁹ In that model, a psychiatrist rounded daily with the ICU team, offering bedside recommendations or full consultations as needed. A subsequent fiscal analysis showed a return on investment of 26.7, meaning the program yielded $26.70 for every dollar invested, providing a strong financial argument for the model’s sustainability.¹⁰

This embedded model is straightforward to initiate and maintain, offering real-time collaboration within the multidisciplinary ICU team. For psychiatrists new to critical care, the embedded approach provides an excellent entry point to learn the environment’s nuances and limitations. However, the model’s dependence on the psychiatrist’s physical presence imposes constraints on scalability, so broader-reaching models may yield greater population impact.

Proactive psychiatric consultation, by comparison, screens a larger population of critically ill patients using predetermined criteria, prompting psychiatric consultations for those who screen positive. One such program in a medical-respiratory ICU (MRICU) screened the patient census each day and provided psychiatric consults for all patients with evidence of delirium, often while patients were still ventilated. 

In an ongoing analysis that has not yet been published, the proactive delirium model is being compared to a usual-care MRICU cohort over a 20-month period. Proactive consultation has reduced average hospital costs by about $7,000 per admission, with even larger savings among older adults (≥70 years: about $12,000 per admission). Hospital LOS in the intervention cohort of 70 years or older is significantly reduced by slightly more than three days.

In an era of bed shortages and constrained resources, these savings reflect meaningful value for patients and institutions alike. Proactive psychiatry enhances care quality by aligning with the evidence-based ICU Liberation Bundle (A-F).¹¹ By prioritizing early intervention for delirium, engaging and educating families, and tailoring pharmacologic regimens to minimize polypharmacy and avoid worsening patients’ critical illness, the psychiatrist becomes an essential member of the multidisciplinary team. Furthermore, psychiatrists’ expertise in adapting communication strategies to patients whose ability to engage is limited can be especially valuable in the ICU. Even ventilated patients can often communicate meaningfully when given the right tools, supporting self-expression and helping identify treatment targets. These interactions embody the World Health Organization’s principle “nothing about me without me.”¹² As light- and non-sedation strategies keep patients more awake, personalized communication accelerates liberation and promotes well-being.

Early psychiatric integration in the ICU fits squarely within value-based care frameworks such as the Institute for Healthcare Improvement’s Quintuple Aim.¹³ This model emphasizes improved patient outcomes, patient satisfaction, clinician well-being, reduced costs, and health equity, all demonstrated benefits of proactive psychiatric consultation. While clinician well-being can be challenging to quantify, improving staff safety can powerfully enhance staff satisfaction. In the ongoing study of the proactive delirium model mentioned above, only one documented assault has occurred in the proactive MRICU group compared with six in the usual care cohort. Benefits to staff satisfaction are critical since clinician well-being underpins a culture of safety and helps prevent burnout and turnover.

The proactive approach also advances health equity. Screening based on objective, needs-based criteria ensures that psychiatric resources reach patients most at risk, a goal difficult to achieve with reactive consultation. A 2024 study found that proactively consulted patients were more likely to have public insurance than those evaluated only by request, suggesting that proactive consultation reduces disparities in access to psychiatric care.¹⁴ Emerging technologies such as large language models and AI-driven screening will likely enhance this population-level precision, further expanding psychiatry’s reach and impact.

Hospital administrators often view psychiatry as a sunk cost rather than a revenue generator. Proactive models challenge that perception; by reducing LOS and cost of care, early psychiatric consultation delivers measurable financial value, particularly among accountable care organizations. Embedding psychiatry in the ICU also improves team efficiency: neuropsychiatric barriers and crises can be addressed by the psychiatric team in real time, freeing intensivists to focus on physiologic management and coordinating whole-person care.

Although long-term outcomes such as post-ICU syndrome have yet to be formally studied in this context, the same principles of population-based screening and early intervention apply. The collaborative care model, widely validated in outpatient settings, offers a parallel framework for post-ICU follow-up.¹⁵ As ICU survivorship rises, attention to psychological recovery will grow in importance for patients navigating the enduring consequences of critical illness.

As ICU medicine evolves toward holistic, longitudinal recovery, psychiatric integration becomes a necessary next step. Psychiatrists in critical care function as behavioral consultants and psychopharmacologic collaborators, bridging psychiatric and somatic domains. Psychiatrists bring a unique ability to interpret neuropsychiatric symptoms in medically complex patients, optimize medication regimens, and engage families to support their loved ones’ recovery. Psychiatry’s involvement also helps mitigate moral distress among ICU staff by offering multifaceted solutions and valuable support in emotionally charged environments.

The professional community has already begun to embrace this transformation. The Academy of Consultation-Liaison Psychiatry established a critical care psychiatry special interest group, which has rapidly grown to become an active, engaging, and productive forum for the expansion of critical care psychiatry as the newest sub-subspecialty within consultation-liaison psychiatry.¹⁶ Critical care psychiatry represents a frontier where psychiatric expertise directly contributes to life-sustaining treatment. It is intellectually rich, emotionally meaningful, and systemically valuable. 

For psychiatrists, the ICU offers fertile ground for meaningful clinical collaboration and impact. For intensivists, psychiatry is a natural ally in improving patient outcomes and team functioning. Together, they can continue to transform the ICU from a place of survival to a setting of longitudinal recovery.

It is time to retire the sentence, “Call me back when they are extubated.” Critical illness is among the most harrowing events a person can experience, knowing that life itself is in the balance. Advances in proactive models of critical care psychiatry call for the integration of psychiatric expertise into the care of our sickest patients from the very beginning, not waiting for a call at all. 


Acknowledgements: The author wishes to thank Mark Oldham, MD, for his editorial guidance.


References

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