Background <p>Psychiatric comorbidities are frequent among hospitalized patients and can adversely affect treatment outcomes, yet referral rates for psychiatric consultation remain low. The COVID-19 pandemic created unique psychosocial and healthcare challenges that may have influenced consultation patterns, particularly in Iran, where cultural stigma often limits mental health care. This study investigated the causes and frequency of psychiatric consultation requests for hospitalized patients before and after the COVID-19 pandemic in Iran.</p> Methods <p>This study was a cross-sectional study of patients hospitalized during the summers of 2019 and 2020 at Vasei Hospital, Sabzevar, Iran. Eligible cases included patients with at least one documented psychiatric consultation. Demographics, referral reasons, DSM-5 diagnoses, and substance use history were extracted. Data were analyzed with chi-square, t-tests, and logistic regression in SPSS 22.</p> Results <p>Psychiatric consultations were requested for 161 out of 3,622 admissions in 2019 (4.4%) and for 147 out of 2,694 admissions in 2020 (5.4%, <i>p</i> = 0.083). Suicide attempts were the primary reason for referrals, but their proportion declined during the COVID-19 pandemic, while incidents of agitation and anxiety increased. Logistic regression analysis revealed that a history of substance use (odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.2–2.8, <i>P</i> = 0.004) and the presence of delirium (OR = 2.4, 95% CI = 1.1–5.3, <i>P</i> = 0.031) were independent predictors of psychiatric consultation during the pandemic period.</p> Conclusion <p>Overall consultation rates remained stable, but diagnostic changes reflected the indirect mental health burden of COVID-19. Strengthening consultation-liaison psychiatry, routine screening, and culturally tailored interventions are essential for future pandemic preparedness.</p> Clinical trial number <p>Not applicable.</p>