In 1955, there was one psychiatric bed for every 300 Americans. By 2005, following the widespread shuttering or downsizing of psychiatric hospitals in the 1990s, that number had shrunk to one bed for every 3,000 Americans.1
In 2008, an estimated 39.8 million Americans age 18 or older had mental illness, which represents 17.7% of U.S. adults.2 In 2013, this number rose to an estimated 43.8 million, or 18.5% of U.S. adults (see Figure 1).3
“It’s like we have returned to the early 19th century, when mentally ill persons were held in prisons or temporarily kept in hospital settings,” says Ricardo Bianco, PsyD, program director of the Master of Arts in counseling and health psychology at William James College in Newton, Mass. “The problem is that the healthcare system did not catch up to absorb the mentally ill population.
“As a result, hospital staffs are inadequately trained, there is insufficient funding for these patients, and there are not enough human resource personnel to manage them. Consequently, hospitalists are overwhelmed with cases that should be primarily treated by psychologists, psychiatrists, and social workers.”
According to David M. Grace, MD, SFHM, hospitalist and senior medical officer at the Schumacher Group in Lafayette, La., two groups of psychiatric patients present to the acute-care hospital environment: those who are there for a primary psychiatric problem and those who have a medical problem and a psychiatric comorbidity. The first group of patients presents distinct challenges. U.S. hospitals lack two-thirds of the minimum number of beds needed to care for this population. The second group is problematic because psychiatric issues often cloud the medical issues of a patient, increasing both diagnostic uncertainty and resource utilization.
Psychiatric patients present a number of problems for hospitalists. First, it is difficult to decipher what comprises a psychiatric issue and what does not because “many psychiatric conditions manifest as physical symptoms and they often require significant resource consumption to diagnose,” Dr. Grace says. Secondly, some patients present with a severe primary psychiatric problem in which they are homicidal, suicidal, or gravely disabled.
In addition, psychiatric patients tend to have a greater incidence of noncompliance with imaging, laboratory work, medication, and general medical care, says Daniel Sussman, MD, a hospitalist at IPC Healthcare, Inc., based in North Hollywood, Calif. He also serves as interim chairman in the department of psychiatry at St. John’s Episcopal Hospital in Far Rockaway, N.Y.
Clinically, potential interactions between psychiatric medications and medically related prescription drugs are always a concern, notes Dr. Sussman, who says more than 70% of patients admitted to St. John’s Episcopal Hospital have a major psychiatric illness in addition to their medical problem. Psychiatric medications, which patients may have tolerated well when they were stable, may be too sedating when patients are ill. Side effects and adverse reactions of psychotropic medications must also be considered when diagnosing and treating medical illnesses. Metabolic syndrome is more commonly seen and is a factor in the development and subsequent treatment of other illnesses.
Another challenge stems from the fact that patients with substantial psychiatric comorbidities can have significant and rapid mood and behavioral changes as well as sudden, volatile, and aggressive outbursts—both verbal and physical.
“Staff members who interact with the patient are at risk if an outburst occurs,” says Emily Fingado, MD, FAAP, a pediatric hospitalist and clinical assistant professor of pediatrics at Nemours/Alfred I. duPont Hospital for Children (Nemours/AIDHC) of the Sidney Kimmel Medical College at Thomas Jefferson University in Wilmington, Del.
Such situations can become scary, particularly if someone with psychiatric expertise is not available to intervene. This can be very frustrating for hospitalists who want to provide high-level care but may lack the training needed to be successful with such patients. This can ultimately lead to burnout, says Sarah Rivelli, MD, medical director of psychiatry clinical services at Duke University Hospital and Duke University Medical Center in Durham, N.C.
Another challenge is that although there are protocols in place designed to follow specific steps for patients with physical illnesses or disorders, that’s not the case for psychiatric illness. “Many hospital facilities are not designed, or have yet to implement, protocols to attend to mentally ill individuals,” Dr. Bianco says.
Because of the unpredictability of patients and lack of practice protocols, mental illness can introduce a wild card into the standard treatment process. A more individualized approach with these patients is needed, but with increasing focus on length of stay and operational efficiency, medical and nursing staffs are pressured to do things quickly and to do more with less. It can be very time-consuming for a nurse to have to explain to paranoid patients why they should take their medication or for a phlebotomist to try to calm patients in order to obtain blood. When patients refuse needed tests, or only provide a limited history, the hospitalist ends up working with incomplete information, which makes choosing and monitoring the treatment approach problematic.
A Look at Best Practices
In light of challenges, some best practices have been identified for handling psychiatric patients. As previously mentioned, most hospital staffs have limited formal training in interacting with psychiatric patients. In fact, the American Board of Internal Medicine only devotes 4% of the certification exam to psychiatry.4
Ideally, staff members who care for psychiatric patients will have specialized or additional training in managing patients with psychiatric conditions or comorbidities. Nemours/AIDHC has a committee assigned to evaluate psychiatric patients’ care and help manage them when a behavioral emergency occurs, Dr. Fingado says. This team, which has been trained on de-escalation, restraint techniques and policies, as well as medications to use in these situations, intervenes when patients have an aggressive event that places patients, visitors, or staff at risk. The team includes nursing staff, the hospitalist on-call, and security personnel and involves the social work, psychology, and psychiatry departments.
Training focused on treating patients with psychiatric conditions should include how to recognize substance abuse and treat substance withdrawal because mental illness and substance abuse often track together, Dr. Sussman notes. At St. John’s Episcopal Hospital, patients with chronic mental illness are not the ones who typically become aggressive or violent. Rather, this is more often the case among patients with substance abuse either in states of acute intoxication or withdrawal.
Recently, Dr. Sussman has seen a significant increase in patients who abuse K2, or spice, a synthetic form of cannabis. Side effects of using K2 include rapid heart rate, anxiety, hallucinations, and paranoia to the point of delusional thinking. These side effects can frequently wax and wane for days after the drug is used, and they can be associated with significant psychomotor agitation and assaultive behavior.
When patients abuse flake, another synthetic drug that has been reported in the Southeast, they tend to become very paranoid and violent. “These patients can be extremely unpredictable and aggressive,” he says. “Patients with dementia can be impulsive and aggressive during care, and caution is needed, but it’s not a directed violence like that seen in patients who are agitated secondary to substance abuse.”
Dr. Bianco advises having a predetermined triage system or a scale that can assess and measure patients’ level of psychological distress, which can ensure timely and appropriate evaluation and treatment of psychiatric patients, as well as toxicology screens and mental health protocols, which can aid in diagnosis.
“Technology is an important tool in facilitating integration, including identifying and screening patients, tracking patient progress, encouraging adherence to clinical protocols, facilitating communication between providers, and evaluating the impact of integrated programs,” Dr. Bianco says. Academic hospitals struggle less with this problem, he adds, because they tend to be more adequately funded in all areas of operations, including the field of mental health.
IPC Healthcare hospitalist James N. Horst, DO, a psychiatrist who manages mental health patients in a long-term care and nursing home facility, says he has found standardized general screening tools to be useful. The Hamilton Depression Scale, Beck Anxiety Inventory, and CAGE exam for chemical dependency can be easily administered and scored in any facility setting, he says. These tests include self-administered questions to which the patient answers yes or no. Laboratory work is a secondary tool in psychiatry since few mental illness disorders are based on medical comorbidities.
Dr. Sussman looks to the past, when psychiatrists were part of medical teams rounding in hospitals, for a solution. “An integrated model provides an approach where patient care is less compartmentalized,” he says. “In this model, clinicians are responsible for making sure their patient is treated, not simply focusing on their individual area of expertise. This involves working more closely with an integrated care management team.”
Ideally, this will occur at every level of care: outpatient, inpatient, and emergency department (ED). New York State is attempting to redesign the Medicaid system in this fashion, with the goal of improving overall care and reducing reliance on inpatient treatment to provide that care. This is an enormous initiative, costing more than $8 billion. If successful, it will result in a more patient-centered care system that treats the whole individual, not just the illness, and will positively impact patients’ overall health.
For now, St. John’s Episcopal Hospital has an active psychiatric consultation liaison service that is staffed by both in-house residents and attending physicians who are there 24-7 to help with psychiatric patients.
A ‘Utopia Management’ Perspective
In a dream world, patients with significant psychiatric problems or comorbidities would have coordinated, multidisciplinary care from admission to discharge, Dr. Fingado adds. Ideally, hospitals would have dedicated rooms or areas in the ED that are safe for patients and staff. Psychiatric patients who require observation or admission to a non-psychiatric hospital would be placed in rooms or units dedicated for psychiatric patients, again providing safety for patients and staff, Dr. Fingado surmises.
In addition, all staff members would have training in behavioral health management, including instruction on de-escalation, restraint techniques, and medication use for patients. Ideally, units would be staffed by specially trained aides, nurses, and healthcare providers (i.e., physician assistants, nurse practitioners, physicians), as well as psychologists and psychiatrists, Dr. Fingado says. This type of management would require buy-in from a multitude of groups, including healthcare administrators, nursing and provider staff, as well as health insurance companies. A reallocation or increase in funds would be needed to help build and staff these types of management models and locations, she adds.
In a perfect world, all hospitalized patients would be adequately screened for mental health issues and have their issues appropriately addressed by well-qualified professionals in real time, Dr. Grace says. Telemedicine services have great potential in helping to meet that goal, he says, and more relaxed regulatory guidelines around telemedicine could help make such physician-patient interactions less difficult. Many, if not most, hospitals currently have limited or no access to qualified mental health professionals, a conundrum based on supply, reimbursement, and need.
“Telemedicine, which is already having great success in neurology and intensive care unit medicine, is a great fit for this space,” Dr. Grace says. “Widespread access to a tele-psychiatrist would bring significant tangible benefits to patients, hospitals, hospital staff, and the population at large, who ultimately pay for healthcare in the nation.”
Dr. Horst says he believes everyone who treats psychiatric patients should have education in psychiatric medicine education. One way to achieve this would be to mandate continuing medical education coursework in mental health disorders.
The Reality of a Utopia
Traditionally, our healthcare system has been designed to react to illness, meaning that physicians treat illnesses when individuals become sick.
“But as science and technology now better understand the etiology of most illnesses, we are more equipped to design more preventative interventions rather than wait for individuals to become sick,” Dr. Bianco says. “Prevention interventions require an initial investment that the healthcare system is not necessarily willing to invest in at this time and a shift in the way it charges for services. If the healthcare system is unwilling to go that route, and we know we can prevent many illnesses by shifting the focus of treatment, consequently, human suffering is augmented and quality of life jeopardized.”
More recently, the general population and providers have acknowledged that healing takes place more effectively when it is applied in more integrated approaches (i.e., the utilization of the bio-psycho-social-spiritual model), Dr. Bianco adds. This greater appreciation is demonstrated by different research studies applied to different populations (both the general public and different providers). Despite this, the system (i.e., training) does not support a full integration of interventions.
“The system continues to operate under the traditional medical model that is fragmented and hyper-specialized,” Dr. Bianco says. “Science has demonstrated that the mind and the body work in more complex ways, requiring a more holistic approach to treatment. Although all segments among providers now understand and accept that, the system they dwell in does not support the daily challenges of treatment.
“Treatment continues to be fragmented as it is the medical model. At this point, at a minimum, a hospital should have a psychiatric department composed of individuals who are adequately trained (e.g., health psychology, behavioral medicine) to absorb a portion of individuals who primarily present with mental health issues.” TH
Karen Appold is a freelance medical writer in Pennsylvania.
- Torrey EF, Kennard AD, Eslinger D, Lamb R, Pavle J. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Treatment Advocacy Center website. Available at: http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_h.... May 2010. Accessed August 18, 2015.
- Results from the 2013 national survey on drug use and health: mental health detailed tables. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, U.S. Department of Health & Human Services website. Available at: http://www.samhsa.gov/data/sites/default/files/2013MHDetTabs/NSDUH-MHDet.... Accessed August 19, 2015.
- Any mental illness among adults. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-.... Accessed August 19, 2015.
- Internal medicine certification examination blueprint. American Board of Internal Medicine website. Available at: https://www.abim.org/pdf/blueprint/im_cert.pdf. January 2015. Accessed August 19, 2015.