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

Dr. Bianco

“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.”

Dr. Grace

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.

Challenges Abound

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.

Dr. Sussman

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.