Wednesday, November 21, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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FEATURE ARTICLE
Does Sonoma County Need an Inpatient Psychiatric Unit?

Edward L. Merrin, MD

With the closure of inpatient psychiatric facilities in Sonoma County, the medical community and the general public have become alarmed, puzzled, outraged or just confused about what is happening. There have been public debates about how many psychiatric beds, if any, we actually need, and for whom these services are appropriate and necessary. The answers are not easy to come by, but looking at the evolution of psychiatric care over the last few decades may provide a useful perspective. 

Recent cuts in inpatient psychiatric services are the latest manifestations of an evolutionary process that has been taking place for more than 50 years. These changes have been propelled by a number of forces, some based on legitimate scientific findings and others on political expediency, ideological biases or financial concerns.[1]

A century ago, most psychiatric care took place in large institutions.[2] These facilities were initially intended to provide humane care and allow patients to eventually rejoin their families and communities. However, the best of intentions did not prevent these sprawling, elegant campuses from deteriorating into human warehouses.[1] Once committed, patients might disappear for years. If patients were released, the community they had once belonged to had moved on, and they were then poorly equipped to live independently. By the 1960s, a countermovement had emerged, inspired partly by sociologist Erving Goffman, who argued that “crazy” behaviors were actually adaptations to living in psychiatric hospitals and not caused by mental illness itself.[3] 

The reduced emphasis on long-term stays was made possible by a revolution in the pharmacologic treatment of psychiatric disorders. Beginning in the mid-1950s, a series of serendipitous discoveries led to reasonably effective treatments for psychosis and severe depression. Patients who had appeared to be hopelessly lost became well enough to rejoin their families or live in community-based programs. Others had their symptoms treated early enough to make commitment to an institution unnecessary.

During the 1960s, two pieces of landmark legislation profoundly affected inpatient psychiatric treatment. The Lanterman-Petris-Short (LPS) Act, passed in California in 1967, became a model for reform worldwide. People with disturbed behavior could only be detained against their wishes if specific conditions were met, and for specifically defined specific periods of time. Judicial safeguards were installed so that a patient’s release was no longer dependent on the results of arbitrary “staffings” held at hospitals. Long-term care was available, but only under specific conditions subject to specialized procedures and hearings.

The second piece of legislation, the 1963 Community Mental Health Act, established federal funding for community mental health centers, overseen by the National Institute of Mental Health. These centers included a mix of outpatient clinics, outreach programs and case management. Acute care took place in crisis centers backed up by small psychiatric inpatient programs. These hospital units emphasized rapid reduction of severe and acute symptoms with the goal of returning patients to their “baseline” level of functioning as soon as possible. For those with chronic illnesses that prevented return to full independent living, community boarding homes replaced indefinite custodial care in state hospitals. Peer-reviewed clinical studies confirmed that even for serious conditions, such as schizophrenia, longer hospitalizations offered no advantage over shorter hospital stays.

The attractiveness of these new ideas, as well as the chance to rescue state budgets from the obligation of maintaining expensive institutions, led to the release of thousands of chronically mentally ill people to local communities. The nationwide census of state hospitals dropped from a peak of 560,000 in 1955 to 184,000 by 1977.[4] Unfortunately, funding for community programs was never adequate, and it has eroded steadily ever since, leaving most of the burden to counties and private insurers. Compounding the problem, many of the mentally ill declined help, and affordable housing for them never kept pace with their numbers. Those with problem behaviors—such as substance abuse, violence or sexual aggressiveness—were not welcome in many residential and treatment settings. Not surprisingly, the nation’s swelling numbers of homeless and incarcerated include a disproportionate amount with significant mental illness.[5] Providing psychiatric care in our jails and prisons has become a major and expensive enterprise.

Meanwhile, short-term psychiatric hospital units have been disappearing at an alarming rate. A shortage of psychiatric beds has become endemic nationwide6 and is now hitting home in Sonoma County, which no longer has any such beds. The problem is largely financial: inpatient psychiatric units operate at a loss. Costs continue to escalate for employees, medications, supplies, services, maintenance, and compliance with regulatory requirements. Caring for the growing number of uninsured and underinsured results in additional losses. Even when there is insurance, the reimbursement is woefully inadequate.

Third-party payers have substantially altered the practice of psychiatry in terms of hospital usage and lengths of stay. Under managed care, every day of hospitalization requires justification for payment on an ongoing basis. Writing progress notes has become an art form, avoiding any hint that a patient might be “better,” perhaps because suicidal thoughts are diminished or hallucinations fading. Appealing adverse decisions might require a psychiatrist to speak to a medical director whose job performance is tied to denying as much care as possible.

To shorten stays, psychiatrists have grown accustomed to shortcuts such as superficial diagnostic assessments, escalation of drug dosages at rates that conflict with scientific findings, and discharge prior to resolution of side effects or to full development of aftercare plans. University programs are under the same pressures. The most recent generation of psychiatrists knows no other style of practice.

These trends have narrowed the criteria for hospitalization far beyond what makes good clinical sense. As beds disappear, the tightening of admissions and the shortening of hospital stays can anger and bewilder families, law enforcement and the community at large. Modern non-hospital alternatives, such as partial hospitalization and intensive case management, have picked up much of the slack, but they can only do so much. An emergency has now been narrowly defined as being placed on a “5150,” or 72-hour hold. The possibility of patients accepting hospitalization voluntarily is almost extinct. The social and clinical ramifications of being on a “hold” are beyond the scope of this article, but they are not trivial. Being sent to distant hospitals begins to return us to the days of old, when mental illness was treated away from the home community.

Sonoma County is big enough to provide inpatient psychiatric services within its borders. But what kind of facility and how large?

The number of psychiatric beds needed varies with community standards. During my teaching career, I developed a set of what then seemed reasonable justifications for inpatient care. Today, changing patterns of treatment, availability of beds, and third-party approval have made some of those justifications difficult to defend. Furthermore, in the past there were more choices of facilities. Now we have a one-size-fits-all model: locked-door high-security units that must address a broad spectrum of clinical problems within one treatment setting.

Certain ground rules are sound and universally accepted. With few exceptions, patients with dementia who are manifesting behavioral disturbances are best treated in situ in nursing homes and similar settings. These patients’ cognitive deficits prevent them from benefiting from a general behavioral treatment setting. Patients with delirium or with acute medical conditions more emergent than their psychiatric problems are best served staying where they are, with the assistance of psychiatric consultation. Intravenous therapy, for instance, is problematic on psychiatric units, and it may even be unsafe. These kinds of determinations should result from collaborative discussions between physicians, rather than turf battles.

Safety criteria and the LPS Act triad of danger to self, danger to others, or grave disability are obvious justifications for hospital admission. However, the intensity of distress experienced by a patient often drops considerably after extensive interviewing, brief interventions of various types, or even an overnight stay in a “crisis” bed. But these strategies don’t work for all patients. The job of identifying which patients can safely avoid hositalization is best left to trained mental health workers, backed up by a psychiatrist. The decision should not rely on whether or not a hospital bed is available.

For other circumstances, the need for hospitalization requires consideration of symptom severity, acuity of changes in mental status or level of functioning, availability of alternatives to hospitalization, or failure of attempts at outpatient management. Medically complicated treatments—such as initiation of lithium treatment in frail patients or the need to concomitantly manage withdrawal from drugs or alcohol—may argue for hospitalization. Severely and chronically mentally ill patients being considered for conservatorship require hospitalization long enough to obtain a temporary conservator.

If there can only be one psychiatric unit in the community, what should it be like? The first consideration should be to avoid separating “mental health care” from medical care. Too often, the shrinking role that psychiatrists have played in mental health administration and planning has resulted in a culture dominated by mental health professionals who feel uncomfortable with the medical community and with dealing with physicians in general. This discomfort does not serve our patients well.

Despite our best efforts, we are imperfect at the craft of differentiating the effects of concurrent medical illness, toxicity from medications, or drug intoxication or withdrawal from those originating entirely from a psychiatric disorder. Moreover, psychiatric patients suffer significant medical comorbidity, much undiagnosed, and their general medical care is spotty at best.[7,8] Although cheaper to operate, a Psychiatric Health Care Facility (PHF) is inadequately staffed to operate at this interface. Ideally, a psychiatric unit within a general hospital—with ready access to consultation by other specialists and easy transfer for acute medical treatment—would be best. If an in-hospital unit is not possible, a free-standing psychiatric facility must have close ties with nearby general hospitals and in-house medical support. 

How many beds are required? There is no definitive answer to this question. Certainly, previous utilization patterns can provide a starting point. But those figures may be distorted by some of the issues discussed above. The need for flexibility in planning to allow for future changes consistent with need would be important.

An inpatient psychiatric unit in Sonoma County would perform an essential community function, but expecting it to pay for itself is unrealistic. As we have learned in recent years, no single health care entity in the county can absorb the operating deficit that adequate psychiatric inpatient care generates. Yet this level of care is an essential service, just like our trauma units, obstetrical wards, police and fire services, and public transportation. What is needed is for all the appropriate parties to pool resources, bury rivalries and conflicting missions, roll up their sleeves, and engineer a way to fill this gaping hole in our health care system.

References

  1. Geller JL, “The last half-century of psychiatric services as reflected in Psychiatric Services,” Psych Serv, 51:41-67. (2000).
  2. Gralnick A, “Build a better state hospital,” Hosp & Comm Psych, 36:738-741 (1985).
  3. Goffman E, Asylums, Doubleday (1961).
  4. Okin RL, “State hospitals in the 1980s,” Hosp & Comm Psych, 33:717-721 (1982).
  5. Lamb HR, Weinberger LE, “Shift of psychiatric inpatient care from hospitals to jails and prisons,” J Am Acad Psych & the Law, 33:529-534 (2005).
  6. “APA council reports: The council on healthcare systems and financing,” Am J Psychiatry, 165:2274-76 (2008).
  7. Kamara SG, et al, “Prevalence of physical illness among psychiatric inpatients who die of natural causes,” Psych Serv, 49:788-793 (1998). 
  8. Fleischhacker WW, et al, “Comorbid somatic illnesses in patients with severe mental disorders,” J Clin Psychiatry, 18:e1-e6 (2008).

 Dr. Merrin, a Santa Rosa psychiatrist in private practice, previously directed inpatient psychiatric care at Memorial Hospital. E-mail: edmerrin@earthlink.net

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