Wednesday, September 22, 2010

Guest Blog: Dr. Douglas Landy on the Crisis in Inpatient Psychiatry

Psychiatrist Douglas Landy, MD, generously permitted me to publish his thoughts about the current crisis in inpatient psychiatry, which I suspect are not unique to New York State [links courtesy of BehaveNet]:

It seems to me that over the years the face of inpatient psychiatry has been changing.  It looks like we are seeing progressively sicker patients, and violence is more common than used to be the case.  These factoids are supported by statistics throughout New York State (length of stay, violence, disability secondary to violence, etc).  It seems to me that a number of factors have brought this about:

1.      More severe psychopathology is tolerated in outpatients.  Many of the people we see on an outpatient basis, at least in mental health clinics, would have been hospitalized when I was a resident, but are now more frequently treated on an outpatient basis rather than on an inpatient basis.
2.      Many of the people who (with the above taken into consideration) are treated on an inpatient basis are harder to place owing to their penchant for inappropriate if not frightening behavior, making them personae non gratae for most placements.
3.      Many of the people that society asks us to care for are more emotional misfits (who have been acculturated to using violence as a means of expressing dominance, social pecking order, and so forth) rather than having a mental illness such as bipolar disorder, etc.  An associated problem is our societal tendency to “pathologize” behaviors that the majority culture of the location dislikes or fears.  Another associated problem is our profession’s wholesale trade of contextual diagnosis for single symptom diagnosis (i.e., racing thoughts = bipolar disorder, end of discussion).  As a result, we are in part contributing to this problem by agreeing that someone who behaves in a way that is not acceptable to the majority culture is mentally ill; and that implies we can treat that mental illness; and so forth.  This is, of course, an entirely separate controversy, but you get the idea.
4.      Because our inpatient models are based on context-based diagnosis driving treatment – as opposed to mere symptom-suppression treatment along with (generally fruitless) attempts to use a model for a problem that is generally not amenable to the inpatient model of treatment (ie, many of the people referred to in paragraph 3) – we fail spectacularly at accomplishing any kind of effective inpatient treatment in this population.
5.      As a result, the inability to place this group, along with error-driven treatment, results in many people being more dissatisfied, and that does not mean the patients alone.  Staff gets overwhelmed by this as well.
6.      Staff dissatisfaction and hopelessness (as well as fear) leads to petty tyranny or abandonment of responsibility, either of which leave the situation rife with the potential for violence and loss of the therapeutic milieu owing to patient “take-over.”  This is exacerbated by continually decreasing money for mental health resulting in lowering staffing to unsafe levels, while bloating administration to ensure that the paperwork is all in order for our “friends” at the regulatory agencies.

My own conclusion is that we need to do a couple of things, some of which are clearly easier than others.
1.        We need to have adequate staffing.
PROBLEM:  Costs money
2.      We need to help society understand that:
  a.      Not all annoying behaviors, even those that are violent, are driven by mental illness.  Even the presence of mental illness does not ipso facto make it the cause of the unwanted behavior.
  b.      With mental illness in general (such as the major mood and thought disorders) and the “softer” diagnoses of personality disorders, impulse control disorders, etc, treatment is not always successful.  In such a case the questions for society are:
    i.      Do we block up the hospital system with people who don’t need to be/shouldn’t be hospitalized?
    ii.      In the case of a criminal act, should such a person be restored to health and then sent back to prison for the remainder of their sentence (ie, guilty but mentally ill)?
    iii.      What should we do with dangerous people who don’t, won’t or can’t respond to treatment and victimize peers and staff in the hospital system where their current lack of criminal behavior precludes incarceration?  Why should the mental health system be responsible for this group (I suppose that you can correctly infer that I object vehemently to the idea that sex offenders who have finished their criminal sentence can be sent to a psychiatric hospital for an indefinite period of time afterwards).
  c.       PROBLEM:  It’s like changing the course of a river.  It can be done but it takes considerable time, energy, and a lot of money.
3.    We need as a profession to be clearer about diagnosis, remembering that symptoms are contextual and not independent phenomena.  The current craze (and I use that word pointedly) for single-symptom diagnosis is merely a rationalization to use medications that perhaps needn’t or shouldn’t be used, considering the ramifications of so doing.  Additionally, the current diagnostic patterns make us all look like fools.  I’m sure that many of have heard (or even said) about a colleague something like, “It’s curious how all his/her patients are Bipolar.”

PROBLEM: It is not clear if the pharmaceutical companies promote this kind of diagnosis/treatment strategy because it’s good for the bottom line, or if their speakers promote this (I can’t say more for fear of libel) to boost their own earnings from the companies (doubtless in which they have already invested as well).  Additionally, we tend as a profession to use medications more than non-pharmacological treatment options, and as a result think more in that way.  I would love to see psychiatric training spend an additional year or so on how effectively to do combination treatment – psychotherapy and psychopharmacology together, which is something you don’t see any more.

Douglas A. Landy, MD
Chief of Psychiatry
Rochester Psychiatric Center

The opinions expressed above are those of Dr. Landy, and do not necessarily reflect the mission or opinions of BehaveNet, Rochester Psychiatric Center or the New York State Office of Mental Health.

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