All our past acclaims our future. . .
Algernon Charles Swinburne (1837-1909)
Most of the general hospitals in this country probably wish that this quotation were true. At present, most of them feel like the man who rode backwards on trains: they would rather look at where they have been than at where they are going.
Following the passage of the Mental Health Services Act in 1946 and the success of psychiatry in World War II, the future of psychiatry seemed bright. The reservoir of psychiatrists grew from about 3,500 in 1945 to about 25,000 in 1975. The burgeoning of private practice in communities imposed the obligation of developing community-based psychiatry in general hospitals, an obligation that the hospitals met by utilizing Hill-Burton funds and later by taking advantage of the Community Mental Health Services Act of 1964. The total number of beds increased by a little over 200,000 from 1960 to 1970, and a substantial number of these beds were psychiatric.
During the 20 years from 1945 to 1965, general hospitals operated relatively free of external controls over bed capacity, rate setting, and staffing patterns; and, with selective admission policies, they discovered that psychiatric services could be run at a slight profit with about 85 per cent occupancy of inpatient beds. With the development of such services, demand was created and admissions flourished. After 1954 - owing to changes in treatment methods, cultural changes in the population, and improved pharmacotherapy for psychiatric illness - lengths of stay diminished. Where satisfactory psychiatric services were developed, psychiatrists tended to cluster and to provide adequate continuity of care for patients discharged after briefer stays. Also fostering early discharge was the growth of intermediate care, such as day treatment centers and outpatient clinics.
Hospitals that took the community mental health center route developed and provided emergency services, manpower training, and education, and began to edge into research, all through the relatively easy availability of NIMH funds. Some added consultation to community service agencies, again supported by public funds or by contracts. Utilization of mental health professionals other than psychiatrists became popular. So did the term "mental health," although it was more a euphemism for services to the mentally unhealthy than a synonym for prevention of disorder and maintenance of health. Services to children and adolescents lagged far behind services to adults, and longterm care for the chronically mentally disabled was still supplied by public facilities or private psychiatric hospitals. For 20 years psychiatry in the general hospital had the best of prospects, with an increased interest in and acceptance of psychiatry by the general public, easy access to funds, increasing staffs, and the expansion of third-party reimbursement for services to the mentally ill.
The services offered continued to be the traditional ones: individual therapy, somatic therapy (principally electroconvulsive treatment), drug therapy, and what later came to be called "milieu therapy." Staffing patterns remained traditional - with the psychiatrist, nurse, and aide constituting the major personnel - but an occasional psychologist or social worker was added to the team and became more important as rime went on. The medical model was not questioned; it maintained its prominent position in the general hospital, where it was supported by the other physicians. Psychiatric liaison with other services enhanced the maintenance of this model.
By the middle 1960s, however, the general spirit of unrest that was abroad in the land started to manifest itself here too. A social model of mental disorders was evolving, and with it appeared a competitive spirit among other professionals toward psychiatrists. Psychologists and social workers, particularly, voiced and demonstrated their ability to accomplish much that psychiatrists were doing, and nurses became disenchanted with their subordinate role in the delivery system. Professional boundaries started to blur, and there developed the "team approach" to service delivery - or, as some said, diagnosis and treatment by committee.
Paralleling the development of treatment by the group was treatment of the group. Those working in community mental health centers tended to assess their experience according to a social model of mental illness and emotional disease to the extent that the whole concept of mental illness was questioned. This process, along with increasing financial support for treatment of mental disorders, attracted a growing number of nontraditional mental health professionals into the field, with demands for autonomy in their modes of practice and reimbursement. Indigenous workers became necessary in many settings, particularly in general hospitals functioning as mental health centers and receiving federal backing. Volunteers were utilized more and more in clinical settings for clinical purposes, as were such paraprofessionale as occupational, recreational, and music therapists. Evaluation of the programs and cost-benefit analysis of therapeutic modalities were sadly lacking. Consumerism was only slightly felt.
The future comes like an unwelcome guest.
Edmund Gosse (1849-1928)
Beginning in 1969, the well oí federal support started to run dry. Prospective budgeting was being instituted for general hospitals as a result of third-party payers' insistence, and there was talk of cost commissions, which actually came into being a short time later. From 1970 to 1975, the changes impinging on general hospitals and their psychiatric services were shocking. Inflation wreaked havoc with budgets; cost controls restricted income; and obligatory evaluations, including utilization review, drove administrative costs ever upward. Expansion of psychiatric services - with their supporting services, outpatient clinics, and special services for drug abusers and alcoholics - created the need for full-time staff. Psychiatrists in private practice began to avoid hospital practice because of diminished managerial control of their hospitalized patients, increased paperwork, and onerous demands on their time for committee meetings, emergency-room coverage, staff meetings, and teaching duties. In addition, the psychiatrist was being wounded by a loss of public esteem and demands to define his specialty and justify what he did clinically. Mental illness was hard to define in sdentine terms, particularly when third-party payers were setting their own limits on what services would be reimbursed. The courts began to intervene with pronouncements concerning patients' rights, adequacy of treatment, and even modes of treatment. Confidentiality came in for its share of conflict, and malpractice settlements drove up the cost of psychiatric care. AU in all, psychiatry's lot was no longer a happy one.
In spite of all these vicissitudes, psychiatric services in general hospitals still provided high-quality care at affordable costs. In 1971, there were 831 psychiatric units in short-term general and other specialty hospitals. The A.H. A. surveyed 522 general hospitals to obtain pertinent data relating to their function.1 The bed capacity of these units ranged from under 12 to over 75, with 53 per cent having 20- to 40-bed units. The median percentage of occupancy was 81, and median length of stay was 13 days. Although there was wide variability in staffing patterns, 58 per cent provided activity programs with occupational therapists, recreational therapists, vocational rehabilitation workers, or others; 39 per cent had a socialwork staff, and 24 per cent a psychology staff. Thirty-one per cent had resident psychiatrists in an active training program.
Surveys2,3 indicate that in 1971 and part of 1972 general- hospital psychiatric units accounted for 542,642, or 31 per cent, of all inpatient episodes. In 80 per cent of the hospitals, total costs for these services ranged from $30 to $80 per patient-day, with a median of about $56. By 1975 the average length of stay in such units had dropped to 11 days, and the average total cost per patient-day was approaching $100. However, the cost of a total "spell of illness" in a general-hospital psychiatric unit was comparable with the cost of a total "spell" in a public facility.
Although the model of service delivery has remained for the most part medical, a varying pattern has emerged among psychiatric units. Such procedures as behavior modification, token economies, patient government, and diverse forms of group therapy have been incorporated into many units. However, electroconvulsive therapy and drug therapy have retained their importance in most units, along with individual psychotherapy.
Evolution is not a force but a process; not a cause but a law.
Edward Williams Morley (1838-1923)
The nature of psychiatric theory and practice has been inextricably linked to the cultural attitudes of a given time or place and to the economics of the culture. The Freudian concepts, which were a synthesis of all that had gone before as well as Freud's personal contribution, were a product of the culture of his time as it was presented through his patients. Adolf Meyer attempted to amalgamate historical and scientific information into a system appropriate to his time and culture. It was predictable that Sullivan and Horney, among others, should respond similarly in the evolution of the art and science of psychiatry. Insofar as the therapeutic application of psychiatry required a long time, and psychiatrists felt the need for an income commensurate with that of their colleagues in the practice of medicine, the economics of the discipline became important. Those who could afford the process might enter psychotherapy, either seriously or faddishly, but the major proportion of psychiatric illness continued to be treated in the traditional state systems.
After World War II, however, the private practice of general psychiatry induced the need for locally based hospital services. The general hospitals responded by permitting the development of both inpatient and outpatient services in their facilities. Since being "in the hospital" was less of a stigma than being "in the asylum" or "in the state hospital," those who could afford to go to the general hospital and who could be satisfactorily treated there chose this route for their care. Paralleling the federal legislation that fostered the growth of such services, insurance companies introduced coverage for hospital treatment and care of physical illnesses and, later, mental and emotional illness. Such coverage was eventually expanded to provide reimbursement for some outpatient services as well, and the procedure was continued in such government programs as FEHB, Champús, Medicare, and Medicaid.
When the expense grew disproportionately to expectations, limitations - both subtle and overt - were instituted as cost controls. Within the past five years, such cost controls have become paramount at both the national and local levels. Hospital cost commissions, utilization review, PSROs, and now PA 93-641 attest to the alarm experienced by the public's elected representatives over the increased costs of general health and mental health care. "Justification" and "accountability" have become watchwords directed towards the hospital industry, which has had to respond with mounting committee structures and paperwork. External controls implemented by consumer groups, legislation, and budgetary restrictions have impinged measurably on general hospitals and their psychiatric services. Inflation has led to hiring freezes, slowdowns in expansion of services, and diversion of staff energies into administrative areas nonproductive of patient care. As a consequence, innovation, except to serve economy, has been curtailed.
In the face of all this, what has befallen the patient? In general, most patients who have sought services for mental and emotional disorders in the general hospital have been able to obtain appropriate and usually comprehensive care. Those seen and admitted to one or another unit of a general-hospital psychiatric service have been the beneficiaries of some sort of insurance or third-party indemnity. Practically all diagnostic categories have been accepted, with behavior and financial status usually determining refusals; the medically indigent have difficulty obtaining locally based services, and patients in some categories are usually excluded - legal offenders, those with personality disorders manifested in aggressive behavior, many alcoholics, and the chronically ill aged. A broad gap also exists between those seeking services and those in need of services who have not been identified or have no knowledge of where to seek services.
Once admitted, fewer than 5 per cent require transfer to another facility. The vast majority are discharged to their homes, but usually require further treatment on an ambulatory basis. Continuity of care has usually been supplied by the referring physician's office, an outpatient clinic, or an agency such as family service or vocational rehabilitation. The desirable close affiliation of such agencies with the hospital has not always been apparent, however. Although no accurate statistics are easily available, estimates imply that the readmission rate to generalhospital-based psychiatric services is about 20 per cent.
In summary, we can assume that all acute, initial psychiatric problems can and probably should be seen first by some element of the general hospital's psychiatric service.
Democracy, which shuts the past against the poet, opens the future before him.
Alexis de Tocqueville (1805-59)
In this country, democracy has evolved in the direction of providing more and more benefits to those who have apparently not been able to obtain them through their own efforts. Such benefits have included both indirect and direct support to those suffering from a variety of problems, including psychiatric disorders. Misfortunes have been defined as injustices; privileges in another age have now become rights; group support has replaced individualism. However, our resources have not kept pace with our rhetoric. These changes have led to expectations that must be met to a reasonable degree, or else both politicians and professionals lose their credibility.
The right to adequate treatment from an accessible resource has impelled the general hospital to broaden its base of services to the mentally disordered and will continue to do so in the future. How hospitals will accomplish this is difficult to envision, but some models of future arrangements can be surmised. Such models will develop in response to National Health Insurance, once this system is operating; to social pressure; and to the changing orientation of mental health professionals. One alternative, obviously, is to continue doing just what is being done now, but under close scrutiny of cost control mechanisms, quality control evaluations, and the critical eye of the consumer. Other options will vary, but all will derive from scientific and socioeconomic factors as well as from legislative changes.
The general hospital has always attempted to fulfill the role of a specialized treatment facility for disease and illness. In all likelihood, it will retain this role, leaving prevention to the social and public health areas. If what we now know as psychiatric illness is eventually no longer considered a pertinent area of medicine but a human behavioral pattern elicited by social and familial stress, then psychiatric services will no longer be needed or utilized as they are now. Such services could also be obviated by neurochemical discoveries, genetic engineering, and breakthroughs in neuropharmacology. For the foreseeable future, I view these events as unlikely. However, the boundaries of psychiatry may well become more sharply demarcated, to the relief of both patient and physician. The limitation of the general hospital to providing treatment for psychiatric illness and disease will not necessarily restrict its relationships with other human-service agencies or its interests and concerns with social trends.
Assuming this view, the psychiatric service of a general hospital becomes one of an integrated group of services provided for a large segment of the population. In smaller communities the hospital might function as the sole provider of comprehensive psychiatric services, but in large communities and urban centers it would probably be only one of a consortium of service agencies. Communication linkages, central transportation services, and centralized storage of patient data will effect economies in such an integrated system of services. Electronic data processing will play an increasing role in collecting and storing information, obtaining histories, ordering further examinations and tests, listing differential diagnoses, recording treatment modalities and outcomes, and filing follow-up information. In spite of problems of confidentiality, pertinent information on file will have to be made available to any facility from which a person seeks psychiatric services.
In a future group-oriented society, early intervention to prevent separation from the group will be demanded. Identification of the need for intervention can be flagged by the computer, utilizing updated information from collaborating human-service agencies. The psychiatric service of a general hospital should plan to provide such interventional services. Levels of service and specificity of services will have to be defined. Alcoholism and psychogeriatric problems, large and increasing difficulties in our population, will require specialized units. Intensive-care units for the severely disturbed and intermediate and rehabilitative services for convalescents can be considered, depending on whether the service wishes to limit its goals to acute short-term treatment or to provide a wider range of services. Again, monitoring for evaluation and continuity of care are essential.
If the general hospital elects to provide comprehensive psychiatric services in a selfcontained manner, independent of other agencies, it will have to restructure both its organization and its delivery system. According to this model, the general hospital should be the center of service delivery to a specific geographic area. For that area, it has to provide central intake, clinical evaluation, and triage to the appropriate divisions of the service system. The service system itself would include several levels of care, dependent on clinical evaluation and severity of need. Triage would result in decisions ranging from "No care needed" to "Admit to intensive treatment unit." Active discharge planning and continuity of care, beginning at admission, would require follow-through by the therapeutic team in conjunction with an aftercare division. Parallel to these operations, an administrative feedback mechanism would provide evaluation, quality control, and cost-benefit analysis.
Inasmuch as a larger and larger proportion of psychiatric patients can be handled outside the inpatient service, consideration will have to be given to expanding the partial-hospitalization programs, outpatient clinics, and minimal-care residential facilities. An outreach team could also function as the follow-up resource. In urban areas, this load may prove too much for one hospital to carry; so a consortium of hospitals could be formed, each taking the responsibility for one or more segments of the operation. All would then cooperate in making clinical information available to each other and collaborate in providing continuity of care and services outside the hospital proper, such as rehabilitation. One other important element would consist of open staffing, with provision for clinical appointments of mental health professionals other than physicians. The levels and degrees of preventive services offered would have to be agreed on. All in all, this is a huge and complex undertaking but not an impossible one, even when emergency services and crisis intervention are added to the list.
Those are only two of a variety of similar models, the major differences being whether a facility chooses to operate independently or in collaboration with other agencies. Other models could be based on more futuristic concepts, but with the inevitable snail' s-pace rate of social and mstitutional changes, discussion of such concepts would project further than the next 10 to 20 years.
All of the above has been predicated on the premise that psychiatry and psychiatric services, specifically in general hospitals, have a viable future. If, in truth, mental illness is a myth, psychiatry is moribund, and social intervention is the answer to our problems, the foregoing can be disregarded. However, I am persuaded that the aberrations in human mental and emotional functioning, accompanied at times by socially unacceptable behavior, still represent a problem within the purview of the health field. Psychiatry has had a long traditional and professional association with medicine and will continue to do so. Because psychiatric disorders are the result of biologic, psychologic, and sociologie factors, the psychiatrist remains the major professional whose training encompasses all of these areas. In addition, Ws training experience inculcates a strong sense of direct personal responsibility that academic training alone can never provide. Given this combination of factors, he will continue to be the primary purveyor of services to those requiring help for their mental and emotional problems.
Some of those suffering from such problems will continue to present cases of sufficient severity to warrant treatment in a structured environment that also provides a degree of asylum. This environment has been and will continue to be provided by the most experienced institution, namely the hospital. There is adequate validation that the general hospital has the capacity to manage all diagnostic categories and that the necessity for transfer to a more secure environment on the basis of behavior alone is minimal. General hospitals are expanding and extending their services and developing quality control mechanisms through utilization and medical care evaluation committees. The elements for continuing survival of psychiatric services are in place.
Even if manpower development programs tend to reduce the production of psychiatrists, there will still be a sufficient number of them to provide clinical training for other mental health professionals and to establish and maintain clinical standards. Any National Health Insurance program will increase demands for locally based services; wherever funds are available, services will expand in spite of the most stringent cost controls. The general population has set a pattern of seeking services from its own community hospital and staff physicians. It is my contention that the public will continue to do so and to create the demand for psychiatric services in a setting that is familiar, representative of security, and responsive to the personal influence of its individual members.
Unfortunately, it is necessary also to take into consideration the present economic and ecologie problems besetting the world, the rapidly diminishing energy resources, urban crowding, and the possibility of a long-lasting, world-wide economic depression. Retrospective studies of admissions to psychiatric services have demonstrated a direct relationship between increased admissions and economic recession. It follows that demands for psychiatric services in bad times will increase for general hospitals as well as for public facilities, and will require innovation in the delivery of such services at reduced cost in the face of diminishing resources. Since our economic cycles have always oscillated, and since general hospitals have weathered the effects of depressions in the past, I assume they can do so in the future.
If psychiatry is to maintain its present status in general hospitals, psychiatrists will have to continue to enhance their relationship, both scientific and professional, with the other branches of medicine. This will require an increasing emphasis on psychosomatic medicine, the intermingling of the biologic with the psychologic aspects of disease, and the inevitable blurring of distinctions between internal medicine and psychiatry. The one remaining and outstanding skill of psychiatry is the philosophy and practice of the art of medicine. I realize that this may be a mixed blessing, since science has superseded art in prestige, status, and acceptability among medical peers, and the art of medicine has been relegated to a markedly subordinate position. Nevertheless, a study of malpractice suits and grievances submitted to medical society ethics committees reveals that most complaints have to do with breaches in professional etiquette, a cavalier attitude towards interpersonal relationships, and unfortunate gaps in communication.
The psychiatrist is still the professional who takes the time to listen, to respond in a humanistic fashion, and to maintain a cooperative working relationship with the patient. Other nonmedical practitioners have learned this lesson extremely well. Perhaps it is time for the psychiatrist to insist on sharing these skills with his colleagues. By so doing, he will make a valid place for himself in the training programs of medical schools and hospitals, and be able to contribute to the continuing education of the entire general-hospital staff. Future innovations may consign him to this role alone, unless he also refines the definition of his work and is able to demonstrate positive results from his efforts. I am convinced that psychiatry is capable of so doing and of maintaining the continuity of psychiatric services in general hospitals under any future modifications of the social and medical systems.
1 . Survey of psychiatric units in general hospitals. Hospital Administrative Services. Chicago: American Hospital Association, 1972.
2. Ozarin, L.. and Taube. C. Psychiatric inpatients: Who, where and future. Am. J. Psychiatry 131 (1974), 98-104.
3. Statistical Notes series, NIMH.