"Read, Think, Observe."
Benjamin Rush, M.D.
There are now about 6,970 public and private general hospitals in the United States, about 2,250 of which have inpatient psychiatric services (AHA Hospital Statistics, 1981). These hospitals, which account for over 30,000 psychiatric beds, may well be the largest system of psychiatric care throughout the country. However, some patients still require long-term residential care.
Historically, this revolution within psychiatry began 50 years ago and it received momentum by knowledge and experience acquired when rendering short-term treatment to soldiers during World War II. When the military psychiatrists returned to civilian life they built new units in the general hospitals. Although these resembled the traditional public model, with a. relatively large number of beds located in a separate area, and longer lengths of stay, they differed programmatically in that they offered high quality intensive therapy associated with favorable staffing ratio. This development was facilitated by concomitant advances in psychopharmacotherapy. Also, the high turnover techniques, along with changes in the attitudes of the people and a better understanding and acceptance of emotional factors contributed to this change.
Outpatient, consultation/ liaison and emergency psychiatric services, as well as partial hospitalizado n programs, brought psychiatric care to an even larger group of patients.1 Because of the variety of treatments comprising these programs, the overall results have been difficult to assess.
Further changes permitted the growth of multidisciplinary and cooperative treatment philosophies, which permitted the application of a systems approach. Staffing patterns included psychiatrists, psychologists, nurses, social workers, activity therapists, aides and sometimes members of the clergy. But as the identity of these professionals became better defined thepromising interdisciplinary model revealed its shortcomings. Indeed, these professionals by training and experience could interview, reach a diagnostic conclusion and offer a range of psychotherapeutic regimens. This apparent competition created a formidable problem for planners who desired implementation of unique and distinct areas of expertise. The confusion arising from this heterogeneous mixture of treatments was compounded by the much revised Accreditation Manual and Consolidated Standards by the Joint Commission on Accreditation of Hospitals (JCAH), which used interchangeably the terms "clinical staff" and "medical staff." The debate continues as the professions jockey for position.2 Vox populi, vos Dei.
Meanwhile, deinstitutionalization policies had overloaded these systems with chronic patients and for a while it looked as though psychiatry in general hospitals was destined to replace state hospitals.3 Instead, the "revolving door" mechanism resulted. While the high readmission rate for these patients was not acceptable, the availability of the services became the most important factor for the alleged success of deinstitutionalization.
The Community Mental Health Centers emphasized non-medical services, facilitating the trust of general hospital psychiatry which followed a parallel and interactive course. As psychiatry moved into the mainstream of medicine in the 1970s, the alliance brought into the system new issues and problems. Psychiatrists became participants with medical colleagues on audit, utilization and peer review committees. They functioned without the benefit of a validated data base. Workable and acceptable criteria had to be developed from a discipline long on phenomenology and short on etiology.
The general hospital itself had changed from the traditional humanitarian and benevolent model into a highly technological, political and fiscal institution. Therefore the basic constructs which had justified the establishment of psychiatric units changed also. If the short-term inpatient treatment was originally viewed as a humane mode, it now became a plausible outcome of new advances, responsive to social, economic and political forces. When this focus was shifted to the fiscal realities of the 1980s, general hospital psychiatry had to prove the cost benefit and cost effectiveness of its services to multiple bureaucracies who demanded accountability. Insurance and other funding sources compelled the policies concerning length of stay of psychiatric patients to be commensurate with that of the hospitalizaron of general medical patients. Since the natural history of the illness could not be changed by decree, the programs were arbitrarily honed to rapid symptom reversal in the acute episode, often with the length of stay averaging two weeks. Prospective payment by diagnosis, suggested by the government, may still require new adaptive solutions.
The advent of patient advocacy also brought lawyers to the psychiatric units. Involuntary confinement , informed consent and competency are within the purview of regulatory agencies and the judiciary. Theoretically one welcomes the ombudsmen system as one of check and balance, but in practice, due process of an adversary system may delay institution of indicated and appropriate treatment.
General hospital psychiatry is now entering an era of specificity. Nosological and conceptual advances along with new technology such as PET findings, biological markers, new insights in psychoendocrinology and genetics will make the diagnoses more specific and treatment modalities more appropriate. The standard psychiatric unit will more closely resemble an intensive care unit and new programs will be aimed at special target populations. In fact the present voluntary and cooperative system has shown limitations regarding the needs of the adolescent, the elderly, the alcohol and drug abuser and the dangerous patient." Much needed outcome studies may show the way and current "trends forecast structural and programmatic changes tailored to the specific needs of these patients. Through creative efforts such programs someday may reflect the competence, motivation and hopes of today's general hospital psychiatrist.
This issue of Psychiatric Annals focuses on inpatient psychiatric units. The authors - clinician/ administrators - discuss their experiences with the complex aspects of clinical psychiatry in the general hospital.
Dr, Boelhouwer and Dr. Grayson, both from Hartford Hospital, discuss length of stay and chart review, pivotal in audit and peer review work. Dr. Pinsker, from Beth Israel Medical Center in New York, reviews some of his experiences in the difficult short-term management of patients with addictive disorders. Dr. Burke from Middlesex Memorial Hospital, Middletown, Connecticut, covers the inside story and the vicissitudes of medicalpsychiatric interface of caring for the medically ill psychiatric patient.
The authors are also members of the American Association of General Hospital Psychiatrists. This group was founded at the 1977 meeting of the American Psychiatric Association in Toronto, when some 20 psychiatrists met informally to promote study, communication and problem solving. Since then the Association has grown and has cosponsored with the American Psychiatric Association and the American Association of Psychiatric Administrators several paper sessions. Three members of the Council have been appointed successive chairmen of the Psychiatric Service Center of the American Hospital Association. Interested psychiatrists are invited to join and help establish a network of visibility, support and effectiveness for general hospital psychiatry.
1. Pasnau RO: Consultation psychiatry at the crossroads: In search of a definition for the 1980s. Hasp Community Psychiatry 1982; 33 ?2}:989-995.
2. Flamm G: Summary of progress. AAGHP Newsletter 1980; 3(3).
3. Baehrach LL: General Hospitals. Hasp Communio· Psychiatry 1979; 30:488.
4. Strain JJ: Needs for psychiatry in the gpncral hospital. Hasp Community Psychiatry 1982: 33:996-1001.