The increase in the number of psychiatric units in general hospitals in the past several decades, and the shift in the location of inpatient psychiatric treatment from state institutions to the community general hospitals, has been nothing short of spectacular. Regardless of the reasons for this change, today's general hospital, as the focal point for the delivery of mental health services,1 has assumed a new role, and along with this have come new opportunities, new responsibilities, and, as with all change, new problems. Our attention is on the area of the care of the medically ill psychiatric patient, a particular responsibility of the general hospital, because the need is great, the psychiatric resources to meet the need are insufficient, and the psychiatric profession has been ambivalent about its role.
The high incidence of co-existing physical illness and psychiatric disorder is well-demonstrated.1'5 A review of studies done since 1936 and reported by Hall et al shows physical illness in psychiatric patients occurring at a rate of approximately 50%, with the incidence in psychiatric inpatienls some four to eight times that of psychiatric outpatients.2 Two present trends assure us that the treatment needs of this population, already high, can only increase. One is the rising number of elderly (those over 65) in the general population - an estimated 38.9 million by 1990. On the average, the elderly spend about four times as many days in short-term hospitals as those under 65, and while 40% of them are free of psychological problems, an estimated 54% show various mental signs and symptoms. Fifteen percent to 25% of the elderly are considered to have significant mental health problems.6'7 The other trend is the deinstitutionalization movement which brings more of the chronically mentally ill under the auspices of the general hospital. A large number of these patients are from the lower socioeconomic segment of the population, where medically related psychiatric symptoms are known to be more common.2
When one looks at the resources available to meet these needs, they are insufficient on several counts. Until relatively recently, most psychiatric residency programs did not include contact with medical or surgical services," and although this situation has improved some as more psychiatric training programs have become active in consultation/ liaison psychiatry, there were trained a substantial number of psychiatrists now practicing in community hospitals who lack practical understanding of the relationship between psychiatry and medicine. The stethoscope is not generally a part of the psychiatrist's equipment, and medical diagnostic and treatment skills, even where well-developed, have often atrophied from disuse. An additional shortage of resources results from the practice of many general hospitals, which despite the known high incidence of psychiatric disorders in an inpatient population, seldom accept transfers to the psychiatric unit from within the hospital itself. Instead, patients are admitted for psychiatric disorders only, and only from the outside community. Greenhill, commenting on this exclusiveness, predicts that "nothing is more self-defeating in the long run for the future of general hospital psychiatry than this exclusion of the medically sick."J
A further contribution to the limited resources results from the ambivalent stance of psychiatry itself, a recent example being the brief but significant dropping and then reinstatement of the internship requirement by the American Board of Psychiatry and Neurology.
The outcome of trends and attitudes such as these becomes apparent in many general hospitals in the care of patients with mixed medical and psychiatric conditions. The treatment needs of this group are met, if they are met at all, not through a well-developed consultation/ liaison service, but by means of an informal consultation network on a physician-to-physician referral basis. Among possible alternatives is the utilization of an acute psychiatric unit that accepts medically ill patients for psychiatric treatment. Such units, often called medical/ psychiatric units, appear to be few in number, exist in teaching hospitals in academic settings, and seem to represent a complex collaboration of departments of psychiatry and medicine,9 with physician staff consisting of both disciplines. The remainder of this article will focus on one variation of the medical/ psychiatric unit as it exists in a community general hospital, and will address some of the advantages and disadvantages that accrue.
The setting on which this article is based is a 315-bed service-oriented, acute care community general hospital located in a city of 37,500. It is the only general hospital serving a large and predominantly rural and suburban county of 129,000. All inpatient services are provided through an open staff, private practice attending model, and except in the psychiatric and emergency departments, there are no hospital-provided outpatient services of any magnitude. The attending staff is philosophically grounded in the advantages of a free enterprise private practice modeí, and the relatively few full-time hospital-employed physicians are looked on with some suspicion and occasional animosity. An understandable vigilance is maintained by the private practitioner, to ensure that "the hospital" does not invade private turf by initiating services that might be construed as competitive or as "practicing medicine," The likelihood of developing a viable hospital-sponsored consultation /liaison service in this atmosphere is practically non-existent, and when the psychiatric needs of medically ill patients are addressed, it is either by consultation or by transfer of the medically ill patient to the psychiatric unit.
The psychiatric unit was developed on the insistence of the non-psychiatric attending staff who needed a facility to care for noisy or disruptive patients (frequently the organic elderly or the acutely intoxicated), so as to not disturb the treatment of others quieter and/ or more obviously medically ill. (Despite much noble rhetoric about the reasons behind the development of psychiatric units in community general hospitals, it is probable that many such units had a similar impetus, at least to some degree.) Whatever its beginnings, the psychiatric unit has grown over ten years into a respected, active treatment setting for acute psychiatric disorders. In addition, it bas continued to serve the hospital system through use of six of its 28 beds for treatment of patients with mixed medical/ psychiatric problems. Anyattending physicians, including psychiatrists, may admit to these six beds, called "acute beds," without benefit of consultation. Admissions by psychiatrists consist primarily of patients too disturbed for any reason to be safely integrated into the ambulatory psychiatric program, or for psychiatric patients needing alcohol detoxification. Admission diagnoses by non-psychiatrists are more varied, and in addition to patients needing alcohol detoxification and those with organic brain syndromes, almost any medical problem is admissible provided there is a concomitant psychiatric diagnosis. Admission guidelines acceptable to the various practitioners who use the unit have been almost impossible to develop, although the seriousness of the medical problem and the amount of medical nursing care needed should be determining factors. Psychiatric nurses staff the "acute beds" on a rotation basis as well as staffing the regular psychiatric program. Problems which arise in the use of these beds are compounded by poor understanding of their potential and limitations, and by the frequent tendency of other departments to view the unit either as another intensive care unit or as if it were shirking responsibility by not being one. Serious drug overdoses, profound alcohol intoxication or impending DTs., and suicide attempts with complicated medical or surgical sequelae are among the conditions which raise special problems.
Since these units have been little studied, there are limited evaluative data concerning the care of medical and surgical patients in them.' Consequently, although there seem to be advantages, these are supposed rather than proven.
Having a unit that can accept transfer patients from other services in the hospital, and provide a back-up for the disturbed medical or surgical patient, is reassuringfor both physicians and hospital staff. Knowing that a patient, though psychiatrically disturbed, can still be cared for within the hospital helps non-psychiatric staff members to attach value to the psychiatric service, and the unit benefits in return.
Another advantage is that the psychiatric unit, where care is provided for the person as well as for the illness, provides the most humane setting for the treatment of medical illness. Nowhere else in the hospital is such a concerted attempt made to meet the combined biological, psychological, and social needs of the patient. One might argue that such coordinated care should be readily available as a matter of course on any nursing unit, but the reality is that the task orientation of manynurses, and their discomfort with psychiatric symptomatology, makes this difficult if not impossible to achieve.
A third advantage is the functional linkage with other systems which promotes the psychiatric unit as an integral part of the hospital. Caring for patients with mixed medical and psychiatric problems requires that physicians other than psychiatrists become involved with and be exposed to the ongoing activity of the unit. Conversely it requires the psychiatrist to develop and maintain or improve medical diagnostic skills and to keep abreast of current developments in medical treatment. Collaboration with medical and surgical colleagues offers the additional advantage of identifying the psychiatrist as a physician, while it informs and demonstrates to the nonpsychiatric physician that good psychiatry is basic to good patient care. It helps in the reaffirmation of psychiatry as part of a medical tradition, and counteracts the impression that it is more closely allied with the social sciences. Considering some of the public mistrust of psychiatry and the contempt in which the profession is held at times by other medical disciplines, this is an important benefit with major implications for overall improved patient care.
A number of disadvantages must also be considered, one of which is that the level of medical care delivered on a psychiatric unit can be less than optimal. Medical skills, like psychiatric skills, need constant practice and refinement or proficiency is lost. Psychiatrists as well as their non-psychiatric colleagues can become narrowly specialized and neglect the profound relatedness of mind and body, and the influence one has on the other in health and disease. This can have unfortunate consequences considering the non-specific nature of much psychiatric symptomatology and the frequency with which unrecognized underlying physical illness can be misdiagnosed as functional psychosis.2 Furthermore, on a psychiatric unit, medical consultations are often not requested, or are as inexpertly requested as are psychiatric consultations, and as a result, medical conditions not immediately obvious may not be considered in a differential diagnosis, or may go unrecognized. Conversely, medical conditions that are diagnosed are at times not optimally treated, or not recognized as being integrally related to psychiatric disorder.
Another disadvantage results when the non-psychiatric consultant has a preconditioned attitude, or bias when evaluating a patient on the psychiatric unit. The patient's physical complaints or symptoms may be minimized, disregarded, or misinterpreted as "functional" in origin, and legitimate physical illness may be undertreated or ignored.
Further problems arise from the system itself. The psychiatric unit is significantly different from other nursing units in an acute care hospital, making il difficult for some to reconcile it with the medical model of illness and treatment. The non-psychiatric consultant often is not familiar with its routines, staff, or methods of intervention. Add to this any anxieties about psychiatric illness or personal vulnerability, and the consultant can be very ill at ease. This undesirable state of affairs is compounded when the unit staff, ignorant of the role or style of the consultant, view him/her as an jnimsive outsider. In these circumstances, there is rich opportunity for mutual misunderstanding, outright mistrust, and even dislike, which may cause the consultant to be unwilling to return to the unit unless it is absolutely necessary, or not to interact with the unit staff in more than a minimal way, to the detriment of all concerned.
At times when consultations occur, the physician of record does not maintain overall responsibility for the management of the patient. Rather, each physician involved in the case assumes, often erroneously, that the others are monitoring closely those aspects of the patient's care pertinent to their own specialty area. The reluctance of the non-psychiatric consultant to visit the psychiatric unit complicates this issue further, and continuity of care becomes problematic. Nursing staff can also be caught in the middle, trying to reconcile what seem at times conflicting orders, or being referred from one physician to another on issues of patient management. The possibility for error rises in direct proportion to the number of physicians writing orders, to the hindrance of coordinated quality care.
Another serious drawback occurs when the perception develops among staff, even if inaccurate, that the unit isa dumping ground for the confused, the bizarre, the unmanageable, the noisy, or the assaultive who are transferred to psychiatry with no clear assessment of Ihe mental status and no clear direction for psychiatric management. When patients too medically ill to be safely treated on a psychiatric unit are admitted, staff anxieties mount concerning their competence as caregivers and their legal culpability should patients receive less than optimal care. Often it is difficult to have a patient transferred off of the psychiatric unit should there be no further indication of the need to be there. In situations such as these, staff can become frustrated and resentfui as large portions of time and energy are spent doing medically-oriented procedures, or bathing, feeding, or restraining patients instead of being actively involved in the therapeutic program provided for the strictly psychiatric ambulatory patients. This can result in considerable staff-physician dissension, as well as being a significant source of low rnoraie and related staff turnover.
In our experience there are both advantages and disadvantages in treating medically ill patients on a psychiatric unit whose primary objective is to provide an active therapeutic milieu for acute psychiatric disorders. No two hospital settings are alike, and the weight attached to these advantages and disadvantages is relative, depending on the particular setting, the medical staff structure and local hospital politics, one's own professional perspective, and the unit staff structure. Nevertheless, it is probable that the disadvantages at least equal, or even outweigh the advantages, and that for the most part, patients in such circumstances may not be as well served as possible.
What then does one do to provide optimal care for the medically ill psychiatric patient, for whom the community general hospital has such a unique responsibility? A well-functioning consultation/ liaison service that collaborates with the medical and surgical services throughout the hospital is one way to provide the psychosocial dimension and the coordinating function necessary for comprehensive care. A variation of this is a new version of the consultation/ liaison model, whereby medically ill patients are admitted, and liaison services are provided to the medical-surgical consultants on the acute psychiatric unit.1 The best alternative may be a psychiatric infirmary, separate from the psychiatric unit, where patients may receive appropriate treatment without the complexities described above. To quote Greenhill:
If the general hospital is to be part of the continuum of psychiatric services, present evidence seems to point to the need for each general hospital to have two inpatient units, one to care for the medieai-surgicai population with psychiatric problems (a psychosomatic unit) and one for patients with acute psychiatric problems.1
Such a unit would require a specially trained nursing component to provide medical as well as psychiatric nursing care. A psychiatrist well versed in general medicine and in the concepts of liaison psychiatry should direct the unit, not only to coordinate the treatment from both a medical-surgical and psychiatric point of view, but also to provide support and training for unit staff, and for the attending physicians, medical and psychiatric, who would utilize the unit. This model would seem best suited to address the many problems surrounding the treatment of the medically complicated psychiatric patient, some of which have been described here.
1. Greenhill MH: Psychiatric units m general hospitals, Hosp Cammunity Psychiatry 1979: 30: 169-182.
2. Hall RCW. Beresford TP. Gardner ER, et al: The medical care of psychiatric patients. Hasp Community Psychiatry 1982; 33:25-34.
3. Bernstein RA: Liaison psychiatry: A model for medical care on a general hospital psychiatric unit. Gen Hasp Psychiatry 1980; 2:141-147.
4. Norton JC Ludwig A: Medical treatment of psychiatric patients: Possible poly pharmacy problems. Hasp Community Psychiatry 1982; 33:305-306.
5. Karasu TB. Waluman SA, Undenmager J1 et al: The medical care of patients with psychiatric illness. Hasp Community Psychiatry I980;3l:463-472.
6. Issues in mental health and aging, in Services. US Depl of Health, Education, and Welfare publication No. (ADM) 79-665, 1979, voi 3.
7. Mental Health and the Elderly. Recommendations for Action. US Dept of Health, Education, and Welfare publication No. (OHDS) 80-20960, 1979,
8. Hackett TP; The psychiatrist: in the mainstream or on the banks of medicine? Am J Psychiatry 1977; 134:432-434.
9. The psych-med unit: lnpaiitni psychiatry's future. Presented al the 135th Annual Meeting of the American Psychiatric Association, Toronto, 1982.