A survey of the literature regarding home-based psychiatric treatment of the home-bound elderly and seriously physically disabled adults, for whom regular visits to a psychiatrist are extremely cumbersome or impossible to accomplish, leaves one with the impression that very few psychiatrists undertake such efforts on an ongoing basis.1 Even programs that attempt to provide such services struggle to provide them on a consistent basis, with difficulty attracting and retaining qualified psychiatrists.2 The effect may be inadequate, infrequent, and disrupted services. However, from a practical, humanitarian, and economic point of view, providing ongoing psychiatric treatment by home visits appears to be a very useful service for such patients and their families.3
This article is based on experience from a 3-year period in attempting to provide psychiatric treatment on a part-time basis for a home-bound population in two boroughs of one of the largest cities in the northeastern United States. The services for each borough was provided on behalf of two separate agencies. The services for each borough were provided by the psychiatrist during the past decade, with the service period for each borough not overlapping with each other. There was about a 5-year period of separation between the time the services were provided for the first and second borough.
The work was provided by the psychiatrist as part of a team, including a social worker and a nurse. However, the psychiatrist almost always made home visits alone. Visiting as a team, except in very unusual circumstances, was not a viable option, logistically or economically. However, information obtained during the visits, and details of treatment provided by the psychiatrist, were shared with other team members by chart entries and oral communications. The psychiatrist traveled by his own vehicle to the homes of patients and, at times (in one of the programs a few years previously), traveled by taxi and, occasionally, by a van service provided by one of the sponsoring agencies.
Finding new patients’ residences, parking spaces, and taxis to return from the patients’ residences when it was necessary, and other related measures, have always been challenges, especially in inclement weather. The global positioning system (GPS) has made it much easier to drive to city neighborhoods that are unfamiliar or difficult to navigate.
Because home-based, ongoing psychiatric treatment is rarely available, once other patients learn that a psychiatrist makes such visits, the number of referrals increases quickly. The ongoing home-based treatment by a psychiatrist provides services that are significantly different from those provided by mobile crisis teams, which make one or two visits in crisis situations and either hospitalize or refer the patient to other agencies for ongoing treatment. In the case of ongoing home-based psychiatric treatment, after the initial evaluation and for most patients, the psychiatrist makes treatment visits for an indefinite period, as the patient’s condition requires.
Except for patients who have been stable for a sufficient period and who can be seen once every 1 to 3 months in follow-up visits, many patients initially seen by the psychiatrist may need fairly intensive treatment and frequent visits and telephone contacts. At times, there may be sufficient reason to recommend hospitalization. However, the elderly, the physically disabled, and their relatives, if they are involved, most often refuse hospitalization because they perceive it as a traumatic event or state that past hospitalizations were unhelpful. In addition, there is no guarantee that, if the patient or someone else arranges to transport them to the nearest psychiatric emergency room, they will be admitted to the inpatient unit. The complex situation caused by the inability to ambulate or by being bed ridden, dementia in many of the elderly, and the fragile general health of many of these patients make them unsuitable candidates for most psychiatric inpatient units. Such predicaments often place the psychiatrist in a clinical, ethical, and legal dilemma. How to negotiate such situations is a skill worth having for anyone undertaking such evaluation and treatment efforts. Years of experience in varied treatment settings, including emergency rooms, inpatient units, busy outpatient settings, and consultation liaison settings in which one comes across such patients, becomes helpful in dealing with such situations.
A preliminary screening to determine whether the patient’s condition is something that can be handled by home-based interventions is necessary to avoid unnecessary turmoil for the patient and others. Reviewing the referral information and asking for clarifications from the referring personnel would help the psychiatrist and others to avoid situations that actually require an immediate 911 call, hospitalization, or what should be handled by mobile crisis teams. Home-based psychiatric treatment addresses the treatment needs of those patients, who, because of their physical infirmities, are unable to visit the psychiatrists or therapists in an office or clinic. Home-based treatment is not intended to deal with emergency situations involving an unknown and uncooperative patient. The psychiatrist needs to decide if the patient can be seen in a home-based setting. If the referral is properly handled and, especially if the psychiatrist is involved in the screening process, this is a decision that can be made easily.
Even patients who are delusional or who are experiencing hallucinations or suicidal ruminations can be treated by ongoing home visits by the psychiatrist, with support from other team members and relatives. A great deal depends on a patient’s cooperation, the therapeutic alliance the psychiatrist is able to forge with the patient, the family support systems available, and the psychiatrist’s experience in dealing with such situations. Above all, the willingness to be of help in complex and difficult situations is an essential quality necessary for all psychiatrists who venture to provide such treatment. Otherwise, one will end up making an initial evaluation, only to reject patients as unsuitable for such treatment.
Because home-based treatment is a voluntary undertaking on the part of the patient, it is important that all aspects of voluntary psychiatric treatment be adhered to and respected. Informed consent should be obtained for all prescribed medications. The exceptions are those patients in whom the courts have declared incompetent to make treatment decisions and who have a legal guardian appointed. In such situations, informed consent should be obtained from the guardian.
There are many situations in which the psychiatrist may be pressured to evaluate and treat patients who do not have capacity to make informed consent. This happens especially in the case of patients with advanced dementia, whose relatives insist the psychiatrist prescribe medications without the patient’s informed consent. The psychiatrist should educate the relatives as to the importance of informed consent and how they can have a guardian appointed by the court. However, the relatives may not be cooperative, at least initially. Of course, if there is a danger to self or others because of the patient’s symptoms, involuntary hospitalization may be necessary.
Common Diagnostic Categories
There are certain broad diagnostic categories that predominate among the elderly and physically impaired patients that are usually seen in home-based psychiatric treatment. Contrary to popular belief, most patients seen do not suffer from dementia, at least not severe dementia. This may be because, by the time severe dementia develops, the patient may already be in a residential setting, usually a nursing home. Many of the very elderly may have dementia, but it is usually mild to moderate in intensity, and some other psychiatric problem is the primary focus of treatment. However, treating patients who have significant dementia that is complicated by severe behavioral problems and psychosis can be a daunting task in the home-based treatment setting. The black box warning issued by the Food and Drug Administration (FDA) about the use of neuroleptics in this group of patients has made this task even more difficult.
Depression-anxiety symptoms are common in this patient population. Often, these patients have a long history of such problems, but frequently the symptoms may have surfaced only after advancing age-related physical impairments started taking their toll. A similar situation occurs, but to a lesser extent, in patients suffering from neurological conditions, such as disabling multiple sclerosis, advanced Parkinsonism, and neuromuscular impairments as a result of stroke. Whether what one observes is a worsening of a long-standing problem or whether it is something that developed primarily in response to the physical disabilities is very important in making treatment decisions. The psychiatrist is the crucial person to distinguish the intricacies that are significant for the proper understanding and treatment of such patients. One can be fooled into thinking that the genesis of observed depression is anxiety. Anxiety symptoms are situational or reactive only in nature. The patient may then begin to exhibit hypomania or mania with or without delusions or hallucinations. As in any population and, perhaps more so, in the elderly patient group, bipolar disorder maybe the cause.
Frequently, one comes across patients who have a history of nearly 25 years of psychiatric symptoms, hospitalizations, intermittent treatment in the community with psychiatrists, or taking an assortment of psychotropic medicines prescribed by their primary care physician. It is common to see patients in their 80s and 90s showing features that clearly call for a diagnosis of bipolar disorder, with the illness being recognized for the first time. A careful documentation of the patient’s history may reveal that such symptoms had been present for a long time, in subtle and not very subtle forms. Often these patients have been receiving antidepressants and anti-anxiety medicines only from their physicians, despite features of bipolar disorder being clearly evident. Often, the request for the psychiatrist to evaluate and treat them at home comes when the patient starts becoming extremely disruptive, combative, and unmanageable. Many of these patients will be have a strong family history of bipolar disorder, as well. Rather than the bipolar disorder being a late-onset one because of a neurological illness, most often the fact is that the illness has been present for years, if not a lifetime, but is only being understood now. It is common to see patients in their 90s who belong to this category.
Depression that is persistent and responds poorly to treatment is another common problem in this patient population. Often, continuing physical problems seem to account for such propensity. However, if one has been involved in the treatment long enough, one may be surprised to see cycles of long depressive episodes interspersed with hypomanic episodes when the patient becomes outgoing and gregarious, or overactive and angry for a few days to months, only to revert into another long bout of depression, with nothing in their physical health or life circumstances having changed to account for such dramatic shifts in mood and behavior.
The patients in home-based treatment who exhibit delusions and hallucinations often also have an associated or underlying mood disorder or dementia. It is very rarely that one comes across a truly schizophrenic patient in this group. Schizophrenia, being a highly debilitating illness that usually emerges in early adulthood, would have caused the patient not to be able to live independently a long time ago. Most such patients are usually living in long-term hospitals, specialized nursing homes, or supervised community residences. This may explain why one does not see many patients one can truly consider schizophrenic in the home-based treatment population. This does not mean that one does not occasionally see patients who have a history of being diagnosed as having schizophrenia in the past. On closer scrutiny, most such patients may have had an episode or episodes when they may have or were suspected to be exhibiting or experiencing delusions or hallucinations, which most likely were accompaniments of an underlying affective illness. However, an erroneous diagnosis of schizophrenia may have been made, which was a common tendency in psychiatry decades ago and perhaps even today. Most such patients would not qualify for a diagnosis of schizophrenia now.
Many, if not most, patients who have significant dementia may have already been receiving medications for it from their physicians or neurologists. If not, treatment for this problem may have to be initiated by the psychiatrist, preferably in collaboration with a neurologist. How effective the treatments available for dementia at present are in this patient population remains an open question.
Not all patients seen by the psychiatrist in home-based evaluation need treatment with psychotropic medications. Given the impairments related to advancing age and multiple other medical and neurological problems of this patient group, all attempts should be made to avoid psychotropic medications, if possible. Considering that almost all such patients are experiencing considerable stress and unhappiness, supportive therapy, family interventions, and providing services to improve their life situation play a crucial role in their well being. These services can be provided by other members of the team or by enlisting the help of others capable of providing such services by home visits. In most cases, at least eventually, the use of psychotropic medicines becomes a necessity. Educating the patient in a supportive manner of the nature of his or her problems and what measures may be helpful is of the utmost importance.
Many patients, when seen initially, are on a long list of medications from their primary care physician and specialists, most of them for their physical problems, but many are on combinations of antidepressants, benzodiazepines, and hypnotics. Increasingly, many may also be found to be receiving neuroleptic medications from their primary care physician, namely quetiapine. Many, however, continue to experience considerable emotional distress or are causing distress to family members and are becoming unmanageable for caregivers because of their disturbed behavior. In this situation, the psychiatrist’s intervention becomes absolutely necessary.
Interaction with Other Prescribing Physicians
Interacting with the multiple prescribers and other caregivers of home-bound patients is especially challenging. There are issues of boundaries between primary care physicians and various specialists. Negotiating these complexities is a difficult task but something the psychiatrist is obligated to try.
It is common to visit a patient in follow-up and find that another physician, usually a primary care physician, has made major changes in the dosage and type of psychotropic medicines the psychiatrist has been prescribing. Sometimes, high doses of psychotropic medicines that may have considerable side effects may have been prescribed for an elderly patient, with refills to last 6 months, as the physician may not plan to see the patient any time sooner.
The psychiatrist has to remain ethical, clinically judicious, and try to be a model for others in these circumstances. If the psychiatrist has never started prescribing for a patient and the patient is doing reasonably well on the medicines prescribed by the primary care physician or others, the psychiatrist must acknowledge that, and let the physician continue with his or her effort. Let the patient and doctor know that you are willing to be of assistance, if needed. If the patient’s condition demands an immediate change in medicines, dosage, or both, explain the reasons to the patient and any caregivers and, at least write a note to the doctor or make a phone call and inform why such changes were necessary. Sometimes, the physician concerned accepts the explanation or may even be appreciative of your efforts. However, sometimes they may not be. At least one has done what was proper and reasonable. Regarding future treatment, the patient, if able, should make the decision whether he or she wants the primary care doctor to be the one to continue prescribing or should decide if the psychiatrist should take over that part of the care.
Enlisting Help from Family and Other Caregivers
With the patient’s permission, counseling any family members or care-givers involved about the nature of patient’s problems and what measures may be helpful is an important aspect of home-based psychiatric treatment. Most people in a large city who need home-based psychiatric treatment today may be living alone. They may have a part-time or full-time home healthcare aide. Some have no family members involved. Almost all of the patients one sees are lonely, in distress, are worried and fearful of their future. For many of them, end-of-life issues have become a reality and constant preoccupation they can no longer ignore. A careful word or two from the psychiatrist to the family members or caregivers can go a long way in making the patients’ lives a bit more tolerable. As for the patient, supportive therapy is key.
Few psychiatrists can afford to provide home-based treatment on a full-time basis. The work is difficult, complex, time consuming, and often frustrating. However, the reward is the satisfaction one derives in providing services for a highly deserving but neglected population, who may otherwise go without help. Unless one works for an agency that has all the modern technology at its disposal and plenty of resources (few, if any, of such agencies do such charitable or philanthropic work), there are significant frustrations involved. Some examples are getting documentation filed properly (all of the state mental health service regulations have to be satisfied). Much of the writing is done in the patient’s residence, but a lot of transcribing and filing must be done at the office when one returns there, often days later. The psychiatrist must also arrange follow-up visits as needed, make sure the patient is available at the scheduled time, arrange for blood work to be done at home and track the results, answer phone calls from the patient and relatives, try to locate patients’ residences, especially in inclement weather, and a myriad other complexities unique to this form of treatment.
Most psychiatrists who do such work are usually sponsored by an agency, usually a charitable or philanthropic one, which may have limited resources. The payment the agency receives for all its services is what Medicare pays and may be inadequate to cover work. The psychiatrist’s remuneration will be in keeping with such circumstances. However, it is a very worthwhile service for the patients concerned, who would otherwise have no treatment or in most cases, very poor quality treatment. On this basis alone, it is a worthwhile endeavor for a motivated psychiatrist to undertake, at least on a part-time basis and at least for a few years in one’s life.
- Reding KM, Raphelson M, Montgomery CB. Home visits: psychiatrists’ attitudes and practice patterns. Community Ment Health J. 1994;30(3):303–305. doi:10.1007/BF02188889 [CrossRef]
- Roane DM, Teusink JP, Wortham JA. Home visits in geropsychiatry fellowship training. Gerontologist. 2006;37(4):142–146.
- Van Citters AD, Bartels SJ. A systematic review of the effectiveness of community-based mental health outreach services for older adults. Psychiatr Serv. 2004;55(11):1237–1249. doi:10.1176/appi.ps.55.11.1237 [CrossRef]