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A 60-year-old grandmother is hospitalized following a suicide attempt via massive overdose. A 21-year-old college student is placed under involuntary commitment due to gross paranoia in the context of first-episode psychosis. A 35-year-old with a history of bipolar disorder is admitted for acute mania.
As recently as 30 years ago, each of these patients would have been hospitalized on an inpatient psychiatry unit for at least a few weeks—in some cases, a month or more. The treating psychiatrist would have possibly taken the patient off all of his medication, examined the pathology, and then started a trial of a new medication—in combination with intensive psychotherapy conducted by the psychiatrist or the social worker. The patient would have been discharged only after his condition had been successfully stabilized and adequate housing and follow-up care had been arranged. For some patients with severe or refractory disease, a psychiatric admission could last six months or longer.
Sadly, this scenario is a distant memory to those working in inpatient mental health.
Psychiatric "micro-hospitalizations" of today
The average length of stay for an inpatient psychiatric admission at present is somewhere between 3 and 10 days, with many admissions lasting only 3 or 4 days—even following a serious suicide attempt or for a patient with serious illness. The patient may simply be restarted on his outpatient medications, observed for a few days, and sent on his way. Individual psychotherapy in the inpatient setting is a thing of the past, and the group psychotherapies offered to teach basic coping skills and provide psychoeducation are far from individual-specific.
These short hospital admissions have been referred to as "micro-hospitalizations," and they are, in my view, causing grave harm to our patients. Patients are often discharged as quickly as possible, as soon as their insurance stops paying (usually when the patient begins to deny suicidal ideation), and without adequate housing and follow-up arrangements in place. In many cases, patients are simply discharged to the homeless shelter or back to the perilous environment from which they came. Many find themselves unable to fill their prescriptions due to transportation or financial issues. The unnecessarily stringent commitment laws make inpatient hospitalization far too difficult, and once the patient is admitted, the doctor must jump through a series of legal hoops to keep the patient—even an acutely dangerous one—against his will.
Emergency room psychiatrists' hands are tied
Those of us who work in the psychiatric emergency room are on the front lines of this national crisis. We know that the patient must meet strict admission criteria in order to justify an admission, namely, the finding of mental illness and imminent dangerousness. Thus, the profoundly depressed patient who denies suicidal ideation, the grossly delusional patient who believes the FBI has implanted a thought monitoring device in his head (but who denies suicidal or homicidal ideation), and the acutely manic patient who has impulsively blown through the entirety of his 401k in one weekend may all fail to meet admission criteria under our current system. We know the insurance companies won't pay, and the commitment laws generally forbid involuntary hospitalization in these non-dangerous situations. We are left with our hands tied—as are outpatient psychiatrists, therapists, and family members.
The problems described above are largely the result of the failed deinstitutionalization movement of the 1960s and 1970s, spearheaded by the antipsychiatry movement, a focus on cost-cutting in healthcare, and the growing influence of the insurance industry on the practice of medicine. The revolutionary psychiatric drugs discovered in the mid-twentieth century helped millions, but the reality is that many severely ill patients struggle even with the best treatment. Many of the chronically ill are hospitalized and rehospitalized every few weeks. Our inpatient units have become a revolving door. The focus on the freedom of the mentally ill loses its meaning when freedom means living in a cardboard box under an overpass, psychotic, suicidal, and without food or water.
Some have suggested a return to long-term state hospitalization for the severely ill. At the height of institutionalization in the 1950s, there were over half a million Americans in state mental hospitals. Now, we have roughly 30,000 inpatient beds across the country. The large state hospitals have all but disappeared, and those that still operate do so at greatly reduced capacity. As unpleasant as the state hospitals were, they were certainly better than the current alternatives—homelessness and imprisonment. Instead of 600,000 in mental hospitals, we now have 350,000 mentally ill in prison and 250,000 homeless. The largest mental "hospital" in the nation is now the Los Angeles County jail. And funding for mental health services continues to be cut by millions each year.
The great unspoken paradox of micro-hospitalization is that in many cases these short stays are not even long enough for treatment to begin working—and everyone knows it. The antidepressant drugs, for instance, can take anywhere between two and six weeks to start working. A patient with rapid cycling bipolar disease may take months to stabilize with lithium carbonate. Psychotic episodes can take weeks or months to remit, even with good pharmacological treatment. Nevertheless, three to seven days in the hospital has become standard. And there is evidence to suggest that shorter hospital stays translate into poorer prognosis, greater rates of readmission, and increased cost.
The growing popular interest in suicide prevention and mental health awareness is a major step forward, but it must be accompanied by a national dialogue on the limitations of our current inpatient system. Otherwise, we will only continue to see an increase in the suicide rate and the overall burden of psychiatric illness. It's time for an overhaul of our national mental health system. Our patients, often the most vulnerable members of our society, deserve so much better.
