Improving Inpatient Psychiatry

A Rant in Twelve Suggestions

I am grateful that, by the end of their stay, my patients are more often than not thankful for the care they receive. But not everyone is thankful, and sometimes for good reason. The fault may lie with a particular staff member (such as the psychiatrist): perhaps I made an error, or there was a tense interaction that left lingering bad feelings. But other times the complaints revolve around various systems issues, including those related to quality of life on the unit. For the past few years, I’ve been thinking about what kind of psychiatric unit I would design if I had a magic wand. I may write that essay someday, but for now, and in the interest of not letting the perfect be the enemy of good-enough, I want to lay out a few thoughts on how many of our inpatient psychiatric units could be improved from their current, often mediocre, state.

I’ve seen psychiatric hospitals that range from decidedly dingy and dilapidated to borderline-decadent. I consider myself fortunate to be working at one of the really good ones, but the reality is that in some places you can’t take it for granted that there are any good ones around at all (and if there are, do they have any available beds?). Given the varying quality among psychiatric hospitals, there will of course be many exceptions to what I’m going to say, but the point is to highlight some general features and patterns of inpatient psychiatric care that, if corrected, would make it both more effective and more humane.

For my purposes here, I will be talking about "acute care” units, where patients typically stay for one or two weeks. Sometimes sicker patients stay longer, but insurance, among other factors, doesn’t make it easy. Most psychiatric units in the US today operate like this. That means I’m not addressing long-term hospitals, state-hospitals, VA hospitals, residential treatment centers, etc., although many of these critiques would probably apply to them as well.

Although some of my proposals may sound relatively easy to implement, the practical realities of getting things done in healthcare makes me somewhat more pessimistic. All would require a lot of money, not to mention significantly more prioritization of psychiatric care at various levels of the medical system, from the hospital board to congressional legislation (eg. HIPAA). But I can dream, and I can write on Substack, where I don’t need to worry about a hospital executive who, after hearing my spiel on how to fix everything under the sun, gives me that look of confused pity that he usually reserves for the guy on the street corner ranting about the end of the world while selling pencils from a cup.

One: Let patients go outside

I don’t have national data on the percentage of psychiatric hospitals with outdoor spaces for patients—I’m not sure the data even exists—but I have neither worked nor trained at a single psychiatric hospital that routinely allows patients to go outdoors. There are a variety of reasons for this: some units are nested within larger hospitals without secure or convenient access to the outside; staffing limitations may prevent patients from being safely monitored while outdoors; elopement is an ever-present concern; and, in acute care psychiatric units, length of stay is short enough that outdoor time is not considered essential.

All these points are reasonable and certainly have some merit, but on the other hand, there is a reason that “getting some fresh air” is widely understood to be good for you. A few days cooped up in a hospital is one thing, but after a week or two without going outside people start getting cranky and irritable. Can’t blame them. For the really sick patient who stays for a month or more, not being allowed outside is positively inhumane. More than once over the years I’ve heard patients observe that you get more outside time in prison than in a psychiatric hospital.

For those psychiatric units located within larger medical hospitals, as many are, this may be an insoluble problem. This gets back to the relative lack of freestanding psychiatric hospitals (with enclosed courtyards), or even psychiatric units that were originally designed with a psychiatric use in mind. Today, many psychiatric units are refitted and repurposed medical units, where access to the outside was less of a concern (although I’ve heard more than one neurologist and internist tell me they too wish it were easier for their patients to go outside).

While some psychiatric units may be able to find clever workarounds and get their patients some outside time, the real solution to this problem (and many others) lies in thoughtfully selecting and designing psychiatric units from the ground up with patient comfort, and not just safety, in mind.

Two: Make the hospital beautiful

You can tell a lot about a culture from its architecture and interior design aesthetic (for anyone who doubts this, I encourage you to visit Washington D.C. and consider how likely it is that any psychologically healthy person could have designed the brutalist architecture that plagues our capital, not to mention the piles of scrap metal that are meant to signify…something?). Apparently, many hospitals used to have reasonably sized art collections lining their halls, but that may be a thing of the past. Now, the beauty of the hospital space is apparently considered irrelevant. I disagree: if you are sick, dying, or out of your mind, the psychological benefit of having a comforting, beautiful space as opposed to one that is cold, industrial, and mechanized, is not trivial.

Many psychiatric units are sparsely decorated, and whatever furnishings they have tend to be of the meaninglessly generic variety. The decor of many is bland and colorless, perhaps with a half-faded mural or two on some wall. Others are filthy. I’ve been to a few psychiatric hospitals that frankly remind me of a truck stop bathroom on the janitor’s day off. The nice ones tend to be “nice” more in the sense of lacking obvious filth (a good thing), rather than actually being pleasant to look at.

There are limitations on what can be done with the physical design and layout of a psychiatric unit due to safety concerns: no sharp corners, nothing on the walls or ceiling from which you could hang something, chairs weighed down and tables either attached to the floor or too heavy to move. A lot of this is unavoidable, but there is no reason that such spaces can’t be made more beautiful with a bit of real art and some attention to aesthetics.

Based on my back-of-the-napkin calculations, anything done in a hospital costs somewhere between 5 and 500 orders of magnitude more than it should, give or take a few zeros. Of all my suggestions here, getting some reasonably non-generic art is probably the cheapest and easiest. Here’s a start, and it costs nothing: why not display art made by patients? It isn’t uncommon to meet patients with significant artistic ability, and I personally know many who would love to have their work on display as inspiration for others.

Pediatric hospitals often stand out with their attention to comforting decor and displays of patient art. Psychiatric hospitals should get with the program.

Three: For God’s sake, the food!

This one applies across the board. Most hospital food is abjectly terrible, while the best is probably comparable to Arby’s on a bad day. And to be clear: I’m not a food snob. One thing I am very thankful for is my broad palate: I can appreciate the best steak you’ll ever have in your life as well as a 7-11 taquito that satisfies the itch only cheap food can scratch. But hospital food is truly depressing.

Personally, I have a policy of refraining from saying something "offends” me. This is more a function of how I manage my own psychology, not some political/cultural statement. But in this case, I’ll say that hospital food is offensive. We may have jettisoned our forefathers’ theories of spirits, humors, vapours, and élan vital, but we would do well to retain their appreciation for the medicinal effects of a sound diet. We need to fix the food if for no other reason than to avoid utter hypocrisy. It is difficult to take your dietician’s advice on a balanced diet seriously when the only things resembling “tasty” on the hospital menu are the chicken tenders and cheesecake.

Four: Exercise equipment and other recreation (that isn’t TV)

Very often patients need a low-stimulation environment to recover—consider someone who is psychotic and terrified, or withdrawing from drugs, or exceedingly anxious—as well as time for reflection and whatever psychological work they need to be doing. This is all well and good. That said, an excessive focus on psychological rehabilitation at the expense of attending to one’s bodily health can and does hinder treatment in various ways. Most notably is the restlessness one sees among patients who are used to exercising, or who are even just moderately active, outside the hospital. A few units may have a stationary bike or some other minimal exercise equipment, but many have nothing more than a hallway to circumambulate and count your laps. Many have equipment from back in the day when the unit was new but has since fallen into disrepair. The better ones compensate with things like group yoga and step aerobics, but these are usually in front of a television and get repetitive.

There are no one-size-fits-all solution here since different units have different patients with different needs and abilities. But a bit more attending to our patients’ health below the neck would do much to improve quality of life.

(And for any hospital executives reading this, I guarantee you that putting in an employee gym, or even a little workout room, would do wonders for morale. Aside from subsidized onsite daycare, this is one of the best investments for your employees you could make.)

Five: Appropriate patient segregation

Psychiatric units segregate patients based on a few characteristics in order to (1) keep everyone safe and (2) treat patients with different needs effectively. On a psychiatric unit, unlike a medical unit, patients are expected to be up and about attending group therapy or some other activity. They walk around the halls talking with other patients and staff. Therefore, there are careful considerations to be made regarding the milieu your unit will have.

The most basic division is between having a child/adolescent unit and an adult unit, for obvious reasons. There are some geriatric units, but these are difficult to find. For adult units, the ones with sufficient space are often further divided, typically by illness severity or type. For example, you may have one floor for psychotic, erratic, or violent patients, while another floor is reserved for those who are higher functioning. The needs of these two floors are very different: staffing requirements, safety precautions, what kinds of therapy will be helpful, etc. Inappropriate patient mixes can result in a toxic milieu, counter-therapeutic or inappropriate patient-patient relationships, and even physical or sexual violence.

The best psychiatric hospitals have multiple specialty units dedicated to treating patients with very particular problems (psychosis, neuropsychiatric, eating disorders, etc.). This is a high bar, but too many psychiatric units are woefully inadequate, being little more than a glorified hallway with a nurse’s station in the middle. This is another problem that may only be solved with the construction of new units from scratch.

Six: More short-term crisis units

A significant number of patients who are admitted to psychiatric units will start asking to leave within a couple days. Some need further hospitalization and are asking to leave because they are psychotic and don’t think they’re sick, or for some other similarly questionable reason. But many want to leave and are justified in their request, because when they came to the hospital they were in crisis, but now the crisis is over, and they are in fact safe to be discharged to outpatient care.

Some hospitals, especially those in big cities, have developed short-term crisis units for dealing with this problem. Often housed in or near the ER and with an “up-to-24-hours” or similar time limit, these beds can be used for patients who need more monitoring to determine whether psychiatric admission is necessary. Perhaps your patient arrived drunk and out of control, and needs time to sober up; or, she decided to consume 100 mg of edibles for her first experience with marijuana, thereby launching her into a day-long nearly-psychotic-level panic attack; or, your patient is a frequent flyer who uses the ER for a combination of legitimate reasons and malingering¹, and you need time to sort out the story before figuring out how to proceed. A good crisis unit is designed to keep patients safe while the crisis abates—or doesn’t—and is staffed by nurses, social workers, security personnel, and psychiatrists who are equipped to help the patients either to discharge or be formally admitted for further treatment.

One benefit of a crisis unit is that it keeps more inpatient beds free for the sickest patients who unquestionably need treatment. Admitting patients to, and discharging from, the hospital is a laborious procedure. Reducing admissions that turn out to be of questionable necessity allows staff to focus on patient care and other pressing tasks. A good crisis unit also frees up other ER beds for incoming patients, which keeps everyone happy (the need to keep patients moving in the ER is a complicated and inevitably inelegant dance, as anyone who has spent six-plus hours in an ER waiting room knows all-too-well).

Seven: More staff

Yes, I know, everyone is short-staffed these days. Here is why it matters for my work. Good nurses are always in short supply, and for good reason: the work is exceptionally tasking and is remunerated relatively poorly. I don’t know what the ideal staff : patient ratio is, but I can say with certainty that if, as I observed many years ago, there are so few staff present that when a fight breaks out on the unit it falls to the sanest patient to jump over the barrier into the (empty) nurses station to hit the alarm button himself, we’ve got a very serious problem.

Leaving aside such dramatic incidents, inadequate staffing slows down every aspect of care, increases the chances that mistakes will be made and not caught, prevents a genuinely therapeutic milieu from forming, and ultimately leads, out of necessity, to people cutting corners. On a psychiatric unit, staff interaction with patients during the day for group therapy, meals, and other activities is an essential part of the treatment. Good nurses, therapists, techs, physicians, all are scarce.

Eight: Easier communication

I’ve lost count of how many times families have told me one of their relatives was psychiatrically hospitalized somewhere and they never once received a call from the hospital. The theme here is: our mania for privacy has gotten totally out of control and is now more harmful than helpful.

This subject particularly annoys me, so I’ll keep this section brief before I build up too much momentum. The long and short of it is that much of HIPAA need to be seriously reconsidered or abolished. The harms caused by the byzantine regulatory apparatus governing patient privacy has long outlived any purported usefulness. Reams of consent forms, checkboxes outnumbering the stars in the sky, untold human hours dedicated to gumming up the works and making everything run as inefficiently as possible…and that’s just the first layer of Hell.

Clinicians may be uncertain about what can and can’t be disclosed, and to whom, which I’d bet leads on average to under-disclosure of relevant medical information. We seem to have forgotten that “valuing and protecting privacy” and “instilling a culture of paranoid fear through an opaque regulatory regime” are not synonymous. The impact of HIPAA on medical research has been somewhere between damaging and disastrous. In my day to day work, these restrictions make sharing medical records with other clinicians very difficult, which is the subject of the next point.

Nine: Shared medical records

This is of an extension of the above problem. There have been efforts in recent years to make it easier for clinicians to access a patient’s medical record from multiple institutions, cutting down on redundancies in treatment and improving communication overall. The results have been mixed. For example, below is a list of organizations in Illinois that participate in Care Everywhere, a “health information exchange” that, within the limits carved out by HIPAA, allowed clinicians to access a patient’s medical records from outside institutions. If patient A shows up at my hospital and has been treated at any of these locations in Illinois, I can view her entire medical record including clinic notes, lab tests, procedures, etc. Everything, that is, except the record of her psychiatric treatment!

In what I can only imagine is a misguided attempt to mitigate “stigma” and protect “sensitive information”, I frequently have to start from scratch with a new patient, even one who has been treated for years at a hospital just a few miles away. Seeing a psychiatrist’s clinic note from another institution in Care Everywhere is very rare indeed. Often their notes are marked as “private” in the medical record by default, rendering them invisible. Sometimes important lab results show up and sometimes they don’t. Often a patient will show up to another hospital in a psychiatric crisis, and I can view the notes from the ER, but if the patient is then admitted to the hospital’s psychiatric unit: radio silence. No more notes, because now the encounter is confidential. Depending on the institutions you’re dealing with, medical care relating to substance abuse and sexual assault may be hidden as well (but that’s probably not even relevant information anyway, right? Right?)

Privacy in psychiatry is important, and I take my patients’ privacy very seriously. But, to my mind at least, there is a world of difference between protecting privacy and hamstringing a doctors’ ability to conduct a basic review of the medical record.

Organizations in Illinois who theoretically participate in Care Everywhere. Source: https://www.epic.com/careeverywhere/?Illinois=1

Ten: Longer length-of-stay

I said I’m focusing on acute-care hospitals, where length of stay is typically on the order of a week or two. But not infrequently, the sickest patients require longer hospitalizations, but not long enough to warrant admission to a long-term psychiatric hospital where patients stay for years (to the extent that more than a handful of such hospitals even exist anymore).

The reality is that severe psychiatric illness takes time to treat, and most patients are discharged from hospitals too early. One common example among many:

Mr. B has bipolar disorder and is hospitalized for mania. After seven days or so of treatment with lithium, divalproex, and olanzapine, his most severe symptoms have resolved, and he is better able to conduct himself appropriately and interact with others in normal fashion. He says he feels fine, that he’s back to his normal self, and is ready to go. That, and his insurance company is saying they think (based on your notes that they are reviewing daily) that he is better and needs to be discharged. Mr. B is discharged with a next-day appointment for an outpatient program. Sometime in the next few weeks, Mr. B returns to the ER in the midst of an even worse manic episode than before, having never shown up for his appointments.

What happened here is that Mr. B was still hypomanic when he was discharged. It is common in mania that, with aggressive treatment, the most severe symptoms can usually be tamed within a week or so. But as patients regain their executive function and can exercise more self-control, they become increasingly able to mask their residual symptoms, thus appearing more well than they in fact are. This is not necessarily intentional deceit (although sometimes it is), but often results from our natural inclination to want to be well and feel well. Treating mania is like putting out a campfire: if you toss a bucket of water on it and walk away, you may have gotten rid of the big flames, but the embers underneath are still hot, and are liable to reignite. This is what happens with rushed hospital stays. Better to take time to douse the flame and be sure the fire is out. Many psychiatric illnesses are like this, not just mania. With even a few more days length-of-stay on average per patient, I’m confident that readmission rates and other adverse events post-discharge could be significantly reduced.

11: More Med-psych beds

Many patients with comorbid medical and psychiatric illness don’t get meaningful psychiatric care.

This one may be less obvious to those of you who are either outside the medical field or are not both psychiatrically and medically ill. Almost all psychiatric units are unequipped to handle medically complicated patients. “Medically complicated” means the patient not only has a psychiatric illness that needs treating but is sick enough to independently warrant a medical bed as well. Hence “Med-psych” beds.

My metropolitan area has around 10-ish million people. Off the top of my head, I’m aware of only one institution with a handful of med-psych beds. If there are others, I haven’t heard about them, and they don’t seem to be advertising.

If you aren’t familiar with psychiatric units, you may not see why this is such a problem. Why can’t you treat medically ill patients on a psych floor? Excellent question. Turns out that there are very good reasons to have clear demarcations between psychiatric and non-psychiatric “medical” beds. Medical patients need a number of additional services that the typical psychiatric patient doesn’t require, such as IV management, medical (as opposed to psychiatric) nursing care, as well as attention from either two physicians—a psychiatrist and internist—or a physician dual-trained in both psychiatry and internal medicine, and those are hard to come by.

Currently, most patients who need med-psych beds are treated on medical floors with a psychiatrist as a consultant. This ensures, at best, that the patient gets whatever psychiatric medications are necessary, but provides none of the benefits of an actual psychiatric unit. If we want to shift concern from the worried well to the sicker among us, this is one place to start.

12: Mental health declarations

Too few of us make thoughtful arrangements for the inevitability of future illness. While psychiatric illness is not inevitable, it is relatively common, and preparation for its arrival is difficult.

In medical school we were taught to encourage patients to fill out advance directives: legal documents that detail one’s wishes for treatment in the event of a future serious/end of life illness that renders you unable to communicate your preferences. This is a very good idea that can save you and your family mountains of hassle and grief down the road. Similar planning for psychiatric illness is far less common, though for many it is no less necessary.

Those with serious mental illness often need repeated hospitalizations. Sometimes the illness renders one incapable of making rational decisions about treatment, and sick patients may refuse treatment that they otherwise supported when they were well. This can happen for all sorts of reasons, although psychosis of one form or another is probably the most common. If a patient truly needs psychiatric treatment but refuses, we are often forced to go to court for legally mandated treatment, a major hassle that can take weeks and almost always reduces trust between the patient and the entire medical field. It is for this reason that I routinely encourage my patients to fill out mental health declarations to avoid such predicaments.

For those afraid that mental health declarations are a gateway drug to involuntarily committing all kinds of deviants, undesirables, political dissidents, or whatever, it’s worth noting that these are pretty specific documents. You can specify the criteria for what symptoms should qualify you for treatment, what treatments you want or don’t want, and even selection in advance (if possible) of the physicians who will determine whether you are at a later time incapacitated.

Here, for example, are the first two pages of the relevant declaration for the State of Illinois:

Source: https://www.dhs.state.il.us/onenetlibrary/12/documents/Forms/IL462-2102.pdf

On the handful of occasions where I have had to force treatment on patients in accordance with their mental health declarations, in every single case they were, once recovered, thankful for that piece of paper.

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I wish I had more practical suggestions for actually implementing some of these ideas. On the other hand, maybe I should be thankful that my work doesn’t (yet) necessitate my becoming a skilled navigator of our labyrinthine and psychotogenic medical-legal bureaucracy.

A lot has been written on how we now live in a “therapy culture”. What would happen if we took even a small percentage of the time and money (and yes, political will) that we spend on our precious therapy culture and directed it to the care of our sickest neighbors?

1. The intentional feigning or exaggerating of illness to achieve secondary gain, such as alleviation from homelessness, avoiding a court date, trying to seek monetary benefits, draining your parents’ bank account out of spite, etc. This is distinguished from Factitious disorder, previously known as Munchausen syndrome, in which someone feigns, exaggerates, or induces illness in order assume and maintain the “patient role”. The lengths some patients go to induce their own illness is truly remarkable, such as contaminating their IV lines with Greek yogurt, feces, or anything likely to cause infection.