Managing Psychiatric Patients in Medical Hospitals

Today's Hospitalist Magazine discusses the challenges of managing psychiatic patients in (medical) hospitals (via Dr. RW):

a young, depressed woman who presents to the ER after a suicide attempt with an overdose of benzodiazepines. The woman is often uninsured, and because there’s no bed at the county mental health facility, she is admitted to—and stays in—the medical ward.

The woman discussed in the above example may languish weeks on the medical ward waiting for a psychiatric bed (at a private psychiatric hospital or at a government psychiatric hospital) to open up- if she's lucky. If she's unlucky and committment paperwork has been filed, she may wait in jail for a psychiatric bed to open up. Assuming she's lucky and she gets to wait in a medical bed, who takes care of her? This role typically falls to the hospitalist (internist), who is often unprepared:

“some hospitalists are not comfortable prescribing the initial dose of certain psychiatric medications, like the newer antipsychotics.” While most hospitalists may be comfortable starting patients on antidepressants, “much further beyond that and their comfort level goes away.”

Of course, a psychiatrist (if available) is usually consulted, but he may only see the patient and leave a note several times a week.

Here are some possible solutions:

1. Reopen psychiatric wards in general hospitals. only 25% of general medical hospitals still have dedicated psychiatric units. Not profitable, so probably won't happen.

2. Open up Med/Psych wards in general hospitals. Not profitable, so probably won't happen. In addition, there are huge insurance issues with Med/Psych wards- mental health care is often covered by a mental health carve out, so the medical insurer and the psychiatric insurer will sometimes each try to deny responsibility for covering the hospitalization.

3. Give psychiatrists admitting/attending privileges at general hospitals and have them be the attending for the patient (after medical stablization). To get psychiatrists to do this, they will have to be subsidized by the hospital like many hospitalists are. Not profitable, so probably won't happen. In addition, there are the insurance issues discussed in #2.

4. The hospitalist groups could hire psychiatric nurse practitioners to help them manage these patients (using some of the subsidy they get from the hospital). Probably the most viable solution.