A delightful, funny, smart young man we know called us on Friday to say that he had stopped his medications a few weeks ago, and now he felt he was entering a mania. We did our best over the weekend to patch things up, got him more medications, talked to him every day, worked with him to make sure that there were friends and family visiting him, but this morning it was clear that it wasn’t working. He was going to have to go to the hospital.
The topic of this post is about how we think about that decision.
These days, especially in California, it can be a real challenge getting in to a psychiatric inpatient unit. There are so few left. (We had about the lowest number of beds per capita in the world ten years ago when we wrote a report on the topic for the California Mental Health Directors Association, and the numbers have continued to go down).
But leaving aside that question. When is a hospital stay something to consider?
First of all, a hospital stay is worth considering if there is serious risk of harm – the person may harm themselves (perhaps even make a suicide attempt) or another person (due to anger or irritability) or may cause serious unintentional harm because of misinterpretations of reality, serious inability to adequately care for self, or from altered states of consciousness due to use of intoxicating substances in an uncontrolled manner.
Whether there is danger or not, a hospital stay should also be considered if the person is seriously impaired in the ability to take care of his or her basic needs…In the extreme, this could mean complete neglect of personal hygiene and appearance and inability to attend to most basic needs such as food intake and personal safety.
A tricky dimension involves the complexity of a person’s problems. If someone has not only serious psychiatric problems, but also substance abuse problems and medical problems as well, the interaction of all of these problems together may necessitate inpatient care because figuring out what is going on is just too hard to do otherwise.
Then there is the issue of the balance between support in the living environment as opposed to stress. Serous stressors include interpersonal conflict or torment, life transitions, losses, worries relating to health and safety, and ability to maintain role responsibilities. Many of these can be managed however if there is good support – availability of adequate material resources and relationships with family members, friends, employers or teachers, clergy and professionals, and other community members.
The availability of crisis treatment options can make a big difference in this dimension. If I could have gotten someone to stay with my patient full time without spending hours on the phone, it might have meant I could avoid referring him to the hospital. Sadly crisis options are also declining in most parts of the country…
Another factor is how likely is the person to get well with some support. If a person has always come out of a crisis before without intensive intervention then, for a number of reasons (including the person’s ability to maintain hope in the face of adversity) a hospital may not be as necessary.
Finally, what is the person’s level of awareness, acceptance and engagement in getting well. If the person rarely, if ever, is able to accept reality of illness and relates poorly to treatment and treatment providers and has an extremely narrow ability to trust anyone then a hospital stay may be more necessary than if the person is actively and positively engaged in taking care of all of their needs as best they can.
There is a longer discussion about these factors on the website of the American Association of Community Psychiatrists, who developed the tool from which I abstracted this blog post.