In an article in the February Psychiatric Services, authors Ira Glick, M.D., Steven Sharfstein, M.D., and Harold Schwartz, M.D., offer a model for psychiatric hospitalization that proceeds in three stages—assessment, implementation, and resolution.
"Traditionally we have assumed that anyone ill enough to require hospitalization needs a careful assessment," said Schwartz. "That requires a certain amount of time, and people who come in with severe psychiatric disorders compounded by use of substances need time to have those substances washed out. Others who come in on multiple medications need to have a reasonable period in which they can be assessed without medication.
"The things we propose are not revolutionary or radical," Schwartz told Psychiatric News. "When medications are introduced, they ought to be introduced one at a time. But we live in an age of polypharmacy, and the evidence base for polypharmacy is conflicting. The current practice in ultrashort stays is not driven by evidence at all, but by the time limitations we have to work with."
More generally, Schwartz lamented the black-and-white dichotomy of debates with community advocates in which treatment in the community is "good" and the hospital is "bad."
"We are talking about a continuum in which ultimately the hospital will play a small role in the life of the patient, and outpatient care will play a large and continuing role," he said. "But the inpatient piece has been whittled down by payers determined to reduce costs to the absolute minimum, and in doing that, we have sacrificed important clinical values."
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