Textbook of Hospital Psychiatry

The concluding chapter of this new textbook of hospital psychiatry, written by its three editors, states that psychiatric hospitals are the hub of any mental health system (p. 470). In most communities, that is no longer true. Indeed the introduction by the same authors points out that “the scarcity of acute psychiatric beds in this country has reached crisis proportions” (p. xix). The number of psychiatric hospital beds has declined precipitously as the withdrawal of general hospitals from inpatient psychiatry has followed the downsizing of state hospitals (1) . The situation is paradoxical on several accounts. First, the need has never been greater, with emergency rooms in many communities “in gridlock with acutely ill psychiatric patients stuck with nowhere to go” (p. xix). Acute psychiatric hospitalizations are brief and crisis oriented, leading to frequent readmissions and imprisonment of many of the more seriously and persistently ill patients. The second aspect of the paradox is that psychiatrists are now better at delivering effective inpatient treatment to people with severe mental illnesses, with improvements in both psychopharmacology and psychological and cognitive treatment.

The book offers no new solutions to problems of the inpatient treatment in the mental health system; instead it is a collection of chapters about inpatient treatment that I found remarkable in their breadth. Chapter after chapter contains practical applications of the biopsychosocial model to the problems of acutely ill patients with a variety of diagnoses. For acutely ill adults, Glick and Tandon give a number of trenchant pieces of advice, including their prohibition against diagnosing patients with “not otherwise specified.” Instead they recommend that the physician “make a working diagnosis as is done in the rest of medicine” (p. 31). Equally wise is a psychosocial comment: “Don’t assume that patients have no significant others (broadly defined); almost everyone has some significant other, even the homeless” (p. 31). The chapter on posttraumatic stress disorder units, by Loewenstein and Wait, has a very sensitive description of how to handle minor medical issues for patients whose medical care has been neglected in the past. They point out that: “In the overreacting patient’s history, he or she may report not getting medical attention unless it was a life or death matter (p. 114).” A unit on psychosis as described by Boronow has to deal with how to give medication to paranoid patients who may refuse it. Boronow recommends that the offer of medication be repeated several times a day because paranoid symptoms often fluctuate over the course of the day. In the chapter on co-occurring substance abuse with mental disorders, Recupero, Fiore, and Dubreuil present a lucid discussion on the problem of smoking on such a unit. They point out that smoking is often considered a lesser target that should be overlooked while the patient is trying to detoxify from other substances, although the evidence indicates that smoking behavior increases the addictive properties of a number of other substances, including alcohol.

Although the book does not predominantly concern itself with systems issues, the chapter by Hepburn and Sederer on the state hospital is a fascinating account of the forces that converge on the governance of a state hospital—from courts and advocacy groups mandating freedom for patients to unions asking for more use of seclusion and restraint to protect their members who work as nurses and staff. The authors’ ability to conceptualize the interaction of these many competing demands in the context of low funding and high needs makes this chapter worth reading several times by anyone charged with responsibility of leadership in a public mental health system.

A series of chapters contrast patient and staff perspectives on care in the inpatient service. The bewilderment of patients trying to understand the rules and regulations was especially poignant. One patient pointed out that it took her several days to understand that she needed to attend group in order to have the privilege of going outside. She stated how mysterious most of the demands on her seemed when she was ill. The staff perspective is equally fascinating. Their distaste for forcible restraints and their risk of injury during this procedure are both detailed.

The book can be read at a number of levels. Some chapters, particularly early in the book, are quite appropriate for medical students, who often fear their rotation on the inpatient psychiatric service and cite it as one reason why they choose not to pursue psychiatric training. The book would certainly be useful for a new resident or a new attending psychiatrist, because many of the most difficult situations are nicely outlined in the book. I found the book an interesting reminiscence of my own student days in psychiatric hospitals, some of which were spent with Steven Sharfstein, the senior editor of the book when he was chief resident of the Day Hospital at Massachusetts Mental Health Center. The authors, all well-known eminent psychiatric educators, have indeed shared their lifetime of experience in their textbook.