Front Matter

Contributors xiii

Foreword xix

Richard J. Pollack

Introduction xxiii

Harsh K. Trivedi, M.D., M.B.A.

Steven S. Sharfstein, M.D., M.P.A.

1 History of Hospital Psychiatry 1

Jeffrey L. Geller, M.D., M.P.H.

Ashley J.B. MacLean, M.D.

PART 1

Inpatient Care

Units by Age Cohort

2 The Child Unit 47

Debra Heck, M.D.

Kathryn Burns, R.N., M.S.N.

3 The Adolescent Unit 67

Yasas Tanguturi, M.D., M.P.H.

Catharyn Turner II, M.D., M.Ed.

4 The Adult Crisis Stabilization Unit 87

Savitha Puttaiah, M.B.B.S., M.D.

Merle McCann, M.D.

5 The Geriatric Unit 113

Caitlin Lawrence, M.D.

Amy Halt, M.D., Ph.D.

Louis Marino, M.D.

Units by Diagnostic Cohort

6 The Developmental Disabilities Co-occurring Unit: Neuropsychiatry Across the Life Span 151

Scott R. Pekrul, M.D.

Robert W. Wisner-Carlson, M.D.

Thomas Flis, M.S.

7 The Eating Disorders Unit 183

Jennifer L. Goetz, M.D.

Steven F. Crawford, M.D.

Harry A. Brandt, M.D.

8 The Forensic Unit 211

Tobias D. Wasser, M.D.

Charles C. Dike, M.D., M.P.H., FRCPsych

Michael A. Norko, M.D., M.A.R.

9 The Psychotic Disorders Unit 229

Edward Zuzarte, M.D.

John J. Boronow, M.D.

Harsh K. Trivedi, M.D., M.B.A.

10 The Substance Use Disorders Co-occurring Unit 257

Sunil Khushalani, M.D., DFAPA, FASAM

George Kolodner, M.D., DLFAPA, FASAM

Specialty Settings

11 The State Hospital 113

Debra A. Pinals, M.D.

Brian M. Hepburn, M.D.

Ted Lutterman, B.A.

12 The Veterans Hospital 151

Anne Marie Stoline, M.D.

Marsden McGuire, M.D., M.B.A.

PART 2

The Continuum of Care

13 Community Mental Health and Hospital-Based Outpatient Services 183

Deepak Prabhakar, M.D., M.P.H.

Manan Shah, M.D.

Jason Addison, M.D.

Jeff Richardson, M.S.W., M.B.A.

14 Residential Treatment for Children and Adolescents 211

Virginia Susan Villani, M.D.

15 Residential Intensive Psychodynamic Psychotherapy for Adults 229

Eric M. Plakun, M.D.

Edward R. Shapiro, M.D.

16 Psychiatric Emergency Services and Interface With the General Hospital 257

Deepak Prabhakar, M.D., M.P.H.

Benedicto Borja, M.D.

Aaron Winkler, M.D.

Rachna Raisinghani, M.D.

PART 3

Hardwiring Excellence

17 Administration and Leadership 399

Gregory Gattman, FACHE

Kelly Savoca, CPA, M.B.A.

Harsh K. Trivedi, M.D., M.B.A.

18 Financing of Care 411

Paul Summergrad, M.D., FRCPsych (Hon)

Bruce J. Schwartz, M.D.

Peter Spyrou, M.D.

19 Quality, Measurement-Based Care, and Outcomes 433

Robert J. Schloesser, M.D.

20 Risk Management 447

Jerry Halverson, M.D.

Nathaniel Clark, M.D.

Terri Schultz, R.N., M.B.A.

Steven Hertig, B.A., CHPC

21 Preventing Conflict, Violence, and Use of Seclusion and Restraint 463

Kevin Ann Huckshorn, Ph.D., M.S.N., R.N., ICADC

Janice L. LeBel, Ph.D., ABPP

22 Lean and Operational Excellence 481

Sunil Khushalani, M.D., DFAPA, FASAM

23 Architecture and Thoughtful Design 503

Harsh K. Trivedi, M.D., M.B.A

Michelle S. Hooper, M.S.H., AIA

Antonio DePaolo, Ph.D.

Thomas D. Hess, M.B.A.

Roger Daub

PART 4

Workforce and Special Issues

24 Psychiatrists, Psychiatric Nurse Practitioners, and Psychologists 517

Todd Peters, M.D.

Kathleen Hilzendeger

25 Psychiatric Mental Health Nursing 537

Laura Lawson Webb, M.S.N., R.N., PMHN-BC

26 Social Work and Rehabilitation Therapies 547

Carrie Etheridge, LCSW-C

Vaune Kopeck, OTR/L

April Sobiech, LCSW-C

27 Working With Families 557

Lisa B. Dixon, M.D., M.P.H.

Thomas Jewell, Ph.D.

Sarah Piscitelli, M.A.

28 From Within: A Consumer Perspective on Psychiatric Hospitals 577

Howard D. Trachtman, B.S., CPS, CPRP, COAPS

Kenneth S. Duckworth, M.D.

Reverend Dr. Norma J. Heath

Ziona Rivera

PART 5

The Future of Hospital Psychiatry

29 Collaborative Care and Emerging Models 591

Ken C. Hopper, M.D., M.B.A.

Roger Kathol, M.D., CPE

30 The Future of Hospital Psychiatry 605

Harsh K. Trivedi, M.D., M.B.A.

Jennifer Weiss Wilkerson, M.H.S.A., FACHE

Thomas Glenn, M.S.F.

Index 625

Color Gallery 633

Sheppard Pratt Health System, Baltimore, Maryland

Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine & Health Sciences, Washington, D.C.

Sheppard Pratt Health System, Baltimore, Maryland

University of Maryland School of Medicine; ERC Pathlight, Hunt Valley, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

Vanderbilt University School of Medicine, Nashville, Tennessee

University of Maryland School of Medicine; ERC Pathlight, Hunt Valley, Maryland

Hasta Advisors, LLC

University of Maryland, Upper Chesapeake Health, Bel Air, Maryland

Yale University School of Medicine, New Haven, Connecticut; Connecticut Department of Mental Health and Addiction Services, Hartford, Connecticut

New York State Psychiatric Institute and Columbia University Vagelos College of Physicians and Surgeons, New York, New York

NAMI: National Alliance on Mental Illness

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

University of Massachusetts Chan Medical School, Worcester, Massachusetts

Sheppard Pratt Health System, Baltimore, Maryland

McLean Hospital/Harvard Medical School, Belmont, Massachusetts

Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island

Rogers Behavioral Health

NAMI Greater Boston Peer Support and Advocacy Network; AMRON International

Sheppard Pratt Health System, Baltimore, Maryland

National Association of State Mental Health Program Directors, Alexandria, Virginia

Rogers Behavioral Health

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

Marshall Craft Associates, Inc., Baltimore, Maryland

TCU and UNTHSC School of Medicine, Fort Worth, Texas

Recovery International, Inc.

New York State Psychiatric Institute and Columbia University, Department of Psychiatry, New York, New York

University of Minnesota, Minneapolis, Minnesota

Kolmac Outpatient Recovery Centers; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland

Georgetown University School of Medicine, Washington, D.C.

Sheppard Pratt Health System, Baltimore, Maryland

Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island

Department of Mental Health, Commonwealth of Massachusetts

NRI, Falls Church, Virginia

University of Massachusetts Chan Medical School, Worcester, Massachusetts

Sheppard Pratt Health System, Baltimore, Maryland; Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island

Sheppard Pratt Health System, Baltimore, Maryland

Department of Veterans Affairs, Washington, D.C.

Yale School of Medicine, New Haven, Connecticut; Connecticut Department of Mental Health and Addiction Services, Hartford, Connecticut

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

University of Michigan Medical School, Ann Arbor, Michigan

New York State Psychiatric Institute, New York, New York

Austen Riggs Center, Stockbridge, Massachusetts

Sheppard Pratt Health System, Baltimore, Maryland

Baptist Behavioral Health, Jacksonville, Florida

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

NAMI Greater Boston Peer Support and Advocacy Network; AMRON International

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

Department of Compliance and Regulation, Rogers Memorial Hospital, Inc.

Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York

Sheppard Pratt Health System, Baltimore, Maryland

Austen Riggs Center, Stockbridge, Massachusetts; Clinical Professor of Psychiatry, Yale Medical School, New Haven, Connecticut

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York

Perry Point VA Medical Center, Perry Point, Maryland

Department of Psychiatry, Tufts University School of Medicine; Tufts Medical Center and Tufts Children’s Hospital, Boston, Massachusetts; World Psychiatric Association

Vanderbilt Psychiatric Hospital; Vanderbilt University Medical Center, Nashville, Tennessee

NAMI Greater Boston Peer Support and Advocacy Network

Sheppard Pratt Health System, Baltimore, Maryland

Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Sheppard Pratt Health System, Baltimore, Maryland

Yale School of Medicine, New Haven, Connecticut; Whiting Forensic Hospital, Middletown, Connecticut

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

University of Maryland/Sheppard Pratt, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

Sheppard Pratt Health System, Baltimore, Maryland

With each passing day, the words of Dr. Brock Chisholm, the first director-general of the World Health Organization and a psychiatrist, become increasingly clear: “Without mental health there can be no true physical health.” The American Hospital Association sees this link throughout our membership, which includes freestanding psychiatric hospitals, psychiatric units within general acute care facilities, and millions of individual clinicians. Even with improved access to community-based care, severely ill patients continue to need the intense and highly tailored medical treatments—for both mental and physical comorbidities—that are provided only in hospitals. As we continue to confront COVID-19, the world’s greatest public health crisis in the past century, it is astounding how much has changed since the last published edition of this textbook … and how much remains the same.

Over the last decade, the field of hospital psychiatry has faced new clinical and policy challenges and opportunities. Spending by insurers for behavioral health treatments has increased significantly, and out-of-pocket spending for behavioral health treatments continues to rise. Accompanying this increase in spending is the nationwide explosion of the opioid crisis, which reminds us of the insidious entanglements of pain and addiction. Increasingly, patients seeking psychiatric care in hospitals suffer from a combination of behavioral and physical ailments, each exacerbating the others, resulting in highly sensitive and complex treatment regimens. As providers treat patients with complex conditions, they also must balance the growing regulatory demands, quality reporting programs, and progressively stricter survey and certification activities that have heaped numerous administrative requirements on hospitals. The ensuing environment of care is a constant juggling act of these pressures with efforts to advance evidence-based care protocols and quality improvement initiatives.

Even in the face of these obstacles, the field has expanded and treatment has evolved. Providers and policy-makers are increasingly aware of the importance of treating the whole person. Research demonstrates that integrating physical and behavioral health care improves outcomes and can reduce the total cost of care. Clinicians across specialties are adding behavioral health treatment into their regular courses of care, while psychiatric facilities and units address not only patients’ physical ailments but also their postdischarge social needs, including housing, transportation, and nutrition. Many psychiatric facilities also are improving their health information technology capabilities to enhance care through the use of electronic medical records and telepsychiatry.

As the field has made progress in a number of areas, many age-old challenges remain. Inadequate reimbursement and insurance coverage for mental illnesses leave both patients and providers desperate for reform. Despite the passage of the Mental Health Parity and Addiction Equity Act in 2008, patients seeking mental health care are twice as likely to be denied coverage for services based on medical necessity as patients seeking physical health care, and behavioral health providers are still reimbursed less than those in other specialties. In addition, the long-standing workforce shortages are worsening, as practitioners in the baby boomer generation reach retirement age and their roles go unfilled by new graduates. The shortages are particularly severe in child, adolescent, and geriatric psychiatry.

These obstacles feed on and into pervasive undercurrents that have been present since the inception of hospital psychiatry. Disparities in access still leave people of color struggling to receive care at all, let alone culturally competent treatment. Individuals in the LGBTQ+ community are more likely to attempt or commit suicide, particularly during adolescence. The aging population is more likely than previous generations to live alone and without behavioral and social supports. And underscoring it all is the stigma associated with mental illness and substance use disorders. While it is encouraging that behavioral wellness has received some increased public attention, including from well-known personalities, unfortunately severe mental illnesses like schizophrenia and other psychotic disorders (the second most common diagnostic group treated in psychiatric hospitals) are associated with even higher levels of stigma than other behavioral health conditions.

Despite this intimidating environment, psychiatric hospitals are adapting and finding new ways of caring for severely ill patients. This textbook orients the practice of hospital psychiatry toward the future while seeking innovative solutions to these long-standing challenges. The forward-looking chapters focus on integrating physical and behavioral health care across specialty units, types of hospitals, and treatment settings. Authors at the vanguard of their field offer insights into modern delivery models that employ strategies such as telemedicine to extend the reach of the clinical workforce. Other chapters expound on the utility of collaborative care efforts, which incorporate professionals from various specialties, to address the full continuum of a patient’s needs. Hospital and health system leaders extend guidance on the infrastructure capabilities necessary to balance the many, and often competing, clinical and administrative demands.

It is fitting that this new edition arrives following the tumultuous year of 2020. The COVID-19 pandemic, social and civil unrest, and the economic recession laid bare the critical and urgent need for behavioral health care. On the one hand, the events of that year have seriously affected the mental health of individuals across the nation, resulting in increases in depression, anxiety, drug overdoses, and self-harm. On the other, the surge in awareness of the importance of behavioral health care has hastened policy actions to enhance funding and ease regulatory burdens on psychiatric providers. This textbook will help the field take advantage of this historic and unprecedented opportunity to advance hospital psychiatry.

The American Hospital Association is proud to represent practitioners who face such a complex and challenging environment with integrity and compassion. As we strive to ensure a regulatory environment that reduces burden and supports innovation, clinicians work tirelessly to provide evidence-based, high-quality, and safe care to patients with acute conditions that are among the most difficult to treat. Together, and with the guidance of the experts featured in this textbook, we hope to continue to advance the practice of hospital psychiatry as we work to advance health in America.

Sheppard Pratt is the largest private, nonprofit provider of mental health, substance use, developmental disability, special education, and social services in the nation. Our path is one that has been marked with tremendous growth, particularly during the most difficult time periods in our field. As only the fifth and sixth chief executive officers for Sheppard Pratt Health System since its founding in 1853, we have chosen to chart a course that is unique among freestanding psychiatric hospitals, and as time has progressed, we remain unparalleled in our ability not just to survive but to adapt and thrive to meet the most pressing need of each decade.

Our 5,000 employees provide psychiatric care across 160 unique programs at more than 380 sites of service. The health system provides the most comprehensive behavioral health continuum, serving patients from more than 40 states and 20 foreign countries annually. As a nationally ranked top hospital in psychiatry by U.S. News & World Report for 30 consecutive years, each year we base our success on how many more people we can help, how many new programs we can create, how we can accept all who need care regardless of their ability to pay, and how we can lead in transforming our field to ensure that every community has access to high-quality psychiatric services.

We hope that the knowledge contained within this textbook will provide valuable knowledge to spur innovation and growth within your own organization as well as provide hope for what is possible in our field. While we acknowledge that many developments are happening at places across the country, we fundamentally believe in three guiding principles that are even more true today than in previous decades: 1) the importance of having a true system of care that spans the continuum of services that patients need for each step in their care journey, 2) the importance of being able to offer services at scale and to ensure access to all comers, regardless of severity of illness or payer-type, and 3) the increasing importance of having a physician executive at the helm of leadership to manage clinical complexity across programs and services, to drive clinical outcomes for each patient, and to generate population-level impact.