Do you think there are disorders/types of patients who would still benefit from very long-term hospitalization?

[futureapppsy2]

The logistics of reimbursement, de-institutionalization (plus all the straight-up abuse that happened in mental institutions prior to that), etc., make these not a reality for all but perhaps the wealthiest of patients, but I can't help but think that there are patients who might actually benefit from this model of care, rather than just being in and out of the hospital while functioning poorly in the community. For example, a family friend has a son with schizoaffective disorder who had his first psychotic break at 18. In the decade since, he's had multiple psychiatric hospitalizations that lasted several weeks and numerous shorter ones, and functions at a fairly low level in the community (lives in an assisted living apartment but doesn't work, do anything in the community, no real relationships, etc) despite having good to excellent outpatient psychiatric care, an incredibly supportive family, good social work support, good access to benefits and treatment compliance assistance, etc. I can't help but wonder if he and similar patients wouldn't overall fair better in a long-term psychiatric institution rather than just being constantly on the verge of or just returning from a hospitalization and really not functioning in the community at all.

Thoughts?

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[PikminOC]

The logistics of reimbursement, de-institutionalization (plus all the straight-up abuse that happened in mental institutions prior to that), etc., make these not a reality for all but perhaps the wealthiest of patients, but I can't help but think that there are patients who might actually benefit from this model of care, rather than just being in and out of the hospital while functioning poorly in the community. For example, a family friend has a son with schizoaffective disorder who had his first psychotic break at 18. In the decade since, he's had multiple psychiatric hospitalizations that lasted several weeks and numerous shorter ones, and functions at a fairly low level in the community (lives in an assisted living apartment but doesn't work, do anything in the community, no real relationships, etc) despite having good to excellent outpatient psychiatric care, an incredibly supportive family, good social work support, good access to benefits and treatment compliance assistance, etc. I can't help but wonder if he and similar patients wouldn't overall fair better in a long-term psychiatric institution rather than just being constantly on the verge of or just returning from a hospitalization and really not functioning in the community at all.

Thoughts?

People should be in the least restrictive setting

 

[wolfvgang22]

People should be in the least restrictive setting

Agreed. That said, realistically many people with a severe mental illness would benefit from a variety of services that we just don't have available, like good case management, skills training, caregiver support, etc. I have some patients that "least restrictive" would be a group home setting, but those just don't exist for adults with limited means in my state. We know what helps such patients that OP is discussing, but the community investment is not there in many communities.

 

[calvnandhobbs68]

For example, a family friend has a son with schizoaffective disorder who had his first psychotic break at 18. In the decade since, he's had multiple psychiatric hospitalizations that lasted several weeks and numerous shorter ones, and functions at a fairly low level in the community (lives in an assisted living apartment but doesn't work, do anything in the community, no real relationships, etc) despite having good to excellent outpatient psychiatric care, an incredibly supportive family, good social work support, good access to benefits and treatment compliance assistance, etc. I can't help but wonder if he and similar patients wouldn't overall fair better in a long-term psychiatric institution rather than just being constantly on the verge of or just returning from a hospitalization and really not functioning in the community at all.

So your example is actually not at all an example of a person I would think would need long term institutional care. In fact, it's exactly the type of person de-institutionalization was designed to keep out of a place like a psychiatric asylum. What's wrong with his life? He's had a few several week long psych hospitalizations in 10 years? That's not bad at all to me...we had plenty of patients who'd hit that in 1 year. About his level of functioning, he functions at what YOU consider to be a "low level". He has supports in place that seem to be overall working to keep him out of the hospital most of the time since he isn't in there constantly. Same could be said for many of my intellectual disability patients who don't do much besides hang out with their caretakers, go to daily programming where they do some activities/games/maybe some menial work if they're high functioning enough, watch TV, eat meals and get a roof over their heads. Many of them seem totally fine and content with this life, even the ones that are severely disabled and don't interact much with any other people. It's the classic case of clinician judged quality of life vs patient judged quality of life. Who are we to judge what makes people happy as long and impinge on their freedoms as long as they're overall physically safe and not harming others?

Now there certainly are patients I agree would truly benefit from long term residential psychiatric care (more akin to the old school months long hospitalizations or even years long asylum stays). These are almost exclusively severely psychotic or severe bipolar disorder patients who can't seem to stay out of the hospital for any prolonged period of time and spent more time in the hospital than out of it (often discharged secondary to insurance problems as noted above to the nearest homeless shelter). Some of them have some level of intellectual disability which then made their SMI even more difficult to treat (interestingly I've experienced only a handful of even profoundly intellectually disabled patients who couldn't be managed in a group home setting if it was just pure intellectual disability/autism). Many of these were either treatment refractory (e.g. multiple antipsychotics at once just to get them to participate in reality) or chronically medication non-compliant to the point that it was leading to all these hospitalizations. All of them were in homeless shelters or on the streets. All of them are certainly food insecure. The lucky ones had made it through the process of filing for SSI and even then would often get taken advantage of or have their money stolen by others. The vast majority also had some amount of drug use that I can only hypothesize was making their severe mental illness even worse.

Group homes for these patients are fairly limited in that this is truly a "least restrictive" setting where they really can't keep the patients from doing things like not taking medications or wandering down the street to smoke some crack. We also all know these group homes are generally **** holes because the staff gets paid crap and are often in parts of town were you can do things like wander down the street to find crack. If we had decent long term locked psychiatric care facilities that weren't set up like the world's worst prisons, I believe many of these patients may find they are truly happier.

Unfortunately I highly doubt this is a sector that society will be wanting to invest in any time soon. Out of sight, out of mind when these patients just wander around homeless talking to themselves in the street and cheaper when they die early from some preventable illness or drug overdose because they can't/won't get proper medical care.

 

[futureapppsy2]

So your example is actually not at all an example of a person I would think would need long term institutional care. In fact, it's exactly the type of person de-institutionalization was designed to keep out of a place like a psychiatric asylum. What's wrong with his life? He's had a few several week long psych hospitalizations in 10 years? That's not bad at all to me...we had plenty of patients who'd hit that in 1 year. About his level of functioning, he functions at what YOU consider to be a "low level". He has supports in place that seem to be overall working to keep him out of the hospital most of the time since he isn't in there constantly. Same could be said for many of my intellectual disability patients who don't do much besides hang out with their caretakers, go to daily programming where they do some activities/games/maybe some menial work if they're high functioning enough, watch TV, eat meals and get a roof over their heads. Many of them seem totally fine and content with this life, even the ones that are severely disabled and don't interact much with any other people. It's the classic case of clinician judged quality of life vs patient judged quality of life. Who are we to judge what makes people happy as long and impinge on their freedoms as long as they're overall physically safe and not harming others?

Now there certainly are patients I agree would truly benefit from long term residential psychiatric care (more akin to the old school months long hospitalizations or even years long asylum stays). These are almost exclusively severely psychotic or severe bipolar disorder patients who can't seem to stay out of the hospital for any prolonged period of time and spent more time in the hospital than out of it (often discharged secondary to insurance problems as noted above to the nearest homeless shelter). Some of them have some level of intellectual disability which then made their SMI even more difficult to treat (interestingly I've experienced only a handful of even profoundly intellectually disabled patients who couldn't be managed in a group home setting if it was just pure intellectual disability/autism). Many of these were either treatment refractory (e.g. multiple antipsychotics at once just to get them to participate in reality) or chronically medication non-compliant to the point that it was leading to all these hospitalizations. All of them were in homeless shelters or on the streets. All of them are certainly food insecure. The lucky ones had made it through the process of filing for SSI and even then would often get taken advantage of or have their money stolen by others. The vast majority also had some amount of drug use that I can only hypothesize was making their severe mental illness even worse.

Group homes for these patients are fairly limited in that this is truly a "least restrictive" setting where they really can't keep the patients from doing things like not taking medications or wandering down the street to smoke some crack. We also all know these group homes are generally **** holes because the staff gets paid crap and are often in parts of town were you can do things like wander down the street to find crack. If we had decent long term locked psychiatric care facilities that weren't set up like the world's worst prisons, I believe many of these patients may find they are truly happier.

Unfortunately I highly doubt this is a sector that society will be wanting to invest in any time soon. Out of sight, out of mind when these patients just wander around homeless talking to themselves in the street and cheaper when they die early from some preventable illness or drug overdose because they can't/won't get proper medical care.

See, I guess that I don't view that as a good quality of life for people with ID/DD, either. I know a lot of people with ID/DD who live really rich lives in the community--activities, dating, jobs, etc., and we would genuinely consider a life spent just watching TV at their group home really not meeting their needs or potential (unless that was all they actually wanted). Same with the folks with SMI I've worked with in psych rehab contexts--a lot of jobs, activities, education, general engagement, and a strong push away from what one of my clinical supervisors called "the cigarettes and couch" outcome of psych rehab. Some people may want that, and that's a valid choice, but most people with SMI and/or ID/DD genuinely want to have friends, relationships, places to go and things to do, but families and patients are told that those are out of reach now and to just settle for the bare minimum in that's still "in the community." I guess if someone's only real interaction/participation in the community is going to psychiatrist appointments and cycling in and out of the hospital, I question whether that setting is really working for them or just looking good on paper as being "in the community."

 

[calvnandhobbs68]

See, I guess that I don't view that as a good quality of life for people with ID/DD, either. I know a lot of people with ID/DD who live really rich lives in the community--activities, dating, jobs, etc., and we would genuinely consider a life spent just watching TV at their group home really not meeting their needs or potential (unless that was all they actually wanted). Same with the folks with SMI I've worked with in psych rehab contexts--a lot of jobs, activities, education, general engagement, and a strong push away from what one of my clinical supervisors called "the cigarettes and couch" outcome of psych rehab. Some people may want that, and that's a valid choice, but most people with SMI and/or ID/DD genuinely want to have friends, relationships, places to go and things to do, but families and patients are told that those are out of reach now and to just settle for the bare minimum in that's still "in the community." I guess if someone's only real interaction/participation in the community is going to psychiatrist appointments and cycling in and out of the hospital, I question whether that setting is really working for them or just looking good on paper as being "in the community."

But that's the thing, finding out what they actually want. If they want to just hang out all day or maybe go out for walks/to the store every now and then or maybe just spend most of their day doing a specific activity, then why would we put them in a psychiatric facility just to do the same thing there? There's plenty of neurotypical people or people who don't have severe mental illness who sit around not doing much else besides the "cigarettes and couch" lifestyle. If the person truly does want more social interaction or a job or whatever, it's really our societal duty to try to be providing these kinds of things through more robust case management/social work support to link to day programs or communities they might do well in rather than put them something akin to very long term hospitalization. I guess my question would be, how do you see years long locked hospitalization helping that person?

As above, the people I would really classify as needing long term locked residential psychiatric care are people who are truly chronically endangering themselves by not having somewhere to sleep or eat or getting assaulted/taken advantage of due to their severe mental illness.

 

[Armadillos]

For anyone who followed a recent thread on here they know I’m no huge fan of involuntary hospitalization in general, however I 100% have patients who would live much more satisfying lives in setting of a well run long term (indefinite) hospitalization.

Many of them essentially already are chronically institutionalized, but instead of 1 stable place it’s just a never ending string of acute psych hospitals, jails, medical hospitalizations, trauma surgery hospitalizations, on the street and short stays in RCFs after DC from the hospitalizations.

 

[singasongofjoy]

What we really need is more group homes / supported living type situations, and access to programming (and transportation to programming) during the day (based on client need/want, of course, but thinking like "clubhouse" model). But as pointed out previously - the support/money just isn't there and is very unlikely to be any time soon. I interned at a clubhouse model place when I was in college and it was incredible for the folks there with SMI.

 

[Mad Jack]

See, I guess that I don't view that as a good quality of life for people with ID/DD, either. I know a lot of people with ID/DD who live really rich lives in the community--activities, dating, jobs, etc., and we would genuinely consider a life spent just watching TV at their group home really not meeting their needs or potential (unless that was all they actually wanted). Same with the folks with SMI I've worked with in psych rehab contexts--a lot of jobs, activities, education, general engagement, and a strong push away from what one of my clinical supervisors called "the cigarettes and couch" outcome of psych rehab. Some people may want that, and that's a valid choice, but most people with SMI and/or ID/DD genuinely want to have friends, relationships, places to go and things to do, but families and patients are told that those are out of reach now and to just settle for the bare minimum in that's still "in the community." I guess if someone's only real interaction/participation in the community is going to psychiatrist appointments and cycling in and out of the hospital, I question whether that setting is really working for them or just looking good on paper as being "in the community."

Quality of life is subjective, as someone else already brought up. If they're distressed by the state of their life I'd say maybe long term commitment would be worthwhile, but if they're perfectly happy who am I to tell them how to live?

 

[FatherPsychiatry]

Definitely seen some factitious disorder that would only benefit from long term hospitalization.

 

[clausewitz2]

Quality of life is subjective, as someone else already brought up. If they're distressed by the state of their life I'd say maybe long term commitment would be worthwhile, but if they're perfectly happy who am I to tell them how to live?

It's not entirely wrong but I am very suspicious of this line of reasoning when it is a) so far outside normative ideas of what constitutes a worthwhile life and b) just happens to correspond to the state we as psychiatrists can achieve most reliably with great whopping doses of available medications (kind of sedated, tired all the time, apathetic, indifferent to just about everything, constantly snacking).

 

[whopper]

Yes.

The problem here is the expense, that many patients in need of this type of thing might not want it, and that there's a lot of patients that may seek this type of thing that don't need it.

I recall a patient while in residency that was discharged from a long-term hospital and did everything she could to get back in despite that she didn't have a severe mental illness warranting long-term hospitalization.

I've also worked in long-term care facilities and a common problem were there were lazy doctors who didn't do anything to get the patients better but just showed up and signed their monthly note without doing anything to advance the case. E.g. a psychotic patient on Risperidone 2 mg a day still psychotic and the doctor for over 1 year never changed the dosage. The patient gets transferred to me, I up the dosage and in 2 weeks he's fine with hardly any symptoms.

 

[Mad Jack]

It's not entirely wrong but I am very suspicious of this line of reasoning when it is a) so far outside normative ideas of what constitutes a worthwhile life and b) just happens to correspond to the state we as psychiatrists can achieve most reliably with great whopping doses of available medications (kind of sedated, tired all the time, apathetic, indifferent to just about everything, constantly snacking).

I mean, usually they keep coming back to us because they are unmedicated, so we usually can get a feel for both how they are on and off of medication. I suppose my counterargument would be that there are plenty of adults without mental illness that live unproducted and/or isolated lives by choice. If we're saying we should institutionalize someone because they aren't socializing or employed/active in the community with schizophrenia, we're drawing a rather arbitrary line between what is acceptable for a healthy person to do with their life versus someone with mental illness. I don't think we, in psychiatry, should be arbiters that deem the lifestyles of others acceptable or not, and that we should always err on the side of an individual's human rights unless they are putting themselves or others in danger. That's just my take, but it tracks pretty well with the way local law is written on the issue

 

[JKinSC]

many patients in need of this type of thing might not want it, and that there's a lot of patients that may seek this type of thing that don't need it.

Holy crap, this. I took care of a lady on 5 separate occasions during residency that, on her first visit to our main inpatient facility, said “This is nice! Y’all gonna have a hard time getting rid of me!” Don’t get me wrong-she had a legit Axis 1 illness. But her biggest problem was personality by a mile.

a psychotic patient on Risperidone 2 mg a day still psychotic and the doctor for over 1 year never changed the dosage. The patient gets transferred to me, I up the dosage and in 2 weeks he's fine with hardly any symptoms.

I know that we don’t really have any real recourse here, but do you ever just manage to work that into conversation when you see them again? “You know? I put that guy on a therapeutic dose, and wouldn’t you know it?!”

 

[mistafab]

from a completely non-medical perspective, it just completely bothers me to think that we could have the right to take away the freedom of someone when they have not committed a crime. It is already hard enough to involuntarily commit people on short term status, I do it though because I know it is the right thing to do.

have you seen these group homes? I would rather die on the street then be committed to one of these places long-term.

 

[K9friend]

I’m a patient, not a psychiatrist, so take what I say with a grain of salt and forgive me if this post is out of place. I joined SDN because I am a pharmacist and have another graduate degree in the health sciences, but I lurk here because I find this forum fascinating as a health care professional who has a mental illness.

I have a chronic mood and psychotic disorder and I definitely think I would have benefited from some sort of long-term intensive treatment earlier in the course of my illness. I went from being a top student to being unemployed and staying in bed 20-22 hours a day for years at a time. I ended up on disability and lived in squalid conditions. It’s remarkably similar to the case @futureapppsy2 wrote about. I don’t think something like a state hospital would have been necessary or helpful - I think it has to be voluntary - but I wish there had been a long-term residential treatment option available to me. I think I needed the type of program where there is initially intensive support with activities of daily living, but that then transitioned into increasingly greater independence up to and including full-time employment in the competitive workforce

I also hear what people are saying about not pushing patients into our vision of recovery – if they are happy living a simpler (in some ways) life in a group home or similar setting, then I think we have to respect that. On the other hand, I can say that when I was staying in bed all day, never showering or cleaning and unable to read more than a paragraph at a time, it wasn’t because I found that fulfilling. I just didn’t have the level of support I needed to do anything more or even dare to dream I could do anything more. I ended up getting a great treatment team and a psychiatrist who pushed me just the right amount, and now I work full time in high-stress job, live in very clean and enjoyable conditions, and have meaningful relationships. I consider my job vital to my recovery and well-being to the point where I want to get a Master’s in Social Work and work to help early episode psychosis patients get stable employment. That said, it literally took me 14 years between my initial episode of psychosis and getting full time, competitive work. I think if I’d had more intensive treatment in the form of residential care or a longer-term partial hospitalization program earlier in my treatment, that could have made a big difference – although to be honest, I am also very stubborn and like to do everything on my own terms, so there’s also that.

This is very long, but I just wanted to share my perspective because I do think this is one area where I can contribute to this forum as a non-psychiatrist. I do think people underestimate both how much support it can take to recover from a chronic psychotic or mood disorder AND how well patients can do when they have the needed support.