What are we actually doing on inpatient units?

[thomasina]

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I'm a PGY-1 on my first psych rotation. I realized that... despite all the time I've spent thinking about and enjoying psych, I'm still not entirely sure what we do for patients on inpatient psychiatry units. It feels like like adult daycare with a lot more affect and agony regarding dispo. Sometimes it feels like we are just throwing meds at the patient and waiting to see what sticks. At the end of a hospitalization, are people really "better"? Is it just that we provide a stable and consistent environment and take care of a good number of ADLs and some other basic things that require executive function?

Some more thoughts: of course none of my patients want to be hospitalized, and this daily bargaining / back-and-forth is kind of deflating. Even the process of obtaining collateral and the way that collateral information is weighed feels a little deflating because I see how disempowered my patients are; when it's their word against someone else's, they're basically fighting an uphill battle no matter what the issue is.

Finally, I feel like so much of the problems are rooted in societal structure that I wonder if simply stabilizing a patient, in places like inpatient psych units, is akin to slapping a bandaid on the whole thing.

Would appreciate any thoughts.

 

[DD214_DOC]

Covering our asses.

There are some that actually get dx and into outpt tx with a first hospitalization. So there's that.


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[nexus73]

Stabilization. Acute stabilization. Then appropriate referral outpatient.

 

[st2205]

For the substance abusers: providing them with a safe detox and an environment for (otherwise) abstinence while they can also make arrangements for further rehab or treatment.

For the manic and psychotic: providing immediate stabilization and hopefully arranging for appropriate follow-up.

For the suicidal: a safe environment until the immediate crisis stabilizes.

For those using the hospital as a coping mechanism: facilitating their avoidance, dependence and imminent decline.

In a lot of ways it's similar to medicine. You may admit someone for DKA. You can treat and correct the acidosis, but you know damn well they're walking out that door (wheeling out, actually) still having diabetes.

 

[Bartelby]

Used correctly, an inpatient unit mostly handles crises. Acute inpatient psychiatry is good for reigning in extreme mania or psychosis, decreasing the odds that an actively suicidal or homicidal patient will act on their current impulses, things like that. This has an important place in psychiatry. I think that voluntary settings, whether they are voluntary rehabs, IOPs, residential programs, outpatient followup, etc. are more conducive to recovery, but locked inpatient units still have a place.

 

[DisorderedDoc417]

I'm a PGY-1 on my first psych rotation. I realized that... despite all the time I've spent thinking about and enjoying psych, I'm still not entirely sure what we do for patients on inpatient psychiatry units. It feels like like adult daycare with a lot more affect and agony regarding dispo. Sometimes it feels like we are just throwing meds at the patient and waiting to see what sticks. At the end of a hospitalization, are people really "better"? Is it just that we provide a stable and consistent environment and take care of a good number of ADLs and some other basic things that require executive function?

Some more thoughts: of course none of my patients want to be hospitalized, and this daily bargaining / back-and-forth is kind of deflating. Even the process of obtaining collateral and the way that collateral information is weighed feels a little deflating because I see how disempowered my patients are; when it's their word against someone else's, they're basically fighting an uphill battle no matter what the issue is.

Finally, I feel like so much of the problems are rooted in societal structure that I wonder if simply stabilizing a patient, in places like inpatient psych units, is akin to slapping a bandaid on the whole thing.

Would appreciate any thoughts.

This is all much more palatable than the desperate, if pathetic, whims psychiatry seems to cling onto in an effort to find that one-size-fits-all biological savior for our field. I'm just happy we finally have instant depression treatment with ketamine, genetic testing to tell us what's really going on, and magnets to fix it. The urine schizophrenia test hoax was a real set back for the field.

 

[mopsych]

This is all much more palatable than the desperate, if pathetic, whims psychiatry seems to cling onto in an effort to find that one-size-fits-all biological savior for our field. I'm just happy we finally have instant depression treatment with ketamine, genetic testing to tell us what's really going on, and magnets to fix it. The urine schizophrenia test hoax was a real set back for the field.

Big ups to the ketamine shout out. I dont know about you but some of my best intakes happen after someone has gotten special k in the ER.

Re: the OPs inquiry--im so confused?!? I thought most hospitals were spg affiliates. What happens with all their points?

 

[singasongofjoy]

From the outpatient side of things I'll tell you the benefits of inpatient that I see include desperately-needed breathing room so the family can reorient themselves, recover briefly from some of the stress, and come up with a better plan to support recovery. Additionally, look at the flip side- those who need to be hospitalized but aren't. Really disorganized folks are much more likely to be victimized or get themselves into some sort of serious trouble. Even if it seems like stabilization is deflating, things would often be much worse not only for the patients but also for their families without inpatient. I've seen situations where it seems like availability of inpatient when needed makes the difference between families feeling like they can regroup and continue to support the individual, versus writing them off and cutting ties because they've exhausted their resources. And getting accurate dx and good community referrals is huge. Like HooahDOc said, sometimes that's what it takes to get either. So thank you to all the folks out there doing inpatient. Now if we could just get more inpatient/stabilization services for my folks with developmental disabilities and comorbid psych issues, that would be fantastic.

 

[FlowRate]

Echoing above a little, I think it's most useful for the acutely psychotic or acutely manic. They come in a danger to themselves (and often others) and leave a different person. (Sometimes, and hopefully they stay on meds this time / hopefully their group home continues their meds this time...)

For the depressed/suicidal/overwhelmed (but not chronically overwhelmed) it's a place to de-stress for a few days. For the severely majorly depressed, it's a month of bull**** followed by ECT, finally.

Then there's the portion that would be better served if 1/10 the cost of their stay was spent on a housing subsidy and suboxone.

I think the day to day work on an inpatient unit can feel very amorphous. It helps to have a clear picture of the goal: what needs to happen for them to be ready to discharge?

 

[FranzLO]

I am just a med student but I assume an inpatient psych unit puts people on medications based on evidence, trial and error, and what has worked in the past. This works with medications in other fields too. Behavioral components, personality disorders, past experiences, all sorts of things contribute also just like they do in other fields. This is why everyone has preventable diseases and do not comply no matter what discipline you are in. "Stabilizing" a patient doesn't cure a disease but finding out some solutions and getting as close to baseline as possible seems like a reasonable goal so I am not really sure what your expectations are. You can't follow people home or out in the world in an uncontrolled environment but this is just reality. I think people get "better" but they may very likely end up back like many do but this is reality. Have you rotated on a heart failure unit? It feels the same to me.

These are just a few of my thoughts and how I look at things as someone going into psych next year. You are most likely dealing with chronic, life-long issues in these patients so helping them through a crisis is very rewarding to me, but at times it does seem like quite a drag.