M Frost. The Medical Care of Psychiatric Inpatients: Suggestions for Improvement. The Internet Journal of Healthcare Administration. 2006 Volume 4 Number 2.
Free-standing psychiatric hospitals in the United States have in common the challenge of delivering appropriate, and consistent physical healthcare to a high risk patient population. Patients suffering from severe mental illness may have limited exposure to the healthcare system except in the form of admission to psychiatric facilities yet they are more likely to have serious medical co-morbidities than the general population. Psychiatric institutions faced with limited resources and a paucity of widely accepted models for the delivery of this type of necessary care rely on variable methods of healthcare delivery. This article examines the need for medical care in free-standing psychiatric facilities, existing barriers to the effective delivery of care and ways that institutions can better structure their non-psychiatric medical services.
Patients suffering from severe mental illness are more likely to have comorbid medical conditions and have a mortality rate higher than that of the general population (1, 2, 3, 4). Rates of pulmonary disease, cardiovascular disease, liver disease, and type 2 diabetes are higher in patients with mental illness (2,5). Smoking, poor diet, sedentary lifestyle, and low socioeconomic class, are more common in the mentally ill and contribute to their poor health (6). Side effects of mental illness treatment also confer health risk; recent studies have demonstrated that use of both typical and atypical antipsychotics is associated with weight gain as well as increases in blood glucose and cholesterol levels (7, 8, 9). Further, symptoms of mental illness can be caused by or exacerbated by underlying medical illness (eg, thyroid disease) (10, 11, 12).
Despite the elevated rates of comorbid medical conditions, detection and treatment of physical illness in psychiatric patients is poor (5, 13). It is estimated that between 30% and 47% of patients with physical health issues do not receive treatment for them (3, 11, 13). Factors contributing to the inadequacy of medical treatment among the mentally ill include patients who may be hesitant to seek medical care due to social withdrawal (14), aggressive or uncooperative behavior in the office, and primary care physician attitudes (4, 11).
For many patients, occasional hospitalization in mental health facilities may be their only chance to receive care for medical conditions (12). However, how medical care is provided to psychiatric patients is highly variable. While most free-standing psychiatric hospitals have a medical consultant available, usually an internist or family practitioner, there is no established standard dictating the provision of medical care in psychiatric facilities. Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards for behavioral health institutions state only that such institutions accept for admission and treatment only those patients whose identified treatment needs can be met by the admitting hospital. JCAHO allows that initial screening and assessments should be performed as defined by the individual organization, and that a process should be in place to provide diagnostic services and treatments that cannot be directly provided by the admitting hospital (14). In general, each institution sets its own policies on how medical care will be provided. The result is a wide array of health care delivery systems and an overall lack of structure (11).
A system is required within each hospital for the screening of patients for disease, the evaluation and treatment of patients with medical illnesses, and the transfer of patients to medical/surgical hospitals if a higher level of care is required (11, 15). Several consensus panels have recommended improved monitoring of the physical health of psychiatric inpatients to improve overall patient health (16). Recommendations include regular monitoring of body weight, blood glucose levels, lipids levels, blood pressure and prolactin levels and signs of sexual dysfunction in patients who receive antipsychotic medications (12, 16, 17). Cardiac monitoring to detect QT interval prolongation is also suggested (16). Improving the medical care of psychiatric patients is necessary to improving their functioning and overall quality of life.
Barriers to Medical Care
Psychiatric facilities face barriers in providing medical care to patients. There may be no rooms set aside for the examination and treatment of patients with medical complaints, and equipment may be limited. Laboratory and radiology facilities may be limited or off-site. The hospital pharmacy, geared mainly toward the treatment of psychiatric disorders, may stock only limited quantities or brands of drugs to treat medical conditions.
In terms of staff, psychiatrists may be unable or uncomfortable with providing physical health care (18, 19). Nurses working predominantly in behavioral health may have little experience in the areas of medical or surgical nursing, which may lead to discomfort in dealing with medical issues. Mental health technicians often have limited clinical experience and may have difficulty in recognizing a patient who requires medical care. Physicians accustomed to working in a traditional medical office or hospital setting may be uncomfortable working in this type of environment, making recruitment of medical consultants difficult. Administrators may be unfamiliar with the potential medical needs of patients and may be unacquainted with the development of treatment policies for nonpsychiatric diseases. Further, patients in mental health facilities might be aggressive, uncooperative or demanding. It can even be difficult for the physician to physically locate the patient so that care can be delivered (11).
Suggestions for Improvement
The following are suggestions for improving the delivery of medical care in psychiatric facilities:
Hospitalization for psychiatric treatment offers an opportunity to provide basic medical care for persons who might otherwise not access the health care system. A standardized approach to medical care, including the timely diagnosis and treatment of nonpsychiatric conditions, would likely improve the overall health of psychiatric patients. Although the available level of medical care, and how that care is provided currently varies widely from facility to facility, there clearly is a need to define standards of care for all psychiatric hospitals. Once established, a proactive, structured plan for providing medical care can help psychiatric facilities directly impact the overall health of patients suffering from mental illness.