Inpatient Care in the 21st Century: We Need More Evidence

This issue of Psychiatric Services includes an Open Forum, “Inpatient Psychiatric Care in the 21st Century,” written by three distinguished psychiatrists, Ira Glick, Steven Sharfstein, and Harold Schwartz. Many will consider their vision of inpatient psychiatry a sensible guide to practice and policy, but others will find it controversial. We have yet to resolve the role of inpatient care in the range of psychiatric services.

In 1894, S. Weir Mitchell, eminent neurologist and novelist, criticized American psychiatry in an invited address on the occasion of the 50th anniversary of the organization that became the American Psychiatric Association. Among other criticisms he asserted, “You have for too long maintained the fiction that there is some mysterious therapeutic influence to be found behind your walls and locked doors. We hold the reverse opinion. … Your hospitals are not our hospitals; your ways are not our ways.” He argued forcefully for the integration of psychiatric hospital care into the medical centers and academic centers of the time. In the 20th century, general hospitals expanded their psychiatric services dramatically and brought scientific psychiatry to patients. The inpatient setting rarely eliminated its locked doors, and inpatient psychiatry rarely shed its role in confinement. As outpatient care expanded and became more effective, the residual role of the hospital was confinement. The principal indication for hospitalization became an issue of safety to prevent harm to the person or to society. The focus on confinement reintroduces the question of what is the most appropriate and effective locus for that role.

Deinstitutionalization and the growth of community care further challenged the role of the hospital. At the time, in response to a series of studies focused on length of hospital stay and alternatives to inpatient care, we asked, “If less is more, is none optimal?” The appropriate answer at the time was “No,” but the optimal form of 24-hour care was anything but clear. It is not clear that “your hospitals” should be “our hospitals,” unless patients need the intensive, high-technology environment of the modern general hospital. Some people with acute mental disorders require a general hospital setting. Not all patients who need 24-hour supervision or confinement, however, need that level of care. For some patients, freestanding psychiatric hospitals, affiliated with academic centers, are a more appropriate, lower-cost alternative to the general hospital. For many others, 24-hour alternatives may be more appropriate than the acute care hospital.

Research on inpatient care has almost disappeared. The Open Forum in this issue provides clinical guidance for inpatient psychiatry. It also reopens many of the key questions that remain unanswered. It is time for more empirical evidence to guide policy and practice.