Ultrashort Stays and a Focus on Recovery

To the Editor: Many thanks to Drs. Glick, Sharfstein, and Schwartz for addressing the timely and important topic of ultrashort psychiatric hospitalizations in their Open Forum in the February issue (1). The concern that brief, formulaic, and discontinuous treatments may lead to poor medical care is not limited to psychiatry (2). In psychiatry, the constant pressure to discharge patients and the view that only biologic treatments are medically necessary interventions are major drivers of ultrashort stays. Our profession has sometimes exacerbated these pressures by embracing what has been called the “bio-bio-bio” model of treatment (3,4).

However, I am not sure that I agree with the authors' argument that ultrashort stays are responsible for clinicians' lack of a person-centered approach. I do agree that this is often the reason put forward, but is it at least partly an excuse? Was psychiatric treatment so recovery focused before length of stay fell to five days? Do we fully believe the assumption that a recovery-focused approach always has to take more time?

A consultation that I recently completed at a nearby hospital illustrates this issue. The patient, a homeless man, was admitted in an acutely agitated state after having been beaten up, his face battered. His treatment team never learned the details of the beating but instead got into a conflict with the patient over his taking psychiatric medications for the agitation. He had never taken psychiatric medications. The team withheld his regular medications in an attempt to determine whether they were contributing to the agitation.

This standoff over medication ended up involving a judge, patient advocates, and the state mental health department, and it cost time. Meanwhile, an opportunity to build an alliance with the patient and learn about the important context of the hospitalization was lost. Did the patient need anything more than short-term PRN psychiatric medications? When the clinicians on the hospital team discharged him (on medications he never wanted and most likely immediately discontinued), did they send the patient back to a potentially dangerous situation where he could be beaten again? Because of their narrow focus on the symptoms in front of them, they would never know the answers to these questions.

I heartily agree with Dr. Glick and colleagues' basic thesis and their cautionary tale about where our profession is with respect to inpatient care. Yet I also think there is much we can do to become more recovery focused even within the system's current constraints. Doing so would serve patients better and would ultimately be more satisfying for clinicians.