Manual of Inpatient Psychiatry
The Manual of Inpatient Psychiatry is a 7×5-inch handbook, authored by two psychiatrists from the University of Michigan's University Hospital. Dr. Casher is a clinical assistant professor with the department of psychiatry and director of the inpatient adult program; Dr. Bess is a clinical instructor and also provides inpatient services. The authors' goal was to provide a synopsis, outlining the majority of issues that psychiatric practitioners encounter on an inpatient unit. They sought to offer a guide to aid daily patient care.
Seven of the nine chapters are organized by diagnoses: schizophrenia, depression, mania, borderline personality disorder, dementia, traumatic brain injury, and dual diagnosis. The last two chapters attend to the young adult inpatient and to documentation. Each chapter's content is organized around answering pragmatic questions, such as how one distinguishes psychosis in schizophrenia from mania in bipolar disorder. Casher and Bess make an effort not only to provide succinct best practices for each inquiry but also to share their own personal philosophies of treatment, which they title as “In our experience” sections. Treatment guidance is offered, which includes not only psychopharmacologic agent review but also management strategies for dealing with psychosocial issues. These issues range from behavioral management tips when serving persons with traumatic brain injury to relapse prevention for the inpatient with mania. The chapter on the inpatient with borderline personality disorder was practical, and Dr. Laura Hirshbein's foreword on the history of inpatient psychiatry was notably refreshing.
Additional areas important to inpatient clinicians that could have been addressed with more depth include issues of safety with risk assessment and management of violence, suicide, elopement from inpatient facilities, and medical comorbidity. This manual would have been more helpful had it given more attention to continuity of care, including the importance of communication for patient hand-offs, family involvement, and teamwork. Attention was also lacking on ethical and legal issues, including capacity assessment, informed consent, confidentiality, treatment over objection, use of restraints, psychiatric advance directives, and the role of second opinions. The assessment and management of persons with malingering and antisocial behaviors are additional areas worthy of greater attention.
Inpatient psychiatry is becoming more and more challenging. Acuity is increasing in a setting of decreasing reimbursement, rising costs, shorter lengths of stay, and increasing oversight and accreditation standards. Safety concerns with high suicide and violence risk are becoming paramount as clinicians simultaneously balance patient rights and recovery. Staffs are coping not only with their own security and that of patients but also with legal quandaries. Patients often are involved with the legal system, be it police involvement, involuntary commitment, or emergency treatment.
Practitioners who work in inpatient settings are in need of a comprehensive resource: a guide for clinicians to navigate such complex terrain. Unfortunately, this manual of inpatient psychiatry is not that single roadmap. However, it does contain some pearls of clinical wisdom for the psychiatric hospitalist traversing difficult situations. Consider this manual as a rudimentary roadmap for medical students, residents, and early-career clinicians—also, it is the perfect size for the lab coat pocket.
