Inpatient treatment planning: Consider 6 preadmission patterns

Table 4

Factors that interfere with patient adherence to psychiatric treatment

Negative attitudes of patient or family about medications, including fear of addiction or distress that medications are symbols of mental illness Caregivers’ lack of cooperation with treatment planning Concomitant substance use Medication side effects Dementia Poor insight into illness Complex medication regimen Persistent psychosis
Source: References 3-10

Restore what worked before. The first treatment goal for patients in categories 2 and 3 is to reestablish previously successful inpatient or outpatient treatment. Unfortunately, many psychiatric hospitalizations result in diagnostic reassessment and medication changes. Readmitted patients often do not require substantial inpatient diagnostic evaluation, and changing their previously successful psychotropics can be counterproductive.

Patients being readmitted often are less-than-honest about treatment adherence, so seek corroboration from family, case managers, other caregivers, or outpatient clinicians. Measuring blood levels of medications or hormones (such as prolactin) that are influenced by medications may help you gauge adherence.

Promote treatment adherence. After you re-establish treatment, the second goal is to promote future adherence. Contact the outpatient psychiatrist to explore the patient’s involvement with outpatient care.

If the patient was nonadherent because of poor insight or misconceptions about the medication—such as fear of dependence, stigma of mental illness, or denial—educate the patient and family/caregivers. If patient and family education prove ineffective or are not possible, consider depot psychotropics.

For nonadherence caused by side effects, consider changing the dosage or rhythm of administration. Simplified dosing schedules might help. Pay close attention to drug-drug interactions with nonpsychotropic medications.

Because drug or alcohol abuse is a common reason for outpatient nonadherence,^7,8 consider chemical-dependency treatment programs for patients with addictions or those whose nondependent substance use causes psychiatric relapse.

Links to outpatient care. In an ideal system, the links between inpatient and outpatient treatment would be seamless. Many real world systems do not work as well, however. Too often patients are admitted and discharged before the outpatient doctor has heard of the admission.

Three inpatient interventions have been shown to more than triple the likelihood for successful linkage to outpatient care:

• communication between inpatient and outpatient clinicians about discharge plans
  
• patients starting outpatient programs before discharge
  
• involving family during the hospital stay.⁶
  

Investigate the therapeutic relationship between the patient and outpatient psychiatrist, and attempt to improve communication and trust. If that fails, refer the patient to another psychiatrist. In either event, the outpatient psychiatrist needs to be well-informed of the patient’s progress and endorse outpatient treatment plans before the patient’s discharge.

Category 4: readmission after stressful event

Even in patients who have been completely adherent with outpatient treatment, a sudden stressful life event can exacerbate psychiatric symptoms and require inpatient care. Examples include:

• death of a family member
  
• departure of a trusted caregiver
  
• onset of an intercurrent medical illness
  
• loss of a job or other financial hardship
  
• loss of housing
  
• anniversary of a traumatic life event.
  

Most patients with serious psychiatric illness react with predictable anxiety, sadness, and/or worsening of psychosis. Those susceptible to using psychoactive substances may relapse and worsen their symptoms.

Although we are trained to look for a “precipitating event” in formulating psychiatric illness, patients might be unable to talk about such preadmission changes. If this information is not readily available, symptomatic deterioration may be misinterpreted as treatment nonadherence, incorrect diagnosis, or other etiology.

Treatment goals. For a patient who has deteriorated because of a psychosocial change, the goal of admission is to address this stressor and return the patient to function. These patients do not require extensive medical or psychiatric assessment, and their previously successful psychotropics probably do not need to be changed.

Patients in this category typically do not need or benefit from diagnostic reassessment or comprehensive laboratory, radiologic, or psychological investigations. Even so, consider the possibility that the patient might be experiencing a comorbid medical illness, drug side effect, or other biomedical change, even in cases of an apparent intercurrent stressful event.

Inpatient treatment is supportive, encompassing grief work and individual and group therapy. Involve the social worker immediately to address adverse changes in the patient’s income, financial status, and residential circumstances.

Continue previous outpatient medications, and modify dosages if indicated by symptom severity. Patients in this group usually require only short hospital stays until the acute symptoms recede and they rebuild sufficient coping skills to address the new stressors.

Category 5: progressive deterioration

Patients who worsen despite adherence with out-patient treatment and have not experienced a new psychosocial stressor are difficult to treat. Similar to patients with an index psychotic episode, deteriorating patients require extensive re-evaluation of diagnosis and treatment trajectory going back several years.