I encountered a paper this week that had me nostalgic for the old days in American psychiatry. The days when people were treated in hospitals to the point that their symptoms remitted before they were discharged. That of course depends on a couple of assumptions. The first is that their symptoms can be treated to that point. There are a number of people with a disease process that cannot be treated to that point. Neurodegenerative disorders like Alzheimer's disease or vascular dementia are good examples, but there are also a number of people who have no known brain insult and yet have treatment resistant depression or psychosis. Their symptoms do not respond or poorly respond to treatment. The second assumption is that the person with the illness recognizes why they need to be in a hospital or some form of intensive treatment and they agree to stay long enough. That is one of the more complicated assumptions because psychiatry is almost exclusively the only medical specialty where the treating physician can disagree with the patient's preference for discharge and put them on a hold pending a judge's decision to order them to stay in a hospital longer. That court decision in most states depends on three standards - danger to self, danger to others, and general ability to care for oneself. Those three standards have been condensed over the years to a single word dangerousness. Practically all inpatient treatment units in the United States are impacted by managed care companies who would generally like people discharged in about 3-5 days irrespective of their diagnosis or treatment plan. Their de facto discharge criteria is dangerousness.
If you are reading this for the first time, it may sound absurd to base a medical decision on an oversimplified legal standard that is designed to not unduly impact the civil liberty of citizens. It is definitely absurd for any number of reasons. If you work in inpatient settings you can have the most carefully crafted treatment plan to restore a person to their previous level of functioning and have to tolerate a managed care case manager or physician ask you "Where is the dangerousness?" If there is no dangerousness the expectation is that the patient will be discharged and if you (as the treating physician) disagree - the insurance company via their own review can just stop paying for the hospitalization. The practical result of all of that politics is that a partially stabilized patient is discharged. That would be bad news if that person was dangerous, but what nobody talks about is that it is probably worse if they are not. First, the vast majority of people that psychiatrists treat in inpatient units are not dangerous but they are having a very difficult time functioning both in terms of symptom management and what they need to manage in life every day. If they are partially treated, it is very likely that they will not be able to follow up with a detailed treatment plan. Managed care companies and the usual critics of psychiatry frequently rationalize this process with global statements like "the outcomes are no different" or inpatient treatment especially involuntary inpatients treatment is not necessary. The problem is that there are very few studies that look at the process. After all, who has an interest in continuing to discharge partially stabilized patients? It is certainly not psychiatrists, patients or their families.
The study I encountered was in the Journal of Clinical Psychiatry this month (1). The investigators are from the Netherlands. They looked at 78 cases of postpartum psychosis admitted to the Mother-Baby Inpatient Unit (MBU) at the Erasmus Medical Center between August 2005 and June 2011. The MBU is a specialized unit to treat cases of severe psychopathology during the postpartum period. Patients with an onset of psychosis or mania within 6 weeks of the delivery were included. They included the typical DSM functional psychosis categories and mood disorders with psychotic features. Substance induced psychosis was excluded. Of the final group 64 patients had only postpartum psychosis and 14 had either a prior episode of psychosis or mania/hypomania. The authors had previously developed a standardized approach to treating postpartum psychosis that involved using typical medications indicated for acute inpatient stabilization. The goal was remission of their symptoms for one week prior to discharge with standard recommendations for pharmacotherapy to maintain symptomatic remission. They were followed for 9 months and by that time 16 patients had discontinued medication with the remainder taking lithium (n=40) or antipsychotic monotherapy (n=8).
The main outcome measure used was the Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool (LIFE-RIFT). That research instrument looked at a number of domains including work, interpersonal relationships, global satisfaction, and recreation. All of these areas have been shown to be adversely impacted in other studies of the problem of postpartum psychosis. As an example the authors quote a study that noted a divorce rate of 18% in a similar cohort of patients. In a previous post on this blog, I made the observation that many women seen in inpatient practice who have a chronic psychotic disorders can be traced back to an initial episode of postpartum psychosis. The authors here note that although they may have had a sample with low premorbid complications their outcomes were generally very good compared to previous retrospective studies and a matched sample of postpartum women. As an example, 88.5% of the women had resumed full work and household responsibilities. In comparison to a general postpartum population, the experimental group showed slightly more anxiety and depressive symptoms due to the the portion of the sample that relapsed. In comparison to a group of patients with first episode bipolar disorder occurring outside of the postpartum period the comparison favored the experimental group. Despite the usual limitations of these studies like sampling bias and missing data, the authors conclude that there is plenty of optimism in the treatment of postpartum psychosis using their methodology. In what I consider to be an understatement of the past three decades in American psychiatry the authors write about how a specialized unit may have biased their results: "Unfortunately, many regions of the world do not have MBU care within a reasonable travel distance for the patient." To my knowledge there are no MBUs at all in the United States. They are inconsistent with the prevailing managed care rationing model for psychiatric care in this country.
This is a very important article for a number of reasons. It highlights the importance of specialized care for women with postpartum psychosis through reduced chronicity and better functional outcomes. The psychopharmacology result with lithium or antipsychotic monotherapy and discontinuing all benzodiazepines prior to discharge is far superior to any result that could be expected in the US. Short stays result in polypharmacy. I would be shocked to see any case of postpartum psychosis not discharged on antidepressants, antipsychotics, benzodiazepines, sleep medications and possibly valproate from American inpatient units. These medications are difficult to manage and the follow up appointments are typically brief and focused primarily on symptoms and medications.
In the trade off between short lengths of stay and unmanageable polypharmacy - it seems like this research group has developed a quality approach. It is time for American psychiatrists to acknowledge that the way inpatient units are run by businesses is not working because they never adequately stabilize patients. That leads to a large population of people who are unnecessarily symptomatic and never recover their baseline level of functioning. That same population may be taking a lot of medication that they don't really need.
George Dawson, MD, DFAPA
Supplementary:
I confirmed that there are no MBUs in the USA and that the median length of stay on the unit described in this study was 55 days.
References:
1: Burgerhout KM, Kamperman AM, Roza SJ, Lambregtse-Van den Berg MP, Koorengevel KM, Hoogendijk WJ, Kushner SA, Bergink V. Functional Recovery After Postpartum Psychosis: A Prospective Longitudinal Study. J Clin Psychiatry. 2017 Jan;78(1):122-128. doi: 10.4088/JCP.15m10204. PubMed PMID: 27631144.
Attribution:
Photo at the top is Erasmus Medical Centre - the affiliation of the lead author in this article and location of the study. It was downloaded from Shutterstock on February 8, 2017 per their agreement specifying editorial and noncommercial use.
Editorial credit: Jaroslav Moravcik / Shutterstock, Inc.
ROTTERDAM, NETHERLANDS - APRIL 1: Erasmus medical centre in Rotterdam on April 1, 2014 in Rotterdam
Interesting - think similar here in the UK. Close young relative finally got treatment for severe treatment resistant depression, took best part of 2 years in hospital to get her to remission and stable and able to monitor herself and manage treatment at home. Very grateful to the doctors who persevered in treating her to remission and I think it is fairly rare, especially among community services seems to be an attitude that the best you can hope for is to struggle along from crisis to crisis
ReplyDelete"especially among community services seems to be an attitude that the best you can hope for is to struggle along from crisis to crisis"
DeleteI think that captures what happens very nicely, although in the US they would rationalize it by saying that you are not "dangerous enough" to be treated in a hospital.
At some point, we allowed insurance companies and governments to compromise psychiatric care with what amounts to a lot of nonsense.