Holding Tank Or Psychiatric Unit?

In the event that it is not obvious, the bulk of my career was spent as an acute care psychiatrist.  I staffed inpatient psychiatric units for about 22 years in one of the most acute care facilities in the largest Metro area in the state of Minnesota. That meant that most psychiatric emergencies, especially those involving aggressive behavior were generally brought to this facility and I was one of a handful of inpatient psychiatrists who would be seeing that person. In order to do that work even reasonably well there has to be a reasonable environment. I am an expert in that environment and this post is about how that environment deteriorated as a direct result of government and business intervention that was designed to turn healthcare over to the business community and out of the influence of physicians.

Before I get into those details, let me describe my current perspective on inpatient psychiatric care from the vantage point of an outpatient psychiatrist.  In October of this year, I will have been working in an outpatient setting for a total of 10 years. I have seen hundreds of people who were detained or admitted to inpatient psychiatric units over that period of time. I always ask them what their care was like and the reviews are never positive.  The most common term that I hear as a description is that it was a "holding tank."  They describe incredible boredom, very brief contacts with staff, and the role of the psychiatrist as asking them if they were suicidal or not. Many of them knew they could adopt a game strategy: "I knew if I said I was not suicidal they would let me go and they did." They often tell me that arbitrary medication changes were made to medications they may have been taking for a number of years. Their psychiatrist or physician was rarely contacted. Follow up in these circumstances is not very good.  They discharge prescriptions were rarely filled and often they did not get an explanation for the medication changes.

My experience trying to get care for people who need inpatient care has been equally unsatisfactory.  I have been overruled by non-physicians working in emergency departments when I referred people in who needed acute care.  There is nobody in the world or the history of the world who knows more about who needs inpatient care than me. I have been unable to refer people for electroconvulsive therapy with severe depression and suicidal thoughts, even directly to the hospital where I used to work. I have been sent severely ill and unstable people to take care of in an outpatient setting - who should have been treated on an inpatient unit.  That level of care in unacceptable to me both as a professional who knows the field and as a family member who wants anyone with mental illness in my family to get the same care and resources as somebody who goes to the emergency department with chest pain.  They currently do not.

How did inpatient psychiatric care fall to such abysmal depths?  Basically by stealing the decision making ability from the physicians who were trained to make the decisions. The decisions I am talking about include treating the patient in a particular setting, the treatments and specific medications offered, and what their overall treatment trajectory would be. Beginning in the 1990s it was possible for an insurance company to deny treatment based on whatever basis they decided and sustain no liability for a wrong decision.  At that time a physician employee or contractor could just call the hospital, have a cursory discussion with the attending physician, and deny care. To illustrate how that works here is one of my typical conversations with one of these "utilization reviewers" from that time. The conversation refers to no specific case but represents an amalgam of these reviewer conversations:

Utilization Reviewer (UR):  "Hello I am Dr. X calling to review the care of Mr. Patient Y.  Why is he on your inpatient unit?"
Me: "He has longstanding depression and for the past two months has been drinking a fifth of vodka per day.  On the day he came in his wife found him sitting at their kitchen table with a loaded firearm saying he was going to kill himself.  He is currently being detoxified and treated for depression."
UR: "He needs to be sent to detox."
Me: "The county detox unit is a social detox with no medical coverage and they refuse to take anyone with suicidal ideation or behavior."
UR: "He needs to be sent to detox".
Me: "Did you just hear what I said?"
UR: "Is he suicidal RIGHT NOW?"
Me: "He has been under my care for less than 24 hours and at this time is at extremely high risk for immediate relapse and high risk for recurrent suicidal behavior. He needs stabilization."
UR: "But is he suicidal RIGHT NOW?"
Me:  "I don't understand what you mean. He has no access to a firearm right now. He is in a hospital."
UR: "Then we are done here. We are not going to cover the hospitalization."

Having many conversations like the one above over the years set the tone for the demise of inpatient care. At one point it was easier to recruit psychiatrists to be utilization reviewers because it was an easier job with no liability and predictable hours compared to psychiatrists trying to actually provide the care.  This process remains one of the greatest unspoken conspiracies in the history of American healthcare and it is the reason for the red transition arrow in the above graphic. It is also the reason why we began incarcerating people with severe mental illness rather than treating them.  It is how county jails are now opening jail facilities that they are calling mental health units. It "saves" any insurance company that adopts these polices a significant amount of money and puts all of the people who should be treated in a safe and supportive environment at risk for that profit to the company.

Holding tank is a term, that has come full circle.  We owe it all to the managed care  industry.


George Dawson, MD, DFAPA