Inpatient Treatment

When is inpatient treatment recommended?

People experiencing illness, with mental and emotional distress, may be admitted into hospital for inpatient psychiatric assessment and treatment. Patients may be experiencing distress caused by the re-emergence of psychotic symptoms, which occur as part of an illness such as schizophrenia, or it may be due to suicidal thoughts, which can occur during a depressive illness. Other causes may be an overwhelming life event, such as the experience of being assaulted or the sudden death of a loved one. A change of environment can sometimes be sufficient to provide relief from symptoms as it may give a person permission to give up normal responsibilities and duties in return for taking on the role and responsibilities of a patient. The responsibilities as a patient involve participating as far as possible in the treatment and rehabilitation processes, co-operating with management plans and adhering to ward routines and policies.

A doctor or mental health professional may have several reasons for suggesting that a person would benefit from admission to hospital.

• The patient may need to have a period of close observation and assessment in order to clarify the diagnosis. This is important since many symptoms (both physical and psychological) can occur in a variety of different psychiatric and physical illnesses. These conditions may require full physical examination and various complex investigations involving blood tests and different types of X-rays, all of which can be difficult to conduct in an outpatient or clinic setting.

• There are often a complex arrays of factors associated with any episode of illness. To understand all of these factors takes time and often involves different members of a multidisciplinary team in getting to know the patient and the family or caregivers. This is often essential to enable the treatment team to identify the various factors contributing to an episode of illness. Such an approach, covering numerous aspects of a person's functioning, allows a holistic treatment plan to be developed.

• Symptoms may need stabilizing in a highly supportive environment. Families can often feel that they lack the skills to care for someone who is acutely unwell. It is important that they do not become over stressed in the process of providing care because they are vital to the recovery process of the ill person.

• A patient may require a change in treatment due to a lack of response to previous treatment. At times, this can be associated with a temporary worsening of symptoms and may best be carried out in hospital because of the high level of medical and nursing care and observation only available in such a setting.

• The hospital is also a place where new coping skills can be learnt. A patient can also learn about the possible reasons for his/her illness and how to prevent another episode. Inpatient facilities have a variety of group and individual programs available so it is beneficial to be an inpatient rather than having to travel back and forth to the hospital each day.

What does the term 'mental illness' mean?

A definition of mental illness* is "a disturbance of thought, mood, volition, perception or memory that impairs judgment to a significant extent, which is not due to intellectual disability, drug or alcohol abuse, antisocial behavior, immoral/ indecent behavior or sexual preference, and is out of keeping with the person's normal religious/philosophical or political beliefs" (Western Australian Mental Health Act, 1996).

* This definition varies around the world, especially when it is also associated with drug addictions and personality disorders, because some countries do not recognize these disorders in their mental health legislation. In some legislatures these conditions may be recognized as disorders for certain purposes but not as disorders that justify involuntary admission.

What is involved in being admitted to a psychiatric hospital?

The process of admission to a psychiatric hospital or clinic can be daunting especially if the person has not visited a mental health facility before or if he/she is being admitted involuntarily. This section will help to explain the different steps that occur and what to expect during the process. If at all possible, having someone with you during this time is useful. A friend or relative can provide support and is often able to give useful information to the admitting team. They may ask questions on the patient's behalf about issues that the patient may feel too nervous or embarrassed to ask about. They can alsohelp the patient clarify and remember information that is explained to him/her that might otherwise be forgotten.

This section is divided into the following sections:

Assessment of the patient.

1. Admission assessment
2. Physical examinations and investigations

Admission to the hospital ward.

1. Arriving onto the ward
2. Observations
3. Professionals in the hospital setting
4. The multidisciplinary treatment team
5. Medications

1. How is the patient assessed?

1a. Admission assessment
The first thing to happen is the assessment process and this may occur in a General Hospital Emergency Department or in a separate Psychiatric Unit Outpatient Department, depending on the public mental health system. The first person to talk to the new patient may be the reception staff in the Emergency Department. They need to ascertain the degree of emergency, that is, how quickly the patient should be seen. This is called triage. Psychiatric emergencies that require urgent attention include suicidal actions and acute psychotic symptoms with obvious behavioral disturbance. In these cases an Emergency Department doctor will see him/her as soon as possible.

Acute life threatening medical emergencies will, however, usually take priority and there can sometimes be a wait. The Emergency Department doctor will ask questions of the patient and the caregivers to ascertain the nature of the problem or symptoms.

It may then be decided that the person does not need to see a psychiatrist. However, if admission to the hospital is recommended, then a psychiatric registrar will then see him/her. Having already seen a doctor prior to seeing the psychiatric registrar, the patient may find this second review repetitive and frustrating. It is, however, the registrars (and their psychiatric consultant who, on the basis of his/her detailed and specialist knowledge of mental illness, make the final decision on the benefits of hospitalization. Decisions about patient admissions are thorough and the emergency doctor (who may have limited experience with mental illness) may confer with other professionals.

The psychiatric registrar will also want to talk to friends or a family member and the patient's GP if they are available. This happens so that all the issues are carefully assessed and the appropriate options decided upon and discussed with the patient and the caregivers (the patient may be too ill to participate fully in this discussion but every attempt will be made to involve him/her). This process takes time and patience is required.

1b. Physical examination and investigations

Physical examination and certain investigations are always required in order to exclude a physical cause for the symptoms. This is a very important part of the initial assessment for anyone presenting at a hospital or clinic with acute psychiatric symptoms. It is common practice for all new admissions to a psychiatric ward to undergo a CT Head scan and an EEG (Electroencephalogram) together with certain blood tests as part of the physical screening process.

It is important to establish that mental symptoms do not result from abnormalities of the thyroid gland, therefore, thyroid function tests are usually undertaken. In other parts of the world, where mental symptoms may commonly result from certain infections or parasitic conditions such as malaria, appropriate tests will be carried out as part of this assessment phase and these are normally done in the first few days following admission. It is vital that such physical causes be detected or excluded and these can include conditions such as brain tumors, strokes, diabetes and various types of epilepsy.

Other blood tests may also be taken at the time of the initial assessment or the next day when you are on the ward. These tests are done for a number of reasons including reviewing liver and kidney function. This can be important if the treatment involves taking medication that may affect either of these organs or if the patient has a pre-existing liver or kidney problem that requires an adjusted dosage of medication. Anemia and vitamin deficiencies are among other conditions that can affect mental state.

2. What will admission to the hospital ward entail?

2a. Arriving on the ward
Although this process may differ depending on whether the admission is voluntary or involuntary, generally, the same things are covered at some point in the process. The nursing staff usually undertake various procedures once the patient is on the ward.

• The main issues and reasons for admission.

• For safety reasons, any medications and potentially dangerous items such as matches, lighters, pocketknives, etc. will be removed. Medication handed in at the time of admission, is not returned when the patient is discharged. These medications may be unsuitable for his/her condition and it is considered to be unsafe to return the medication to the patient.

• Items of value, such as jewellery or large sums of money, will be placed into a locked storage facility. These items can be accessed during certain hours in the hospital and they will be returned upon discharge.

• Involuntary patient rights under the Mental Health Act will be clarified.

• A room will be provided. Ideally, all services would like to provide each person with his/her own room but this is not always possible so some patients may have to share with another person of the same sex. Most units are mixed but single-sex wards do exist in some areas.

• The primary nurse will be introduced. Many services provide one primary nurse plus one secondary nurse to care for patients (nursing staff work either a morning, afternoon or night shift).

• The use of alcohol and/or illicit drugs is prohibited in a hospital. Most hospitals will have signs up stating the procedure if an inpatient uses such substances. In some cases, use can lead to discharge, particularly for a voluntary patient.

• Treatment may include medication and therapy groups so it is important to take part in all aspects of the management plan.

• Visiting times are often kept to the evening. During the day patients may be required to participate in therapy groups and to be available to be seen by a psychiatrist and other staff. If families have difficulties in attending at these times, in most cases, something can be worked out by talking to the primary nurse.

2b. Observations
These can involve physical observations such as measurements of blood pressure, temperature and pulse. These observations may be important if the patient has just been started on new medication, which can cause side effects such as changes in blood pressure, etc. If he/she has had problems with appetite, nursing staff will be asked by a doctor to monitor the intake of food and fluids to ensure the patient is eating and drinking enough. In such a case, the patient may need to be weighed regularly. This is particularly important when treating eating disorders such as anorexia nervosa and bulimia.

Other observations may be carried out by nursing staff including attendance at therapy groups and movements on the ward, sleeping patterns and how the patient's symptoms have change during the day. A lower level of observation will require the staff to be aware of patients' whereabouts at all times, therefore, checks may be done every 15 or 30 minutes.

Intensive nursing and observation may be required and this would be carried out by a mental health nurse who would stay with the patient at all times. Staff may assess that more intensive nursing is required and decide that the patient's needs are better served in the Intensive Care Unit (ICU). This is normally a smaller unit with fewer beds and a higher ratio of nursing staff. People in the ICU may have been admitted under the Mental Health Act (i.e. an involuntary admission) so the doors to this unit are usually locked.

2c. Professionals in the hospital setting
A number of different doctors may treat patients during the stay in hospital and this can be confusing. If the patient is unsure as to the treating doctor is, ask one of the staff on the ward.

• Admitting doctor
  Normally, this will be the registrar (a trainee specialist psychiatrist often called a 'resident' in other countries). This doctor will continue to see the patient once he/she has been admitted throughout normal office hours, however, after hours medical staff are usually rostered on duty and become the duty doctors. A patient's care will almost certainly be the responsibility of a mental health team.

• Intern/resident
  This is a junior doctor, who is normally one or two years away from finishing their general medical training and who is initially responsible for all of the medical needs of the patients allocated to him or her. Many psychiatric inpatient facilities do not have such junior medical staff unless they are part of a General Teaching Hospital. The intern/resident tends to look after all patients on the one ward and is involved in completing the initial assessment, including organizing physical reviews and investigations. He/she may also become involved in dealing with any concurrent physical problems patients may have that could be contributing adversely to their mental state. An intern is in the process of obtaining experience in psychiatry and may be planning to complete further training in psychiatry.

• Psychiatric registrar
  This doctor is more senior than an intern or resident. They have completed several years of general medicine after graduation as a doctor and are often undertaking specialty training in psychiatry. Some registrars may have been GPs or medical registrars prior to deciding to take up psychiatry and therefore have broad experiences.
  
  The registrar is normally the doctor who patients will see on a regular basis during their stay. The registrar will discuss the diagnosis and treatment with the patient (and the family/caregivers where possible) and will plan the treatment. He/she will discuss these matters on a regular basis with the supervising consultant and plans may be modified accordingly. The registrar oversees the intern/resident to ensure assessment is accurate and completed. As well as having responsibilities for people admitted under the consultant on the ward, they also see people in outpatient clinics and have 'on duty' responsibilities. This means that they do not always stay on your ward and they will probably set times to see the patient and/or the family. The registrar may also have duties outside the hospital where they will see people in their homes, or with GPs and they may also have training responsibilities, e.g. attending lectures and tutorials.

• Consultant psychiatrist
  A consultant psychiatrist is a doctor with a specialist medical qualification in psychiatry. Consultants are legally and ultimately responsible for patients' clinical care. A consultant may not see patients as frequently as the registrar, however, they will be actively supervising the treatment through consultation with the registrar and the treating team. They will review the initial diagnosis and assessments and, together with the patient and the registrar, will set treatment goals for the admission. As well as their clinical responsibilities (i.e. those related to treating patients) they usually have many other roles, e.g. teaching, research and administration.

2d. Multidisciplinary treatment team
A multidisciplinary treatment team consists of several other mental health professionals who work together with the medical and inpatient nursing staff. They include:

• Mental health nurse
  Mental health nurses have qualifications in providing nursing care to people with mental health problems. Their duties include asking questions about the development of symptoms; assessing and monitoring the severity of such symptoms; dispensing and supervising the taking of medication; and providing education and support to patients and their families.

• Occupational therapist
  Occupational therapists (OT's) are professionals who have undertaken tertiary education and have specialized in the assessment of the functioning of an individual in various physical, social and vocational areas. They aim to help people achieve and maintain their highest level of independence. They also have skills in certain treatments, such as relaxation training and are skilled at working with individuals and groups. In the inpatient setting, an OT can help to explore creative and leisure activities; assist patients in dealing with stress; build on the skills needed for daily living such as budgeting and cooking; and help facilitate a comprehensive discharge plan.

• Social worker
  A social worker has undertaken tertiary training in social work and in social administration. Social workers aim to improve a person's well being through the promotion of social justice and social change. They liaise with many services, including public housing, rehabilitation agencies and other appropriate government facilities, e.g. disability services. They have specific therapeutic skills in individual counseling and family work. They can also facilitate group work for education, therapy and support. Social workers have a number of legal responsibilities including the writing of reports. They train and supervise other social workers and students and are required to be involved in their own professional development and maintenance of skills. They play an important role in planning for discharge and they continue to work outpatients.

• Clinical psychologist
  The clinical psychologist is a trained psychologist who has undertaken specialization in clinical psychology. The clinical psychologist may be involved in patient care by providing neuropsychological and other assessments such as intelligence or personality tests, or providing specific psychological interventions or therapy. They assist the clinical team in arriving at extended diagnostic assessment of various mental health problems and usually bring a powerful research approach to these matters. They undertake therapeutic assessment and therapeutic management, e.g. cognitive behavioral therapy (CBT) on an individual or group basis.

• Pharmacist
  The pharmacist advises and assists medical staff in the decision-making process with regard to specific medications or medication in general. They provide up-to-date information on drugs including side effects and possible interactions and may conduct education sessions about medications.

• Community mental health nurse
  A community mental health nurse is a nurse who has trained in mental health care in both inpatient and outpatient settings. If, on discharge there are ongoing issues that may interfere with your recovery it may be suggested that you see a community mental health nurse after you leave the hospital and perhaps on an ongoing basis. These specialist nurses can visit the patient at home or in other settings. They can provide support and counselling; monitor and supervise medications; and keep an eye on the patient's mental health. They may also liaise with the treatment team and the GP and they are able to assist in specific treatment, e.g. in applying exposure behavior therapy programs used in treating agoraphobia. They can assist the patient and caregivers in becoming involved in other supportive networks in the community thus reducing the need for him/her to be unduly dependent on the more centralized mental health services.

2e. Medications
In hospital settings, all medications are written up on a medication prescription sheet. All medications are written on such sheets in order for nursing staff to administer them accurately. This ensures that the right person takes the right amount of the right medication at the right times of day. This sheet also includes medications that the patient may administer, such as over-the-counter medication including the oral contraceptive pill and Ventolin inhalers.

The medical staff will discuss any changes to medications. If the patient is allergic to any drug, it is vital that he/she talks with the doctor or nurse and describes the symptoms experienced. If he/she is very anxious or aroused the patient can request, or the medical staff may prescribe, medications such as a sedative. This is called 'PRN' or 'as required' medication.

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What is involuntary treatment?

Involuntary treatment is when a person is admitted to a psychiatric facility without his/her consent. Involuntary admission and treatment occurs when a person is suffering from a mental illness and is unwilling or unable to accept help or is lacking insight about the illness (because of the nature of some psychotic illnesses) and it is the opinion of a doctor that treatment is necessary.

Mental health is considered to be a right for all people. Hence, the law protects people who are unable to consent to treatment due to the nature of their mental illness. The purpose of such legislation is to protect the rights of the mentally ill whilst at the same time facilitating treatment. It attempts to balance the right of the individual to treatment, with the person's right to autonomy and free will. Such legislation differs depending on which state or country you live in.

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What is involved in the referral process for involuntary admission?

In Australia, any medical practitioner, e.g. a GP, Emergency Department doctor or a consultant surgeon can refer a person for psychiatric assessment after he or she has personally examined the individual. They must have reasonable grounds to suspect the person has a mental illness requiring treatment. The length of time such an assessment can vary. In Western Australia, the medical practitioner has 48 hours, after seeing the patient, in which to make the involuntary referral.

In some parts of the world other mental heath professionals can undertake extra training to become recognized as an accredited or authorized mental health professional. This gives the authorized mental health professional specific and clearly defined powers to make involuntary referrals for assessment if a medical practitioner is unavailable. Such individuals can include senior community mental health nurses and social workers with recognized experience in acute mental health assessments. In countries, such as Australia, where there are problems in servicing vast rural areas and doctors may not be readily available, this process becomes very important.

Once a person has been referred for such an assessment it becomes a legal requirement that they attend. If necessary, the police may be asked to assist in escorting a person to a designated place for assessment.

What is the criteria for involuntary admission?

In order for a medical practitioner or an authorized mental health professional to complete an order for involuntary admission for assessment, the individual must be assessed as having a mental illness. They must also usually fulfill some or all of the criteria listed below. These may vary depending on the state or country involved. The following criteria are based on the Western Australian Mental Health Act. (1996).

1. Admission is necessary to:
   • protect the health and or safety of the individual or of any other person;
   • protect the individual from self-inflicted harm (this can be serious financial harm, lasting or irreparable harm to important personal relationships, or serious damage to the reputation of the person); and
   • prevent the person from doing serious harm to property.
2. The person has refused to, or due to the nature of their illness is unable to, consent to treatment.
3. It is considered that management via a community-based program will not provide adequate protection for the individual or other persons.

How is involuntary status reviewed?
In most places, a person who becomes an involuntary patient has a right of appeal against the decision. Many countries require the doctor to justify the decision to treat a person involuntarily, often at a formal hearing of a Review Board or Tribunal. This review process gives the involuntary person the right to ask questions and to be represented by a lawyer and/or support person. Review Boards are able to discharge a person from involuntary treatment if they conclude that such detention is unnecessary. After the hearing to review involuntary status the applicant is usually given the reasons for the decision.

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How do patients gain access to their medical records?

Patients in a hospital have the right to read their medical notes, however, they are normally required to make formal application for such access (patients do not have to give a reason for wanting to read the files). After the application is received the hospital may be required to make the file (usually a photocopy) available within a certain period of time. Under certain circumstances not all of the notes will be supplied. This is done because certain entries in files may be detrimental to the patient's health or to the success of the treatment process or may be of possible danger to third parties.