August 2011  << Back  

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Manual of Inpatient Psychiatry

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Michael I. Casher and Joshua D. Bess. New York, NY: Cambridge University Press; 2010; ISBN 978-0-0521-14154-3; pp 168; $50 (paperback).

Inpatient psychiatry is a diminishing, yet still a large part of psychiatric training and practice for many psychiatrists. It is, in a way, a first serious training ground for dealing with severely mentally ill patients. Discussions of managing severely mentally ill patients in the inpatient setting are a part of most psychiatric textbooks, and occasionally a topic of an entire book. Two inpatient psychiatrists, Drs. Michael I. Casher and Joshua D. Bess, wrote yet another contribution to the inpatient literature, Manual of Inpatient Psychiatry. Let’s make one issue clear, this manual is just about inpatient psychiatry and not about other hospital-related services such as day hospital, consultation-liaison, or emergency psychiatry.

This little book consists of a foreword and 9 chapters. The foreword, “American inpatient psychiatry in historical perspective,” is written by Dr. Laura D. Hirshbein, an historian of psychiatry. Dr. Hirshbein writes “the history of inpatient psychiatry is the history of psychiatry itself” (p vii). I hope this is not the case, because (I, a practicing outpatient psychiatrist, apologize to all inpatient psychiatrists for this statement) it would mean psychiatry is slowly but surely dying! Some of us remember the “good old” days when stays were much longer, something substantial really happened during the inpatient stay, and inpatient psychiatry was the major part of psychiatric practice, training, and income (the last one still is, in some cases). That has gradually changed. The hospital stay is much, much shorter and mostly focused on only acute management of severe mental illness and frequently just on providing a safe environment for suicidal or homicidal patients for a few days. I remember the mother of one of my patients who rejected the notion of hospitalization for her son. He kept having side effects from various medications and was not improving, yet his mother called hospitalization a joke, telling me “they will change all meds and will ask you to titrate the doses after his discharge, we have been through this…” This is a sad state of affairs, not to be blamed so much on inpatient psychiatrists as rather on insurance companies and the overall attitude toward the cost of care we provide. But back to the book.

The 9 chapters review 9 topics the authors consider salient to inpatient psychiatry: 1. The inpatient with schizophrenia; 2. The inpatient with depression; 3. The inpatient with mania; 4. The inpatient with borderline personality disorder; 5. The inpatient with dementia; 6. The inpatient with traumatic brain injury; 7. The inpatient with dual diagnosis; 8. The young adult on the inpatient unit; and 9. Clinical documentation on the inpatient unit. The chapters are accompanied by numerous tables, charts, case vignettes, and even an illustration. The selection of the tables and charts looks—and frequently is—practical, but is idiosyncratic and at times seems out of place. For instance, I am not sure how many inpatient psychiatrists would use the “rule of 3s” table for diagnosing bipolar spectrum disorder. The chapters are organized around questions and answers; some examples from the first chapter are:

  • Why might a patient with schizophrenia be admitted to a psychiatric unit?

  • How does the inpatient clinician approach an interaction with an acutely psychotic patient?

  • What historical information is important with a first-break patient?

  • What is the initial work-up of a psychotic patient?

  • How does one distinguish psychosis in schizophrenia from mania in bipolar disorder?

  • What factors are considered when a patient with known schizophrenia is admitted?

  • What factors are involved in choosing an antipsychotic medication?

  • What other medications are useful for inpatients with schizophrenia?

  • How do you manage the acutely agitated schizophrenic inpatient?

  • How do you evaluate and manage suicide risk in patients with schizophrenia on the inpatient unit?

  • What is the overall treatment plan for patients with schizophrenia in the hospital?

The questions in the remaining chapters are similar and adapted to each topic.

The writing of the entire volume is simplistic, the advice frequently is an idiosyncratic hodge-podge, at times over-referenced and sometimes not referenced (like the statement on page 13 that fluphenazine decanoate’s effect lasts 2 weeks). At times it is difficult to understand why some information is included—for example, the statement “…post-menopausal depression in women is more likely to be the melancholic sub-type, with particularly strong HPA alteration” (p 27). Some tables seem incomplete, eg, correlates of treatment resistance (p 34) do not mention severe psychosocial stressors such as serious financial difficulties (bankruptcy, etc.). I also am unsure how beneficial the discussion of neurobiology and etiology of borderline personality disorder would be for inpatient management of this disorder.

I am not clear how useful this small book would be to all those mentioned on the cover (practitioners, residents, students) because I did not find it very useful. I mentioned my issues with the writing and I would also add the lack of prioritizing the information. I also missed the coverage of some areas, such as eating disorders, inpatients with severe medical illness and delirium, and geriatric inpatients (other than those with dementia). Another problem is the chapters are positioned in what I would call an “inpatient vacuum”; there is nothing mentioned about discharge planning (a serious weakness of many inpatient psychiatric institutions in my geographic area) and about the involvement of other disciplines (which, I hope, are consulted and supervised by the inpatient psychiatrists).

I hope this book’s tiny size is not the symbol of the diminishing role of inpatient psychiatry and this book is not the ultimate illustration of inpatient psychiatric practice in this country. Last but not least, $50 is truly a hefty price for what I described.