A letter from America: rescuing inpatient psychiatry
- Professor J C Markowitz, Research Psychiatrist, New York State Psychiatric Institute; Clinical Professor of Psychiatry, Weill Medical College of Cornell University, New York, USA;
In recent decades, American insurance companies have severely restricted medical reimbursement and access to treatment. Within this general trend, they have discriminated against psychiatry more than most other specialties, and have slashed in particular the most expensive facet of psychiatric care: inpatient treatment.1 The mean length of psychiatric stay in American hospitals has fallen from months to a handful of days. Realistically, how effectively can clinicians treat severely ill psychiatric patients in a three or four day hospital stay? Meanwhile, reimbursement for inpatient care has fallen so low (in some cases to 39% less than actual costs) that American hospitals have begun reducing psychiatric beds as well as lengths of stay.2 Patients in managed care plans are less likely to receive inpatient care than patients in fee-for-service plans.3
This drastic change in inpatient psychiatric care has had little to do with its clinical effectiveness and much to do with the managed care mantra of cost cutting. The promise that increased reimbursement for less costly day hospitals and outpatient services would compensate for this inpatient decline has proven false. This unholy precedent is being echoed in other countries as governments try to conserve medical funds.4
Managed care, alas, is a euphemism for managed cost. Caring for patients is beside the point. Its goal is to save money and to earn money for insurance “stakeholders” rather than to provide optimal treatment for “consumers” (the erstwhile patients). The underlying philosophy is hard-nosed capitalism, not social welfare or the common weal. Insurance coverage, rather than clinical judgment, often determines individual patients’ treatment. Indeed, many treatment decisions are ultimately made not by doctors but by insurance company clerks, whose main job is to deny care. Patients hate the system almost as much as do their doctors, who face unending paperwork, lengthy phone calls to fight for approval of care, and lower reimbursement. Few American patients or physicians would recommend this system of health care to their global brethren.
American medicine, which a generation ago was largely a system of independent private practitioners, has rapidly been transformed into salaried care under the aegis of managed care corporations.5 The problem started with the Employee Retirement Income Security Act (ERISA), a 1974 US statute that effectively preempted lawsuits against insurance plans. Given such legal protection, managed care companies subsequently dictated benefits—or lack thereof—while taking no responsibility for consequent effects on patients’ health. This allowed them to make profits through the denial of care, effectively tying the hands of doctors and turning away patients from needed care. Meanwhile, managed care spokespeople cynically protested that they were not making medical decisions: that was up to physicians. (Michael Moore’s 2007 quasi-documentary movie Sicko provides a vehemently angry, polemical, not invariably objective, but often on-target attack on the American health care reimbursement system. Mental health coverage would have offered him a still greater field day.) Struggling to work within such a treatment system raises ethical challenges for psychiatrists.6
The brevity of inpatient stays has essentially eliminated inpatient psychiatric research in America. Inpatient admissions have become brief pharmacological interventions in a controlled environment, with scant attention to the historically important interventions of milieu and psychotherapy. Hence American readers may consider a recent research study involving inpatient psychotherapy by Schramm and colleagues bemusing if not irrelevant (see Evidence-Based Mental Health 2008;11:46).7 8 Yet longer term inpatient care (here, five weeks!) does still exist in Germany.
Schramm and colleagues randomly assigned 124 inpatients with major depressive disorder either to the combination of interpersonal psychotherapy (IPT) and antidepressant medication or to medication plus psychoeducational “clinical management”. This study, the first to test IPT for inpatients, was rigorously designed and enrolled significantly depressed patients, who were not recruited by advertisement. IPT, a weekly outpatient treatment,9 was delivered in concentrated dosage: 15 thrice-weekly individual sessions plus eight group IPT sessions. Seventy one per cent of the combined treatment group met criteria for treatment response, versus 51% in the comparison group. At three-month follow-up, only 3% of patients who received IPT and medication had relapsed, compared with 25% in the comparison group.7 A study limitation is that subjects randomised to IPT received longer therapeutic attention than control subjects. Still, the controls received far more attention than most American inpatients likely do. Ideally, inpatient IPT patients should have transitioned to outpatient IPT; it is not clear that this occurred.
This study suggests that, given sufficient time, inpatient treatment can have benefits, and that inpatient depression-specific psychotherapy augments pharmacotherapy. It seems rational to adapt and apply empirically-validated outpatient psychotherapies like IPT and cognitive behavioral therapy10 to inpatient treatment. Indeed, adequate inpatient stays of high treatment intensity might have greater effectiveness than more meagre hospitalisations and less intensive outpatient care, and might actually save money in the longer term. While no one would advocate a return to the historical use of asylums for patient warehousing, appropriate inpatient treatment may have crucial value for our sickest patients.
Future research might compare inpatient IPT and pharmacotherapy à la Schramm to briefer, American-style hospitalisations and outpatient care. There may yet be hope for appropriate inpatient treatment, if it can be given a chance. Yet even if further research replicates these treatment benefits, can science beat back changes driven by corporate finance?
Competing interests: None.