Acute Care Psychiatry: Diagnosis and Treatment
The statement, “Acute treatment is brief” (p. 341), might be a good introduction to this book. I was frankly worried that the authors were about to present an apology for managed care psychiatry and would try to convert me into a true believer in the benefits and bright side of the present demise of psychiatric treatment. In fact, the introduction misled me, with its truncated, idiosyncratic, and highly creative history of the “four revolutions” in psychiatry, calling this latest the “revolt of the payers.” Describing their text as the product of the economic revolution in health care, the authors note that “acute care of the major mental disorders is now provided in a host of intensive treatment environments: intensive outpatient treatment (more than two visits per week), home care, partial hospital, respite care, acute residential care, and the inpatient unit that is rapidly becoming the ICU of psychiatric services.”
I should not have worried. This book is a balanced, critical, and at times provocative examination of a rapidly developing subspecialty that is becoming core knowledge for our residency training programs. It is much more than the title suggests, and perhaps, in a way, it attempts to cover too much territory. It is a terrific textbook, with outstanding chapters on assessment and triage of the suicidal patient, the violent patient, and the demented patient, and it also covers the treatment of specific disorders in a comprehensive and thorough manner. The case examples are extraordinarily good.
This book details the heart of the matter that troubles so many psychiatrists, i.e., forcing the treatment of chronic illnesses into the Procrustean bed of acute care. In the beautifully written and organized chapter on depression, the authors state the case well:
The economic climate of health care and its global effect on psychiatric treatment have become increasingly apparent. Inpatient treatment of depressive illness has been reduced dramatically, secondary to improved early recognition of mood disorders, enhanced pharmacological management strategies in outpatient settings, and use of alternative acute care settings. Hospitalization has been principally limited to patients who are dangerous to themselves.…The rapid turnover of patients associated with managed care creates controversy and concern among clinical staff members and trainees. No patient, for economic or other reasons, should be released from a secure setting until the staff members have judged that it is safe for the patient to leave.
I found the chapters on substance-related disorders, childhood and adolescent disorders, and borderline and antisocial personality disorders particularly useful. I note that these are the chapters that have the input of Dr. Sederer. The very important chapter by Drs. Ira Glick and John Clarkin on family intervention suggested to me that perhaps it took managed care to force us to do what we have been saying for decades is so important but have not really done until the present time. The chapter on focal psychotherapy by Dr. Michael Bennett is a gem. I also enjoyed reviewing the McLean Hospital treatment plan for bipolar and psychotic disorders.
A suggested subtitle for section 3, Administrative Aspects of Acute Care Psychiatry, might be “The Harvard Survival Guide for Psychiatric Hospitals in the Era of Managed Care.” This section covers medical, legal, and ethical issues, treatment guidelines, assessment of quality of care, professional compensation, and record keeping. There are a few chapters that seem out of place, but they are quite good and add balance. I do not understand, however, why the chapter on primary care is in the book. It is well written and informative, but to what purpose? This book is not written for primary caregivers. The book suffers only slightly from the inevitable jolts in style and syntax from chapter to chapter caused by the inclusion of multiple authors. On the whole, I was glad for the opportunity to read it, and I will keep it on my desk. I hope our residents and our psychiatric leaders read it.
