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Tuesday, October 26, 2010

Should I hospitalize my teen (or child) for depression, aggression or anxiety?

Recently, some parents have reported to me that school staff had told them that they should take their child to a hospital psychiatric ward for treatment. In all the cases, the children were suffering from worrying, anxiety, and were also refusing to go to school. When parents were trying to make the children go to school, they would become aggressive, sometimes hitting the parent or a staff person, or make statements like "I'm going to kill myself."

It is not appropriate for school staff to suggest psychiatric hospitalization, or to discuss any treatment options with parents. 
Discussing treatment options should be done by a licensed mental health professional, after the professional has conducted an evaluation. 

Inpatient psychiatric hospitalization will almost always
involve medications and a serious diagnosis. It's not something to be
taken lightly. It should never be used as a way to "teach kids a lesson."

Also, school staff should not discuss with parents what could be "wrong" with their children with regards to diagnosis. For example, one staff person apparently told a child that he had "something wrong with his brain" after showing him pictures of an apparently abnormal brain.

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I was once a Clinical Director of a residential facility, and during my time there, I completed about 300 psychiatric hospitalizations; additionally, I worked for a short time at Christ Hospital's inpatient psychiatric unit.

Inpatient Hospitalization is the highest "Level of Care" for mental health problems. There are a variety of Levels of Care which vary in location, restrictions, type of treatment and frequency of treatment:

The lowest Level of Care setting is "office-based" psychotherapy where the frequency may be anywhere from once a month or less all the way up to 3 times a week. This can include multiple types of therapy, such as chemotherapy (medications) along with group or individual therapy. Sessions are usually 45 to 60 minutes, but they can be longer.

The next level of care is outpatient treatment in a hospital, which is often called, "partial hospitalization." This includes 3 or more days a week, at a hospital with groups and individual therapy, and it almost always includes medications.

Inpatient psychiatric treatment is next, and this may be anywhere from 23 hours up to 2-3 weeks for short-term, and one to six months for medium term. This will include medications and sometimes other treatments like ECT. The highest Level of Care is Long term psychiatric hospitalization, and this may be for 6 months to one or more years.

Children suffering from worrying, anxiety, and refusing to go to school have no need for a higher level of care other than psychotherapy in an office-based setting. There's no scientific research that shows that higher levels of care are more effective at treating school refusal or anxiety than office-based psychotherapy.

Although, outpatient hospitalization (partial hospitalization) programs may help; out-patient psychotherapy is probably the best place to start. The problem with school refusal behaviors is that there tends to be no quick fix. Children who are refusing to go to school have probably been suffering from anxiety problems for a year or more. Also, children and teens are often resistant to the process of therapy - they want the outcome of feeling better, but they don't want to do the work to get there, because effective therapies for anxiety typically require that people change their behaviors (face their fears).

In Illinois, there are laws which govern psychiatric hospitalization. For example, adults may be hospitalized against their will by a licensed mental health practitioner, such as a Social Worker, Psychologist or Psychiatrist. However, and in general, children cannot be hospitalized against their will by anyone other than their mom or dad (or guardian).

There are three criteria used to determine whether or not someone should be hospitalized involuntarily. However, since inpatient treatment is so restrictive and costly ($1,000 per day or more, in addition to lost time at work or school, along with the stress of the experience), the same criteria are usually applied to decisions about voluntary admission.

The criteria for whether someone should be admitted to a psychiatric hospital unit are any one of the following, as determined by a licensed mental health practitioner:

A person who is mentally ill and who because of his or her illness is reasonably expected to inflict serious physical harm upon himeslf or herself or another in the near future.

A person who is mentally ill and who because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious physical harm.

A person who is mentally retarded and is reasonably expected to inflict physical harm upon himself or herself or othres in the near future.

You can see that each criteria starts with a statement of fact, that the person is "mentally ill." (or mentally retarded). A diagnosis of mental illness can only be made by a licensed mental health practitioner (LCSW, Psychologist, Psychiatrist, or other Physician). Also, the patient must be in imminent danger of causing serious harm to self or others. Threats of suicide need to be evaluated by a licensed mental health professional. Not all physicians or pediatricians are trained in assessing for suicide risk.

Psychiatric hospitalization is meant to protect people from seriously harming themselves or others, either directly or indirectly. Most people, most of the time are not in danger of harming themselves or others - even if someone says, "I want to die," or "I want to kill myself," it does not mean that hospitalization is necessary. It takes textbook and experiential education to know how to assess for imminent danger to self or others. The presence of risk factors for suicide are not reason enough to hospitalize someone. Protective factors need to be considered, too, as well as the ability to implement a safety plan in the community when risk factors are present, in order to avoid inpatient hospitalization.

Even when people are hospitalized, there's no guarantee of safety. Nearly 1,000 suicides occur in psychiatric wards each year in the US. Also, many suicides occur within 90 days after hospitalization; so, hospitalization interventions do not always cure people of their suicide intentions. People still need on-going treatment. Additionally, teens who take medications only have a higher post-hospitalization suicide rate than teens who are in psychotherapy.

In my opinion, psychiatric hospitalization is over-used. It's a professional judgment call, but there are issues that complicate the decision to hospitalize someone. For example, if a Medical Doctor has a financial relationship or contractual relationship with the hospital to where the patient is being sent, then to me, their decision to hospitalize someone may be impacted by that relationship. Also, some mental health practitioners worry about being sued by a patient's family if the patient commits suicide; for many professionals, it seems safer to err on the side of caution; however, patients can sue for wrongful hospitalization, too, or at least not pay their bill!

Another issue is whether the benefits of hospitalization will outweigh the costs. This is not easy to measure, but it is worth considering by actually writing down all the pros and cons of each option and weighing them. An important question to ask is, "Can this person be taken care of at home and still be safe?"

When I was a Clinical Director, we always considered this question. In many cases we were able to keep a resident safe in the facility by putting them under close supervision for 72-hours minimum, increasing counseling sessions, removing any objects that they could use to cause harm, and perhaps increasing their medication does or adding a sedative medication to reduce intense moods.

I have known some patients who said that their doctor wants them to "go to the hospital to adjust my medications." This is not a valid reason, since it is not one of the three criteria for admission, but it can be done under voluntary admission; however, I can't imagine that an insurance company would cover the costs of a voluntary admission under the presenting problem of "medication adjustment." That might mean that the Medical Doctor would have had to write in the chart that the patient was in imminent danger to self or others in order to the insurance company to cover the charges, or, that the patient was telling their psychiatrist things that they weren't telling their therapist. Any scenario in this case is not good.

With regards to children, there is another issue worth mentioning. Parents can voluntarily admit their children for inpatient psychiatric hospitalization, but, if a mental health practitioner recommends inpatient hospitalization for a child, then the parents might be obligated to follow that recommendation, and not following that recommendation might constitute medical neglect. Cases of suspected medical neglect may be reported to the Illinois Department of Child and Family Services for investigation. Additionally, if a report of suspected medical neglect is not made to DCFS by the practitioner, then that practitioner might be liable for failure to report neglect. Moreover, parents can sue a practitioner for not calling DCFS about them! This is a complex legal issue - I'm not a lawyer and this not legal advice, but just an illustration of how complex the issues of psychiatric hospitalization can be.

Mental Health Advice DisclaimerThe information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

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