Impatient Psychiatry

Sick In Sick Out

During the early years of my career, I worked primarily on inpatient units—both general and dual-diagnosis. In later years, although I stepped away from full-time inpatient work, I remained closely involved: covering when needed, consulting on especially challenging cases, and serving as the discussant for ritualized case conferences with trainees at all levels. Even toward the end, when my involvement was increasingly shaped by financial pressures and shrinking lengths of stay, I always approached the work with my feet firmly planted in a clinician’s shoes.

In short, I have an intimate understanding of inpatient psychiatric services. My experience is rooted in New York City and inevitably reflects the realities of dense urban environments. Still, I suspect many of the issues I describe transcend geography. That said, New York’s high rates of homelessness, limited housing, and extreme seasonal weather create additional challenges, and I welcome perspectives from colleagues practicing in different regions.

In my view, the quality of inpatient psychiatric care has sharply declined. Despite our pride in “advancements” and the increased societal focus on mental health, we are doing worse by the patients who rely on hospitals during their most vulnerable moments.

When I speak of quality, I mean both outcomes and the patient experience—an experience that, in our current system, strongly shapes how care is judged. Although inpatient psychiatry can be lifesaving, many patients experience it as unpleasant, uncomfortable, demeaning, and simply demoralizing. Here are some of the reasons I believe inpatient care continues to deteriorate despite improved biological therapies:

The physical environment.
In efforts to eliminate suicide risk (a worthy goal) and cut staffing costs (a harmful one), inpatient units have begun to resemble correctional facilities more than therapeutic spaces. Beds are heavy composite slabs bolted to the floor, often without headboards. Nightstands are nonexistent. Closets are open shelves. Shower doors are foam “saloon” flaps incapable of holding even a towel. Faucets have been replaced by holes that produce a thin trickle of water. Bathroom fixtures take inspiration from prison designs. Soft furnishings such as drapes are gone, replaced by institutional blinds controlled only by staff—another small but symbolic loss of autonomy. Many of these changes aim to enhance safety, but increased staffing could achieve the same goal while restoring a human element. Personal items and street clothes are discouraged. Even pencils must be rubberized, and a crayon is a privilege. Highly distressed, fragile and frightened people are housed in spaces that further disempower and dehumanize them. With every revision of safety regulations, the environment grows more austere, making “healing environment” an increasingly ironic phrase.

Reduced staffing and the erosion of continuity.
Budget cuts have pushed nursing ratios to inadequate levels. The shift toward 12-hour schedules—understandable from a lifestyle standpoint—means most nurses now work three days a week. In the past, a five-day schedule offered continuity: a patient might have the same nurse for most of their hospitalization. Today, a new nurse often appears each day, making it harder to build therapeutic alliances with the very professionals tasked with “nursing” patients back to health. Even under the old model, the burden of documentation limited time for genuine conversation. Now, with increased ratios and ever-expanding forms, scales, and screens, the time available for meaningful connection is even slimmer.

The loss of key therapeutic roles.
Social workers, once central to family meetings and in-depth discussions of psychosocial challenges, are now consumed by the urgent need to discharge. It has become a relentless game of whack-a-mole, driven by bed pressures rather than clinical readiness. Psychologists—who often provided the sole psychological perspective on rounds and suggested behavioral interventions to prevent violence, seclusion, or restraint—have been eliminated from many units as an “unnecessary expense.” Their departure accelerates the shift toward purely medical psychiatry. With younger psychiatrists trained almost exclusively in this model now leading units, any hope of including a psychological approach has nearly vanished.

Increased Medicalization of the field.
Not all patients that are admitted to a psychiatric unit need to be treated with medications. Yet few if any leave without them and often more than just one or two. When I speak to the clinicians who work on these units, I hear a few reasons, the most trite being that the insurance company would refuse to pay for an admission if the patient was not prescribed medication. Not only are these medications then continued by the outpatient psychiatrists, but the erroneous diagnosis then stick. A simple interpersonal or social crisis that prompts an admission, now is sets up for years of care. Timid and unquestioning providers continue these medications ad nauseum. Healthcare costs balloon and so on.

Pressures to shorten length of stay.
While minimizing unnecessary hospitalization is a reasonable goal, the pendulum has swung too far. Patients are increasingly discharged while still actively symptomatic and in the midst of acute episodes. In cases of mania or psychosis, this often results in rapid re-hospitalization—sometimes multiple times in quick succession. If the patient cycles through different units or hospitals, clinicians may mistakenly conclude that medications are ineffective, triggering unnecessary regimen changes or, worse, harmful poly-pharmacy. (See my earlier post on this.)

Less time with patients, more time with computers.
Combine shortened stays, reduced staffing, and ballooning documentation demands, and the outcome is predictable: vanishing patient contact. Two decades ago, the main challenge on an inpatient unit was finding an available interview room. Today, the challenge is finding a free computer. I often say—only half joking—that the sound of psychiatry used to be a thoughtful “hmm-hmm.” Now it’s the relentless clicking of keys. Few clinicians even look for a quiet space anymore; most barely have time to stand at the bedside, conduct a perfunctory risk assessment, and complete the mandated safety plan before rushing back to their keyboards.

I take great pride in being a psychiatrist and continue to celebrate the lifesaving role our field has played for so many individuals. I still find deep satisfaction in watching acute episodes respond to the treatments we prescribe and in witnessing the progress we’ve made—both in clinical effectiveness and in minimizing side-effect burden.

Yet as I write this, I can’t help but wonder: are these simply the reflections of a curmudgeon casting a shadow on a field enjoying a renaissance in our understanding of mental illness? Or should we, in fact, be taking a harder look at how to further reduce our patients’ suffering and push back against some of the troubling changes I’ve described? I welcome your views