Inpatient Evaluation and Management of First-Episode Psychosis
Richard Fraser
Peter Burnett
Patrick McGorry
Rationale for a First-Episode Psychosis Service and Inpatient Unit
Inpatient units are often the first point of entry to mental health services for new patients and their families. Patients who need inpatient care are likely to be more disturbed, have less insight, and be at greater risk of harm or neglect than those who can be treated in an ambulatory setting. Yet the experience of hospitalization itself can be traumatic,1 and if not handled well may impair subsequent engagement and treatment alliance.
Potential benefits of early intervention and treatment in psychotic illness include reduced morbidity, speedier recovery, better prognosis, preservation of psychosocial skills, preservation of family and social supports, and decreased need for hospitalization.2 Other aims of an early intervention service include minimizing the use of restrictive and coercive practices, initiation of low-dose atypical antipsychotic medications, and maintenance of continuity of care.3 A long duration of untreated psychosis (DUP) may be detrimental,4, 5, 6 and during recent years the idea that neurotoxicity occurs during onset of illness has gained credence.7 Intervention early on in a critical period may improve outcome by minimizing damage.8 This is the philosophy underpinning the early-intervention ethos,9 and inpatient units have a particularly important role to play in fostering these principles.10
The goals of inpatient care for first-episode psychosis (FEP) have some elements in common with other psychiatric inpatient care, and this chapter will not duplicate discussions elsewhere in this book. The authors focus on a young person’s FEP inpatient service, such as the one at ORYGEN in Melbourne, Australia. The Early Psychosis Prevention and Intervention Center (EPPIC) at ORYGEN is one of the first youth-specific services and has developed an expertise in the early identification and treatment of psychosis in young people. Some of the key principles are outlined in Table 11.1.
Optimal treatment for psychosis requires a staging approach to illness.11,12 Staging allows a more sophisticated approach to management based not only on diagnosis but also on the phase of illness.13 A young person with a first episode of psychosis will need a very different service from an older person with established schizophrenia. Adult psychiatric services are not always geared up to engaging and treating young people with emerging psychotic disorders. Often the symptoms are not severe enough or specific enough to gain entry into mainstream services. Delay in recognition, engagement, and treatment initiation may result,14 often with a traumatic first crisis admission when either the family support structure can no longer cope or the behavioral disturbance of the young person is so severe it cannot be ignored. There may be police involvement, restraint, and traumatization of not only the patient but also the family and those involved in the admission process. Although it is desirable to offer treatment in the least restrictive setting with home-based treatment of FEP, hospitalization is often necessary for a short period of time to assess and initiate treatment for those who are too unwell or too risky to manage in the community.
TABLE 11.1 GOALS OF INPATIENT CARE | |||||||||||
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Conversely, a service set up specifically to identify proactively and engage those with FEP early on in the illness aims to minimize trauma and maximize chances of engagement and retention in therapy.15 There is an increasing number of such services worldwide as well as specific organizations (International Early Psychosis Association, IEPA) and research centers (Early Psychosis Prevention and Intervention Center, EPPIC, Melbourne, Australia).
The incidence and prevalence of mental illness vary with age, with high rates in adolescence and young adulthood. More than 75% of all serious mental health and related substance use disorders commence before age 25 and approximately 14% of 12- to 17-year-olds and 27% of 18- to 25-year-olds experience such problems in any given year. A recent study showed that 40.8% of patients had their onset of psychosis between the ages of 15 and 19 years.16 A youth mental health model takes into account a developmental perspective and the age-specific needs of younger people. These data relate to young people with FEP; those with a later onset of psychosis will not be addressed in this chapter (see Chapter 16).
An Ideal Setting
General adult psychiatric inpatient units typically contain 24 beds or more with one communal area. Because of the need to care for a wide variety of disorders and a patient group with predominantly long-standing mental health problems, the setting is not ideal for the patient with FEP. Patients with FEP are mainly a younger group and are unlikely to have experienced mental health inpatient facilities in the past. They are usually medication-naive, more impulsive yet unknown quantities as far as risk is concerned, and more likely to have comorbid substance use disorders. They are still developing in all areas including social and cognitive domains. As a result their needs and those of their families are different from those with established mental illness.
Consequently, the authors recommend where possible a dedicated inpatient unit for patients with FEP (including those within 3 years of diagnosis) with smaller numbers of beds—a 16-bed unit divided into two or three subunits. A separate locked area can be used for more intensive care and to provide a low-stimulus environment for up to four patients. If it is not possible to provide a dedicated unit then part of an existing ward could be used for this purpose. The FEP inpatient unit needs to be able to provide a positive initial experience of the mental health service as these first few days of contact are crucial to developing a good therapeutic alliance and maximizing the chance of retention in treatment. The environment should be as low-key and homely as possible in order to minimize “culture shock” on arrival and to promote an atmosphere of safety and healing. Attention should be paid to important personal issues including flexible visiting times for families and friends, a family room for parents to stay overnight, access to telephones, and a space to prepare snacks. Leisure facilities should include a television area, music facilities, and recreational facilities where possible. An outdoor area for exercise and fresh air is desirable. Although ward policy may not allow smoking, if this is allowed there should be a designated area for this.
Locked-door policies are generally not appropriate despite many of the patients being involuntary. Generally research supports the idea of an open ward in order to promote a less restrictive atmosphere and increased patient and family satisfaction.17 Patients who are a serious absconding risk can be managed in the low-stimulus locked area or maintained on 1:1 observation rather than locking the whole unit.
Information regarding the inpatient unit, mental health law, the management of various disorders, and substance abuse should be provided in written form in an easily accessible location. New patients need to be oriented to the unit as soon as feasible. Clinicians must bear in mind that patients with FEP and their families may have misconceptions and fears about such places largely based on myths from the media and popular culture.
Referral Process
An acute FEP inpatient unit needs to be able to accept referrals at any time. At ORYGEN, the youth assessment team triages referrals and considers alternatives before admitting. Patients with FEP may have significant histories of substance use, legal problems, and risky behaviors that need to be identified at the point of referral. Occasionally admissions are elective, for example, to initiate clozapine treatment or for an inpatient assessment of a complex presentation.
Involuntary Admission
Many people experiencing FEP have limited or no insight. Outpatient treatment of those with aggressive or suicidal behavior may be unacceptably risky, and initiation and supervision of treatment may be difficult in the community. In such cases involuntary admission may be necessary. This process can be frightening and disempowering for the patient and family. Retraumatization may occur if there have been previous incarcerations, for example, prison or forced deportation. A clear and transparent care plan should be presented to the patient and family including information about the relevant mental health law. Families and treaters are often concerned that the therapeutic alliance will be damaged by this process, as indeed it may be, although clearly in these situations the risk of not admitting will take precedence. Providing the patient and family with clear explanations will make the team less likely to be accused of trickery or foul play. The alliance can be repaired later on. Indeed, patients and families will often agree later that the detention was necessary and appropriate.18
Involuntary admission should be for as short a time as possible and in the least restrictive environment. The patient’s wishes should be respected wherever possible. Often negotiation of personal issues such as access to a computer, seeing visitors, or having accompanied leave from the unit can assist in allowing the patient to maintain some autonomy and control in what otherwise may be experienced as a jail sentence.
The use of community treatment orders (outpatient commitment) where available can facilitate early discharge from hospital and embraces the philosophy of treating in the least restrictive environment. In the authors’ experience, if engagement and psychoeducation are addressed enthusiastically during the inpatient stay, the need for involuntary community treatment is reduced.
When to Admit
The need for hospital admission arises when the risks to self or others cannot be managed safely at home, when home support is insufficient or has been overstretched, or when lack of insight impedes assessment and treatment in the community. In a recent study at EPPIC three-quarters of the patients with FEP were admitted to an inpatient unit at some stage during the first 3 months of treatment.19 Admission should not be seen as a failure on the part of the family or the community team. A brief spell in hospital should be framed as a chance for all key players to get to know each other better and for engagement to be nurtured.
Wherever possible, admission should be arranged before a full-blown crisis has developed and police are required to assist the process. In an integrated FEP service the patient with an evolving psychosis
is already in treatment with a lower chance of unexpected crises precipitating admission. Of course sometimes a “difficult” admission cannot be avoided. In these cases it is essential that the team be aware of risks and maintain the safety of patient, family, and professionals while being mindful of minimizing trauma and stigmatization during the process.
is already in treatment with a lower chance of unexpected crises precipitating admission. Of course sometimes a “difficult” admission cannot be avoided. In these cases it is essential that the team be aware of risks and maintain the safety of patient, family, and professionals while being mindful of minimizing trauma and stigmatization during the process.
Engagement and Interview Technique
Engagement is arguably the most important factor in ensuring an optimal outcome from treatment in FEP or indeed any illness. Adherence to medication is notoriously poor in medicine and particularly in psychiatry where insight may be compromised.20 Special skills are required to engage a young person with FEP. Common ground needs to be sought so that patient and clinician are able to agree on the first steps forward. No particular style of interviewing works better than another, although a less interrogative approach is preferred, with active listening, frequent checking that information is correct, and use of lay language where possible. Crucially with this patient group clinicians should try to “be themselves.” Young people with FEP are likely to be guarded and suspicious, may be frightened, and may be intimidated by those in authority. A genuinely caring attitude and interested demeanor helps to put patients at ease.
Wherever possible, patients need to be provided with options regarding management. This flexibility will limit their sense of lost control and foster a trusting relationship. Often when insight is impaired this ability to gain the trust of the patient allows treatment to begin and coercion to be avoided. Early on in the engagement process the clinician should respect the patient’s interpretation of psychotic experiences as much as possible. Confrontation at this stage is likely to be counter-therapeutic. This stance needs to be balanced by the clinician’s own judgment of the situation and the provision of relevant information and advice regarding treatment (see Table 11.2).
Assessment
The assessment process can be seen as the first step in engaging the patient and family with the service. Careful integration of the assessment process should minimize the number of clinicians involved and unnecessary duplication of data-gathering.
A comprehensive assessment includes a clinical history focusing on evolution of the psychotic episode from prodrome or at-risk mental state through transition to frank psychosis. Onset of symptoms, course, duration, and ameliorating factors are all important to consider, and collateral information from different sources including family and other professionals is required to verify and complete the picture. Possible risk factors for psychosis should be sought including family history, perinatal history, developmental history, premorbid personality, and organic factors such as epilepsy or brain injury. The latter are rare
in this age-group but should not be overlooked. The workup for such organic conditions is discussed extensively in Chapter 5.
in this age-group but should not be overlooked. The workup for such organic conditions is discussed extensively in Chapter 5.
TABLE 11.2 ENGAGEMENT TECHNIQUES | |||||||||||||
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Exploring the history of psychiatric and medical problems together with past treatment and investigations is important. Potential precipitants of the psychotic episode should be enquired after, such as substance use and psychosocial stressors. A careful evaluation of risk is essential, particularly of suicide and violence, and must be incorporated into the formulation and management plan. Overall, the clinical history should aim to inform the treating team of “why this person, with this illness, at this time?”
Some aspects of mental state examination are worth mentioning in relation to FEP. It is important to be aware of situational and diurnal variations in presentation. The patient may conceal psychotic symptoms to avoid prolonged hospitalization or perceived unnecessary treatment. Different staff may elicit different symptoms. Presentation may alter over the course of the day. Early on patients tend to be lethargic; energy level and agitation may increase in the afternoon.
As patients with FEP are new to psychosis and are still developing cognitively their symptoms may not be classic. Early in the acute phase of illness the psychosis may be more florid, with perplexity and fear prominent features. Delusions may be fleeting and poorly formed or systematized. Equally, because of the variable presentation it may be difficult to determine with confidence what is psychosis and what is within the broad range of normal for the young person’s developmental stage. Some beliefs that appear unusual to the clinician are culturally sanctioned. If the DUP has been lengthy there has been more time to develop a system around the beliefs, and the patient may experience less distress. Indeed, the family or carers may have come to accept some of these beliefs as personality-based rather than part of an illness. A shorter DUP is associated with fewer bizarre delusions, but these may be discussed quite readily with the clinician.21
Depressive and anxiety symptoms are extremely common and should be looked for actively. These symptoms are unwelcome for the patient and therefore can serve as the common ground on which to initiate a treatment plan in those with poor insight. Insight itself is multifactorial and requires special attention. It is not a binary construct but rather a continuum implying individuals’ understanding of their well-being and the need to access appropriate treatment. Cognitive function, mood, and level of arousal all affect insight.
Cognitive functioning and the negative symptom profile need assessment as these affect the prognosis for functional recovery. Those whose cognitive functioning has been significantly impaired by the FEP are less likely to make a full functional recovery. This may be related to the possibility of direct neurotoxicity as a result of longer DUP.22 Similarly the presence of significant negative symptoms makes a full functional recovery less likely.23
WARD-BASED ASSESSMENT
Although it is possible to assess a patient with FEP in a community setting, the inpatient unit provides a secure environment where risk can be managed and a more intensive assessment can be carried out. In FEP this includes a behavioral assessment, mental state assessment, and risk assessment with contributions from all members of the interdisciplinary team. An initial period of 24 to 48 hours’ antipsychotic-free observation provides valuable information regarding initial presentation, evolution of symptoms, and influence of setting in order to formulate better the individual patient’s illness and ensure appropriate treatment. When psychotic presentations are complicated by substance use, vague symptoms, or an unsubstantiated history this period allows for careful consideration before initiating antipsychotic drug treatment. This period is not treatment-free. Benzodiazepines are recommended for symptomatic relief of anxiety and promotion of sleep. Psychological support, good nursing care, family work, and addressing of physical health needs also occur during this time. If there is very disturbed behavior or significant aggression, emergency treatment including antipsychotic medication may be needed.
NEUROPSYCHOLOGICAL ASSESSMENTS
Neurocognitive deficits in psychosis are well documented. Patients with FEP appear to have some cognitive impairment already,24 with further impairment occurring during the early course of the illness
and then plateauing.25 Deficits include attentional, information processing, and verbal memory and learning impairments. Brain changes observed using imaging studies correlate reasonably well with these neuropsychological deficits and indicate involvement of prefrontal and temporal regions.26
and then plateauing.25 Deficits include attentional, information processing, and verbal memory and learning impairments. Brain changes observed using imaging studies correlate reasonably well with these neuropsychological deficits and indicate involvement of prefrontal and temporal regions.26
In recent years it has become increasingly evident that cognitive dysfunction is an important determinant of outcome variables such as work and psychosocial functioning. The degree of cognitive impairment also has an impact on insight, medication adherence, and coping skills. Consideration needs to be given to postdischarge planning when impaired memory and cognition are likely to reduce ability to manage medication, appointments, and therapy or psychoeducation.
Both nonprescribed and certain prescribed (e.g., benzodiazepines, anticholinergics) medicines are likely to cause further impairment in the already cognitively challenged and may also lead to either self-medication or nonadherence. Information needs to be provided in clear format, in lay terms, in multiple media (oral, written, and visual) and on several occasions in order to maximize impact. Involvement of family and carers where appropriate also aids in getting the message across. Atypical antipsychotic medication may ameliorate neurocognitive deficits (see subsequent text).
Intelligent quotient (IQ) and personality testing is not generally valid while a patient is acutely psychotic. Involvement of a neuropsychologist at an early stage during recovery is sometimes useful when learning problems are suspected. Premorbid level of functioning can be estimated from school or college reports and prior psychometric testing. In practice not every patient with FEP can get neuropsychological testing, but such testing can provide valuable prognostic information as well as allowing for monitoring of progress.
Ultimately, those with significant neurocognitive deficits may benefit from vocational advice as a return to previous work or college placement may not be realistic and may place undue stress on the individual. This potentially paternalistic attitude must be balanced with an open-minded view and a hopeful outlook to avoid the danger that the clinician, not the illness, prevent people with psychosis from pursuing their goals.
RISK
An initial risk assessment must be carried out at the point of admission in order to ensure safety of the patient, others, and the environment. In reality this process of assessing risk began before admission. Collateral information will have been gathered where possible. A formal risk assessment tool aids in assessment, but this should be used in conjunction with clinical judgment. Effective communication of risk is crucial in safely managing any psychiatric patient. With patients having FEP there may be more unknown variables because they are new to treatment and potentially more aggressive, agitated, substance-using, and impulsive than patients who are already in treatment. They are generally medication-naive and unlikely to have had a complete physical workup.
Suicide
Suicidal ideation is common in patients with FEP. Up to 23% experience such thoughts, and 15% have a history of previous suicide attempts.14 Ten percent to 15% of psychotic patients eventually commit suicide with the risk highest in the first few years of illness.27 All patients should be asked about suicidal ideation, intent, and planning. Inquiry does not increase likelihood. Gentle but focused inquiry can happen toward the end of interview once some rapport has been established. Further discussion of suicide risk assessment is offered in Chapters 2 and 9.
Risk of suicide in FEP can be increased by factors including psychosocial stress, current substance use or withdrawal, and psychotic symptoms such as command auditory hallucinations and paranoid delusions. Protective factors also need to be considered and can provide the clinician with ideas for interventions aimed at decreasing risk. Suicide risk assessment must include a discussion with the patient about how to get help on the inpatient unit should suicidal feelings arise—whom to alert and what sorts of interventions might be initiated. Suicide risk in patients with FEP is changeable, especially early on in the admission. Frequent risk assessment reviews should be carried out, especially at times of change such as lowering of level of observation or at discharge. It is not unusual for patients with FEP to expect a quick fix, so a realistic time frame needs to be negotiated in order to minimize frustration and impulsivity.
In the inpatient setting, it is important to pay attention to the history and behavior of the patient, not just what he or she says about current intent. Most of the successful inpatient suicides denied intent shortly before the act. Agitation is a reliable indicator of suicidal thinking.28 Significantly, early intervention in psychosis has been shown to reduce suicide risk.21,29
Violence
Assessment of violence risk shares much with suicide risk assessment. There are static factors including history of aggression and personality as well as demographic variables such as male gender and younger age. Clinical, dynamic variables appear to be more important predictors of violence for acutely psychotic patients in the inpatient setting. These dynamic risk factors include hostility, suspiciousness, agitation, and cognitive impairment. Substance use is an important risk factor and is discussed in the subsequent text. In the FEP inpatient population, those at greatest risk of violent behavior appear to be recently admitted males.18
The ward environment and culture deserve special mention. Design of the ward needs to allow patients a degree of space and privacy where possible but without compromising safety, access, and visibility. When acutely unwell young people are placed together in close proximity and possibly involuntarily the chances of aggressive outbursts are increased as feelings of threat, frustration, and anger are acted out. Staff require training in managing such behavior, both preventive and acute. Locked wards where nursing and medical staff are inaccessible much of the time behind doors breed an “us and them” culture. Increasing demands for cigarettes, leave, and medication lead to frustration on the part not only of patients but also of the staff, leading to the potential for further division. Staff morale, training, and ward milieu all contribute to minimizing this effect and maximizing satisfaction amongst patients, families, and professionals. Incidents of violence need to be reported and analyzed in order to learn and adapt ward policy to prevent these behaviors from becoming entrenched. Patient violence needs to be managed proactively. Unchecked, it becomes a major source of dissatisfaction and demoralization for staff, especially nurses who bear the brunt of its effects.
Risk to environment
Acutely psychotic patients, who may be paranoid, agitated, and frightened, are at risk of harming their environment. This includes damage to property because of primary aggression (antisocial or substance-related) and also because of delusional beliefs, command auditory hallucinations, or disorganization. Management might include nursing in a low-stimulus environment, one-to-one observation level, and adequate medication such as short-term use of benzodiazepines.
Absconding
The risk of absconding from the inpatient unit is increased early on in an admission, during substance withdrawal, when insight is impaired, and when therapeutic alliance is limited. Patients who abscond tend to be younger males with frequent readmissions, paranoid and manic presentations, and comorbid substance use or antisocial personality traits.18
Although it may be tempting to keep wards locked to prevent elopement, in the authors’ view the overall outcome is to produce an unpleasant environment that increases the risks of aggression, nonadherence, and oppositionality.17 Therefore while initially it is advisable to err on the side of caution if there are concerns about absconding, the team should be realistic about what the actual risks are should the patient abscond and concentrate on developing an alliance rather than being unnecessarily restrictive. In the authors’ experience, where possible it is usually better to negotiate leave from the unit for patients allowing them some control and hence decreasing the risk of absconding. An individualized care plan should seek to address this issue and is preferable to sweeping ward policies regarding locked wards.
Vulnerability
People with psychotic disorders are vulnerable to exploitation and victimization by others. Within inpatient units with high levels of acuity there are opportunities for vulnerable patients to become
victims of violence, sexual harassment or assault, and other crime such as theft of personal belongings. Particularly vulnerable patients should be identified early and measures taken to protect them such as one-to-one nursing until they are more settled.
victims of violence, sexual harassment or assault, and other crime such as theft of personal belongings. Particularly vulnerable patients should be identified early and measures taken to protect them such as one-to-one nursing until they are more settled.
Nonadherence to treatment
Treatment nonadherence in FEP may be more common than in other psychiatric populations. Although not a great deal of research has been carried out in this area, estimates in the region of 60% nonadherence rates in FEP populations have been quoted.30 Clearly this confers a significant risk of early relapse in psychotic illness, leading to further behavioral disturbance and readmission.31 Treatment nonadherence in a young group with FEP could be interpreted as a normative response and denial of illness. Younger people are cognitively less mature and may feel immortal or beyond the usual rules of society and life. Although this is an understandable response to danger or bad news, clinicians need to address this faulty schema in order to minimize chances of nonadherence, not only to medication but also to other aspects of treatment. An initial assessment of patient attitude to treatment, explanatory model of illness, and family attitudes to treatment will help inform the clinician of likely stumbling blocks when planning and initiating treatment. Using the lowest possible dose of an atypical antipsychotic in order to minimize side effects is likely to have a positive effect on adherence, as is inclusion of the patient in formulating the management plan and involvement of family and carers early on.
Treatment nonadherence also occurs on inpatient units even with supervision of medication. It should be suspected when there is unexpected deterioration in symptoms or failure to improve.
Social/Occupational Functioning
Functional recovery in FEP has to some extent been overlooked until recently. Achieving remission from positive and negative symptoms is often the goal, and the most commonly used objective outcome measurements such as the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Symptoms Scale (PANSS) reflect this. EPPIC data show that although >90% of FEP patients make a symptomatic recovery, only 50% make a functional recovery, that is, a return to their previous role, perhaps as a student or employee.32 Because of the usual age of onset, FEP is likely to interfere with important developmental tasks including completion of education and starting work.
Research has shown that early psychosocial interventions improve vocational outcome.33,34 During an inpatient stay there should be some assessment of social functioning to get an idea of premorbid abilities, support networks, and goals. Occupational therapists are able to provide assessments of functioning to guide postdischarge management, especially if independent living is a possibility. Functional aspects of recovery should begin to be addressed on the inpatient unit where resources exist for a practical evaluation of daily living skills and social strengths and weaknesses. Inpatient groups are particularly useful in alleviating boredom while assessing living skills and preparing patients for more structured programs after discharge.
Outcome Measurements
Psychotic symptoms are often the focus of attention, but other outcomes are also important including nonpsychotic psychiatric symptoms, side effects of medicines, psychosocial functioning, disability, satisfaction with services, substance use, and family burden.2 Various tools are used to measure these outcomes, such as the BPRS, Clinical Global Impression (CGI) scale, the Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS),35 the Quality of Life Scale (QLS),36 and the Global Assessment of Functioning (GAF) scale.
Diagnosis
Diagnosis in FEP is not particularly stable, with approximately 25% of initial diagnoses altering over the first 6 months.37 Nonetheless, in order to formulate a management plan a working diagnosis is
necessary. The authors advocate an interdisciplinary approach using an integrated biopsychosocial model to generate this diagnostic formulation. It can be difficult to make a stable or precise diagnosis of subcategories of psychosis early on in the first episode. Symptoms and signs can change and vary in intensity. Comorbid substance use, personality disorder, and normal variations in development can obscure the underlying illness. The threshold for diagnosis of psychosis can at times appear arbitrary. At EPPIC the authors have defined it as the duration and intensity of psychotic symptoms that would indicate use of antipsychotic medication. Operationally this equates to the presence of clear-cut delusions, hallucinations, or severely disorganized speech lasting at least 1 week.18
necessary. The authors advocate an interdisciplinary approach using an integrated biopsychosocial model to generate this diagnostic formulation. It can be difficult to make a stable or precise diagnosis of subcategories of psychosis early on in the first episode. Symptoms and signs can change and vary in intensity. Comorbid substance use, personality disorder, and normal variations in development can obscure the underlying illness. The threshold for diagnosis of psychosis can at times appear arbitrary. At EPPIC the authors have defined it as the duration and intensity of psychotic symptoms that would indicate use of antipsychotic medication. Operationally this equates to the presence of clear-cut delusions, hallucinations, or severely disorganized speech lasting at least 1 week.18
Related posts:
The Ins and Outs of 200 Years of Psychiatric Hospitals in the United States
Psychosocial Approaches in Inpatient Psychiatry
Legal Issues in Inpatient Psychiatry
Psychiatric Education on the Inpatient Unit
The Patient with Borderline Personality Disorder
Evaluation and Management of Substance Use Disorders on the Inpatient Psychiatric Unit
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