The Elderly Psychiatric Inpatient
Vassilios Latoussakis
Sibel A. Klimstra
Dimitris N. Kiosses
Balkrishna Kalayam
George S. Alexopoulos
Aging is associated with physiological and psychological changes that may alter the manifestation, course, and treatment response of both general medical and psychiatric disorders. With advancing age, mental health problems develop ever more frequently in the context of medical and neurologic illness. Adopting a “geriatric-friendly” approach means to be attuned to those age-associated changes and to the complex interactions of mental and physical factors in the elderly population.
Beginning in the early 1980s, many recognized the benefits of treating medically ill elderly patients in specialized geriatric units as opposed to mixed-age medical units.1,2 Similarly, elderly patients (i.e., those older than 64 years) in need of acute inpatient psychiatric care may benefit more from an admission into a specialized geropsychiatric unit as opposed to a mixed-aged unit. Over the last 25 years, an increasing number of geropsychiatric units have been established in general hospitals in recognition of the uniqueness of this age-group and the importance of integrating psychiatric and medical care in this population.
On a specialized geropsychiatric unit, elders are more likely to receive comprehensive medical and cognitive assessments, monitoring of psychopharmacologic side effects and blood levels, and aging-sensitive aftercare referral.3
Within a geropsychiatric unit, multidisciplinary teamwork and the use of mental health assessment protocols have been found clinically important.4 In a study of 31 inpatient psychiatry units across the country, geriatric professionals were surveyed to understand what practices were adopted for optimal care. Physical modifications included handrails, tub lifts, specialized furniture such as moveable gerichairs, recliners, lowered and/or electric beds and hospital beds, wheelchair accessibility, specialized flooring, and increased walking areas. Safety emphasis included restraint reduction, fall prevention plans with protocols and screening, and monitoring of physical signs and symptoms such as pain, dysphagia, and oral intake. Increased family contact was encouraged. More than 75% of all specialized geriatric units provided reminiscence groups, family and patient education, exercise and music groups, and recreational/leisure activities. Fifty-five percent of the units used nurse-led groups. Challenges to care included nursing staffing shortages, lack of staff training in geriatric psychiatry, patient medical acuity, balancing restraint/seclusion regulations with fall prevention, and discharge placement difficulties. Excellence in multidisciplinary care (67% of respondents) was the factor most commonly identified for a successful unit. Additional factors included availability of geriatric medicine physicians and on-unit services.5 Readily available on-unit geriatric medicine and neurology consultation services are optimal, given the high degree of medical comorbidity.
The adaptation of successful geriatric psychiatry inpatient care within existing mixed-age frameworks is an alternative milieu model to an independent geropsychiatry unit that, while perhaps ideal, may not be feasible for administrative or financial reasons. Faced with these limitations, one study describes an inpatient “geropsychiatric unit without walls.” A senior team program for geropsychiatric inpatients was created within an existing adult inpatient unit of a general hospital. Geriatric patients were clustered together, physical modifications were made including a senior team lounge near the nursing station, and staff received geriatric care training. Remarkably, over the first 14 months of the program, the elderly “fall” rate was reduced and no geriatric patient required restraints.6 Additional geriatric milieu management
requires awareness that cognitive impairment may limit psychotherapy; the use of “behavior as communication” becomes critical. Tolerance of wandering behaviors, while monitoring safety, is encouraged.7
requires awareness that cognitive impairment may limit psychotherapy; the use of “behavior as communication” becomes critical. Tolerance of wandering behaviors, while monitoring safety, is encouraged.7
The most common primary diagnosis among elderly psychiatric inpatients is depression, which accounts for 33% to 73% of cases. Dementia complicated by psychosis or behavioral disturbances is the second most common primary diagnosis, followed by psychotic disorders (10%), bipolar disorder (8% to 10%), substance-related disorders (6% to 7%), and delirium (4% to 5%).8, 9, 10, 11
Despite the general trend toward shortened inpatient length of stay,12 certain factors predict protracted stays among psychogeriatric patients:8 higher Brief Psychiatric Rating Scale positive symptoms scores, electroconvulsive therapy (ECT), falls, pharmacologic complications, history of multiple psychiatric hospitalizations, legal proceedings for continued inpatient treatment, delays in consultations, and lack of ECT on weekends.
The chapter is organized along the lines of the customary phases of inpatient work: admission, evaluation, management, and discharge. This is done more for convenience of organization than to suggest that there are clear demarcating lines between those phases.
Admission
Psychiatry patients who are older than 64 years are almost twice as likely to be treated as inpatients, compared with younger adults.13 They can be admitted from a variety of settings—medical inpatient units, assisted living or skilled nursing facilities, or the community.
Two clinical problems are especially relevant in the elderly and frequently trigger a psychiatric inpatient admission: suicidality and inability to care for oneself.
Case Vignette
The 81-year-old white retired accountant took his own life by shooting himself in the head. His daughter had returned unexpectedly to pick up something she needed for an errand and was horrified to discover him lying on the floor of his bedroom. On the bed, he had left a note directing her on financial matters. She had known that he was having a rough time lately. A few years ago, his wife had passed away after a long battle with colon cancer. Since then, he had seemed more sullen, but things had taken a turn for the worse several months previously when his oldest son and his family moved away to another state. Usually keeping to himself, the only things he had enjoyed were spending time with his grandchildren and taking care of the garden. After they left, he had grown more silent and made frequent cynical and pessimistic remarks about himself and the world in general all the while denying feeling depressed. He had stopped attending to his garden and did not leave the house for days. His heart was failing him too. Three weeks before his death, he had visited his primary care doctor who had made some changes in his regimen for congestive heart failure and prescribed clonazepam for anxiety. More recently, his sleep had deteriorated; he paced for hours in the middle of the night and, on a couple of occasions, his daughter had heard him talking to himself or somebody else with harsh words. He had refused to seek psychiatric help throughout this period and had gotten increasingly upset when she urged him to talk to someone about the way he felt.
Suicidality affects the elderly disproportionately. Although they represent 13% of the population, they account for 18% of completed suicides.14 Elderly white males are mostly responsible for the increased suicide rate, which, for those older than 75 years, is almost double that of the general population.15 Elderly persons attempt suicide less frequently than younger adults, but when they do they use more
violent means of suicide and are more likely to succeed in taking their own lives.16 Firearms, which account for 70% of suicides among those 70 years and older, independently increase the risk for suicide.17
violent means of suicide and are more likely to succeed in taking their own lives.16 Firearms, which account for 70% of suicides among those 70 years and older, independently increase the risk for suicide.17
As the vignette illustrates, elderly with depression are less likely to report depressed mood or suicidal ideation compared with younger people.18,19 Indeed, most of the elderly who commit suicide have never made a previous attempt and have never received psychiatric treatment. The single most significant risk factor for suicide in the elderly is a depression diagnosis. Both major and nonmajor depression increase the risk for suicide,20 although depression severity is highly correlated with suicide risk in the elderly.21 Psychotic depression, active or remitted alcohol and substance use disorders, impaired functional level, and bereavement or recent loss also increase the risk of suicide in the elderly.22,23 Psychotic depression often requires inpatient treatment because of the increased suicide risk, and the likely need for combination pharmacotherapy or ECT warranting close monitoring, especially in the frail elderly with medical comorbidities.24
Case Vignette
Mrs. R, now almost 75, always preferred to have lunch at the local senior citizen center. Her chronic bronchitis, congestive heart failure, and marked obesity restricted her agility and it took her almost 45 minutes each way to walk the three blocks from her first-floor walk-up apartment to the center. The social workers greeted her with warmth everyday. These short exchanges were, on most days, the only meaningful interaction for Mrs. R, who had been estranged from her two adult children and lived alone for as long as anybody remembered. Every few years or so, she would draw attention upon herself by accusing a staff member or one of her senior peers of something sinister, usually stealing, eavesdropping, or plotting something against her. Her accusations were never substantiated. In the wake of such an incident, she would stop dropping in for lunch for a few days but then she would reappear. After one such incident though, she was not seen at the center for more than a month. The senior social worker alerted the adult protection services and a field worker paid a visit to Mrs. R. With the help of the building’s superintendent, they entered her apartment only to discover Mrs. R lying on the floor, unable to get up, mumbling something about “strange odors coming from the people upstairs.” She was malodorous, had not eaten or taken her medications for days, but kept insisting they leave her alone.
Cognitive impairment and medical comorbidities frequently coexist in elderly psychiatric inpatients. Elders with dementia are often admitted for severe behavioral disturbances or uncontrolled aggression. As in the case just described, when a community-dwelling older person becomes incapable of self-care, an admission is warranted. Such patients may be dehydrated, malnourished, and unable to adhere to their medication regimens. Because of their physical frailty, cognitive deficits, or medical comorbidities, it may be unsafe to evaluate and treat their psychiatric problems as outpatients.25 When medically ill or medically high-risk patients require inpatient psychiatric treatment, a combined medical/psychiatric geriatric unit offering integrated monitoring and treatment26 or a psychiatric unit within a general medical hospital are preferred treatment settings.
Diagnostic Evaluation
Evaluation should systematically attend to elderly specific factors such as the frequent coexistence of general medical and neurologic illnesses. Elderly psychiatric inpatients, like elderly general medical inpatients, have on average five to six active medical problems.10 The inpatient psychiatrist needs to collect historical information about psychiatric, general medical, and neurologic issues including all
medical conditions and medicines. Inquiry about any cognitive decline or deterioration in function or nutritional status is essential. Other sources of information such as family members, caregivers, and previous treaters should be sought because psychiatric illness as well as cognitive impairment may impair recollection or insight in the elderly.
medical conditions and medicines. Inquiry about any cognitive decline or deterioration in function or nutritional status is essential. Other sources of information such as family members, caregivers, and previous treaters should be sought because psychiatric illness as well as cognitive impairment may impair recollection or insight in the elderly.
Alcohol and over-the-counter and prescription medicines such as opiate analgesics and benzodiazepines are more commonly abused than illicit substances in the elderly27 and warrant specific inquiry. Such substances may cause mood and/or cognitive disorders and lead to withdrawal syndromes.
Past psychiatric history should attempt to differentiate between early-onset and late-onset disorders such as depression, mania, or schizophrenia because they may be associated with distinct clinical and treatment-response characteristics. Family history should include episodes of mood or cognitive illness in blood relatives, attempted or completed suicides, as well as any medical or neurologic illness giving rise to a psychiatric syndrome. An elderly-specific social history should focus on social support or isolation, including whether involved family members live locally, financial and retirement status, and any recent losses leading to bereavement. The ability to perform basic and instrumental activities of daily living is also included here.
Mental status assessment is not complete without a cognitive assessment. A brief, widely used, global standardized instrument is the Mini Mental State Examination (MMSE). It assesses domains of orientation, memory, concentration, language, and constructional ability. It is not sensitive in assessing executive function, a domain that may be impaired in dementias and geriatric depression. The clock drawing test, also a brief and standardized instrument, can reveal executive dysfunction in the depressed elderly28 and in elderly patients with a normal MMSE.29 Another brief and effective tool for dementia detection is the Mini-Cog,30 which combines a three-item recall question and the clock drawing test, and performs at least as well as the MMSE in culturally diverse elderly populations.31
A targeted but systematic physical, including neurologic, examination is necessary. Normal neurologic changes found in aged populations—such as head or neck tremors, muscle atrophy of the hands, restricted conjugate upward gaze, reduced vibration sense, and nonspecific gait disturbance—should not be confused with neurologic disease. On admission, the nutritional and functional status should be routinely assessed, including gait assessment and fall risk. Risk factors for falls in the inpatient geropsychiatric setting include cardiac arrhythmias, degenerative neurologic disorders (Parkinson disease, dementias), and use of mood stabilizers or ECT.32 Postural hypotension also predisposes to falls33 and sitting/standing vital signs should be a routine part of vital sign assessment.
Laboratory tests may assist in differential diagnosis, especially when medical factors are thought to contribute to or cause psychiatric signs and symptoms, and are routinely used to assess the safety of initiating a medication trial (e.g., lithium) or ECT. Upon admission, laboratory screening may include electrolytes, blood urea nitrogen/creatinine, fasting blood glucose, liver function tests, thyroid function tests, lipid profile, complete blood count, urinalysis, urine toxicology, and possibly blood alcohol level. Drug levels for nortiptyline, desipramine, lithium, valproic acid and digoxin, and prothrombin time/international normalized ratio (if warfarin is prescribed) should be ordered. Chest x-ray is usually part of the pre-ECT and delirium workups. Electrocardiogram (ECG) is often ordered.34 For dementia workup, routine laboratory orders include serum chemistries, renal, liver and thyroid function tests, vitamin B12, and complete blood count. Syphilis serology, urinalysis, erythrocyte sedimentation rate, heavy metal and toxicology screening, human immunodeficiency virus (HIV) testing, chest x-ray, electroencephalogram (EEG), ECG, and lumbar puncture may be ordered based on clinical suspicion.35 Initial dementia evaluations generally include a structural neuroimaging study such as magnetic resonance imaging (MRI) or noncontrast computed tomography (CT), especially in those younger than 65, in the presence of vascular risk factors, and when focal neurologic lesions are suspected. Functional neuroimaging studies are currently limited to special circumstances. In particular, Medicare will cover a positron emission tomography (PET) study as part of the differential diagnosis of patients with clinical symptoms of frontotemporal dementia.
Management
The main goal of inpatient psychiatric treatment is to initiate safe and effective acute-phase therapies while managing medical comorbidities, maintaining the patient in a supportive environment, and providing appropriate aftercare referral and treatment recommendations.
For ease of presentation, this section will examine medication and psychosocial approaches separately. The treatment of delirium and dementia with behavioral disturbances will be discussed first, followed by schizophrenia, geriatric depression, and geriatric bipolar disorder. Emphasis will be placed on the treatment of the two most common geropsychiatric syndromes in the inpatient setting, severe depression and dementia with behavioral disturbances.
PSYCHOPHARMACOLOGIC APPROACHES
Guiding Principles of Inpatient Geriatric Psychopharmacology
Starting dose and titration speed should be individualized. Although side effects often appear at lower dosages in the elderly compared to younger adults, chronologic age is only one factor to be considered. Equally important is the knowledge of general physical health status and co-occurring general medical and psychiatric disorders. In light of this, “start low and go slow” may apply differently to different elderly patients.
Usual target doses depend on diagnosis and class of medication used. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have similar target doses in the elderly as in younger adults, whereas the target dose for neuroleptics in the elderly is diagnosis-dependent. Compared with younger adults, the elderly require lower target doses for schizophrenia and lower doses still for dementia-related psychosis and behavioral disturbances.36,37 Because adequate target dose is critical, the “start low and go slow” principle may have to be revised to “start low, go slow, but get there.”
The list of coadministered medicines should be scrutinized to uncover potential drug-drug or disease-drug interactions A number of on-line drug information databases38 as well as software programs for handheld devices39 can be used to assist in the detection of drug-drug interactions. Their routine use by clinicians, on admission and when adding a new medicine, should be considered.
Caution is advised when psychotropic medicines are used on an as-needed (p.r.n.) basis. Such use may cloud the clinical picture and result in knee-jerk reactions in response to fleeting symptoms rather than a targeted treatment plan. It is crucial to review the use of p.r.n. medication regularly to prevent drug accumulation.
Delirium
The increased prevalence of dementia, multiple medical and neurologic comorbidities, and polypharmacy in the elderly make that age-group particularly susceptible to delirium. Differential diagnosis from common psychiatric syndromes such as dementia, depression, hypomanic and manic states, schizophrenia, and substance use disorders is not an easy task. Especially in patients who are not hyperactive or agitated, and therefore do not present an acute behavioral problem in the inpatient setting, delirium is frequently missed.40,41 Delirium should be viewed as a medical emergency that, unless treated, may lead to significantly worsened outcomes including greater mortality and morbidity, prolonged hospital stays, and increased rates of institutionalization. Therefore, when in doubt, it is prudent to assume the diagnosis of delirium. Key clinical features of delirium include the acute or subacute development of disturbances in attention and orientation, sleep-wake cycle, and psychomotor functions.
Psychomotor disturbances in delirium may give rise to hyperactive, mixed, or hypoactive clinical subtypes. The latter two subtypes are more common than the hypoactive and less likely to be recognized despite being associated with a more severe illness.40,42 A systematic workup must then proceed while attending to the safety of the delirious patient. A careful history and physical and neurologic examination may guide the selection of more tailored workups.
In the search for possible etiologies of delirium, it is helpful to remember that (a) delirium is often multifactorial;43 (b) risk factors already identified during the admission assessment could guide further workup; and (c) delirium is frequently caused by non-CNS-related conditions such as infections (e.g., urinary tract infection), dehydration, and polypharmacy.44
While basic workup (complete blood count, electrolytes, liver and renal function tests, glucose, ECG, urinalysis, chest x-ray, and erythrocyte sedimentation rate) is being completed, medical or neurologic consultation may be sought. Further patient-specific tests may be warranted. Management should
proceed hand in hand with diagnostic assessment. Environmental measures are an integral part of management and should always be considered. The main goals of environmental manipulations are (a) to correct or optimize any sensory deficits (use of glasses, hearing aids and dentures, adequate lighting, noise reduction, etc.), (b) to promote familiarity or orientation to surroundings (a visible clock and calendar, presence of a relative or family photos, frequent reality orientations, etc.), and (c) to ensure a reassuring and clear communication style by staff and family members.
proceed hand in hand with diagnostic assessment. Environmental measures are an integral part of management and should always be considered. The main goals of environmental manipulations are (a) to correct or optimize any sensory deficits (use of glasses, hearing aids and dentures, adequate lighting, noise reduction, etc.), (b) to promote familiarity or orientation to surroundings (a visible clock and calendar, presence of a relative or family photos, frequent reality orientations, etc.), and (c) to ensure a reassuring and clear communication style by staff and family members.
Antipsychotic medications are the mainstay of pharmacologic management of delirium. Benzodiazepines should be avoided, except in alcohol or benzodiazepine withdrawal. Haloperidol, administered orally or intramuscularly, is helpful in most agitated patients. More recently, atypical antipsychotics have emerged as alternative options but further study is warranted before advocating their use.44
Dementia with Neuropsychiatric and Behavioral Disturbances
Neuropsychiatric and behavioral disturbances associated with dementia include psychosis and a spectrum of agitated behaviors, such as aggressive, physically nonaggressive, and verbal/vocal agitated behaviors. When such behavioral disturbances present a danger to self or others or cause a significant decline in functioning, an inpatient psychiatric admission is warranted for the elderly demented patient. During the inpatient geropsychiatric stay, specific targeted treatment symptoms should be identified and tracked. Because the etiology of behavioral disturbances in dementia is often multifactorial, a comprehensive assessment is warranted. Common causes of agitation in patients with dementia include delirium (superimposed on dementia), depression, and psychosis. Other important causes include dyspnea, dysuria, abdominal discomfort from constipation, and pruritus.36,45 Finally, a number of patients present with “idiopathic” agitation syndromes, that is, behavioral disturbances in the context of a dementing disorder with no other identifiable cause(s).
NONPHARMACOLOGIC APPROACHES
Common and perhaps easily reversible causes of problematic behaviors in the demented elderly patient include space restriction, environmental over- or understimulation, a sudden decline in a patient’s ability to communicate, and problems in the approach or style of the caregiver toward the patient.36,46 Environmental manipulations, although frequently overlooked, may be beneficial and include optimizing hearing and vision, reduction of overstimulation, speaking in a soft and supportive tone, improving communication through nonverbal means, or attending to the patient during calm periods as well.
PHARMACOLOGIC APPROACHES
First, delirium should be ruled in or out and, if necessary, treated appropriately. In the presence of agitated depressive symptoms, an SSRI trial is indicated. When delusions are present, antipsychotics are recommended by expert consensus. Antipsychotics are favored by experts even in nondelusional patients, although they may not be as efficacious as when delusions are present.36
However, more recently, antipsychotic use in the elderly has come under increased scrutiny. The U.S. Food and Drug Administration (FDA), in April of 2005, issued a public health advisory, which required all manufacturers of atypical antipsychotics to add a Boxed Warning to their labeling describing a 1.6- to 1.7-fold mortality increase, primarily due to cardiac-related events or infections, in elderly patients with dementia and behavioral disturbances (FDA, 2005). An independent meta-analysis of randomized controlled studies of atypical antipsychotics found death occurring slightly more frequently with atypical antipsychotics versus placebo (3.5% vs. 2.3%).47 Another large retrospective mixed diagnosis study found that elderly patients on antipsychotic medication for 180 days or less had a higher risk of death with conventional compared to atypical antipsychotics (relative risk = 1.37).48 More recently, the National Institutes of Mental Health-sponsored Clinical Antipsychotic Trial of Intervention Effectiveness-Alzheimer disease (CATIE-AD) conducted a double-blind, placebo-controlled study of ambulatory outpatients with Alzheimer dementia and behavioral problems such as psychosis, agitation, or aggression. Patients were randomized to treatment with olanzapine, quetiapine, risperidone, or
placebo and followed up for up to 36 weeks. Time to treatment discontinuation for any reason did not differ significantly among the medication and placebo groups. Median time to discontinuation due to lack of efficacy was significantly longer with olanzapine (22.1 weeks) or risperidone (26.7 weeks) than with quetiapine (9.1 weeks) or placebo (9.0 weeks). Discontinuation rates due to intolerance, adverse effects, or death were 24% with olanzapine, 18% with risperidone, 16% with quetiapine, and 5% with placebo. However, findings from this ambulatory study may not directly apply to the demented elderly inpatient with likely more severe behavioral problems.
placebo and followed up for up to 36 weeks. Time to treatment discontinuation for any reason did not differ significantly among the medication and placebo groups. Median time to discontinuation due to lack of efficacy was significantly longer with olanzapine (22.1 weeks) or risperidone (26.7 weeks) than with quetiapine (9.1 weeks) or placebo (9.0 weeks). Discontinuation rates due to intolerance, adverse effects, or death were 24% with olanzapine, 18% with risperidone, 16% with quetiapine, and 5% with placebo. However, findings from this ambulatory study may not directly apply to the demented elderly inpatient with likely more severe behavioral problems.
Therefore, it is prudent to exercise judgment in the use of all antipsychotics—atypical or conventional—for severe behavioral disturbances in dementia. The inpatient clinician initiating an antipsychotic trial should keep in mind that antipsychotic response times differ depending on diagnosis. Whereas dementia-related behavioral response may take several weeks, antimanic response may be seen in 2 to 4 days and antipsychotic response in schizophrenia within 1 week. For that reason, clinicians are in danger of generalizing their experiences, which may lead to overdosing and serious side effects. A useful inpatient strategy is to initiate and maintain atypical antipsychotics at low dosages, using, for a time-limited period, low-dose standing benzodiazepines (with heightened fall precautions) to treat dementia-related agitation symptomatically until the therapeutic effect of antipsychotics is established. Agitated and aggressive behaviors in AD have responded to risperidone at a dosage of 1 mg per day or olanzapine a dosage of 5 to 10 mg per day.48,49 The clinician should discuss with the family the risks with antipsychotic use, including the risk of metabolic syndrome, cerebrovascular accidents (CVAs), or even death. Clinicians should document (a) their rationale for using an antipsychotic, including a discussion of the risk/benefit ratio, (b) other approaches considered or attempted first, and (c) the risk of withholding antipsychotic treatment.
Cognitive enhancers such as cholinesterase inhibitors or memantine, although not useful in the acute control of behavioral disturbances in demented inpatients, may be helpful in the long term because they have shown to improve not only cognitive, but also behavioral, emotional, and psychotic symptoms.50, 51, 52, 53, 54 Similarly, SSRIs, although likely more useful in preventing future episodes than treating the current one, may be considered for dementia-related behavioral disturbances.
Schizophrenia
Early- versus late-onset schizophrenia
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) does not distinguish between late-onset and early-onset schizophrenia. Part of the reason may be that even the age after which the term late onset applies is unclear, with some requiring onset after age 40, others at 45 or even 60.55 Nevertheless, there are clinical, neuropsychological, and genetic differences. Although delusions and hallucinations are common to both groups, symptoms tend to be milder in late-onset schizophrenia, with negative symptoms, thought disturbances, and first-rank Schneiderian symptoms being less prominent. Neurocognitive deficits exist in both chronic and late-onset schizophrenia. There is disagreement as to whether patterns of cognitive impairment are similar or markedly different with cognitive decline and dementia occurring earlier (within 5 years) in the late-onset schizophrenic group.56 First-degree relatives of patients with late-onset schizophrenia have lower prevalence of the disease compared to first-degree relatives of patients with early-onset schizophrenia.57
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
Recurrently Readmitted Inpatient Psychiatric Patients: Characteristics and Care
The Patient with Borderline Personality Disorder
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