Alternative to Hospitalization — Is There Such a Thing?

by Tony Salvatore, M. A.

Over the years (decades actually), I have often heard the phrase “alternative to hospitalization” used in conversations about the suitability and capability of some community-based mental health services to serve as a substitute for inpatient psychiatric care. The implication being that use of these alternatives would be less expensive, less restrictive, less stigmatizing, and less traumatizing than hospitalization while being equally effective. This phrase and the promise that it bespeaks is always taken as a valid assertion and never (in my experience) challenged by users, advocates, or providers of mental health services.

My intuition told me that there was something illogical about this phrase, but I never spoke up because I always assumed that the service in question was being presented as a means of deterring admissions involving individuals who could be safely and effectively treated in community settings. I was wrong. I have discovered that many people strongly believe that the need for inpatient psychiatric care can be met outside of a freestanding psychiatric hospital or a psychiatric unit of a community hospital. Moreover most of those espousing this view also seem to believe that inpatient psychiatric care is over-utilized because adequate substitutes are or could be available.

There are a number of misconceptions about psychiatric hospitalization. One is that it should be up to the patient who, after all, would seem to be in the best position to know if inpatient care is needed. Another is that hospitalization should follow from a determination by an outpatient provider, in the form of a referral, that this level of care is needed. Still another is that admission is solely at the discretion of the psychiatrist covering intake at the hospital. Of these, only the last has any degree of validity. A psychiatrist does indeed order an admission, but it is not based on her or his decision alone.

What is often not understood is that there are explicit criteria for an inpatient psychiatric admission that must be met. These criteria have been established by the various parties regulating, offering, or paying for inpatient psychiatric care. They are based on clinical need and appropriateness for this level of care. Satisfaction of these criteria are the primary purpose of the psychiatric evaluation that must precede any inpatient admission. The criteria of medical necessity for inpatient psychiatric care are basically clear. The individual must:

  1. Have a primary psychiatric diagnosis, excluding intellectual disability, substance abuse, or dementia, unless these conditions co-occur and are secondary to the presence of a diagnosed psychiatric disorder. (NB: Psychiatric diagnosis by itself does not equate to need for hospitalization.)
  2. Require ongoing 24-hour clinical management, monitoring, supervision, and assessment by psychiatry and nursing to develop, implement, and modify the treatment plan, which cannot be done in a less controlled care environment.
  3. Be at significant risk of harm to herself/himself or to others because of an imminent risk of suicide, assaultive behavior, or homicide, represent a risk to self because of psychosis, or demonstrate a serious inability to care for one’s self.

These criteria clearly indicate that, when strictly and correctly applied, there is, in fact, no alternative to, or substitute for, inpatient psychiatric care when that is what an individual needs. There is no single community-based program or any combination of such programs that can deliver the degree of safety, supervision, or service intensity that can be provided in an inpatient psychiatric setting. Put more plainly, someone either needs hospitalization or someone does not, yes or no.

Here is a suggestion: Use an “alternative to inappropriate hospitalization” instead of improperly using hospitalization. Inpatient care should be turned to when it is the only option capable of meeting the individual’s needs. Any other use is unnecessary, wasteful of a limited resource, and potentially harmful. Inpatient psychiatric care is not a “Plan B” for problems that cannot be otherwise resolved. It is not a stand-in for shelters or rehabs that have no beds. It is not a respite for frustrated family members or providers. It is not an alternative to incarceration when the offense is unrelated to any underlying serious mental illness.

There is no alternative to psychiatric hospitalization and psychiatric hospitalization is not an alternative to any other service.

Responsible Reporting of Suicides

NB: While the commentary below originally appeared in The Philadelphia Inquirer in 2004, the issues discussed are, sadly, just as relevant today.  There have been some changes in the manner in which suicide is reported in the media, however there are still glaring misconceptions about the appropriate way to cover a suicide, if it is appropriate in the first place, terms to use and terms to avoid, and a lack of knowledge about facts, risk factors, and warning signs.  The hope is that this article will serve as a reminder about the importance of responsible reporting of suicides and the responsibility of media outlets to provide relevant facts and information.  

Report Suicides Responsibly

by Tony Salvatore, MA

Like many, I was saddened to read of the deaths of David Wallace and his wife, Joan, particularly of the means by which they died (“Eminent architect dies in double suicide,” July 20).

Given David Wallace’s stature, and the comparative rarity of double suicides, I understand why this tragic situation would receive significant media attention. However, from my suicide-prevention perspective, the nature of The Inquirer’s coverage raises a number of concerns.

First, the article appeared on the front page. Second, it included a fairly detailed description of the method by which the couple ended their lives. Third, it made no effort to put the deaths into the context of suicides among elders. Sadly, these are increasing in what is often called a silent epidemic.

A number of organizations have offered guidelines for coverage of suicide. They seek to raise awareness that some vulnerable, high-risk individuals may carry out their own suicides by reading detailed news accounts of how others took their own lives. One such set came in 2001 from the Annenberg Public Policy Center of the University of Pennsylvania, acting in concert with national suicide-prevention organizations.

The report, “Reporting on Suicide: Recommendations for the Media,” explicitly discourages the placement of such stories on the front page or at the top of a broadcast. It is understood that suicides involving prominent persons, public circumstances, multiple deaths, or the very young are generally considered newsworthy. The Wallaces’ deaths fell into two of these categories and merited coverage. However, front-page treatment was not necessary.

Of greater concern was the detailed description of the lethal means that the Wallaces employed – another practice that the Annenberg report discourages.

These details, which I obviously choose not to get into here, were not essential to reporting this loss. Moreover, given that some may see these deaths as rational suicides – Joan Wallace was in hospice care; David Wallace had cancer – some circumspection was in order.

So-called copycat suicides are not limited to youths. It is to be hoped that The Inquirer would not have described the means used in reporting a high-profile teen suicide. The same judgment should have applied here.

Lastly, the Wallaces, David Wallace in particular, were in an age group at high risk of suicide, a fact not well known. According to data from the Centers for Disease Control and Prevention, there is a suicide by someone over 65 every 90 minutes, which amounts to 16 such deaths daily in the United States. Elders account for 20 percent of all suicides but represent only about 12 percent of the population. White men over 85 have a suicide rate six times higher than the national average.

Statewide, says the Pennsylvania Department of Health, there were more than 1,200 suicides among people 65 and over from 1997 through 2001 and fewer than 400 among those 19 or younger.

This same pattern prevails in Southeastern Pennsylvania, where elders accounted for more than 18 percent of all suicides in the same period and youths represented less than 6 percent of the losses.

The point is not that greater numbers make elder suicides more distressing than those at the opposite end of the age spectrum. Rather the point is that The Inquirer, having chosen to highlight the deaths of David and Joan Wallace, could have used this opportunity to inform its readers about the little-known incidence of suicide in the “golden years.”

Depression and hopelessness play a prominent role in elder suicide. Neither condition is normal at any age. Caregivers and health-care providers could have been alerted to these possible precursors to suicide in elders.

The Inquirer could also have noted that frailty makes the elderly less likely to survive suicide attempts. And it could have mentioned that greater social isolation makes it less likely that elders attempting suicide will be discovered in time to save their lives.

With the accelerated aging of our society, we must pay more attention to elder suicide and how the media should treat it. Suicide prevention is obviously not the media’s primary job. Nonetheless, it can play a powerful role in educating the community about this preventable problem.

Tony Salvatore is director of development of Montgomery County Emergency Services Inc., a nonprofit emergency psychiatric agency in Norristown.