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.

Serious Mental Illness and Gun Violence

by Tony Salvatore, MA

mhfirearmsAs an adult mental health crisis center serving southeastern Pennsylvania for almost forty years, Montgomery County Emergency Service is closely following the public discussion regarding violence and serious mental illness.  We deal daily with many of the concerns that have been raised.  Our input was sought by the Commonwealth of Virginia in the wake of the Virginia Tech situation.

As has been noted, such violent events cannot be foreseen and there is often very little opportunity to prevent their occurrence.  Sadly, such events can happen anywhere with no forewarning.  We agree that much more can be done to reduce the risk of such behavior in our communities.  Here we want to share some of the measures in place to do just that in Montgomery County.

First, our work is premised on the evidenced-based reality that the overwhelming majority of people struggling with serious mental illness do not engage in violent acts of any nature.  A very few do and we are prepared to deal with such cases.  However, shootings involving individuals with psychiatric histories in Phoenix, Aurora, and, closer to home, at Western Psychiatric Institute in Pittsburgh, are very rare, but well-publicized.

It is important to understand that as devastating as these events are, they involve only a very small fraction of those with serious mental illness.  Our experience, as supported by NAMI and other mental health advocacy groups, is that individuals with mental illness are far more likely to be victims of violence than perpetrators.  Many of those we serve come to us with severe emotional and physical trauma as a result of exposure to violence and abuse.

Second, because many of those with serious mental illness are very likely to have contact with emergency responders as a consequence of their illness, we have engaged local police and other law enforcement agencies as our partners in creating an early warning system for identifying and getting help as appropriate for those experiencing mental health crises.  We provide ongoing training to all criminal justice personnel in recognizing the signs of mental illness and the basics of crisis intervention.

We provide much more than knowledge and skills.  We back-up what we teach with 24/7 availability to officers in the field to answer questions, and give referrals and advice on resolving a situation in a manner that assures the safety of all parties and leads to the provision of emergency services by our facility or by community resources when the need is less urgent.  Police, in turn, keep us apprised of contacts with individuals at-risk that may warrant follow-up by our Outreach Program.

Third, we facilitate the ability of concerned individuals, including friends and family members, hospital emergency departments, and behavioral health providers, to arrange involuntary emergency psychiatric evaluations for individuals felt to be a danger to themselves or others because of mental illness.  Through the Montgomery County Department of Behavioral Health and Developmental Disabilities, we administer the emergency psychiatric provisions of the state mental health statutes.

We agree that our state and national mental health policies and spending should fit emerging needs and that existing behavioral health resources must be enhanced.  However, we also feel that every effort must be made to make full use of what is on hand to do everything possible to deter possible harm and meet needs as they arise.  To this end, our staff maintain currency on applicable mental health law and community resources so that we can aid those bringing potential emergency situations to our attention in understanding options, making a decision, and mobilizing the optimal intervention.

Fourth, as part of our responsibility to meet the emergency mental health needs of those who are unwilling or unable to do so we also fulfill the requirements of PA Act 77 that restricts purchase or ownership of firearms in Pennsylvania to anyone who is involuntarily admitted to a psychiatric hospital.  Information on all such admissions in Montgomery County is submitted to the PA State Police for entry in a state-wide data base.

Fifth, people with behavioral health problems may get involved with the criminal justice system apart from any crisis situation.  On their behalf, our assistance is sought by District Attorneys, Public Defenders, private defense attorneys, District Justices, Common Pleas Judges, Probation Officers, family members, and the police in clarifying the mental health status and needs of particular individuals.  This happens because our staff is seen as understanding mental illness, being able to assess an individual’s crisis level, and having a strong understanding of mental health laws and regulations. This capability represents a further layer of risk reduction.

Lastly, we fulfill our duties with an acute awareness that our actions have significant consequences for community safety, the welfare of at-risk individuals, and for their personal rights and liberties also.  Accordingly, we feel very strongly that the current prevailing interest in public safety at all costs be tempered by a concern for the rights and privacy of vulnerable individuals who present no threat to the community’s welfare.

Fixing the Mental Health System: Some Starting Points

by Tony Salvatore, M. A.

Every time there is some event anywhere involving mental illness in any way there are cries to “Fix the mental health system!”  There is no denying that the US mental health system needs “fixing” but perhaps we need to look more closely at some of the reasons that this is so and at some of the efforts underway to at least mitigate this state of affairs.

Government under-funding has compelled some providers to “cherry pick” and focus mainly on healthier, wealthier patients.  However, at the same time, the mental health system has become the default provider for the problems that the other community services “silos” do not elect to help.  Some individuals with serious mental illness may go underserved because many mental health providers are dealing, often ineffectively, with clients who have dementia, substance abuse disorders, intellectual disability, and little, if any, mental illness.

Psychiatric beds exist for those who require inpatient psychiatric care because they are a danger to themselves or others due to psychiatric emergencies, such as suicidality or psychosis, or serious illness-related mental health crises.  In most communities there are a dearth of such resources.  Where they are present they may be largely occupied by people who do not need this level of care but for whom other options are unavailable.  Scarce beds may also be filled with treatment-seekers and malingerers.  Such individuals do not benefit from inpatient psychiatric care and deny treatment to those who might.  Psychiatric hospitals have become “Plan B” for the rest of the mental health system as well as for other service sectors.

Efforts are being made on many fronts to divert individuals at risk of incarceration from contact with the criminal justice system.  Police are unavoidably “mental health first responders” because of their public safety role.  In many areas, mental health providers have acted to assure they are trained to recognize signs of potential mental illness and how to safely deal with an individual with severe mental illness.  Montgomery County Emergency Service has been providing such training to local law enforcement agencies and others since 1975.   Elsewhere, police departments have adopted the Crisis Intervention Team (CIT) model.  Programs of this nature divert many whose criminal justice contacts are related to their mental illness from arrest and prison.

Mental health courts are in place and reduce the likelihood of imprisonment of those with mental illness whose offenses are serious enough to bring them into the court system.  Routine court oversight of treatment adherence brings the weight of the judicial system to bear and assures that all parties to care arrangements live up to their responsibilities.  In our service area the “intercept concept” has been used to identify points at which persons with mental illness can be diverted from the criminal justice system.  One “intercept” point with high potential for re-incarceration is after leaving prison.  Forensic outreach services can facilitate community re-entry and providing mental health training to probation and parole personnel to reduce “violations” related to mental illness.

For those with mental illness already in prison or who were not candidates for diversion, the correctional system in some states making changes  In Pennsylvania, for example, the Department of Corrections is creating special housing units for inmates with serious mental illness “who do not fit in well with the rituals of prison life.”  This approach, while far from optimal, establishes settings that may not worsen the existing mental illness, offer some protection to vulnerable inmates, and lessens assignment to solitary confinement.  This addresses the reality that some offenders belong in the correctional system but should be able to access appropriate mental health care when needed.

What our discussion so far shows is that perhaps there is really no such thing as a “mental health system” anymore but rather that mental health-related functions have been dispersed as the entity once charged with managing them has proved increasingly unable to do so.  This may provide an opportunity to resolve the problems presented by the Cartesian mind-body split and adopt a holistic model of health care treating all illnesses and disorders whether based in the brain or in other organs.  This is occurring as behavioral health professionals are being integrated into both primary and specialty health care practices.  Such integration will enhance the effectiveness of psychopharmacological therapies and provide for more effective resolution of side effects and drug-to-drug reactions.

Recently, ethicists at the University of Pennsylvania (JAMA, December 2014) called for a “return to asylums” as a “fix.”  It is unlikely that re-institutionalization will ever take place.  Nonetheless, dismantling the state hospital system did not obviate the need of some individuals with severe and chronic mental illness for long term residential care.  While there will be a need for psychiatric hospitals to stabilize those with acute exacerbations of chronic mental illness, there is really no need for even a state hospital level of care thereafter.  Many patients could be “stepped down” to sub-acute levels of care for stays of three to six months during which treatment plans could be developed with the involvement of the patient, family, and outpatient providers.  Such transitional care could prevent the rapid re-entry stressors of discharges to home from inpatient psychiatric care that drive revolving door re-admissions and drive patients unable to engage with outpatient care to homelessness, substance abuse, and, in too many cases, police contact.

To sum up, perhaps a mental health system that served people whose primary needs primarily related to mental illness would need less fixing than one serving all comers, being all things to all people, and poorly serving all.  Perhaps the best way to fix the mental health system is to assure that other systems do their jobs rather than off-load those they do not wish to serve.  Once this is done attention can be given to deficiencies inherent to the mental health system.

Suicide Attempt Survivor Support: A Critical Unmet Need

Montgomery County has a serious problem with suicide, losing over one-hundred residents yearly.  It is probably less well-known that the county has a much bigger problem with non-fatal suicide attempts, all of which raise the individual’s life time suicide risk, and many of which subsequently become fatal attempts.

There is little data on the incidence of suicide attempts, an act in which a person with intent to die acts on a plan using potentially lethal means.  Many attempts occur without coming to anyone’s attention. Those that do usually are as a result of a need for medical treatment, self-reporting by the individual in seeking help, or when there has been an intervention.

Depending on age and gender, the ratio of suicide attempts to fatalities varies widely. Youths make more attempts than adults, men make considerably fewer attempts then women, elders tend to die on their first attempt.  Lethality of means, particularly firearms, accounts for these disparities.

Individuals with serious mental illness, especially schizophrenia, bipolar disorder, and major depression, attempt suicide more frequently than those without these conditions.  Alcohol abuse and dependence figure highly in suicide attempts. Imminent and actual suicide attempts account for a significant number of voluntary and involuntary psychiatric hospitalizations.

We could go on, but suffice it to say that focusing suicide prevention on individuals who have made a suicide attempt would likely save a lot of lives, enhance the recovery prospects and duration of those who may re-traumatize themselves when beset by even passing suicidal thoughts, and free up ERs and psychiatric hospitals to address other needs.

In 2012, the Action Alliance, a national suicide prevention coalition, identified support for attempt survivors as a priority for focus in the revised National Strategy for Suicide Prevention (NSSP).  This led to a national Suicide Attempt Survivors Task Force to help forge a path for stopping suicide attempts and deaths by engaging and supporting people with lived experience of a suicidal crisis.

In 2014, the Pennsylvania Adult Suicide Prevention Plan included an objective (9.1) to “identify all suicide strategies and services that respond to and care for individuals affected in the aftermath of a suicide attempt…and promote awareness of these resources.”  This state plan will presumably motivate the implementation of aftercare resources for suicide attempt survivors at the county level.


There are few suicide attempt support groups anywhere.  A 12-step based “Suicide Anonymous” group met for several years in Norristown, but ceased when its leader moved out-of-state.  At present, the only such support resource that we know of anywhere near Montgomery County is a “Suicide Anonymous” group in Burlington County, NJ:

Rise Above/R.I.T.E. Center

Twin Oaks Community Services

693 Main Street Building C

Lumberton, NJ 08048

1st Floor, Center Door

Group and Skype: 7:00pm 2nd and 4th Thursdays

Skype Only: 1st, 3rd, and 5th Thursdays


So why such a paucity of support groups in a major metropolitan area that probably has support groups for every other malady known to humanity?  Liability for self-injury or fatalities among group participants is often cited.  This probably would not apply to a peer-led group and has not proved insurmountable in the few provider-based groups around the country.  Bigger problems are stigma and finding peer facilitators.  (It is likely that there are a number of Certified Peer Specialists who have “lived experienced” of a suicide attempt as well as group facilitation skills.[i])  Indifference toward the needs of attempt survivors is an issue.  Perhaps those affected by recurrent episodes of acute suicidality will at some point step up.


Repeatedly hospitalizing those who make or almost make suicide attempts may be more part of the problem than part of the solution.  Clearly inpatient care may be indicated for stabilization and safety but there is no evidence of any long-term preventive value.  Moreover, the first 30 days after discharge from a psychiatric facility are a very high risk period for suicide.  Many readmissions within 30 days of discharge involve suicidal behavior.


Here are some on-line information resources on this topic:




[i] See “Peer Specialists can Prevent Suicide” Behavioral Healthcare, September 30, 2010 at

The Crisis Continuum

By Tony Salvatore, MA

Mental health consumers and providers, and often family members and others, often use the term “crisis” to encompass a wide range of personal, interpersonal, and environmental situations with current or anticipated negative consequences. This “one size fits all” concept of a crisis is overly simplistic, obscures or minimizes the complexity of the situation, and impedes effective intervention and resolution.

Mental illness-related crises vary in scale and in terms of how they affect the individual. They also seem to follow trajectories and may move to higher levels of risk. All may be triggered by life events (or an individual’s anticipation of an adverse life event) that produces emotional discomfort or even the recurrence of psychiatric symptoms. Continue reading

Do 90% of Suicide Victims Really Have Serious Mental Illness? (Part 1)

By Tony Salvatore, MA

Anyone who turns to the print or electronic sources for insight on the topic of suicide and mental illness will encounter this statement in some form: Ninety percent of suicide victims had a psychiatric disorder.(1)  The implication of this contention is almost causal in nature, and it has taken on the trappings of a veritable “truth” of suicide prevention that is rarely questioned.  Mental illness has been shown to be a factor in suicide, but “the relative importance of mental disorders compared to social strains is not fully clear.”(2)

Here we will look into the origins of this assertion and consider some issues with its underlying methodology.  In Part 2, we will look at some actual data on the incidence of mental illness in suicide victims, examine mental illness and suicide from the perspective of current theories of suicide, and show mental illness in its proper role as a suicide risk factor. Continue reading

Do 90% of Suicide Victims Really have Serious Mental Illness? (Part 2)

By Tony Salvatore, MA

In our previous blog, we looked at the use of the psychological autopsy method in suicide research and questioned this approach and its results.  Here we will consider some “hard” data on the incidence of psychiatric diagnoses in suicide victims at the time of death, look at how the role mental illness plays in two current theories of suicide, and argue that mental illness is a serious suicide risk factor but not necessarily the key independent variable in the onset of suicidality in at-risk persons.

Some Countervailing Data

The Centers for Disease Control and Prevention’s National Violent Death Reporting System (NVDRS), has collected data on suicide from death certificates and other sources from sixteen states.[1]  In 2008, of 9276 suicides, approximately 45.4% had a diagnosed mental illness at death.  The NVDRS has found that “mental health problems were the most common circumstances among suicide decedents” in the US.  However, the incidence in a very large population of victims is half that reported by psychological autopsy studies.  Continue reading


Behavioral Health’s “Elephant in the Room”

By Tony Salvatore, MA

Among the many unwieldy problems in behavioral health, one looms especially large. This pachyderm-sized concern is “chronic suicidality.” This is repetitive parasuicidal behavior involving suicide threats and acts without any intent to die. It may arise at any time and convert low-risk situations into what appears to be a potential life-threatening psychiatric emergency.

Chronic suicidality seems to co-occur with a desperate “need” for shelter, inpatient care, or residential rehabilitation. Dramatic and emphatic suicide threats are voiced with an effect that comes from much practice. Immediately, urgent attention is forthcoming, doors open, and then the suicidal crisis usually subsides.

Curiously and incongruously such “suicidal” individuals who project themselves to be at imminent risk of self-destruction may still feel the need for a smoke break or a sandwich. Equally surprising is that despite the depth of their despair they have often managed to pack for what they hope will be a long stay in a hospital or rehab. Continue reading