Zack Williams, MD, PhD

🧵The (Dying) Art of Prescribing an Inpatient Admission ( from a previous post) 🚨1/2 Much like the declining use of Clozapine, MAOIs, and Lithium, the practice of prescribing a well-organised and targeted inpatient admission is gradually losing its prominence. Here are my insights as an inpatient psychiatrist over the last 10 years and why it’s one of the most powerful interventions in psychiatry. 👇 There is a misconception in psychiatry that in-patient psychiatry is only about the acutely unwell or acute psychosis. This cannot be further from the truth. In my role, I navigate through a myriad of cases, covering a broad spectrum, often at the end of multiple opinions and referrals from across the country. Inpatient psychiatry, while capable of addressing acute cases, offers a unique advantage beyond the acute spectrum. 1. It sets up a powerful foundation for Understanding and Problem Solving. 2. It allows the psychiatrist, the team and the patient the opportunity to maximise the potential of treatment. 3. The aim is to maximise patient functioning “If I had an hour to solve a problem, I'd spend 55 minutes thinking about the problem and five minutes thinking about solutions”. (Einstein) The Value of In-patient Admission: 1/ Information points : When it comes to problem-solving, the most valuable ingredients are information points. In-patient admission helps generate a concentrated source of information. Consider it a melting pot where insights from registrars, psychologists, social workers, occupational therapists, nursing staff, and medical colleagues blend, compressing years of information into just a few weeks. Add information points from the patient and family through daily observations, which act as powerful material for problem-solving. 2/ A unique holding and containing environment: Daily throughout the entire duration of the admission, a psychiatrist holds and contains the patient's information in their mind that doesn’t stop at the end of the day. Each implemented step prompts the psychiatrist to contemplate the anticipated change or outcome. 3/ The Initial Stages: The initial phase of the admission often involves psychopharmacology (symptom relief moving to more targeted pharmacology as the formulation evolves), as a significant amount of treatment resistance involves untreated biological/medical components. In the initial stages, it's not just about treating the severe symptoms; it's about enhancing pattern recognition. Robust pattern recognition is built upon four pillars: Phenomenology - Neuroscience - Psychopharmacology - Treatment Choice The most effective approach to boost pattern recognition involves repeatedly cycling through the stages of: Predict - implement - evaluate - change within a condensed timeframe. Consider it akin to mini-audits, and more significantly, envision the invaluable learning from this iterative process! Inpatient admission condenses years of interventions into a compact, well-defined, and strategically managed process. It ensures the patient can witness tangible changes, like improvements in cognition, activity, sleep, and perception (PACES), all to achieve reasonable homeostasis. This part is relatively easy. 4/ Testing Hypotheses (System 2 Thinking): An in-patient admission curtails the psychiatrist's dependence solely on their judgment. It underscores the principle that 'improvement is a multi-opinion endeavour.' The unconscious yearning for improvement within the doctor is subjected to the litmus test of actual improvement, as observed by other team members. Moreover, accountability takes centre stage. The management of medication-induced side effects becomes the responsibility of the psychiatrist, operating within the broader team framework. This approach can ‘force’ thoughtful consideration in the choices of treatments. Continued 👇