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Acute psychiatry bed shortage contributing to iatrogenic deterioration in general hospital wards

I note the recent communication by Allison et al. in relation to the debate about acute and sub-acute mental health beds (Allison, 2014). I would like to add my perspective as a Consultation Liaison Psychiatrist at a tertiary hospital. I wish to describe a syndrome of clinical deterioration affecting patients with psychiatric illness who are in general hospital wards after completing care, waiting a further admission to an acute care mental health facility for treatment. Across Adelaide we are aware of a high number of patients in this situation. This predicament occurs in the context of the systematic practice of prioritising patients waiting for mental health care in the Emergency Departments in order to meet N.E.A.T. targets for assessment and admission (Maumill, 2013). I believe South Australia’s mental health planning strategy (South Australia’s Mental Health and Wellbeing Policy, 20102015) focusing on acute psychiatric inpatient bed closures and investment in subacute mental health beds has contributed to a persistent mismatch between the demand for admission for acute mental health treatment and the supply of acute mental health beds. These patients display deterioration in their clinical state across a wide range of signs and symptoms. This deterioration can be observed across a wide range of psychiatric diagnoses including mood disorders, psychosis and anxiety disorders. Symptoms include, but are not limited to, a worsening of depressed mood, increasing paranoia, increased frequency and intensity of panic attacks and worsening psychomotor retardation or agitation. This deterioration does not occur in patients with medical or surgical diagnoses who may be waiting for further care in the same general hospital environment. I suspect that factors related to the general hospital environment interact specifically with various psychiatric illnesses to cause this deterioration. These environmental factors include prolonged bed rest, low levels of privacy, shared bays, reduced natural light exposure, high ambient noise levels, and occasional use of physical restraint. These factors are generally not found in acute mental health care environments. We must not expect that a patient can simply wait in some sort of suspended state with unchanged clinical symptoms until they are admitted to an appropriate care environment. This iatrogenic deterioration has implications for the patient and the system that cares for them. Well staffed and funded Consultation Liaison Psychiatry services go some way to mitigate the harm from this syndrome, but do not solve the problem. With recognition of iatrogenic deterioration we can research, treat and intervene better to prevent it occurring.