As a psychiatry resident at New York University School of Medicine, Dr. Brady G. Case noticed – and heard from older psychiatrists – that inpatient treatment had changed dramatically, especially for children and teenagers, with ever-shorter hospitalizations even for their sickest patients.
Case set out to quantify this trend. He and a team of researchers analyzed federal data on psychiatric patients under 17 discharged from about 1,000 community hospitals across the nation, looking at 1990 and 2000 figures and comparing the diagnoses, lengths of stay and referrals to other facilities.
They reported their findings in this month’s issue of the Archives of General Psychiatry: From 1990 to 2000, the total number of inpatient days and mean charges per visit each fell by about half, and the median length of stay dropped by 63 percent, from 12.2 to 4.5 days, even as the share of patients with psychotic and severe mood disorders increased.?
PBN: Lengths of stay have declined over the decades as psychiatrists decided it wasn’t good for most children to be hospitalized for weeks, months or even years. Is that a factor here?
CASE: The perception I had from my supervisors and teachers was that … they really were being pushed … by the insurance companies, by the hospitals, by the expectations of others. … On the other hand, I think a lot of clinicians, especially in child psychiatry, are not excited about admitting kids. They don’t like to split up families, and they see inpatient admissions as disruptive. … [But at this point], I think most clinicians I know would say we can’t go any further than we’ve gone. … It’s hard for me to imagine doing all that much for seriously ill kids in less time than we currently use. Now Bradley [which wasn’t part of this study] is a little bit different.
My experience here has been that the median stay is a little over a week.
ISO 9001:2026: A Practical Opportunity to Build for What’s Next
For Rhode Island manufacturers, ISO 9001 has been much more than a certificate on the…
Learn More
PBN: Have the standards for discharging patients changed?
CASE: If you ask clinicians who’ve been working through this period, I think many of them would say they’ve had to readjust their expectations for what can be accomplished during a stay and what they would require to see in terms of changes before making a discharge.
This study doesn’t really address that question, though.
PBN: A lot of these kids are being treated with psychotropic drugs.
Have the full effects even kicked in by the time they’re discharged?
CASE: In this period, there was a really dramatic increase in the use of medications for kids. … We know from other studies that the use of antipsychotics in children has increased something like fivefold. So it’s probably the case that a lot of the kids are leaving with prescriptions. … I think it’s only safe if the follow-up is adequate.
The FDA’s standard of care for antidepressants in children, for example, is that they must be seen weekly for the first month. … It may be that requirements or recommendations about frequency of contact and duration of treatment may be increasingly prevalent.
PBN: At this point, do we know whether kids have adequate supports?
CASE: I think that is the question. … It is true that psychiatry – and child psychiatry in particular – has become more creative in setting up intermediate-level services that address problems that office-based psychiatrists would have trouble handling … such as SafeQuest [Bradley’s day hospitalization program for teens]. … But it’s not clear to me that most communities have access to these types of services, so I am worried.
PBN: Your study also found a sharp increase in some of the more serious diagnoses.
CASE: With bipolar disorder, 2.9 percent of the admissions were for bipolar in 1990; 15.1 percent were for bipolar in 2000. … During a period when managed care dominated, it’s not surprising that more severe diagnoses would be more heavily represented … if the standards for admission have gone up. … And there’s some evidence from my data that people are just calling things differently. Substance-use disorders used to be the principal diagnosis in 16 percent of admissions in 1990; that’s fallen to 4.8 percent. However, as a secondary diagnosis, it has gone up, from 9.8 percent to 16.7 percent.
… I think that’s in part because it’s very difficult to admit a kid for a substance-use issue, because of insurance issues.
PBN: Do you have a sense of whether children really are sicker, overall?
CASE: My data doesn’t really indicate one way or the other. What is interesting in my data is that the stated goal of managed care is to adequately match illness severity and treatment. … But in our data, it looks like the lengths of stay fell most for the diagnoses that are most severe. … What’s emerging is a more-uniform length of stay for all kids, regardless of diagnosis. That, to me, is concerning just on its face.
PBN: Do you see a need for legislation to assure children a certain number of days in the hospital if they need them, just as there are minimums for women giving birth?
CASE: I think it is the case that compared with the rest of medicine as a whole, psychiatry has sustained more significant cuts in the length of stay … and child psychiatry has sustained even more significant changes. My data doesn’t really tell you whether that is safe or not. Overall, what I can tell you is that inpatient providers are doing more with less. But I do think states should be interested in this question, what the quality of inpatient care is, and whether the dispositions that are being made seem, in general, adequate.
INTERVIEW: Dr. Brady G. Case
POSITION: Clinical fellow in child and adolescent psychiatry, Brown University School of Medicine; staff psychiatrist, Bradley Hospital and Rhode Island Hospital/Hasbro Children’s Hospital
BACKGROUND: Though it’s still early in his career, Case has already practiced psychiatry in a wide range of settings, from New York’s Bellevue Hospital Center, to the Manhattan Veterans Administration Hospital, to specialized facilities such as the Manhattan Psychiatric Center and now Bradley Hospital. He’s also been active in research, with two primary interests: the delivery of mental health services to children and adolescents, and the effectiveness of treatments for mood, anxiety and substance-abuse disorders.
EDUCATION: B.A. in social studies, 1997, and M.D., 2002, Harvard University; resident in psychiatry, 2002 to 2006, and resident trainee on the National Institute of Mental Health clinical research track,
2004 to 2006, New York University School of Medicine
RESIDENCE: Barrington
AGE: 31
