Management of Serious Mental Illness: Specialized hospital care and subsequent continuum of care

Treatment adherence is a well-known challenge in caring for people with schizophrenia and other serious mental illness. When patients fail to adhere to their treatment program, the risk for relapse, hospital readmission, homelessness, and self-harm increases. 

“People with severe mental illness have an average lifespan that is about 20 years shorter than the average American,” said Harsh K. Trivedi, MD, MBA, president and CEO of Sheppard Pratt. “But we have had people in our outpatient programs for 20, 30, or 40 years, who say, ‘Many people in my family died in their early 50s, but I’m 60 years old and alive today because of Sheppard Pratt.’” 

Sheppard Pratt is a national leader in providing comprehensive mental healthcare regardless of diagnosis. The broad, unparalleled continuum of care transitions patients from highly specialized hospital services all the way through outpatient programs and into the community, where services beyond healthcare--including access to shelter, clothes, education, vocational training, and family support—help ensure that recovery is sustainable instead of episodic.

“It’s not enough to help someone with severe mental illness get better through an acute inpatient stay; we need to wrap around that person the care and services they need to succeed,” Dr. Trivedi said. 

For someone with severe mental illness, their journey with Sheppard Pratt begins on what they may consider to be the worst day of their lives. 

“They’re in crisis, they may be suicidal or hearing voices, and they may not know how to tell what’s real or what’s not,” Dr. Trivedi noted. “We’ve created a series of ‘front doors’ to care within Sheppard Pratt that are not only humane and accessible, but most importantly, get people to the care they need quickly. We have Psychiatric Urgent Care centers where anyone can walk in without an appointment, be evaluated, and immediately referred to the most appropriate care. Our outpatient clinics have same-day appointments with mental health professionals. And we are the one hospital in Maryland that’s a receiving hospital with direct referrals from every emergency department in the state.” 

Sheppard Pratt also meets people with severe mental illness where they are, through a program of mobile crisis teams that can provide interventions in schools, at work, or even on local park benches.  

Inpatient Care

Hospital-based inpatient care at Sheppard Pratt’s two primary campuses, centrally located in the mid-Atlantic, is led by a team of highly experienced, dedicated, and compassionate behavioral health professionals who specialize in caring for schizophrenia and other serious mental illness.

“Having this kind of inpatient unit that specializes in very severe psychiatric illness is quite unique,” said Boglarka Szabo, MD, medical director of adult services at Sheppard Pratt’s Towson campus. “We care for extremely sick people who often cannot be managed in other settings, and we know how to get them better, with deep expertise in medication management and neuromodulation.”

Neuromodulation options at Sheppard Pratt include electroconvulsive therapy (ECT) for the management of severe bipolar and unipolar depression, catatonia, schizophrenia, and other psychotic illnesses, as well as transcranial magnetic stimulation (TMS) for the treatment of refractory major depression.

“Today’s ECT is highly controlled, allowing us to modulate many of the details of what we’re giving, including the length of the pulses, how many we deliver in a row, and the amount of energy behind them,” noted Monica Rettenmier, MD, the service chief of ECT for Sheppard Pratt. “We can fine tune the dose to deliver only as much energy as is needed to make the treatment therapeutic for each specific patient.”  

ECT may cause memory loss during a treatment series, which often creates hesitance in patients and their family members. “An individual might forget what they had for dinner the night before, or a conversation they had, or a movie they watched, although memory typically goes back to baseline after treatment concludes,” Dr. Rettenmier explained. “If someone is very concerned about that side effect, we can minimize the effects of ECT on memory by applying the energy only in a right unilateral fashion, where the energy is focused on the right side of the brain, and we protect the left side where much more processing happens. That said, bilateral ECT is still the most effective and fastest approach to move someone forward and get them feeling better as quickly as possible.”

An ECT treatment cycle typically ranges from eight to 14 sessions. Studies have shown it to produce an 80% to 90% response rate for severe refractory depression, and at least a 50% response rate in treatment-resistant schizophrenia.

“The results can be particularly dramatic in catatonia,” Dr. Rettenmier said. “Catatonic people will stop eating, drinking, or moving, and stand or sit for hours on end in odd postures. It’s a manifestation of severe mental illness that overloads the brain so much it almost stops functioning. After ECT, these patients can often respond very quickly and start talking, eating, and caring for themselves again.”

Patients in Sheppard Pratt’s inpatient unit for severe mental illness, which accommodates up to 22 individuals, have structured days that include group and individual therapy sessions with occupational therapists, mental health professionals, and nurses, focused on illness education and coping skills. 

Comprehensive Services

For patients who don’t require hospitalization but still need significant direct care, Sheppard Pratt offers two of the only day hospitals specializing in psychotic illness in the country. “These are typically chronic patients with ongoing needs, such as medication adjustment, establishing housing, and other issues,” Dr. Szabo said. “They receive a lot of individual attention from nursing and social work staff, and groups focused on symptom management, coping skills, and managing day to day life with a chronic, often severe psychiatric illness.” Sheppard Pratt’s inpatient unit and day hospitals are companion programs, with the same doctors and clinical staff, ensuring comforting continuity for those transitioning between levels of care. 

Patients discharged from care in Sheppard Pratt’s inpatient or day hospitals can still rely on a wide and deep array of services from the comprehensive behavioral health provider. 

“We follow these patients throughout their lives,” Dr. Trivedi said. “We have, in a very intentional way, made key investments in more than 1,200 housing units, supportive employment, vocational training, legal aid, and collaborative relationships with primary care. We provide all of that under one roof, so that our patients can achieve the best outcomes and live their best lives regardless of diagnosis, age, or level of care needed.”

From the inpatient to the outpatient setting, a Sheppard Pratt patient receives consistent quality care whenever and wherever it is needed.

“Would we like someone to come to us and never have to return? Of course, but that’s not always the reality with severe psychiatric illness,” Dr. Szabo said. “We have the mindset as providers that these people are our responsibility. The safety and familiarity of our setting is, in and of itself, therapeutic. Patients come to us in a crisis, and they see familiar faces, people they know and trust, and they start to settle down even before beginning treatment. Our work can be challenging, but our clinicians all really care about these patients, and the patients know that.”