Jerrold Pollak, Ph.D., is a clinical psychologist and neuropsychologist. He lives in Portsmouth.

The number of patients across the adult age range with serious co-existing medical and psychiatric conditions who require inpatient-level care continues to rise.

Contributory factors include the aging of the population as well as the enhanced recognition of the complicated evaluation and treatment needs of patients with this “dual diagnosis” clinical status. This increase in medical/psychiatric patients includes a surprising number of young adults.

The co-occurrence of consequential medical and psychiatric conditions has negative synergistic effects on a patient’s everyday functioning and quality of life and is a daunting challenge for the development of timely and effective interventions that address these two broad categories of illness.

Examples abound: A middle-aged man with a significant history of depression and psychosocial trauma develops worsening mood symptoms, including suicidal preoccupation, in the context of ongoing outpatient chemotherapy for cancer.

A young adult age woman with, heretofore, medication responsive seizures experiences a marked worsening of pre-existing anxiety and depressive mood symptoms. In response to increased hopelessness about her life referable to the worsening of her mental health difficulties, the patient opts to discontinue anti-seizure medication treatment. Efforts are unsuccessful at stabilizing this neurologic condition on an outpatient basis resulting in a potentially life-endangering situation.

Psychiatric inpatient programs will typically decline the referral of these patients for admission due to the severity and complexity of their medical problems.

Medical inpatient services are wary of admitting such patients because of concern about being ill-equipped to address their psychiatric needs. However, the medical exigencies will normally supersede the psychiatric difficulties and the patient will be admitted to a medical unit.

Following a medical stay, the disposition is usually a transfer of the patient to an inpatient psychiatric service (sometimes at another hospital) or a discharge to a community mental health center following treatment of the medical condition(s) and after the medical inpatient service has made reasonable efforts to attenuate the co- occurring psychiatric difficulties/symptoms.

These are sub-optimal outcomes as these patients would be much better served by integrated medical and psychiatric services in the same inpatient setting in order to increase the probability of establishing an accurate set of neuropsychiatric diagnoses and a successful discharge to outpatient mental health care.

Preferably, a combined medical/psychiatric stay should include psychological/neuropsychological testing, which is rarely available in either medical or psychiatric inpatient and outpatient settings. Such specialized assessment can help to clarify the complex interaction of medical and psychiatric factors at play in a given case and, hence, assist in elucidating a patient’s neuropsychiatric status and treatment needs as well as generate recommendations for outpatient services following discharge.

Elderly patients with stable and reasonably well-treated medical conditions but with worsening and potentially endangering psychiatric difficulties/symptoms, which clearly warrant inpatient-level care, can usually be satisfactorily accommodated by established geriatric inpatient psychiatry programs.

Unfortunately, there are no truly integrated medical/psychiatric inpatient services in New Hampshire for adults of any age.

This situation persists despite the development of such programs in other states decades ago and, in recent years, the mergers of hospitals in New Hampshire as well as the acquisition of other New Hampshire hospitals by Massachusetts-based medical centers/teaching hospitals. Presumably, such mergers and acquisitions would have led to the creation of an inpatient service of this kind in New Hampshire but, to date, this has not been the case.

When compared to the continuation of non-integrated inpatient care, a combined medical/psychiatric inpatient program may well prove to be cost-effective in terms of several important outcome criteria: Shorter length of inpatient stays, decreased recidivism, reduced utilization of outpatient care as well as bestowing a renewed sense of hope and purpose to patients and their loved ones.

A combined medical/psychiatric inpatient service may also have positive downstream effects by sparking an interest in the education and training of clinicians in the community mental health center system regarding the programmatic needs of these patients.

Historically, these centers have played an invaluable role in facilitating and maintaining a successful transition of patients from inpatient psychiatric care to outpatient psychiatric services but for some years now they have been faced with trying to address the needs of an ever increasing number of medical/psychiatric patients.

Therefore, the development of education and training programs for clinical staff in these centers to more effectively meet the healthcare challenges of these patients would clearly be beneficial.

The time is long overdue for the establishment of a medical/psychiatric inpatient service in New Hampshire.

Meeting this goal in a timely manner would, as a start, require a resolute coalition of psychiatrists and other physicians, psychiatric nurse practitioners, non-medically trained, albeit, “medically minded” mental health clinicians, as well as the participation of healthcare advocacy groups.