General considerations NIMH federal agency patient room for<unk> c research, Maryland, USA Individuals receiving<unk> c treatment are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a<unk> c physician or other<unk> c practitioners by various paths, the two most common being self-referral or referral by a primary care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in countries such as the UK and Australia, by sectioning under a mental health law. A<unk> st or medical provider evaluates people through a<unk> c assessment for their mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and<unk> c rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged<unk> c problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the<unk> st, especially if blood tests and medical imaging are performed. Like most medications,<unk> c medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts, serum drug levels, renal function, liver function or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious conditions, such as those unresponsive to medication. The efficacy and adverse effects of<unk> c drugs may vary from patient to patient. Inpatient treatment<unk> c treatments have changed over the past several decades. In the past,<unk> c patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Average inpatient<unk> c treatment stay has decreased significantly since the 1960s, a trend known as deinstitutionalization. Today in most countries, people receiving<unk> c treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalization. However, in Japan<unk> c hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months.<unk> c inpatients are people admitted to a hospital or clinic to receive<unk> c care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the United States and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. People may be admitted voluntarily if the treating doctor considers that safety is not compromised by this less restrictive option. For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Internationally, mental health laws vary significantly but in many cases, involuntary<unk> c treatment is permitted when there is deemed to be a significant risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on a treating physician's recommendations, without requiring consent from the patient. Inpatient<unk> c wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, pharmacists,<unk> c nurse practitioners,<unk> c nurses, clinical psychologists, psychotherapists,<unk> c social workers, occupational therapists and social workers. If a person receiving treatment in a<unk> c hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision and may be put in physical restraints or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own. In many developed countries there has been a massive reduction in<unk> c beds since the mid 20th century, with the growth of community care. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason. Even in developed countries, programs in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others. Alternatives to<unk> c hospitals that may actively offer more therapeutic approaches include rehabilitation centers or "rehab" as popularly termed. Outpatient treatment Outpatient treatment involves periodic visits to a<unk> st for consultation in his or her office, or at a community-based outpatient clinic. During initial appointments, a<unk> st generally conducts a<unk> c assessment or evaluation of the patient. Follow-up appointments then focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient's mental and emotional functioning, and counseling patients regarding changes they might make to facilitate healing and remission of symptoms. The frequency with which a<unk> st sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person's condition, and depending on what the clinician and patient decide would be best. Increasingly,<unk> sts are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a<unk> st would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy". This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by<unk> sts. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. Because of this shift in practice patterns,<unk> sts often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.
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