Responding to Psychiatric Crises
Featured Guest: Dr. James Hart
For today’s show, I sat down with Dr. James Hart, who serves as the medical director of Rolling Hills Hospital. Located south of Nashville, Tennessee, Rolling Hills is an acute care psychiatric hospital that provides short-term interventions for individuals experiencing mental health crises. Dr. Hart shares how his team stays prepared for responding to the wide array of time-sensitive psychiatric emergencies that present at their doorstep and explains how electroconvulsive therapy has evolved to become a safe, effective treatment option that can often work faster than medication.
David Condos: Hello and welcome to this episode of Recovery Unscripted. I’m David Condos and this podcast is powered by Foundations Recovery Network. For today’s show, I sat down with Dr. James Hart, Medical Director of Rolling Hills Hospital. Rolling Hills is an acute care psychiatric hospital that provides short-term interventions for individuals experiencing mental health crises. James shares how his team stays prepared for responding to the wide array of time-sensitive psychiatric situations that present at their doorstep, and he explains how electroconvulsive therapy has evolved to become a safe, effective treatment option that can often work faster than medication. Now, here’s James.
David: All right, I’m here with Dr. James Hart. How are you doing today?
Dr. James Hart: I’m doing very well. Thank you for having me.
David: First, let’s have you tell us a little bit about your personal background and how you got started in the world of medicine.
James: Sure. I’m originally from East Tennessee. I came to Nashville to attend Vanderbilt University and basically never left. I ended up graduating from Vanderbilt with a degree in medicine and completing psychiatry training there.
David: What would you say drew you to that field of psychiatry and behavioral health specifically?
James: That’s a really good question. Sometimes I question myself, “Why did I do this?” I’ve always been interested in the brain and in the mind. In college, I was interested in both biology and philosophy, so psychiatry seemed to really be a good blend of those interests that I have.
David: Now you’re the medical director at Rolling Hills, correct?
David: Could you tell us a little bit about what that current role you have entails?
James: Sure. I do day-to-day psychiatric treatment. I see my patients like the other physicians in the hospital, but also I’m part of the management team as well. Some of the executive decisions, decisions about treatment programming that we’re going to do, helping the other doctors, assisting them. That falls under the umbrella of the medical director role.
David: Backing up a little bit, for anyone who is listening who is not familiar with Rolling Hills or maybe not familiar with that type of psychiatric hospital, how would you describe the overall philosophy and the mission there?
James: Rolling Hills is a 120-bed hospital. It’s located in Williamson County. It’s not a rural area, but it’s certainly got some space about it. I think impressions are made in the first few seconds when you meet someone or something, so the first impression is very nice. Then getting admitted to the hospital is not like your typical emergency room admission to a community medical facility. It’s an easier process than that. It’s a smoother process. It doesn’t feel medical, so to speak. It’s an acute care psychiatric hospital, which means that we provide short-term interventions for individuals in crisis. Typically, someone would come to us who is not feeling safe with themselves, for example, or who has put themselves at risk with substance abuse or who has become confused and unable to take care of themselves.
David: Could you tell us a little bit about the team that you have around you at Rolling Hills?
James: I’d love to. We have a great team. One of the things that make me want to go to work every day are the people that I get to work with. We have very good people who are hands-on, day-to-day individuals that work with our patients. We have excellent nursing staff and then we have a very good social work staff. It’s a combination of physician, social work, nurses and technician that as a team manage the patients that come there.
David: How does the social work aspect fit in with the other clinical parts of that team?
James: They talk directly to the patient. They also interface with the families and they do a big part of the discharge planning where finding them the next level of care to go to when they leave the hospital for example.
David: Okay, so transitioning aspect.
James: Yes. Helping them reintegrate back into the community when they leave.
David: What would you say is one or two things that you enjoy most about the role that you have there?
James: The number one thing is watching people get well. People come into our hospital, they’re very distressed. They’re not doing well or otherwise they wouldn’t be there. In a hospital setting with the resources that we have, you can see very rapid improvement and it’s very rewarding to see someone come in at the end of their rope and leave feeling optimistic.
David: Like you mentioned, a lot of the patients who come to Rolling Hills are going through some form of a crisis and are in need of immediate acute care. How would you say the approach is different for helping patients with short-stay care for those types of emergencies as opposed to other longer stay types of psychiatric care?
James: Well, the immediate thing is helping them maintain their safety. We can provide very intense observation of them to help keep them safe. A question I frequently get from my patients if they’re going to go to the hospital is, “How long do I have to be there?” Usually, the first thing I would say is, “Let’s not measure it by how long do I have to be there before I leave. Let’s think about how long does it take to get well?” Because when you get well, leaving takes care of itself. The average length of stay at Rolling Hills is about eight days, but what we do is we treat each person individually. Individual needs can vary and the illnesses that we’re treating might vary in their average duration.
Some of the detoxification from substance abuse might be shorter, some of the older adult issues might be longer but if you look at the average, it’s around eight days. It’s an acute care facility, it’s not a long-term facility. Additionally, we’re doing diagnostic evaluations. Why did they get to the point they’re in? What caused them to end up this way? You see an individual who presents to our hospital and then there’s detective work going on to sort out what got them to this point and what can we do to help them address that.
David: Right, so reverse engineering the last few phases that got them there?
James: Absolutely. When Rolling Hills was built and opened its doors–once a hospital opens its doors, it never closes them. And since it’s been opened, it’s open 24 hours a day, seven days a week because that’s the nature of the human condition that we deal with. You can’t schedule a crisis. Rolling Hills is always there if you need a crisis evaluation. We have counselors present around the clock if you need to come in for reassessment to help determine what your needs are.
David: Yes, so people can just come in whenever they’re in this situation, right?
James: They can, yes. We always have someone there.
David: I guess one example of a crisis that may benefit from this type of acute care is one that involves suicidal thoughts or attempts. What are some ways that Rolling Hills specifically helps patients who come in in that type of situation?
James: One of the things that I’ve seen is that someone who is suicidal and comes into our hospital, they usually get an immediate sense of relief because they know that they no longer have to protect themselves from themselves, they know that we’re going to keep them safe. That relieves an emotional burden right away and allows them to step back and reevaluate. Additionally, we’ve removed them from the stressful environment that was contributing to those thoughts and feelings. Taking them out of their stressful environment, taking away the burden of them having to keep themselves safe usually gives them some immediate relief.
David: Rolling Hills offers several different programs to meet the needs of different age groups, illnesses, disorders. Could you tell us about some of the specific programs that you offer and how they help patients with their unique needs?
James: Sure. We have an adolescent program, which is intended for individuals roughly from age 13 to 18. We have an adult unit for the younger adults up to age 55 or so. We have an older adult treatment program for individuals in their 50s, 60s and upwards that may have developed some late life issues. We have two different programs for individuals who have become confused or psychotic and maybe need more intensive treatment. Typically, individuals in that situation might suffer from bipolar disorder, schizophrenia, other psychotic conditions. Some of them might have some extreme confusion due to drug abuse, so they’ve lost contact with reality.
David: Yes, so they’re having some kind of extreme episode or maybe it hasn’t been treated and it just snowballed into the situation that they’re in then?
James: It is. A lot of times, these individuals maybe have stopped taking their medication or missed appointments and gotten off track somehow and have developed confusion from that.
David: You mentioned the adolescent-specific program, what are some of the challenges that you face with helping adolescents find healing for mental and behavioral health issues?
James: Adolescents have a lot of challenges. They’re trying to become independent adults; that’s difficult. They have the peer pressures that they face in their school setting. They’re trying to separate, individuate from their parents which doesn’t always go smoothly. They sometimes lack the judgment and sense of perspective that you have and as adult to make good decisions. Impulsivity is a frequent problem; some of them have substance abuse issues. In addition to that, you’re not only working with the adolescent, but you’ve got to work with the entire family, because they’ll be going back to a family environment. So you’re treating really the family system there.
David: The techniques or the methods of treatment, are they very much different from the adults? I guess treating the family system would be a specific emphasis, but what else?
James: A lot more family involvement. A lot more reliance on social work input who primarily is involved with the family. If you’re administering medicine, you need to be more careful with your medications, because these are young people who are typically medication naive. There’s more diagnostic focus there, because a lot of psychiatric illnesses have their onset during this age group. You need to be very careful about your diagnostic approach to make sure you get it right and get them on the right path of treatment.
David: Yes. The same question for the older adult population. With your geriatric program, what are some of the specific challenges with that population?
James: Well, that’s interesting that you bring that on the tail end of the adolescent population, because it in some ways mirrors the adolescent in that also there’s a lot more family involvement because you may have younger family members, children, other siblings that are having to take care of them when they go home, because they’re not capable either physically or cognitively of taking care of themselves. You’ve got to get them on board with the treatment plan as well. It’s an analogous in some ways to the adolescent population but just at the other end of the spectrum.
David: It comes full circle a little bit, where they need that family system of support as well.
David: Another specific type of therapy that I saw you offer is electroconvulsive therapy. Could you first tell us how ECT works and what types of conditions it can help?
James: I’d be happy to. Electroconvulsive therapy, or ECT, has been around for many years. It’s always been a part of treatment in psychiatry. It continues to be utilized today. Some people are surprised to hear that, but if you look at the treatment algorithms for various psychiatric illnesses, such as depression or depression with psychosis, ECT is always one of the recommended treatments. The reason for that is it has always been and still remains the single most effective treatment we have for severe depression. Even with the advent of new medications and therapies, ECT remains the gold standard for treatment. You asked me how it works and first, let me say that no one knows how anything works in psychiatry. [laughs]
If you read about any medication, the first line is, “We don’t exactly know how this medication works.” We have our theories as to how things work, and there are theories as to how ECT works. The theory that is most appealing to me is that what ECT does is has the brain release its natural anticonvulsants, if you will. We use anti-seizure or anticonvulsant medicines in psychiatry to treat mood disorders. With ECT, we cause the brain to have a seizure while you’re under anesthesia. Brains don’t like to have seizures, so they have their own mechanisms to stop a seizure from occurring. We think it’s inducing those mechanisms to stop the seizure that treat the underlined mood disorder. It does it in a way that’s more effective than any medication by itself.
David: Interesting. The brain produces some of the same things that medicine is trying to recreate, so you’re just triggering that?
James: Yes. You’re inducing the brain to create its own natural medications, if you will.
David: Is this something that would be used in a crisis situation or is this later on, as part of a larger plan? How and when is it used?
James: Practically speaking, most people would utilize the ECT after they’ve failed several medication trials or other kinds of therapy. In some situations it goes up the ladder in priority a little bit. For example, if someone’s acutely suicidal or at some immediate risk, ECT might be considered more quickly, because it’s more effective and works faster. The classic indication for ECT is someone who’s gotten depressed, that they’ve developed confusion or psychosis from their depression. But it’s also used in bipolar disorder, it can treat depression and mania, agitation caused from other forms of psychosis, such as schizophrenia or dementia. It has a variety of uses. It’s not for everything, but when it is selectively utilized, it’s the single most effective treatment we have.
David: How is the ECT that you offer today different from maybe what people think of when they think of ECT from the ’40s or ’50s?
James: Or the movies?
David: Yes, exactly.
James: Yes. The primary differences are that the anesthesia that we use is much more effective. In fact, when ECT was first utilized, they didn’t use anesthesia. Now, the patient is given IV medication, they’re completely put to sleep, like with any other medical procedure, so that all the experience is going to sleep in waking up three or four minutes later. We also use medications that block the muscle movement of the seizure itself. If you were to walk into a room while we’re doing a treatment, you might not even notice that we’re doing a treatment, because the individual is not physically having a seizure like you would see if someone spontaneously had a seizure on the street. Additionally, they’ve got more sophisticated with the electrical stimulus used to cause the seizure, to minimize any cognitive side effects that it might cause.
David: It sounds very controlled.
James: Very controlled.
David: As you mentioned, outpatient is another part of what you do. When might outpatient care be the right choice instead of inpatient?
James: One of the factors that would determine which path you go down there, is a safety issue. If there’s any concern about patient safety, we’re going to go with an inpatient route. An individual might be more appropriate for an outpatient setting that we offer if their symptoms are significant, but they don’t feel that they’re in danger. We have a variety of outpatient settings there. It ranges from outpatient psychiatric appointments like with myself or one of our other doctors, to a program called intensive outpatient treatment, where you might come for a couple hours in the evening or to get off work for example. Then we have a partial hospital program, where people come during the day for a full day, but then they go home at night. We have a spectrum of intensity of services available to them.
David: Is that determined by the doctors or how are those choices made as far as the levels of care?
James: Yes, it’s primarily a physician-driven determination as to what level they need. A lot of times it’s a step-down process. You might start out in an inpatient setting, and then transition to the partial hospital setting, and then maybe the intensive outpatient or regular outpatient treatment from there.
David: We’ll wrap up with this last question. Everyone who serves in this field has their own personal reasons for wanting to further their cause of behavioral or mental health. Why is helping people find recovery important to you?
James: It’s important for a couple reasons. One, as I mentioned earlier, I enjoy seeing people get well. We watch people improve in psychiatry, we get to see it happen in a short period of time with inpatient psychiatry. Another thing I like about it is psychiatry is one of the few specialties in medicine where you really actually get to treat the whole person and you get to listen to people. Medicine has become very fragmented, it has become very time-intensive as such that individual doctors these days, it seems like, only get to focus on a symptom and they don’t get to listen to the whole individual and incorporate all of that into their treatment plan. Psychiatry is one of the few areas where you can still do that.
David: You get a little deeper beyond just the quick, surface items?
James: Exactly. You integrate both their physical issues and their emotional or behavioral issues into one aspect of care.
David: Yes, because they’re all really affecting each other, right?
James: They all do. You can’t separate it out.
David: Yes, all right. Well, thank you, Dr. Hart, for being with us.
James: Thank you for having me, it’s been my pleasure.
David: Thanks again to Dr. Hart for joining us. Now, I get to introduce another installment of our ongoing segment called Minute of Mindfulness. Together, we’ll take the next 60 seconds to slow down, take a deep breath, and focus on this present moment. As always, I’ll open things up with an inspirational quote, and then I’ll rejoin you to close out the episode. Today’s quote comes from William James, an influential 19th-century philosopher and pioneering psychology educator, who has been called the father of American psychology. He said, “Seek out that particular mental attribute which makes you feel most deeply and vitally alive, along with which comes the inner voice which says, ‘This is the real me.’ And when you have found that attitude, follow it.”
This has been the Recovery Unscripted podcast. Today we’ve heard from James Hart, Medical Director of Rolling Hills Hospital. To read more on their services, visit rollinghillshospital.org. And thank you for listening today. Please take a second to give us a rating on podcast app and subscribe so you won’t miss out on what we have coming up. See you next time.