Most patients with uncomplicated depression can be treated as an outpatient, while inpatient care is generally reserved for people with severe or treatment-resistant depressive symptoms, significantly impaired reality testing due to accompanying psychosis, high suicide risk, and/or impaired self-care [1]. Many patients whose initial presentation is so severe as to warrant hospitalization will have “failed” outpatient treatment. Even though such patients already have an established outpatient team, the inpatient psychiatrist should be prepared to reevaluate the patient’s diagnosis and overall plan as part of a “fresh look,” and attempt to understand why the patient is not responding well to outpatient treatment.

Treatment-refractory depression patients are also sometimes referred for hospital admission with a specific plan for initiation of a course of electroconvulsive therapy (ECT) [2].

With the near-universal deployment of electronic health records (EHRs), the audience for clinical documentation is growing ever larger. People who might read inpatient psychiatric notes can be sorted into groups across several domains (Figure 9.1). Potential readers are clinicians (including trainees), overseers, patients, and participants in legal proceedings (discussed later) [1, 2]. The group of clinicians includes oneself, other team members, consulting colleagues, and the patient’s future providers. It also includes medical students, residents, and other trainees who are working with the patient. Overseers can include internal utilization review (UR) staff, individuals performing external UR (i.e., on behalf of third-party payers), internal quality assurance (QA) assessors, and external QA assessors (i.e., regulators and licensing agencies) [3–6].

First, a clarification of vocabulary is needed. In this chapter, the terms “dual diagnosis,” “substance use disorder[s],” “[name of substance] use,” and/or “[name of substance] dependence” are used. The more modern term “co-occurring disorder” is virtually synonymous with “dual diagnosis,” both of which reference the coexistence of a clinically significant use of drugs and/or alcohol with a primary psychiatric illness (an example of this would be bipolar disorder with cocaine dependence). Of course, a patient can have a substance use disorder (SUD) without having a dual diagnosis – i.e., without a separate, primary psychiatric illness [1]. The assumption is made that, unless mentioned specifically, clinical situations discussed here involve patients who do have a primary psychiatric illness in addition to a SUD. Also, although the fairly recent, though now outdated, DSM-IV criteria differentiated between substance abuse and substance dependence, this volume (again, unless specifically mentioned) does not make that distinction.

Most inpatient clinicians have little problem recognizing classic mania, as it presents with a familiar complex of signs and symptoms: elation, expansiveness, rapid speech with flight of ideas, grandiosity, spending sprees, and hypersexuality [1]. A manic episode can usually be differentiated from a psychotic break in schizophrenia in that many manic patients will exhibit people-seeking behavior as well as an overall quality of overactivation (Table 3.1). However, this pattern of acute euphoric mania may be less common than in the past. Increasingly, patients require hospitalization for manic symptoms combined with irritability, suicidal preoccupations, and dysphoric mood (in the older literature, in fact, this syndrome was termed “dysphoric mania”). This is the so-called mixed state, which – depending on one’s definition – 40% of bipolar patients will experience at some point in their clinical course [2].