What Are the Differences Between Inpatient Medical Hospitalization & Psychiatric Hospitalization?

Inpatient medical hospitalization and inpatient psychiatric hospitalization are the two highest levels of care for individuals with severe eating disorders. Medical hospitalization focuses on stabilizing critical physical health conditions, while psychiatric hospitalization provides crisis intervention and intensive mental health support. Understanding the differences between these two levels of care helps providers and families make informed treatment decisions for those in need.

Treatment Options for Severe Eating Disorders

Eating disorder care can be delivered in a variety of settings, depending on a patient’s needs. Because the severity of an eating disorder can vary, it’s important that providers and patients understand the differences between the different levels of care and make well-informed treatment decisions.

The six levels of eating disorder care

There are six levels of specialized eating disorder care as outlined in the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders, Fourth Edition. In order of highest to lowest level of care they are:

• Inpatient medical hospitalization
• Inpatient psychiatric hospitalization
• Residential treatment program
• Partial hospitalization program
• Intensive outpatient program
• Outpatient program

Whenever possible, it is best to refer patients to specialized eating disorder programs, as they are specifically designed to improve eating disorder symptoms and restore weight in the majority of underweight patients.

Medical Hospitalization vs. Psychiatric Hospitalization

Inpatient medical hospitalization

Inpatient medical hospitalization is the highest level of eating disorder care. Inpatient medical hospitalization is necessary to treat the severe medical complications that can accompany an eating disorder, like:

• Severe bradycardia
• Gastroparesis
• Osteoporosis and osteopenia
• Endocrine dysfunction
• Electrolyte disturbances

Inpatient medical hospitalization is a short-term treatment program, and most patients only stay at this level of care until they have been medically stabilized and can be safely discharged to a lower level of care.

Patients are monitored 24/7, including when they use the bathroom or eat. At this level of care there usually isn’t an expectation to eat around other patients.

Because patients are medically compromised, physical activities, including walking or standing unassisted, are limited to prevent injury and facilitate weight gain. Patients are usually transported via wheelchair. Activities that are not physically taxing, like knitting, reading or web browsing are encouraged during down time.

Medical management

Another differentiator between inpatient medical hospitalization and other levels of care is the level of medical management available. Patients at an inpatient medical hospitalization level may require a level of monitoring that isn’t available in inpatient psychiatric hospitalization, like:

• Vital monitoring
• Intravenous fluids
• Daily lab monitoring
• Tube feeding
• Certain medications

Inpatient medical hospitalization can also offer a wider breadth of medical services, including occupational and physical therapy. Because inpatient medical hospitalization programs are often affiliated with hospitals, they also have access to a network of different medical specialties, including:

• Cardiology
• Neurology
• Gastroenterology
• Endocrinology

Other interventions

Even though the primary focus is medical stabilization, psychiatric, psychological and social work services also are typically available to ensure patients have the tools to manage their emotional wellbeing during their stay.

Who is inpatient medical hospitalization for?

The recommended admissions criteria for inpatient medical hospitalization is as follows:

• Weigh less than 70% of ideal body weight or have a BMI <15, even without the current presence of medical complications
• Drastic weight loss (>10% in six months or >20% in one year)
• Heart, kidney or liver failure or compromise requiring acute treatment
• Electrolyte imbalance or dehydration
• Acute medical complications of malnutrition (seizures, syncope, cardiac failure, pancreatitis)
  • In adults:
    • Heart rate of <40 bpm
    • Blood pressure <90/60 mmHg
    • Glucose <60 mg/dl
    • Potassium <3 mEq/L
    • Temperature <97°F
  • In adolescents and children:
    • Heart rate near 40 bpm
    • Blood pressure <80/50
    • Blood pressure changes (>20 bpm increase in heart rate or >10 mmHg to 20 mmHg drop)
• Requiring an NG tube or special feeding modality

Inpatient psychiatric hospitalization

Inpatient psychiatric care takes place in a psychiatric hospital or a psychiatric unit care setting. Patients in this treatment setting are medically stable, but still require acute psychiatric care. The goal of inpatient treatment is to stabilize the patient and ensure they are not a danger to themselves or others, with stays usually lasting up to 30 days. Inpatient psychiatric hospitalization is ideal for patients who need psychiatric treatment and continuous support.

An inpatient psychiatric unit may offer:

• Crisis intervention and stabilization
• Medication management
• Psychotherapy and/or psychoeducation
• Case management
• Recreational therapies
• Group therapy

Like inpatient medical hospitalization, inpatient psychiatric care takes place in a hospital setting. While some units may offer private rooms, it’s more common for two patients to share a room. While group therapy may be offered, care is more isolated than in a residential treatment environment and there aren't usually outings or activities outside of planned therapies.

Crisis intervention

This level of care may be necessary following a suicide attempt or another mental health crisis that doesn’t require extensive medical monitoring.

Inpatient psychiatric hospitals and units offer crisis intervention experts needed at this level of care, which aren’t available at lower levels of care like residential treatment programs and intensive outpatient programs. Inpatient psychiatric care can also be an opportunity to identify, diagnose and/or begin medication therapy for any co-occurring psychiatric disorders that may be exacerbating or exacerbated by an eating disorder.

Who is inpatient psychiatric hospitalization for?

The recommended admissions criteria for inpatient psychiatric hospitalization are as follows:

• The presence of a specific suicide plan with high lethality or intent
• Very poor-to-poor motivation to recover and preoccupation with intrusive and repetitive thoughts
• Requiring a highly structured environment to eat and gain weight
• An existing psychiatric disorder that would require hospitalization
• Needing supervision during and after all meals
• Needing supervision in bathrooms and unable to control daily episodes of purging
• Absence of family, severe family conflict or problems or lives alone

Which level of care is best for you or your patient?

Treatment should be offered in the least restrictive setting possible that will effectively address the eating disorder. There is no algorithmic approach that can determine the optimal care setting with certainty, and patients will differ in what factors influence what level of care is most appropriate.

There are a number of factors that can suggest a higher level of care is needed:

• Low weight in relation to estimated individually determined target weight
• Rate of recent weight loss
• Medical complications of purging
• Evidence of medical instability
• Approaching a weight at which instability previously occurred in the patient
• Additional stressors that affect the patient’s eating disorder behaviors
• The degree of the patient’s difficulties in collaborating in their care
• Co-occurring psychiatric symptoms or diagnoses
• Insufficient weight gain or worsening eating disorder symptoms despite treatment¹

References

1. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders. Fourth Edition. (2023). https://doi.org/10.1176/appi.books.9780890424865
2. Medical stabilization for eating disorders. (2021, February 26). ACUTE. https://www.acute.org/resource/medical-stabilization-eating-disorders
3. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders. Third Edition. (2010).