General hospital psychiatry: are its roles and functions adjunctive or pivotal?

General hospital psychiatric divisions are an important part of the mental health care delivery system; however, in Canada and the United States, their role and function have not been well defined. In most places, the general hospital is peripheral to the mental hospital, and is thus an adjunctive element in the resulting two-tier mental health care delivery system. The adjunctive type of general hospital psychiatric division provides brief treatment to highly selective types of patients, and is relatively inaccessible to a wide variety of patients. In contrast, the general hospital can be central to the mental health care delivery system--in a pivotal position to patients, other mental health facilities, and community agencies. Important features of the pivotal type are: defined catchment areas, broad admitting criteria and effective discharge planning, linkages with extramural and community programs, staff reorientation, appropriate architectural features, and the ability to hear and respond to the needs of the community. The pivotal type of general hospital psychiatric division can provide appropriate levels of inpatient care, as well as the linkages and backup to extramural and community programs for the long-term mentally ill. The mental hospital would no longer be used as a backup for general clinical disorders, involuntary patients, or patients usually rejected by adjunctive hospitals. There would be collaboration with other agencies in developing programs for special clinical groups (low prevalence disorders), as well as for alcoholism, psychogeriatrics, and adolescent disorders. This article reviews the current polemic on the role and function of the general hospital psychiatric division, as part of the mental health care delivery system.