综合医院精神科设置状况及其作用的对照研究

目的调查上海综合医院精神卫生服务资源及临床医师培训等现状,为制定综合医院精神卫生服务政策提供相关依据.方法(1)对上海市15家三级综合医院和14家二级综合医院的精神卫生服务现状进行问卷调查.包括医院规模及医疗服务资源,精神卫生服务机构设置及人员配置状况,会诊联络精神医学开展情况等.(2)选择两家已开设和未开设精神卫生服务科室的三级综合医院,对临床医师参加精神卫生培训情况、对精神卫生知识、对开展精神卫生服务工作意向的认识等进行对比分析.结果(1)开设精神卫生服务科室的医院为17家,占58.6%,提供精神卫生服务的专科医师人数为65人,平均3.2名/千张床位.(2)已开设精神卫生科室的医院中精神科会诊率平均为0.63%,未开设精神卫生科室的医院中精神科会诊率平均为0.10%,二者具有显著性差异.(3)所有调查医院均未成立由精神科医师和临床医师共同参加的会诊联络小组;缺乏专职的会诊联络医师常规地参与临床和宣教工作;(4)已开设精神卫生科室医院的临床医师在接受精神卫生培训、掌握精神卫生知识程度以及对开展精神卫生服务的工作意向等方面均显著优于未开设精神卫生科室的医院.结论设立精神卫生机构,提高各级综合医院的精神卫生服务的能力势在必行.     

上海市综合医院精神卫生服务现状调查

目的 了解上海市综合医院精神卫生服务资源等现状。方法 对上海市区15所三级和14所二级综合医院的精神卫生服务现状进行问卷调查。内容包括:医院规模及医疗服务资源;精神卫生服务机构设置及人员配置状况;会诊联络精神病学开展情况以及医院对临床医师进行精神卫生知识培训情况等。结果 (1)在29所综合医院中,17所甲等医院设置精神卫生科室,占59％,显示近年来综合性医院开始重视精神卫生服务工作。(2)已设立精神卫生科室的医院中精神科年会诊率为0.63％;而未设立的医院中精神科会诊率为0.10％,两者间差异具非常显著性(P>0.01)。(3)在被调查医院中仍有55％的医院未开展或仅是偶尔开展会诊联络精神病学工作。(4)精神科医师以不同形式和程度参加各科医疗工作;(5)已设立精神卫生科室的医院其临床医师在接受精神卫生培训方面显著优于未开设精神卫生科室的医院。结论 需要大大提高综合医院精神卫生服务能力,且设立精神卫生机构势在必行。     

非精神科医师对精神障碍处理现状调查

目的：了解上海市非精神科医师对精神障碍处理的能力和方式。方法：对上海市7家医院的1016名非精神科临床医师进行了自制问卷调查。结果：非精神科医师在临床工作中对患者的精神状况或情绪的关注存在较大差距;对可能有精神障碍的患者大多数医师会选择请精神科人员进行会诊;有近三分之一的医师对精神卫生知识培训存在消极态度。结论：非精神科医师对精神障碍识别和处理能力需要进一步提高。     

《精神卫生知识远程网络》教学效果的学员反馈问卷分析

目的了解上海市综合性医院非精神科执业医师对精神卫生知识的了解、掌握和需求情况,使远程网络培训教学和管理更趋完善.方法采用自制问卷调查方法向39家市综合性医院进行调研.结果接受远程教学培训的3862名非精神科执业医师中,有效回答反馈问卷2653名,其中,91.75%感到培训很必要;96.04%对精神卫生问题较为关注;整体而言,培训后相关知识得到提高.结论精神卫生知识远程网络教学培训非常必要,基本达到预期目标.     

中国医师协会精神科医师分会综合医院精神卫生工作者联盟成立

2005年12月24日，来自全国综合医院和精神专科医院不同学科的25名医师，在广州召开了中国医师协会精神科医师分会综合医院精神卫生工作者联盟（Fed-MHiGH）成立大会。基于在各自岗位上已经开展的实践经验，大家对综合医院的精神卫生服务发展方向进行了讨论。一致认为联盟的成立，将为综合医院非精神科医师与精神科专业人员搭建一个相互沟通和促进的平台，为患者提供更为人性化、整合性的医疗服务提供了良好的契机。     

郑州市综合医院精神科院际会诊102例回顾分析

目的探讨郑州市综合医院开展精神科院际会诊的现状及临床特点。方法对2010-01—2011-12郑州市综合医院邀请郑州大学第一附属医院精神医学科或郑州市第八人民医院进行精神科院际会诊102例患者的一般情况、邀请会诊医院及科室分布、原发病、会诊原因、会诊后诊断及治疗情况进行回顾性调查、统计和分析。结果邀请精神科会诊的综合医院以二级医院居多,会诊科室中内、外科占前两位,最常见的精神科诊断依次是:抑郁症、神经症、器质性精神障碍、精神分裂症等。结论二级以上综合医院应开设精神、心理科以及时处理院内各科患者的精神、心理问题。未设置精神、心理科的综合医院,开展精神科院际会诊,既有利于临床各科各类精神障碍患者得到及时、准确的专科诊治,又有利于会诊—联络精神病学的发展,同时应加强综合医院各科医生精神、心理知识的教育培训。     

精神科医师转岗培训教学实践探讨

为加强精神科医师培养工作，提高基层精神卫生服务能力，建立健全精神卫生体系，开展 精神科医师转岗培训至关重要。通过开展精神科医师转岗培训项目，从理论知识、临床实践、社区实践 等教学内容方面学习，同时从教师能力、教学理念、形式等教学模式方面进行优化，采用多种教学模式 相结合，穿插强化培训班以强化教学内容，并严格全面考核以评估培训效果。通过对精神科转岗学员 系统的培训，精神科转岗学员重点掌握了基本理论知识和临床基本技能，熟悉精神卫生工作服务模式， 达到胜任精神科医师岗位的基本要求，从而进一步完善各级医疗机构，尤其是县级医疗机构的精神科 医师培养，提高精神卫生服务的可及性，缓解精神卫生人力资源短缺的不足。     

本世纪初我国社区精神卫生工作发展展望

本文探讨本世纪初我国社区精神卫生工作发展趋势，结合国内外有关文献，提出了自己下列几点意见：(I)社区精神卫生工作在1万人口左右的小社区中，只能由通科医师兼管，通科医师需经几周培训，掌握10种常见精神疾病与lO种常用价廉良效精神科药物；在10万人口左右的中等社区中，逐步普及精防站或精神卫生专科医疗点，有2～3个专科医护人员为辖区内1千名精神病患者提供医疗服务；在100万左右人口的大社区(县城或大城市的市辖区设立30～300个床位的精神病院，为社区内1万名精神病患者提供医疗服务。(2)建立3支精神卫生工作队伍，一支是各级精神病专科医院内的精神科医护人员组成，第二支是有独立人员编制，不同行政管理与隶属关系的社区精神卫生工作者队伍；第三支是县以上综合医院中的精神科或心理科队伍，他们由临床心理医师(临床医学本科毕业生，有处方权)与心理治疗师(非医学本科毕业，但经过正规心理咨询与心理治疗培训，无处方权)组成，主要处理功能性躯体不适，神经症，性格、情绪与行为障碍，心身疾病的药物与心理治疗，以及精神病的联络会诊工作。(3)提出lO年之内政府增加精神卫生工作专项拨款5～lO亿，即可建立覆盖全国的精神疾病防治网，使我国精神科按人口比例计算的专业医务人员数和病床数达到当今世界各国的平均水平，改变目前精神卫生工作相当滞后的局面。(4)提出对于1600万精神病患者，政府在目前与今后，只能优先解决其中1％～10％的病人的最低生活保障与社会医疗保障问题，即“三无”病人与危害社会与家庭安全的病人，其余绝大部分病人的问题只能在实现全民社会医疗保险与全民最低生活保障制度时一并得到解决。而且精神病人的主体是慢性精神分裂症、精神发育迟滞与老年痴呆，他们的未治率高，病残后生命年长，是社会福利与社会保障的重点与难点。     

上海市社区卫生服务中心精神卫生服务基本情况的调研与分析

目的为了贯彻实施<上海市精神卫生条例>,推动社区卫生服务中心建立精神科门诊或心理健康咨询门诊,更好地为市民提供精神卫生服务,上海市疾控精神卫生分中心开展了对全市社区卫生服务中心精神卫生服务与需求基本情况的调研.方法调研采用表格式登记表登录方式,应用构成比进行相对数分析.结果调研数据显示全市有26.16%的社区卫生服务中心尚未开设精神科/心理健康咨询门诊;社区精神科医生仅208人,其中,中专及以下的学历占55.29%,77.88%的人员是初级职称,约四分之一服务人员从未接受过任何精神卫生方面的培训,这在一定程度上影响了对社区人群的服务.讨论建议各级卫生行政部门应当重视社区卫生服务中心建立精神科/心理健康咨询门诊,并为社区卫生服务人员接受精神疾病知识教育创造条件.     

濮阳市精神卫生服务现状与对策研究

目的 对濮阳市2007年精神卫生服务现状做一全面调查,为政府相关部门制定精神卫生工作规划提供依据.方法 采用问卷调查法与小组访谈法.结果 全市有精神卫生专科医院4家,精神科床位292张,精神科医师45人,精神科护士91人,平均分别为0.81张/万人,1.24人/10万人,2.51人/10万人;病床使用率为75.04%;医疗设备简陋,缺乏先进诊疗设备和高层次的人才;4家医院总收入为626万元,平均2.48万元/人;2家医院有少量差额拨款,政府投入严重不足;全市仅有4家综合医院开设精神科.精神卫生专业人员风险大、待遇低;公众精神卫生知识匮乏,一些重要的精神卫生问题未被公众识别,精神疾病患者的就诊率低.结论 建立全市精神卫生工作统一管理协调机构;加大政府财政投入;加强专业人员培养;完善全市精神卫生服务体系和网络建设;加大精神卫生知识宣传力度,消除社会对精神痛患者的偏见与歧视;从政策入手妥善解决重性精神痰病患者的基本医疗问题.     

Characteristics of patients presenting for emergency psychiatric assessment at an English hospital

OBJECTIVE: The needs and characteristics of patients who are referred for psychiatric emergency services vary by the source of referral. Such differences have wider implications for the functioning of the mental health care system as a whole. This study compared three groups of patients in a two-month cohort of 189 patients who were referred for emergency psychiatric assessment at a hospital in England: those who were referred by general practitioners (family physicians), those who were receiving specialist services from community mental health teams, and those who arrived at the hospital from the broader community. METHODS: The three groups were compared on demographic characteristics, clinical and service use variables, risk to self or others, factors that contributed to the emergency presentation, and ratings on standardized scales of functioning. RESULTS: The patients who were receiving specialist services from community mental health teams had high rates of psychosis, often relapsed, and had a history of contact with a psychiatrist. These patients were the most likely to be admitted to the hospital after emergency assessment. The patients who had been referred by general practitioners tended to have fewer indicators of social problems and were more likely to be experiencing a new episode of mental illness. Their referral to the emergency department was most likely to be deemed inappropriate by emergency department clinicians. The patients who came from the broader community were more likely to be male and to exhibit self-harming behavior, substance misuse, and behavioral difficulties. CONCLUSIONS: The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.     

综合医院医学心理门诊医师对抑郁症的识别

目的 了解综合性医院精神科门诊中专科和非专科医师对抑郁症的识别情况及对抑郁症的治疗模式和临床疗效,并对其相关影响因素进行分析,为制定综合医院精神卫生服务政策提供相关依据。方法 收集来自上海市9所综合性医院精神科门诊中的抑郁症患者47例,分为专科医师组20例和非专科医师组27例,在入组时、治疗第2周、第4周、第8周、第12周时,进行汉密顿抑郁量表24项（HAMD^24）、汉密顿焦虑量表（HAMA）、健康状况调查问卷（SF-36）、修订社会功能缺陷筛选量表（SDSS）、自编的药物依从性评估等量表的评定。结果 （1）综合性医院精神科门诊中专科医师对抑郁症的识别显著高于非专科医师组（χ^2=12．68,P〈0．01）。（2）专科医师组对抑郁症的治疗疗效优于非专科医师组（χ^2=7．16,P〈0．01）,两者在治疗后第8周及第12周HAMD、HAMA总分减分率上有显著性差异。（3）两组在治疗第12周时SF-36各因子分均较入组时有显著提高。结论 综合性医院精神科门诊中专科医师在对抑郁症的识别、治疗疗效上优于非专科医师;非专科医师对抑郁症的识别及诊治能力有待进一步提高．相关的卫生管理体系作用需要进一步加强。     

Mental health reform and evolution of general psychiatry in Ontario.

OBJECTIVES: To discuss developments in Ontario mental health reform, describe general psychiatric services in contrast to tertiary services, describe guidelines for the training of general psychiatrists, and suggest what changes may be required to develop an integrated mental health system (IMHS). METHOD: We review the Ontario government's recent blueprint for mental health reform and the Canadian federal government's document on best practices in psychiatry, in the context of defining general psychiatric services and their relation to tertiary services. From this, we consider the education of general psychiatrists and make suggestions for their training. RESULTS: General psychiatric services correspond to first-line and intensive psychiatric services delivered by community mental health agencies, community psychiatrists, and general hospitals for patients with moderate or serious mental illness. Many suggest that psychiatrists are not being trained to meet the needs of a reformed mental health system. An education program for general psychiatrists should include training in a wide range of community and general hospital settings, work within a multidisciplinary mental health team, and experience working in a shared care model with family physicians. CONCLUSIONS: Along with training general psychiatrists better, we must also develop recruitment and payment incentives, which would allow general psychiatrists who are based in the community and general hospitals to work within an IMHS.     

Establishing a nurse-based psychiatric CL service in the accident and emergency department of a general hospital in Germany

Introduction

Patients with mental health problems in accident and emergency departments (A&E) are frequent users and often difficult to handle. Failure in managing these patients can cause adversities to both patients and A&E staff. It has been shown that nurse-based psychiatric consultation–liaison (CL) services work successfully and cost effectively in English-speaking countries, but they are hardly found in European countries. The aim of this study was to determine whether such a liaison service can be established in the A&E of a German general hospital. We describe structural and procedural elements of this service and present data of A&E patients who were referred to the newly established service during the first year of its existence, as well as an evaluation of this nurse-led service by non-psychiatric staff in the A&E and psychiatrists of the hospital’s department of psychiatry.

Subjects and methods

In 2008 a nurse-based psychiatric CL-service was introduced to the A&E of the Königin Elisabeth Herzberge (KEH) general hospital in the city of Berlin. Pathways for the nurse’s tasks were developed and patient-data collected from May 2008 till May 2009. An evaluation by questionnaire of attitudes towards the service of A&E staff and psychiatrists of the hospital’s psychiatric department was performed at the end of this period.

Results

Although limited by German law that many clinical decisions to be performed by physicians only, psychiatric CL-nurses can work successfully in an A&E if prepared by special training and supervised by a CL-psychiatrist. The evaluation of the service showed benefits with respect to satisfaction and skills of staff with regard to the management of psychiatrically ill patients.

Conclusion

Nurse-based psychiatric CL-services in A&E departments of general hospitals, originally developed in English-speaking countries, can be adapted for and implemented in a European country like Germany. Open access: This article is published with open access at link.springer.com.     

Introduction: research at the interface of medicine and psychiatry

Linkages between psychiatry and other medical specialties have become increasingly evident over the past decade. Reinstatement of the medical internship for psychiatric trainees, expansion of psychiatric liaison services, growth of general hospital psychiatric units, determination of the extensive role served by nonpsychiatric physicians in providing mental health care, and research evidence of the economic benefits of incorporating mental health services in general health settings all have served to break down artificial boundaries between mental health and general health concerns. The psychiatric consultation-liaison service initiated in 1981 by the NIMH at the NIH Clinical Center in Bethesda has afforded opportunity for numerous collaborative research projects with clinical investigators of various categorical disease programs. In addition to offering new etiological insights into psychiatric and general medical illnesses, the work described in this symposium promises to move clinical practice closer toward the Engel model of biopsychosocial medicine.     

综合性医院医学心理科会诊的回顾性分析

目的：探讨综合性医院医学心理科会诊情况。方法：2004年9月至2009年9月期间医学心理科会诊534例,分析其申请科室、申请理由以及精神障碍的诊断和处理。结果：综合性医院医学心理科会诊中最常见的精神科诊断是脑器质性精神障碍、躯体疾病所致精神障碍、神经症和心境障碍。结论：应在综合医院积极开展会诊-联络精神病学服务颇为重要。     

综合医院精神心理科会诊患者特点分析

目的 了解综合医院精神心理科联络会诊的原因、患者的科室分布、病种构成及处理情况,以更好地指导精神心理科医生的联络会诊工作,为进一步完善会诊精神医学在综合医院内的发展提供参考.方法 本研究采用回顾性方法复习综合医院住院患者的精神科会诊情况,分析在现代医学模式下综合医院的患者对精神卫生服务需求的特点,汇总2012年1月-2013年12月精神心理科联络会诊病历,资料完整者共612例,对一般人口资料、各科会诊人数及病种构成、会诊原因、诊断、处理构成等情况进行描述分析.结果 全部临床科室都有邀请精神心理科会诊,比例最高的科室前5位为：神经内科113例（18.5％）、心血管内科83例（13.6％）、消化内科69例（11.3％）、干部科56例（9.2％）、急诊科52例（8.5％）.病种主要为神经症性、应激相关的及躯体形式障碍151例（24.7％）,心境障碍139例（22.7％）,器质性精神障碍108例（17.6％）,伴有生理紊乱和躯体因素的行为综合征84例（13.7％）;精神科用药以SSRIs类药物、非典型抗精神病药物及苯二氮革类应用较多.结论 综合性医院各科存在较多的精神医学问题,住院患者伴发的精神障碍涉及各类疾病,综合医院就诊的患者精神心理障碍应引起重视,精神科会诊联络非常重要,可以提高临床各科医师对精神障碍的认识,减少或消除人们对精神科会诊的顾虑与不信任,提高会诊效率,治疗躯体疾病的同时应及时使用心理和药物等多种干预手段,使患者得到全面康复,从而提高患者的生命质量.     

Expenditures on mental health and addictions for Canadian provinces in 2003 and 2004

OBJECTIVE: To measure total public and private expenditures on mental health in each province. METHOD: Data for expenditures on mental health services were collected in the following categories: physician expenditures (general and psychiatrist fees for service and alternative funding), inpatient hospital (psychiatric and general), outpatient hospital, community mental health, pharmaceuticals, and substance abuse. Data for 2 years, 2003 and 2004, were collected from the Canadian Institute for Health Information (hospital inpatient and fees for service physicians), the individual provinces (pharmaceuticals, alternative physician payments, hospital outpatient, and community), and the Canadian Centre on Substance Abuse. Totals were expressed in terms of per capita and as a percentage of total provincial health spending. RESULTS: Total spending on mental health was $6.6 billion, of which $5.5 billion was from public sources. Nationally, the largest portion of expenditures was for hospitals, followed by community mental health expenses and pharmaceuticals. This varied by province. Public mental health spending was 6% of total public spending on health, while total mental health spending was 5% of total health spending. CONCLUSIONS: Canadian public mental health spending is lower than most developed countries, and a little below the minimum acceptable amount (5%) stated by the European Mental Health Economics Network.     

Geriatric psychiatry in the general hospital: the integration of services and training

This article describes the development of a new psychiatric service for the elderly based in a university general hospital. The service aims to provide and coordinate comprehensive psychiatric care for a defined population and also to serve as a tertiary care unit with academic responsibilities. As part of the Department of Psychiatry, this specialized service is fully integrated into all the major clinical and teaching components of the department. As the demand for more geriatric psychiatry services and training increases over the next decade, innovative ways of responding to this need will have to be developed. This integrative model in a general hospital setting has enhanced the quality of health care delivery to the elderly at the same time as improving training and recruitment.