What should general hospital psychiatry do in a community?]

Some experiences in Nagano Red Cross hospital and Nagano Prefecture are presented, and the role of general hospital psychiatry (GHP) in a community is discussed. Psychiatric services in Nagano prefecture with population 2.21 million consist of four blocks. Our unit is in north block, providing treatment for acute phase and, in 2000, 1504 cases were new outpatients, daily outpatients were 198 cases and new inpatients were 604 cases including 146 emergency inpatients. In fiscal 2001, 25.6% of notifications of involuntary hospitalization from all psychiatric hospitals were submitted from GHP occupying 12.9% psychiatric beds, and 129 notifications from our unit were largest in Nagano prefecture. Total 7 GHPs with beds are presented by some data, suggesting two types as GHP. One type has relatively many new inpatients by small beds with short-term hospitalization like our GHP, and another type has relatively small new inpatients by large beds with long-term hospitalization like conventional mental hospital. It is necessary for GHP to pursue the former type, and to functionally differentiate from psychiatric hospital. Results of psychiatric emergency system in Nagano prefecture are presented. Designated hospitals are our GHP with 60 beds in north block, Prefectural Hospital with 310 beds in south block, National Sanatorium with 280 beds in east block and rotating 5 psychiatric hospitals with total 968 beds in west block. GHP with 60 beds hospitalized more emergency new cases than other psychiatric hospitals with large beds and discharged 84% of emergency inpatients to their home. Recently, short-term hospitalization of general hospital beds has rapidly progressed, and shared goal settings are needed, and treatment plans with teamwork by various types of experts have started from community-based home care. This teamwork will be expected throughout community psychiatric services. Although until today GHP's ward unit is financially disadvantageous, patients anticipate medical care of GHP on same level as a part of general hospital of course. For community psychiatric care and short-term hospitalization it is necessary for GHP to cooperate with various types of social resources. As for users of rehabilitation facilities in Nagano prefecture, GHP outpatients occupy 27.2%, and as for day care users, these occupy 19.6%, thus GHPs are able to cooperate with facilities. Above-mentioned facts indicate there is high necessity as a GHP, not a psychiatric hospital or a clinic. Cooperation between GHP and other social resources including welfare services will enrich community psychiatric services. GHP is a wide entrance for psychiatric care from a viewpoints of whole psychiatric care. When GHP accepted all patients on demands from acute cases to chronic, manpower will be diffused, and safety of medical care will be undermined. Therefore, psychiatric triage mainly functioning to treat early stage in severe cases with combined medical and psychiatric illness above all is necessary for GHP in order to offer proper treatment to a community. Accessibility in early stage of disease, priority of seriously ill patients and rehabilitation programs at a community as daily life space are essential for community mental health. We believe the first role of GHP in a community is to seek for psychiatric treatment on same level as general medicine. The second role is the psychiatric triage in order to function as GHP in a community. The third role is to cooperate with other social resources in a community. In order to promote the above it is necessary to self-evaluate GHP concerning the difference with specialized psychiatric hospitals or clinics. From these viewpoints GHP will become a core of community psychiatry. Currently, however, preparation concerned with GHP is poor compared with other advanced countries, so an aggressive improvement in medical policy is expected.     

Psychiatric emergency and somatic disorders

The authors made a survey in the setting of the Ste Anne hospital Emergency outpatient clinic to determine the incidence of somatic troubles in mental patients during a crisis situation. 1,000 patients were examined during a 24 day period. More than half of somatic problems had not been addressed to priori to Psychiatric consultation. More over, during those psycho-organic troubles, no precise information had been made available in half of the patient population. In 3% of cases, hospitalization could not continue in a psychiatric setting, which points to both the difficulty in assessing the medical capacity of psychiatric institutions ("secteurs") and acceptance of mental patients by the general medical hospital.     

Service use by elderly patients after psychiatric hospitalization

The extent and source of services used by older adults discharged to a community setting after a psychiatric hospitalization were examined in a prospective follow-up study. Patients were asked about service use in structured telephone interviews one month after hospital discharge. Subjects had comorbid medical conditions and high levels of functional impairment. Service use was low, highly skewed, and spread across three sectors of care-mental health specialty care (38 percent of the services), general medical care (35 percent), and social services and formal aging services (27 percent). Most service episodes were related to mental disorder.     

Predictors of missed first appointments at community mental health centers after psychiatric hospitalization

OBJECTIVE: This study was conducted to determine the practical, readily accessible predictors of missed first outpatient appointments in a community mental health setting after psychiatric hospitalization. METHODS: Data were collected from treatment team members and from charts of 234 consecutively discharged patients from two inpatient units in a large, urban, county hospital. Data on whether the patient attended the first scheduled outpatient community mental health appointment were gathered by telephone contact with outpatient clinics. Outcome data were available for 221 patients. Bivariate tests examined a variety of demographic, psychosocial, and clinical characteristics that may be associated with nonadherence. Significant predictors were entered into a logistic regression model to determine effect estimates (adjusted odds ratios). RESULTS: In bivariate tests, a number of variables were predictive of nonadherence with the first scheduled outpatient appointment. In the logistic regression model, the four characteristics that were independently significant predictors included involuntary legal status at discharge or leaving against medical advice, not having an established outpatient clinician, axis IV problems related to the primary support group (for example, death of a family member or health problems in the family), and number of days from hospital discharge to the follow-up appointment. CONCLUSIONS: Clinical, policy, and programmatic implications may be elaborated by studying risk factors for nonadherence in a community mental health setting. Given the multitude of problems associated with nonadherence, interventions should be tailored around specific characteristics that elevate the risk of nonadherence, especially nonadherence in the form of failure to attend the first appointment after psychiatric hospitalization.     

Hospital versus home care for the acutely mentally ill? Preferences of caregivers who have experienced both forms of service

OBJECTIVE: Demonstration studies of community treatment as an alternative to hospitalization have reported high degrees of satisfaction by family carers. We aimed to determine the extent of carer preference for hospital versus community treatment for acute mental illness in a routine setting where carers had experienced both service types. METHOD: Patients who had contact with both a hospital inpatient service and a Crisis Assessment and Treatment (CAT) team within the previous 5 years were identified. Seventy-seven family carers of these patients completed a questionnaire which identified their preference for services, and psychological and demographic variables likely to be predictive of their choice. RESULTS: Only half the carers preferred a CAT service to treat their relative in the event of a future relapse. Psychological variables were better predictors of choice than were demographic variables. CONCLUSIONS: The proportion of caregivers who prefer community treatment for acute psychosis may be smaller than previously thought. The lower carer satisfaction found here may be associated with the short-term interventions of Victoria's CAT teams, the severity of acute relapses and the duration of the patient's mental health problem.     

Geriatric referrals to a psychiatric consultation-liaison service

Geriatric patients constitute a significant proportion of referrals to a psychiatric consultation-liaison service, accounting for 29% of referrals in the present study. Organic mental disorders, the most common psychiatric diagnosis, were identified in 51% of geriatric referrals. The next most common psychiatric conditions were affective disorders and adjustment disorders, each of which were diagnosed in 17% of geriatric referrals. Transfers to in-patient psychiatry were unusual and the most common recommendations were for psychotropic medications, further medical investigations, and for psychosocial and behavioural interventions to be carried out by the ward staff. Although more specialized psychogeriatric units and community treatment resources are necessary, it is likely that the general hospital setting will continue to be important in the diagnostic assessment and short-term management of medical-psychiatric problems in the elderly.     

Psychiatric disorders and the need for mental health services among a sample of orthopedic inpatients.

This report concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed.It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.^1–6 Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19%–86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.^3,7,8 Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified.In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.^2,4,9–12 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients.     

Combat stress casualties in Iraq. Part 1: behavioral health consultation at an expeditionary medical group

PURPOSE: We review the role of military mental health professionals in consulting with inpatient medical patients and staff at a combat hospital and aeromedical evacuation staging facility in Iraq. CONCLUSIONS: Behavioral health consultation with medical and surgical patients during hospitalization and prior to aeromedical evacuation can help identify patients with combat stress exposure that may require future mental health follow-up. PRACTICE IMPLICATIONS: Extensive use of civilian mental health practitioners including nurse psychotherapists and psychiatric nurse practitioners will be needed to provide psychiatric care for the large number of U.S. veterans who return from deployment with combat stress related disorders.     

Effects of patient and health-system characteristics on community tenure of discharged psychiatric inpatients

OBJECTIVE: The purpose of this study was to identify the differential effect of patient and health-system characteristics on length of stay in the community among recidivist psychiatric patients. METHODS: Data on demographic and clinical characteristics and mental health service utilization were collected for patients with at least one previous psychiatric hospitalization (N=1,972) who visited a psychiatric emergency department at a university hospital in Leuven, Belgium, between March 2000 and March 2002. Logistic regression analysis was used to compare the characteristics of patients with a short (less than two months), intermediate (two to 12 months), or long (12 months or longer) stay in the community between their last hospital discharge and referral to the psychiatric emergency department. RESULTS: One in three patients visited the psychiatric emergency department within 30 days of discharge from a psychiatric hospitalization, and 43 percent of the patients visited within 60 days of discharge. Patients with a short community stay were more likely to be unemployed and to have had a discharge against medical advice, a short previous hospitalization, no aftercare plan, and a history of two or more previous hospitalizations. Longer community stays were predicted by the presence of a personality disorder. CONCLUSIONS: For patients with a history of psychiatric hospitalization, early psychiatric recidivism may be more highly influenced by health-system characteristics than by the presence of severe mental illness.     

Psychiatric units in general hospitals: 1979.

Despite the network of community mental health centers, the general hospital has become the focal point for the delivery of mental health care in the U.S. The author presents an overview of the psychiatric unit in the general hospital, including its history, structure and function, and its relationship to the hospital itself and to the continuum of mental health services in the community. The units' goals are not clearly defined but appear to be crisis intervention, acute treatment, correction of decompensation, prevention of chronicity, and speedy return of the patient to the community; there is little attempt to serve chronic patients. Paradoxically, the psychiatric unit also does not serve the hospital it is part of, as it rarely accepts patients from medical-surgical wards. The author summarizes evaluation studies related to general-hospital psychiatric units and recommends, among other points, truly evaluating the effects of short-term treatment and eliminating the current competition for the shortest stay.     

Extended hospital care as treatment of choice.

A review of the histories of six patients who failed to adapt to community living after hospital discharge identified six factors that are predictive of serious maladjustment in the community. The are the absence of a family or soical network, repeated threats of violent behavior, previous hospitalization, poor previous functioning, inability to take responsibility for medical and mental health treatment, and suffering. Patients identified by two or more factors are likely to be unable to cope with life outside the hospital. The authors question whether attempting to maintain such patients in the community is desirable in terms of economic cost and patient suffering.     

Inpatient logistics and planning needs

Those responsible for the planning of new comprehensive community mental health centers providing short-term hospitalization should realize that about one-third of all patients using inpatient services will have to use them more than once, and this may eventually compromise the center's availability to new patients. If separate administrative structures exist for the center and the state hospital system, close cooperation between the two will be essential. Ninety-two of 395 patients in this study eventually needed long-term care.     

Coordinating a multiple casualty Critical Incident Stress Management (CISM) response within a medical/surgical hospital setting

The medical/surgical hospital environment presents numerous challenges to a Critical Incident Stress Management (CISM) Team Coordinator responsible for implementing a psychological crisis intervention. Often this person is responsible for managing a response to a large in-house multiple-casualty incident, sometimes involving fatalities. Many mental health professionals have not had the opportunity to work in a medical/surgical healthcare facility and consequently are not familiar with the environment (and agency culture) that exists within these employment settings. This article will review important factors to be considered during the initial assessment of a critical incident in a hospital setting, logistical concerns that are unique to this setting, and the subsequent planning of the Critical Incident Stress Management Team crisis management response.     

Reform in mental health services in Israel: The changing role of government,HMOs, and hospitals

Conclusion We have described the background for the reform of mental health services in Israel. This reform is in response to public dissatisfaction that led to the government to set up the Netanyahu Commission which suggested far reaching reforms in health care. The proposed solutions are integrated and geared toward making mental health services more comprehensive and available in the community, in general, and specifically in the primary medical setting. This redefines the role of hospital care in psychiatry for only patients who cannot benefit from less restrictive care. These changes will hopefully render the system more consumer oriented and financially more efficient.The authors are grateful to Thomas McGuire for comments on an earlier draft of this article.     

General hospital suicides--a psychological autopsy study in Finland

Although both severe medical disorders and mental disorders are established risk factors for suicide, it is not known if patients who commit suicide in general hospitals differ from others. This study investigated current mental disorders and other clinical characteristics among general hospital suicide victims and compared them with other suicide victims in an unselected nationwide population. Drawing on data from a psychological autopsy study of all suicides (N = 1397) in Finland during one year, all suicides committed by patients in a general hospital setting were identified. Retrospective DSM-III-R consensus diagnoses were assigned and general hospital suicide victims were compared with other suicide completers in terms of clinical characteristics. Twenty-six general hospital suicide victims, 1.9% of all suicides, were identified. Subjects who completed suicide during general hospital treatment were older and used more violent suicide methods than other suicide victims. One or more diagnoses of psychiatric (Axis I) disorders were assigned for 88% of the general hospital suicide victims. Overall, the most prevalent disorder was major depression, which was more common among the general hospital suicide victims, even when age was controlled for. The findings of this study suggest that most people who commit suicide during a spell of general hospital treatment suffer from current mental disorder, as do suicide victims in general. The recognition and treatment of major depression in particular should be improved in order to prevent suicide in general hospitals.     

Alternatives to the mental hospital: use of residential facilities for long-term psychiatric care.

We examine the use of the mental hospital and alternative residential facilities by 149 chronic psychiatric patients in Ontario. All major movements of patients since the time of first admission were recorded, including the number of episodes and duration of hospitalization and placement in alternative facilities and in the community. Clinical and social variables thought likely to influence use were correlated with duration, placement, and mobility. In spite of the lack of formal criteria for placement, relatively discrete and homogeneous populations were found in each facility and clear patterns of use could be distinguished. For many patients, their present placement represents their most typical setting and implies a particular route through the psychiatric services. We describe factors relating to different types of movements, and emphasize the continuing importance of the mental hospital in long-term psychiatric care.     

Outpatient compliance of psychiatric emergency room patients by presenting problems

In the present study, a cohort of patients who came to a psychiatric emergency room in a general hospital, and were not referred for hospitalization, were analyzed in regard to the amount and rate of subsequent contact with community mental health and substance abuse agencies. Patterns of service receipt and the differential impact of service use on hospitalization and/or return visits were analyzed by three major problem types: (1) psychiatric; (2) psychiatric/substance abuse; and (3) substance abuse. The analysis of these subgroups yielded valuable information about how the service system and/or different groups of patients in crisis respond to the system.This study was funded by a grant from the Office of Program Evaluation and Research, Ohio Department of Mental Health.     

Discharge dynamics and related factors of newly-admitted patients in psychiatric hospitals

The focus of psychiatric services in Japan is being shifted from hospitalization to community care, and the Ministry of Health, Labour and Welfare aims for the prompt discharge of newly-admitted patients. Correspondingly, it set a goal to lower the "mean residual rate (MRR)", which indicates the discharge dynamics of newly-admitted patients, to 24%. As a measure to achieve this goal, the present situation should be investigated in each homogeneous patient group. In this study, we conducted a survey of newly-admitted patients to investigate discharge dynamics and related factors by the diagnosis and type of hospitalization. Out of 1,459 psychiatric hospitals to which we sent questionnaires, 183 (12.5%) replied. Each hospital completed questionnaires regarding a maximum of 5 patients for each type of hospitalization (voluntary hospitalization [VH], hospitalization for medical care and protection [HMCP], and involuntary hospitalization ordered by the prefectural governor [IHOPG]) between October 2005 and January 2006. We weighted the obtained patient data in proportion to the estimated total number of patients, and analyzed valid data on 1,784 patients. The MRR for the whole sample was 29.4%. By diagnosis, dementia showed the highest MRR (45.6%), followed by schizophrenia (34.9%); depression, bipolar disorder, and alcoholism showed the lowest MRRs (20-21%). We calculated MRRs by the type of hospitalization for dementia and the other diagnoses separately, considering confounding effect between the diagnosis and type of hospitalization (markedly high proportion of HMCP observed in dementia). In dementia, HMCP showed a higher MRR (46.8%) than VH (43.7%). In the other diagnoses, IHOPG showed the highest MRR (43.7%), followed by HMCP (34.5%) and VH (25.6%). Dementia differed from the other diagnoses in the distribution of residential settings before admission, with a higher proportion of residential care facilities (25.5%) and hospitalization in other departments (19.3%). In dementia, the residential setting after discharge showed a similar distribution, and death was also frequent (6.6%). Multivariate analyses revealed that a long stay (one year or longer) was significantly associated with a residential setting before admission, the type of ward at admission, a founder (a private hospital or public/university hospital), and symptom severity at admission in schizophrenia; and with the type of ward at admission and hospital founder in dementia. In schizophrenia, the risk of a long stay was higher on hospitalization in other psychiatric hospitals (odds ratio [OR] : 28) and other departments (OR: 18), and living alone (OR: 2.1) than in living with the family by residential setting. The risk was also higher in psychiatric long-term care wards than in general psychiatric wards by the type of ward (OR: 3.0), and in private hospitals than in public/university hospitals by hospital founder (OR: 3.0). Additionally, the higher risk was associated with higher symptom severity assessed using a 6-point scale (OR: 1.3 per point). In dementia, the risk was higher in senile dementia wards than in general psychiatric wards by the type of ward (OR: 2.9), and in private hospitals than in public/university hospitals by hospital founder (OR: 6.8). The most frequently reported direct causes of a long stay were problems regarding a family's acceptance (51.5%), poor improvement of symptoms (48.8%), and poor recovery of daily living abilities (44.0%). In dementia, physical diseases (20.8%) and undecidedness of residence after discharge (29.2%) were also frequent. Considering the elapsed time after survey, the low response rate, and the data analyses with sampling bias adjustment, the results should be interpreted carefully. Nevertheless, the discharge dynamics and related factors in newly-admitted patients varied with the diagnosis and type of hospitalization. Particularly, schizophrenia and dementia, as well as IHOPG and HMCP, showed high MRRs and frequent long stays. Additionally, a long stay was related to patients' demographic and social characteristics. Adopting measures suiting patients' characteristics and arranging treatment and casework for patients at high risk of a long stay are important to facilitate community care.     

A Community Approach to Helping Disabled Children in Jamaica

Private sector hospitals are the main provider of mental health care in Japan. More than four-fifths of psychiatric beds are privately owned. Unlike Western countries, private sector hospitals in Japan serve all citizens enrolled in the universal public health insurance system. Private sector hospitals in Japan are only allowed to be nonprofit corporations. Mental health system is still inpatient oriented. Mental health professionals have recognized the importance of movements toward community mental health, but changes have been slow. The shortage of social resources in the community is one reason why many patients have experienced prolonged inpatient care unnecessarily. Although the Ministry of Health, Labor, and Welfare has declared its commitment to mental health reform, it is very difficult to establish public community mental health system from scratch because of financial problems. The Japanese mental health system received only 0.38 percent of the gross domestic product in funding. In Japan, some hold an overly optimistic view that hospitalization costs can be cut by transferring inpatients to residential community care facilities and that the savings generated can be used to pay for acute psychiatric care. However, this proposition is unfeasible because hospitalization costs have been reduced to a level equal to or below that of residential care costs in the other developed countries. Japan has established a system called hospital ward specialization. Under this system, psychiatric wards have been divided into units specializing in various areas of care. This system is not helping to decrease the number of hospital beds or the inpatient populations and has been found to be hindering deinstitutionalization in Japan. It will be necessary in the future to transition from a medical fee-for-service system that promotes long-term hospitalization and large-scale expansion to one in which downsizing correlates with better financial results.     

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.