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A preliminary study of staff perception of psychiatric services in general hospitals
A Preliminary Study of Staff Perception of Psychiatric Services in General Hospitals Hiroto Ito, Ph.D., Yasuhiro Kishi, M.D., and Hisashi Kurosawa, M.D. Abstract: There has been increasing recognition of the importance of integrating physical and psychiatric care under growing economic pressure. We conducted a survey of staff perception on psychiatric services in four general hospitals. The purpose of this study was to see differences among the staff in their recognition and expectation of the role of the psychiatric department and the need for psychiatric and other staff to work more closely together. Although 81% of psychiatrists recognized their role in acute psychiatry, only 42.6% thought that acute psychiatry was the most important role of psychiatry. Mood disorders were recognized as a psychiatric category in 95.2% of psychiatrists and 54.8% of nonpsychiatrist physicians. Overall satisfaction with psychiatric services in psychiatric and other staff were 54.0% and 68.2%, respectively. Although 85.7% of psychiatrists answered that they supported staff in other departments that have psychiatric or psychological problems, only 53.5% of those staff in other departments were satisfied with their support. Staff in other departments expected psychiatric staff to establish consultation hotlines and to visit other departments regularly. Our results suggest that there are discrepancies between psychiatric and other staff in their perception of psychiatric services, and it is our belief that those gaps must be bridged for better collaboration in general hospitals. © 1999 Elsevier Science Inc.
Introduction It is reported that about one-quarter of those patients with physical disorders suffer psychiatric disorders or psychological problems [1], but a large proportion of them go undiagnosed or misdiagnosed [2,3] and the result is longer hospital stays [4]. Timely psychiatric interventions for patients Department of Health Care Economics, National Institute of Health Services Management, Ministry of Health and Welfare, Tokyo, Japan (H.I.) and Department of Neuro-Psychiatry, Nippon Medical School, Tokyo, Japan (Y.K., H.K.). Address reprint requests to: Hiroto Ito, Ph.D., Department of Health Care Economics, National Institute of Health Services Management, Ministry of Health and Welfare, 1-23-1 Toyama, Shinjuku-ku, Tokyo 162-0052, Japan.
General Hospital Psychiatry 21, 57–61, 1999 © 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
with psychiatric comorbidity can improve patients’ overall care and reduce the total hospital cost [4,5]. For that, collaboration among staff beyond the boundaries of psychiatry and other departments is essential. Consultation-liaison psychiatry services are developed in Japan [6], but like other countries, most current services are relatively limited to minimal emergency care [1]. It is necessary to strengthen C-L psychiatry in a general hospital for the purposes of earlier intervention and avoidance of wasting health care resources. The literature describes examples of the problems in psychiatry to work with other departments, that the stigma still exists, and suggests that all disciplines speak the same language [7]. Before developing strategic C-L psychiatry programs, we need to know whether psychiatric staff have different perceptions than staff in other departments. If there are any discrepancies in their perception, the first step is to establish a common view. We conducted a survey of staff perception of psychiatric services in general hospitals, and hypothesized that staff of other departments might not be satisfied with psychiatric services because they do not understand the role of the psychiatric department. We also found that psychiatric and other staff have different levels of recognition of psychiatric illness and consequently, slightly different goals.
Methods Settings Based on a list from the Japan Society for Quality in Health Care (JSQua), we asked 10 hospitals if they would consent to participate in the survey by mail. One psychiatric hospital and two general hospitals without psychiatric beds were excluded from seven
57 ISSN 0163-8343/99/$–see front matter PII S0163-8343(98)00056-5
H. Ito et al.
candidate hospitals because their services were different from those of the other candidates. The total number of beds in the four general hospitals in this study was 4099, and of those, the total number of psychiatric beds was 728 (17.8%). In the four hospitals there were 558 psychiatric inpatients and 567 psychiatric outpatients in the index day. Mean age of the inpatients was 50.9 (SD 5 16.3) years old, and included 275 (49.3%) males and 283 (50.7%) females. According to ICD10, the number of inpatients diagnosed as having schizophrenia, mood disorders, organic disorders, neuroses, and others were 338 (60.6%), 71 (12.7%), 56 (10.0%), 23 (4.1%), and 70 (22.6%), respectively. Mean number of admissions (95% CI) and length of stay (95% CI) were 4.30 (3.92– 4.68) and 1676 (1437– 1915) days, respectively. Of 558 inpatients, 287 (51.4%) were treated by both psychiatrists and other physicians. Of the 567 outpatients, those diagnosed as schizophrenia, mood disorders, organic disorders, neuroses, and others were 175 (30.9%), 150 (26.5%), 36 (6.3%), 116 (20.5%), and 90 (15.8%), respectively. Mean treatment period at the psychiatric department (95% CI) was 2364 (2315–2754) days, and of these, 160 (28.3%) patients also received treatments from other departments during the same period.
Subjects Subjects of the study included the staff of psychiatric and other medical/surgical departments in the four general hospitals. There were 274 staff members in the psychiatric department: 21 medical doctors (7.7%), 231 nurses (84.3%), and 22 other staff members (8.0%). In other departments, we questioned 129 staff members: 31 chief physicians (24.0%), 74 chief nurses (57.4%), and 24 (18.6) administrators.
Questionnaire Questionnaires consisted of 1) characteristics of responders (age and professions), 2) cognitive understanding of characteristics of both inpatient and outpatient, 3) overall satisfaction of psychiatric services for psychiatric patients and staff in other departments who have psychiatric or psychological problems, and 4) expectations for future psychiatric services in a general hospital.
Statistical Analysis We used the Chi-square test for categorical data, Kruskal-Wallis test for rank data, and t-test for
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comparison of means among staff groups. We excluded ’unknown’ and ’no answer’ for these comparisons. After comparison of responses between psychiatric and nonpsychiatric staff, we compared responses between psychiatrists and nonphysician psychiatric staff.
Results Since responses were not significantly different among each profession in other departments, we compared perception of each profession in the psychiatric department with overall staff perception in other departments. Table 1 shows staff recognition of inpatient characteristics and the present services of the psychiatric department. Although psychiatric staff perceived psychiatric patients as having longer stays than staff of other departments perceived (Z 5 3.75, p , 0.001), psychiatrists perceived psychiatric patients as having shorter stays compared with other psychiatric staff (Z 5 2.61, p , 0.01). Of all staff, 145 (42.6%) answered acute care as the most important role of psychiatry. About half of staff in other departments (45.0%) recognized the current psychiatric services as acute care, whereas more than half of psychiatric staff recognized them as other services, such as chronic care and rehabilitation (x2 5 14.2, df 5 4, p , 0.01). Psychiatrists, however, recognized the main psychiatric role as acute care significantly more than other psychiatric staff did (x2 5 29.5, df 5 4, p , 0.001). Table 2 shows recognition of diagnosis of inpatients and outpatients of the psychiatric department (multiple choice). Fewer physicians in other departments recognized patients with mood disorders as psychiatric patients than psychiatrists did. Several interesting findings were noted in satisfaction with services of the psychiatric department (Table 3). Staff in other departments were significantly more satisfied than psychiatric staff (Z 5 3.18, p , 0.01). Most of the staff were satisfied in general with psychiatric services, but 115 (42.0%) staff members in the psychiatric department and 34 (26.3%) in other departments showed dissatisfaction with psychiatric services. In the psychiatric department, nurses were significantly less satisfied with psychiatric services than other staff (Z 5 3.25, p 5 0.01). The number of staff in the psychiatric and other departments who were very satisfied with C-L psychiatry were 38 (13.9%) and 58 (45.0%), respectively (Z 5 5.33, p , 0.001).
Staff Perception on Psychiatric Services
Table 1. Recognition of staff on characteristics of inpatients and present services of psychiatric department (%) Other departments Total (N 5 129)
Psychiatric department Psychiatrists (N 5 21)
Nurses (N 5 231)
Other staff (N 5 22)
Total (N 5 274)
2 (9.5) 6 (28.6) 4 (19.0) 7 (33.3) 0 (0.0) 2 (9.5)
23 (10.0) 23 (10.0) 43 (18.6) 63 (27.3) 66 (28.6) 13 (5.6)
2 (9.1) 2 (9.1) 1 (4.5) 12 (54.5) 1 (4.5) 4 (18.2)
27 (9.9) 31 (11.3) 48 (17.5) 82 (29.9) 67 (24.5) 19 (6.9)
13 (10.1) 32 (24.8) 26 (20.2) 36 (27.9) 12 (9.3) 10 (7.8)
1 (4.8) 17 (81.0) 1 (4.8) 1 (4.8) 1 (4.8) 0 (0.0)
14 (6.1) 66 (28.6) 59 (25.5) 77 (33.3) 1 (0.4) 14 (6.1)
0 (0.0) 4 (18.2) 5 (22.7) 11 (50.0) 0 (0.0) 2 (9.1)
15 (5.5) 87 (31.8) 65 (23.7) 89 (32.5) 2 (0.7) 19 (6.9)
7 (5.4) 58 (45.0) 23 (17.8) 28 (21.7) 5 (3.9) 8 (6.2)
Average length of stay (days) ;49 50;99 100;199 200;500 500; Unknown Major role of psychiatric department Emergency Acute care Chronic care Rehabilitation Consultation liaison Unknown
Table 2. Recognition of diagnosis of patients of psychiatric department (%) (multiple choice) Inpatients
Organic mental disorders (F0) Psychoactive substance use (F1) Schizophrenia (F2) Mood disorders (F3) Neuroses (F4) Behavioral syndromes (F5) Personality disorders (F6) Mental retardation (F7) Psychological developmental disorders (F8) Behavioral and emotional disorders in childhood and adolescence (F9) Unspecified mental disorders (F10) Epilepsy Others No answer
Outpatients
Psychiatrist (N 5 21)
Nonpsychiatrist physician (N 5 31)
Psychiatrist
Nonpsychiatrist physician
20 (95.2) 19 (90.5) 18 (85.7) 20 (95.2) 19 (90.5) 16 (76.2) 20 (95.2) 16 (76.2) 14 (66.7)
22 (71.0) 17 (54.8) 24 (77.4) 17 (54.8) 20 (64.5) 12 (38.7) 16 (51.6) 15 (48.4) 11 (35.5)
20 (95.2) 18 (85.7) 20 (95.2) 18 (85.7) 20 (95.2) 17 (81.0) 20 (95.2) 19 (90.5) 16 (76.2)
23 (74.2) 20 (64.5) 25 (80.6) 18 (58.1) 27 (87.1) 17 (54.8) 21 (67.7) 15 (48.4) 14 (45.2)
16 (76.2) 16 (76.2) 15 (71.4) 8 (38.1) 1 (4.8)
16 (51.6) 20 (64.5) 17 (54.8) 2 (6.5) 28 (90.3)
17 (81.0) 14 (66.7) 19 (90.5) 9 (42.9) 1 (4.8)
20 (64.5) 23 (74.2) 19 (61.3) 3 (9.7) 28 (90.3)
Although 85.7% of psychiatrists answered that they supported the staff in other departments who have psychiatric or psychological problems, only 53.5% of those staff in other departments were satisfied with their support. For the future, the rate of psychiatrists’ and other departments’ staff who expect C-L psychiatry to be
an important service was 85.7% and 63.6%, respectively (Table 4). There was the least expectation for chronic psychiatric care in all groups. As an effective method for C-L psychiatry, psychiatrists described a visit to other departments, however, other groups expected the establishment of a hotline in addition to a regular visit.
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Table 3. Satisfaction with services of psychiatric department (%) Other departments Psychiatrist Nurse Other staff Total Total (N 5 21) (N 5 231) (N 5 22) (N 5 274) (N 5 129) Psychiatric department
General satisfaction with psychiatric services Very satisfied Satisfied Unsatisfied Very unsatisfied No answer Satisfaction with C-L psychiatry Very satisfied Satisfied Unsatisfied Very unsatisfied No answer Consultation on staff’s problems of other departments Very satisfied Satisfied Unsatisfied Very unsatisfied No answer
4 (19.0) 12 (57.1) 5 (23.8) 0 (0.0) 0 (0.0)
10 (4.3) 105 (45.5) 95 (41.1) 12 (5.2) 9 (3.9)
0 (0.0) 17 (77.3) 1 (4.5) 2 (9.1) 2 (9.1)
14 (5.1) 134 (48.9) 101 (36.9) 14 (5.1) 11 (4.0)
12 (9.3) 76 (58.9) 31 (24.0) 3 (2.3) 7 (5.4)
5 (23.8) 15 (71.4) 1 (4.8) 0 (0.0) 0 (0.0)
29 (12.6) 94 (40.7) 14 (6.1) 3 (1.3) 91 (39.4)
4 (18.2) 7 (31.8) 3 (13.6) 0 (0.0) 8 (36.4)
38 (13.9) 116 (42.3) 18 (6.6) 3 (1.1) 99 (36.1)
58 (45.0) 44 (34.1) 6 (4.7) 0 (0.0) 21 (16.3)
3 (14.3) 15 (71.4) 2 (9.5) 1 (4.8) 0 (0.0)
27 (11.7) 90 (39.0) 29 (12.6) 9 (3.9) 76 (32.9)
3 (13.6) 12 (54.5) 0 (0.0) 1 (4.5) 6 (27.3)
33 (12.0) 117 (42.7) 31 (11.3) 11 (4.0) 82 (29.9)
45 (34.9) 24 (18.6) 4 (3.1) 2 (1.6) 54 (41.9)
Table 4. Expectation for future services of psychiatric department (%)
Psychiatrist (N 5 21)
Nurse (N 5 231)
Other staff (N 5 22)
Total (N 5 274)
Other departments Total (N 5 129)
14 (66.7) 16 (76.2) 8 (38.1) 16 (76.2) 18 (85.7)
79 (34.2) 88 (38.1) 76 (32.9) 153 (66.2) 117 (50.6)
7 (31.8) 6 (27.3) 5 (22.7) 11 (50.0) 9 (40.9)
100 (36.5) 110 (40.1) 89 (32.5) 180 (65.7) 144 (52.6)
60 (46.5) 59 (45.7) 39 (30.2) 76 (58.9) 82 (63.6)
2 (9.5) 0 (0.0) 2 (9.5) 14 (66.7) 0 (0.0) 2 (9.5) 1 (4.8)
27 (11.7) 80 (34.6) 5 (2.2) 28 (12.1) 37 (16.0) 10 (4.3) 44 (19.0)
1 (4.5) 7 (31.8) 0 (0.0) 5 (22.7) 0 (0.0) 2 (9.1) 9 (40.9)
30 (10.9) 87 (31.8) 7 (2.6) 47 (17.2) 37 (13.5) 14 (5.1) 48 (17.5)
9 (7.0) 45 (34.9) 2 (1.6) 37 (28.7) 8 (6.2) 9 (7.0) 110 (85.3)
Psychiatric department
Expected activities of department of psychiatry (multiple choice) Emergency Acute care Chronic care Rehabilitation C-L Expected method for C-L psychiatry Lecture Hotline Department of referral system Visit other departments Stay in other department Participation on case conference No answer
Discussion Recently, integrated physical and psychiatric care has been emphasized when attention is paid to quality and cost of care. Contrary to our hypothesis,
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our results showed that staff in other departments were relatively satisfied with the current psychiatric services in general hospitals, and indicated that they recognized the necessity for psychiatric services and that psychiatric staff seemed to meet the
Staff Perception on Psychiatric Services
needs of other departments. Consequently, there was a high degree of satisfaction in both psychiatric and other departments. However, some potential problems were indicated. First, some staff members showed dissatisfaction with psychiatric services. We can assume this response might come from negative experiences because they work in the same hospital. Second, staff perception of psychiatric disorders differed between psychiatric and other departments. Mood disorders, one of a core of psychiatric disorders, were especially not recognized as psychiatric disorders by other staff. It may be that staff of other departments do not understand that mood disorders need psychiatric care, but rather, a natural competence for coping with medical illness. Or they may not want to refer such patients to psychiatrists because they think they can handle them. Previous research revealed that the rate of mood disorders in patients referred to the psychiatric department in general hospitals was lower than that of other diagnoses [8]. It was a sharp contrast to the results of the western studies in which the most common referrals were mood disorders [2,3,9]. Many patients with mood disorders have been treated by nonpsychiatrist physicians, and depression is the most common mood disorder in Japan. However, Boland et al.[3] warned about overdiagnosis and misdiagnosis of depression and overlooked diagnoses such as delirium and dementia by nonpsychiatrist physicians. Either of these disorders extend hospital stay. In our study, only 6.8% of inpatients and 12.0% of outpatients were referred to the psychiatric department, and potential patients with psychiatric comorbidity can be estimated to be higher. A more efficient referral system is needed. Psychiatric care should be clarified for patients who need it and better access to psychiatric assessment is required. Third, we should note differences in the perception among professionials within the psychiatric department. Nurses recognized their major role as rehabilitation of chronic patients with long stay. Psychiatrists, on the other hand, perceived themselves as providers of acute psychiatric services. It is partly because nurses spend most of their time caring for chronic patients, and psychiatrists devote most of their energy to establishing treatment plans for newly admitted patients. The discrepancy in the perception of the role of the psychiatric department also indicates problems of psychiatric services in Japan. Since acute and long-term care have not been clearly separated in the Japanese health system, the most serious prob-
lem is generally regarded as care for the long-term institutionalized patients. At the same time, however, psychiatrists in general hospitals need to provide acute care and C-L psychiatry. In this study, we found that psychiatrists saw an increasingly important role of the psychiatric department to administer acute care; chronic care for patients was still a serious problem. Our study forsees a future theme for “acute psychiatry.” A future policy of psychiatric services is not yet integrated in Japan. Our results of this preliminary study suggest that there are some discrepancies between psychiatric and other departments, and some examples of measures are suggested to solve the problems of psychiatric services in general hospitals such as a crisis hotline and regular visits by the psychiatrist. In the future, however, we should focus on the potential contributing factors to discrepancies. Further research is needed to identify daily activities in participating general hospitals that would effectively promote collaboration between psychiatry and other departments. For effective intervention at the right time, better C-L psychiatry can be achieved by the same positive perception of psychiatric services among all staff in general hospitals. Hopefully, such efforts will provide a direction for the development of psychiatric services in general hospitals.
References 1. Mayou RA: Psychiatry, medicine and consultationliaison. Br J Psychiatry 171:203–204, 1997 2. Vaz FJ, Salcedo MS: A model for evaluating the impact of consultation-liaison psychiatry activities on referral patterns. Psychosomatics 37:289–298, 1996 3. Boland RJ, Diaz S, Lamdan RM, et al: Overdiagnosis of depression in the general hospital. Gen Hosp Psychiatry 18:28–35, 1996 4. Hall RCW, Frankel BL: The value of consultationliaison interventions to the general hospital. Psychiatr Serv 47:418–420, 1997 5. Goldberg RJ, Stoudemire A: The future of consultation-liaison psychiatry and medical-psychiatric units in the era of managed care. Gen Hosp Psychiatry 17:268–277, 1995 6. Kurosawa H, Iwasaki Y, Watanabe N, et al: The practice of consultation-liaison psychiatry in Japan. Gen Hosp Psychiatry 15:160–165, 1993 7. Rebecca V: Quality standards intend to bring psychiatry, primary care into closer collaboration. JAMA 277: 366–367, 1997 8. Ito H, Shu SG, Kishi Y, et al: A preliminary study of psychiatric services in general hospitals. Jpn J Gen Hosp Psychiatry (in Japanese) 10:30–36, 1998 9. Taintor Z, Gise LH, Spikes J, et al: Recording psychiatric consultations: a preliminary report. Gen Hosp Psychiatry 1:139–149, 1979
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Introduction It is reported that about one-quarter of those patients with physical disorders suffer psychiatric disorders or psychological problems [1], but a large proportion of them go undiagnosed or misdiagnosed [2,3] and the result is longer hospital stays [4]. Timely psychiatric interventions for patients Department of Health Care Economics, National Institute of Health Services Management, Ministry of Health and Welfare, Tokyo, Japan (H.I.) and Department of Neuro-Psychiatry, Nippon Medical School, Tokyo, Japan (Y.K., H.K.). Address reprint requests to: Hiroto Ito, Ph.D., Department of Health Care Economics, National Institute of Health Services Management, Ministry of Health and Welfare, 1-23-1 Toyama, Shinjuku-ku, Tokyo 162-0052, Japan.
General Hospital Psychiatry 21, 57–61, 1999 © 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
with psychiatric comorbidity can improve patients’ overall care and reduce the total hospital cost [4,5]. For that, collaboration among staff beyond the boundaries of psychiatry and other departments is essential. Consultation-liaison psychiatry services are developed in Japan [6], but like other countries, most current services are relatively limited to minimal emergency care [1]. It is necessary to strengthen C-L psychiatry in a general hospital for the purposes of earlier intervention and avoidance of wasting health care resources. The literature describes examples of the problems in psychiatry to work with other departments, that the stigma still exists, and suggests that all disciplines speak the same language [7]. Before developing strategic C-L psychiatry programs, we need to know whether psychiatric staff have different perceptions than staff in other departments. If there are any discrepancies in their perception, the first step is to establish a common view. We conducted a survey of staff perception of psychiatric services in general hospitals, and hypothesized that staff of other departments might not be satisfied with psychiatric services because they do not understand the role of the psychiatric department. We also found that psychiatric and other staff have different levels of recognition of psychiatric illness and consequently, slightly different goals.
Methods Settings Based on a list from the Japan Society for Quality in Health Care (JSQua), we asked 10 hospitals if they would consent to participate in the survey by mail. One psychiatric hospital and two general hospitals without psychiatric beds were excluded from seven
57 ISSN 0163-8343/99/$–see front matter PII S0163-8343(98)00056-5
H. Ito et al.
candidate hospitals because their services were different from those of the other candidates. The total number of beds in the four general hospitals in this study was 4099, and of those, the total number of psychiatric beds was 728 (17.8%). In the four hospitals there were 558 psychiatric inpatients and 567 psychiatric outpatients in the index day. Mean age of the inpatients was 50.9 (SD 5 16.3) years old, and included 275 (49.3%) males and 283 (50.7%) females. According to ICD10, the number of inpatients diagnosed as having schizophrenia, mood disorders, organic disorders, neuroses, and others were 338 (60.6%), 71 (12.7%), 56 (10.0%), 23 (4.1%), and 70 (22.6%), respectively. Mean number of admissions (95% CI) and length of stay (95% CI) were 4.30 (3.92– 4.68) and 1676 (1437– 1915) days, respectively. Of 558 inpatients, 287 (51.4%) were treated by both psychiatrists and other physicians. Of the 567 outpatients, those diagnosed as schizophrenia, mood disorders, organic disorders, neuroses, and others were 175 (30.9%), 150 (26.5%), 36 (6.3%), 116 (20.5%), and 90 (15.8%), respectively. Mean treatment period at the psychiatric department (95% CI) was 2364 (2315–2754) days, and of these, 160 (28.3%) patients also received treatments from other departments during the same period.
Subjects Subjects of the study included the staff of psychiatric and other medical/surgical departments in the four general hospitals. There were 274 staff members in the psychiatric department: 21 medical doctors (7.7%), 231 nurses (84.3%), and 22 other staff members (8.0%). In other departments, we questioned 129 staff members: 31 chief physicians (24.0%), 74 chief nurses (57.4%), and 24 (18.6) administrators.
Questionnaire Questionnaires consisted of 1) characteristics of responders (age and professions), 2) cognitive understanding of characteristics of both inpatient and outpatient, 3) overall satisfaction of psychiatric services for psychiatric patients and staff in other departments who have psychiatric or psychological problems, and 4) expectations for future psychiatric services in a general hospital.
Statistical Analysis We used the Chi-square test for categorical data, Kruskal-Wallis test for rank data, and t-test for
58
comparison of means among staff groups. We excluded ’unknown’ and ’no answer’ for these comparisons. After comparison of responses between psychiatric and nonpsychiatric staff, we compared responses between psychiatrists and nonphysician psychiatric staff.
Results Since responses were not significantly different among each profession in other departments, we compared perception of each profession in the psychiatric department with overall staff perception in other departments. Table 1 shows staff recognition of inpatient characteristics and the present services of the psychiatric department. Although psychiatric staff perceived psychiatric patients as having longer stays than staff of other departments perceived (Z 5 3.75, p , 0.001), psychiatrists perceived psychiatric patients as having shorter stays compared with other psychiatric staff (Z 5 2.61, p , 0.01). Of all staff, 145 (42.6%) answered acute care as the most important role of psychiatry. About half of staff in other departments (45.0%) recognized the current psychiatric services as acute care, whereas more than half of psychiatric staff recognized them as other services, such as chronic care and rehabilitation (x2 5 14.2, df 5 4, p , 0.01). Psychiatrists, however, recognized the main psychiatric role as acute care significantly more than other psychiatric staff did (x2 5 29.5, df 5 4, p , 0.001). Table 2 shows recognition of diagnosis of inpatients and outpatients of the psychiatric department (multiple choice). Fewer physicians in other departments recognized patients with mood disorders as psychiatric patients than psychiatrists did. Several interesting findings were noted in satisfaction with services of the psychiatric department (Table 3). Staff in other departments were significantly more satisfied than psychiatric staff (Z 5 3.18, p , 0.01). Most of the staff were satisfied in general with psychiatric services, but 115 (42.0%) staff members in the psychiatric department and 34 (26.3%) in other departments showed dissatisfaction with psychiatric services. In the psychiatric department, nurses were significantly less satisfied with psychiatric services than other staff (Z 5 3.25, p 5 0.01). The number of staff in the psychiatric and other departments who were very satisfied with C-L psychiatry were 38 (13.9%) and 58 (45.0%), respectively (Z 5 5.33, p , 0.001).
Staff Perception on Psychiatric Services
Table 1. Recognition of staff on characteristics of inpatients and present services of psychiatric department (%) Other departments Total (N 5 129)
Psychiatric department Psychiatrists (N 5 21)
Nurses (N 5 231)
Other staff (N 5 22)
Total (N 5 274)
2 (9.5) 6 (28.6) 4 (19.0) 7 (33.3) 0 (0.0) 2 (9.5)
23 (10.0) 23 (10.0) 43 (18.6) 63 (27.3) 66 (28.6) 13 (5.6)
2 (9.1) 2 (9.1) 1 (4.5) 12 (54.5) 1 (4.5) 4 (18.2)
27 (9.9) 31 (11.3) 48 (17.5) 82 (29.9) 67 (24.5) 19 (6.9)
13 (10.1) 32 (24.8) 26 (20.2) 36 (27.9) 12 (9.3) 10 (7.8)
1 (4.8) 17 (81.0) 1 (4.8) 1 (4.8) 1 (4.8) 0 (0.0)
14 (6.1) 66 (28.6) 59 (25.5) 77 (33.3) 1 (0.4) 14 (6.1)
0 (0.0) 4 (18.2) 5 (22.7) 11 (50.0) 0 (0.0) 2 (9.1)
15 (5.5) 87 (31.8) 65 (23.7) 89 (32.5) 2 (0.7) 19 (6.9)
7 (5.4) 58 (45.0) 23 (17.8) 28 (21.7) 5 (3.9) 8 (6.2)
Average length of stay (days) ;49 50;99 100;199 200;500 500; Unknown Major role of psychiatric department Emergency Acute care Chronic care Rehabilitation Consultation liaison Unknown
Table 2. Recognition of diagnosis of patients of psychiatric department (%) (multiple choice) Inpatients
Organic mental disorders (F0) Psychoactive substance use (F1) Schizophrenia (F2) Mood disorders (F3) Neuroses (F4) Behavioral syndromes (F5) Personality disorders (F6) Mental retardation (F7) Psychological developmental disorders (F8) Behavioral and emotional disorders in childhood and adolescence (F9) Unspecified mental disorders (F10) Epilepsy Others No answer
Outpatients
Psychiatrist (N 5 21)
Nonpsychiatrist physician (N 5 31)
Psychiatrist
Nonpsychiatrist physician
20 (95.2) 19 (90.5) 18 (85.7) 20 (95.2) 19 (90.5) 16 (76.2) 20 (95.2) 16 (76.2) 14 (66.7)
22 (71.0) 17 (54.8) 24 (77.4) 17 (54.8) 20 (64.5) 12 (38.7) 16 (51.6) 15 (48.4) 11 (35.5)
20 (95.2) 18 (85.7) 20 (95.2) 18 (85.7) 20 (95.2) 17 (81.0) 20 (95.2) 19 (90.5) 16 (76.2)
23 (74.2) 20 (64.5) 25 (80.6) 18 (58.1) 27 (87.1) 17 (54.8) 21 (67.7) 15 (48.4) 14 (45.2)
16 (76.2) 16 (76.2) 15 (71.4) 8 (38.1) 1 (4.8)
16 (51.6) 20 (64.5) 17 (54.8) 2 (6.5) 28 (90.3)
17 (81.0) 14 (66.7) 19 (90.5) 9 (42.9) 1 (4.8)
20 (64.5) 23 (74.2) 19 (61.3) 3 (9.7) 28 (90.3)
Although 85.7% of psychiatrists answered that they supported the staff in other departments who have psychiatric or psychological problems, only 53.5% of those staff in other departments were satisfied with their support. For the future, the rate of psychiatrists’ and other departments’ staff who expect C-L psychiatry to be
an important service was 85.7% and 63.6%, respectively (Table 4). There was the least expectation for chronic psychiatric care in all groups. As an effective method for C-L psychiatry, psychiatrists described a visit to other departments, however, other groups expected the establishment of a hotline in addition to a regular visit.
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Table 3. Satisfaction with services of psychiatric department (%) Other departments Psychiatrist Nurse Other staff Total Total (N 5 21) (N 5 231) (N 5 22) (N 5 274) (N 5 129) Psychiatric department
General satisfaction with psychiatric services Very satisfied Satisfied Unsatisfied Very unsatisfied No answer Satisfaction with C-L psychiatry Very satisfied Satisfied Unsatisfied Very unsatisfied No answer Consultation on staff’s problems of other departments Very satisfied Satisfied Unsatisfied Very unsatisfied No answer
4 (19.0) 12 (57.1) 5 (23.8) 0 (0.0) 0 (0.0)
10 (4.3) 105 (45.5) 95 (41.1) 12 (5.2) 9 (3.9)
0 (0.0) 17 (77.3) 1 (4.5) 2 (9.1) 2 (9.1)
14 (5.1) 134 (48.9) 101 (36.9) 14 (5.1) 11 (4.0)
12 (9.3) 76 (58.9) 31 (24.0) 3 (2.3) 7 (5.4)
5 (23.8) 15 (71.4) 1 (4.8) 0 (0.0) 0 (0.0)
29 (12.6) 94 (40.7) 14 (6.1) 3 (1.3) 91 (39.4)
4 (18.2) 7 (31.8) 3 (13.6) 0 (0.0) 8 (36.4)
38 (13.9) 116 (42.3) 18 (6.6) 3 (1.1) 99 (36.1)
58 (45.0) 44 (34.1) 6 (4.7) 0 (0.0) 21 (16.3)
3 (14.3) 15 (71.4) 2 (9.5) 1 (4.8) 0 (0.0)
27 (11.7) 90 (39.0) 29 (12.6) 9 (3.9) 76 (32.9)
3 (13.6) 12 (54.5) 0 (0.0) 1 (4.5) 6 (27.3)
33 (12.0) 117 (42.7) 31 (11.3) 11 (4.0) 82 (29.9)
45 (34.9) 24 (18.6) 4 (3.1) 2 (1.6) 54 (41.9)
Table 4. Expectation for future services of psychiatric department (%)
Psychiatrist (N 5 21)
Nurse (N 5 231)
Other staff (N 5 22)
Total (N 5 274)
Other departments Total (N 5 129)
14 (66.7) 16 (76.2) 8 (38.1) 16 (76.2) 18 (85.7)
79 (34.2) 88 (38.1) 76 (32.9) 153 (66.2) 117 (50.6)
7 (31.8) 6 (27.3) 5 (22.7) 11 (50.0) 9 (40.9)
100 (36.5) 110 (40.1) 89 (32.5) 180 (65.7) 144 (52.6)
60 (46.5) 59 (45.7) 39 (30.2) 76 (58.9) 82 (63.6)
2 (9.5) 0 (0.0) 2 (9.5) 14 (66.7) 0 (0.0) 2 (9.5) 1 (4.8)
27 (11.7) 80 (34.6) 5 (2.2) 28 (12.1) 37 (16.0) 10 (4.3) 44 (19.0)
1 (4.5) 7 (31.8) 0 (0.0) 5 (22.7) 0 (0.0) 2 (9.1) 9 (40.9)
30 (10.9) 87 (31.8) 7 (2.6) 47 (17.2) 37 (13.5) 14 (5.1) 48 (17.5)
9 (7.0) 45 (34.9) 2 (1.6) 37 (28.7) 8 (6.2) 9 (7.0) 110 (85.3)
Psychiatric department
Expected activities of department of psychiatry (multiple choice) Emergency Acute care Chronic care Rehabilitation C-L Expected method for C-L psychiatry Lecture Hotline Department of referral system Visit other departments Stay in other department Participation on case conference No answer
Discussion Recently, integrated physical and psychiatric care has been emphasized when attention is paid to quality and cost of care. Contrary to our hypothesis,
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our results showed that staff in other departments were relatively satisfied with the current psychiatric services in general hospitals, and indicated that they recognized the necessity for psychiatric services and that psychiatric staff seemed to meet the
Staff Perception on Psychiatric Services
needs of other departments. Consequently, there was a high degree of satisfaction in both psychiatric and other departments. However, some potential problems were indicated. First, some staff members showed dissatisfaction with psychiatric services. We can assume this response might come from negative experiences because they work in the same hospital. Second, staff perception of psychiatric disorders differed between psychiatric and other departments. Mood disorders, one of a core of psychiatric disorders, were especially not recognized as psychiatric disorders by other staff. It may be that staff of other departments do not understand that mood disorders need psychiatric care, but rather, a natural competence for coping with medical illness. Or they may not want to refer such patients to psychiatrists because they think they can handle them. Previous research revealed that the rate of mood disorders in patients referred to the psychiatric department in general hospitals was lower than that of other diagnoses [8]. It was a sharp contrast to the results of the western studies in which the most common referrals were mood disorders [2,3,9]. Many patients with mood disorders have been treated by nonpsychiatrist physicians, and depression is the most common mood disorder in Japan. However, Boland et al.[3] warned about overdiagnosis and misdiagnosis of depression and overlooked diagnoses such as delirium and dementia by nonpsychiatrist physicians. Either of these disorders extend hospital stay. In our study, only 6.8% of inpatients and 12.0% of outpatients were referred to the psychiatric department, and potential patients with psychiatric comorbidity can be estimated to be higher. A more efficient referral system is needed. Psychiatric care should be clarified for patients who need it and better access to psychiatric assessment is required. Third, we should note differences in the perception among professionials within the psychiatric department. Nurses recognized their major role as rehabilitation of chronic patients with long stay. Psychiatrists, on the other hand, perceived themselves as providers of acute psychiatric services. It is partly because nurses spend most of their time caring for chronic patients, and psychiatrists devote most of their energy to establishing treatment plans for newly admitted patients. The discrepancy in the perception of the role of the psychiatric department also indicates problems of psychiatric services in Japan. Since acute and long-term care have not been clearly separated in the Japanese health system, the most serious prob-
lem is generally regarded as care for the long-term institutionalized patients. At the same time, however, psychiatrists in general hospitals need to provide acute care and C-L psychiatry. In this study, we found that psychiatrists saw an increasingly important role of the psychiatric department to administer acute care; chronic care for patients was still a serious problem. Our study forsees a future theme for “acute psychiatry.” A future policy of psychiatric services is not yet integrated in Japan. Our results of this preliminary study suggest that there are some discrepancies between psychiatric and other departments, and some examples of measures are suggested to solve the problems of psychiatric services in general hospitals such as a crisis hotline and regular visits by the psychiatrist. In the future, however, we should focus on the potential contributing factors to discrepancies. Further research is needed to identify daily activities in participating general hospitals that would effectively promote collaboration between psychiatry and other departments. For effective intervention at the right time, better C-L psychiatry can be achieved by the same positive perception of psychiatric services among all staff in general hospitals. Hopefully, such efforts will provide a direction for the development of psychiatric services in general hospitals.
References 1. Mayou RA: Psychiatry, medicine and consultationliaison. Br J Psychiatry 171:203–204, 1997 2. Vaz FJ, Salcedo MS: A model for evaluating the impact of consultation-liaison psychiatry activities on referral patterns. Psychosomatics 37:289–298, 1996 3. Boland RJ, Diaz S, Lamdan RM, et al: Overdiagnosis of depression in the general hospital. Gen Hosp Psychiatry 18:28–35, 1996 4. Hall RCW, Frankel BL: The value of consultationliaison interventions to the general hospital. Psychiatr Serv 47:418–420, 1997 5. Goldberg RJ, Stoudemire A: The future of consultation-liaison psychiatry and medical-psychiatric units in the era of managed care. Gen Hosp Psychiatry 17:268–277, 1995 6. Kurosawa H, Iwasaki Y, Watanabe N, et al: The practice of consultation-liaison psychiatry in Japan. Gen Hosp Psychiatry 15:160–165, 1993 7. Rebecca V: Quality standards intend to bring psychiatry, primary care into closer collaboration. JAMA 277: 366–367, 1997 8. Ito H, Shu SG, Kishi Y, et al: A preliminary study of psychiatric services in general hospitals. Jpn J Gen Hosp Psychiatry (in Japanese) 10:30–36, 1998 9. Taintor Z, Gise LH, Spikes J, et al: Recording psychiatric consultations: a preliminary report. Gen Hosp Psychiatry 1:139–149, 1979
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