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Evaluation of The First Medical Psychiatry Unit in Japan
(1)Medical Psychiatry Unit,Tachikawa Hospital, Tokyo, Japan
(2)Department of Psychiatry and Behavioral Science, Tokai University School of Medicine, Kanagawa, Japan (3)Department of Psychopathology, Tokyo Institute of Psychiatry, Tokyo, Japan
(1) Note: The on-line version contains additional text not in the publication.
Abstract
The first Medical Psychiatry Unit (MPU) in Japan was established in 1990. In this article, the clinical experiences during the first four years of this unit are presented and the characteristics of the unit between the first two years and the latter two years are compared. The number of patients, the average length of stay, the primary psychiatric disorders as well as the combined physical diseases and their outcomes are presented.
The data suggest that while the experience of the MPU is limited, the MPU plays an important roles in Japan as 1.) an appropriate clinical setting for patients with combined medical and psychiatric illness, 2.) a strategic model for dealing with psychiatric patients in the general hospital, 3.) an educational setting for psychiatric residents to become more familiar with medicine and surgery, and 4) an opportunity for non-psychiatric resident to become familiar with psychiatric illness and treatments.
Introduction
In Japan, the majority of mental health care is performed in mental hospitals. In 1992 , there were 290.9 psychiatric beds for one hundred thousand of the population, of which 85% of beds for psychiatric inpatients were provided by private mental hospitals (1). The number of psychiatric beds are currently sufficient for patients with psychiatric diseases, psychiatric care systems for the mentally disabled have been gradually developed, and we have a health insurance system that covers all diseases for the entire population.
There is still a major problem in Japan, however, which is the lack of a system of care for patients with combined physical and mental illness. There are a few non-psychiatric physicians working at mental hospitals and there is insufficient equipment for making a diagnosis and treatment plan for concurrent physical diseases at these hospitals. In cases of serious physical diseases, these patients are usually transferred to a general hospital with psychiatric beds, though there are few such institutions.
Significant difficulties may occur when patients with serious mental illness are admitted to a general hospital ward. Most psychiatric wards in general hospitals in Japan were originally developed for patients with mild mental disorders such as neurotic disorders, depression, psychosomatic diseases etc. Because of this state of affairs, one of the major problems for mental health care in Japan is the treatment of psychiatric patients with concurrent physical disease.
In this context, a unique system for the treatment of patients with combined medical and psychiatric disease was introduced in 1981, the " Tokyo Metropolitan Project for the Mentally Disabled with Physical Comorbidity". In this system, five institutes in the Tokyo metropolitan area were designated as treatment centers for psychiatric inpatients with concomitant physical illness and they recieve support funding from the city.
Tachikawa Hospital, affiliated with Keio University Medical School is located in the western area of Tokyo, is the only unit out of these five that actually functions as a combined med-psych unit in a general hospital (2,3), the others are located in psychiatric hospitals and consequently do not have the necessary ancillary medical support facilities. The Tachikawa unit is a semi-locked psychiatric 63 bed ward . Formerly, mentally ill patients with physical disease were treated by non-psychiatric physicians on the psychiatric ward where their psychiatric disorders were cared for by psychiatrists.
We frequently encountered cases which required more intensive observation and care, such as cardiac arrest and respiratory insufficiently, and often, non-psychiatric physicians were not available. Also, there were many cases in which ongoing care for conditions such as electrolyte imbalance, decubiti, fever and central venous hyper-alimentation (CVH) were needed on a daily basis. There was also the opinion that these physical conditions should be treated by psychiatrists under the supervision of surgical and/or medical specialists. Because of these factors, a Medical Psychiatry Unit (MPU) was established in 1990 for the first time in this country.
This is in contrast to the reasons for the establishment of these units in the United States where there is an intense pressure to reduce costs (4,5). Although there is no Diagnostic Related Group (DRG) system of payment in Japan, it is well-known that medical and psychiatric comorbidity increases disability (6,7), impairs function (6,8), and leads to more use of health services in the long run (9-11). A 1992 report noted that more than 20 MPUs exist in the United States (12). In Japan, a public health insurance plan, most often the national health insurance plan, covers 100% of the Japanese nationals, who pay relatively low copayments, and get reasonably good quality of care. There is no DRG, but the goverment completely determines price of each medicine, examination and treatment. As increasing medical costs have gotton more serious, the goverment started to decrease reimbursements causing considerable friction .
There are currently no guidelines in Japan for establishing an MPU or for quality assurance therein because the Tachikawa MPU is the first and only one in Japan. These guidelines will develop over time as MPU's become more popular. At this point, the only only guideline-like principles used are from literature on the MPU experience in the United States and the charter purpose, "a system for patients with serious psyhciatric and medical problems". Currently, most patients on the unit have serious mental symptoms that preclude them from being on medical wards (ie.serious suicidal attempts, violent behavior, aggressive refusal of medical treatments, agitation, wandering or escaping medical wards), aor on psychiatric wards because of need for medical treatments, such as IV hyperalimentation, artificial respiration etc. In the future, we also want to include less severe diseases, such as depression with minor physical symptoms and psychosomatic disorders.
While no medical students rotate on the unit there are three psychiatric PGY 2-3 medical staff members who applied to the MPU who are interested in becomming "medical psychiatrists", though there are no formal qualifications.These physicians completed a one-year internship in psychiatry at the Keio university hospital in psychiatry, and while not officially residents anymore recieve clinical supervision. There is no requirement in Japan for a four-year psychiatric residency in order to become a psychiatrist and the number of years one spends in a university residency program varies from university to university. There are no medical residents. Specialists from each area from both outside and inside the hospital are invited to give lectures and there are educational unit-rounds once a week.
Though development of MPUs is a new conceptual model of care for the psychiatric problems, its applicability as an overall model of general hospital care is still unclear (3), and a task force in the United states is currently developing practical guidelines for establishing these units (4).This article will atempt to add data on the applicability of MPU units by a discussion of the clinical experience of the MPU in Japan during a recent four year period and the importance of such units in Japan.
Methods
Tachikawa Hospital is a general hospital which has 15 clinical specialties and 500 inpatients beds. The MPU is a semi-locked ward, i.e., locked only at night, has 63 beds, of which two are for intensive medical care and four are seclusion rooms. The staff includes four full-time psychiatrists, 28 nurses, three clinical psychologists and one psychiatric social-worker.
All medical charts were surveyed from 1990 through 1993 and the cases were divided into two groups: the initial two years from 1990 through 1991 and the latter two years from 1992 through 1993. The number of admissions, average length of hospital stay, primary psychiatric diagnoses, and concomitant physical disorders and their outcomes were compared between the two periods.
Results
Table-1 (Not available on-line) shows the admission data for the two periods. In the latter two years, the number of admissions increased by 39% over the initial two year period. The mean age of the patients was older (p<0.01) , and the average length of hospital stay shortened to nearly half, from 142 days to 67 days. The number of admissions through the Tokyo Project was the most common, but the number of admissions from other general hospitals without psychiatric units also increased.
The psychiatric diagnoses for the two periods are shown in Table-2 (Not available on-line). Almost half of the patients had schizophrenia in both periods.
We also summarized the distribution of medical diagnoses (Table 3-Not available on-line). The most frequent diagnosis was carcinoma. A large number of concomitant medical diagnoses were categorized as 'others', indicating that psychiatric patients transferred to the MPU had a wide variety of physical conditions. Approximately 20% of inpatients had no physical disease, all of whom were followed at the outpatient psychiatric clinic at Tachikawa Hospital. This is because the MPU is also available for psychiatric patients without physical illness, although patients with combined physical and psychiatric illness are given priority for admission.
The outcome for patients admitted to the MPU is shown in Table 4 (Not available on-line). 74% of physical illness were recovered or improved on discharge, while 65% of psychiatric disorders remained unchanged. Out of 338 inpatients during the latter two years, only 18 patients died because of their physical disease.
Discussion
The findings indicate that, in the latter two years, the functions and roles of the MPU were better established. Although our MPU was originally developed according to the guidelines of the Tokyo Project, the number of inpatients transferred from general hospitals increased up to 3.3 times in the latter period compared with in the initial period.
An increasing number of patients with minor physical ailments such as hemorrhoids, cataracts, etc., in addition to more serious disease such as cancer and ileus were seen. This indicates that the establishment of the MPU stimulated the referring psychiatrists working at mental hospitals to recall that even minor physical problems in the mentally ill need to be treated appropriately.
The average length of stay at the MPU decreased over the four years, reflecting that efficiency of the unit improved as well as that patients with even minor physical diseases were more likely to be admitted to the MPU. A study of an MPU in the United States found a decrease in of length of stay from 20 days in 1984 to less than 15 days in 1986 (13). The average length of stay at the MPU in Tachikawa Hospital of 67 days compares with 24 days on the general wards at Tachikawa Hospital, 44 days in general hospital medical wards in Japan, and 601 days in psychiatric hospitals in Japan (1).
One of the reasons for long length of stays in Japan is due to the lack of skilled nursing facilities in Japan and consequently the hospital functions in this regard to some degree especially for bedridden patients unable to care for themselves. Additionally, there is no decrease in payable medical fees over time and only a slight decrease in payments for nursing care over time. Also, because medical payments are considerably lower than in the United States there is less pressure to discharge. Because psychiatric symptoms worsened in only one case (0.3%) this suggests that the MPU plays an important role in offering a clinical setting where mentally ill patients with physical disease can recieve optimal psychiatric care .
Proper nursing training and motivation to work on these units is also of great importance (14,15). Because there is no speciality system for Japanese nurses, who usually rotate through various departments, Japanese nurses become more "generalists" than "specialists" across the board. In this context there is limited liability for nurses. The majority of the nurses had previously worked on a surgery ward or in the operating room and were quite reluctant to work with psychiatric patients at first. Psychiatric patients often don't show their appreciation for recieving care and this also decreases morale.To compensate, the psychiatric staff tries to stimulate interest in psychiatric problems and their treatments and goes on outings and dinners with the nursing staff. This kind of activity is very important for successful staff relationships in Japan by making the work environment as a kind of "family" (16).
While there is no specific course for nurses regular lectures by the attending staff are given. Medical training for the psychiatrists is mostly on the job with some help from medical colleagues. Medical liability litigation in Japan is still quite low for psychiatry and though it is rising somewhat in the other specialties it is still a small concern compared to the United States. More structured training and credentialing may become important for physicians and nurses in the future as liability conditions change.
In Japan, the minimal requirement for adequate medical treatment is the best effort put forth by specialists in each area, though there is no board certification system for psychiatrists in Japan. Because the psychiatrist may not be considered as specialist for physical treatments in the MPU there is some concern about this. The primary purpose of psychiatrist in MPU, however is to create the best environment for treating combined med/psych illeness. In otherwords, to give the other specialists a more amicable clinical setting to carry-out medical care for patients with psychiatric/behavioral problems,rather than trying to do wide range of medical treatment themselves. Right now, however, night/weekend medical coverage is done by one of the MPU psychiatrists. A psychiatrist who lives on the hospital grounds is available on 24 hrs/365 days basis for emergency medical and/or psychiatric problems.
Compared to western countries, the lesser degree of liability concerns with the nurse generalists and the psychiatrists doing medical procedures may be related to the Japanese ideology of the division of labor. Chie Nakane, a Japanese professor of social anthorpology, described it as, "For the group there is advantage to be gained from the effective mobilization of the group force by maximizing the potential ability of individual members...in Japan the ideology of the division of labor is not well developed, and the Japanese in general hold fairly strong convictions that one man can do another's job whenever this may be necessary... Japanese are often surprised in the West by the rejection of a small request by a person ...by saying it was not his job" (17).
Financially, the reimbursement of psychiatric treatment, especially for inpatients, is surprisingly low in Japan. While psychiatric beds make up 18.5% of all hospital beds the cost for psychiatric care is 6.7 % of all medical cost(1). The average in-patient reimbursement for psychiatry is approximately U.S.$3000.00 per month. Psychiatrists working at mental hospitals are often in charge of many inpatients, and most general hospitals have no or a few psychiatric beds. General hospital psychiatric practice needs to resolve this financial predicament and the use of MPUs may be the answer because of the more favorable insurance payments for psychiatric inpatients with physical diseases. In other words, the establishment of an MPU has considerable financial merit for general hospitals in Japan.
The MPU has also helped solve some of the problems that are inherent on a consultation/liaison service (ie.-The consultee does not follow the consultant's recommendations, nurses do not know how to implement behavioral programs on a medical ward(18). Psychiatric patients with serious violent or suicidal behavior (19) cannot be treated on medical wards because of lack of seclusion rooms and no social rehabilitation systems (such as occupational therapy, recreation room, etc.) or rooms for psychotherapy and an MPU has these advantages.
MPUs also offer opportunities to non-psychiatric physicians to see patients other than those in their respective specialties and this gives them an opportunity to see psychiatric patients, which can help to decrease the 'stigma' of psychiatric illness and increase their knowledge of psychiatric disorders and treatment. Also, psychiatrists' attention to physical illness contributes to the 're-medicalization' of psychiatry, which helps to improve our image with the other specialties and promotes teamwork.
Additionally, the MPU gives psychiatric residents a chance for additional medical/surgical training. One of the problems of current post-graduate education for psychiatric residents in Japan is that they are rarely given an opportunity to treat medical or surgical patients. The MPU is an excellent clinical setting in which psychiatric residents can learn about the other medical specialties as well as psychiatry (18). It can also offer them training in psychosomatic medicine, holistic medicine, etc.
The above points emphasize both the educational as well as administrative roles and clinical usefulness, for the MPU as has also been demonstrated in the United States. The distribution of psychiatric diagnoses and concurrent physical illness seen in our MPU, however, is different from the data in the U.S. This may be due to the different types of patients seen in different institutions. Also, the average length of stay is different and this is probably because of differences in the health insurance system.
In conclusion, the data suggest that while the experience of MPU is limited, the MPU has important roles in Japan as, 1) an appropriate clinical setting for patients with combined medical and psychiatric illness, 2) a strategic model for dealing with psychiatric patients in the general hospital, 3.) an educational setting for psychiatric residents to become more familiar with medicine and surgery, and 4) an educational opportunity for non-psychiatric residents to become familiar with psychiatric illness and treatments.
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