PSYCHIATRIC SERVICES IN GENERAL HOSPITALS—A Report of the Northern California Psychiatric Society's Committee on the Need for Psychiatric Services in General Hospitals

A study made by a special committee appointed for the purpose by the Northern California Psychiatric Society found that a real need exists for local psychiatric services in general hospitals of the Northern California area. Such services can be provided readily—and in some communities are already available. A broad segment of the population looks to the general hospital to provide diagnosis and care and so enable the patient''s prompt recovery from psychiatric disorders. The study further emphasizes the importance of such factors as a competent psychiatric chief, adequate staff and personnel and good planning in organizing inpatient and outpatient facilities and integrating treatment so that all the functions of the hospital are available to psychiatric patients. Granted these special considerations, the services can be provided more easily than many physicians, including some psychiatrists and administrators, suppose.     

An Emergency Psychiatric Service in a General Hospital

The same extensive range of general hospital facilities should be allocated to emergency psychiatric illness as are available for other medical conditions. During the study herein reported, for every three medical consultations in the emergency ward of a large general hospital, two psychiatric consultations were requested. Over a two-year period when 24-hour coverage by psychiatric consultants was instituted, such assessments increased from 148 to 340 (during the first four months of each year); the increase in police referrals was outstanding, rising from 16 to 105. The general wards of the hospital assumed greater responsibility for further medical treatment, while committal to the mental hospital declined. Many more psychiatric patients could have been treated in the general hospital if facilities had been available. The development of an emergency psychiatric service is not an easy process and co-ordination with other psychiatric resources is required. Residents in training face situations in the emergency ward which are not encountered in any other aspect of their clinical experience.     

Meeting the challenge: providing anesthesia services in rural hospitals.

Although the volume and intensity of surgery done in rural hospitals are not sufficient to support a fully trained staff anesthetist, it is not practicable for all surgical, anesthesia and obstetric services to be provided by specialists in referral centres. As the study reported by Chiasson and Roy in this issue shows (see pages 1447 to 1452), general practitioners (GPs) with limited additional training in anesthesia already play an important role in the provision of these services in rural areas. To ensure that there is a continued supply of physicians prepared to meet the needs of small communities, funding and opportunities for supplemental training in surgery, anesthesia and obstetrics must be made available to GPs.     

Use of psychiatric services by patients in a general hospital.

OBJECTIVE--To identify physical disorders associated with increased rate of use of psychiatric services. DESIGN--Retrospective analysis of routine abstracts of general hospital inpatient records linked with those of psychiatric care, for inpatients with physical disorders with possible psychiatric associations and for controls. SETTING--Oxfordshire health district. SUBJECTS--Inpatients aged 15-64 years discharged from general hospitals during 1975-85 with a diagnosis among 14 selected diagnostic groups (including potentially life threatening conditions, chronic disabling diseases, and non-specific symptomatic conditions) and control inpatients with acute conditions. MAIN OUTCOME MEASURES--Observed and expected numbers of patients receiving psychiatric care. RESULTS--Observed use of psychiatric services before and after index admission was close to that expected for controls. For most other diagnoses the observed use was significantly increased in the year preceding and that subsequent to the admission. For four diagnostic groups it was significantly greater in the year after admission than in that before (acute myocardial infarction (ratio before to after 2.17, 95% confidence interval 1.5 to 3.3), cancer (2.05, 1.7 to 2.5), diabetes mellitus (1.89, 1.4 to 2.9), and chest pain (1.78, 1.3 to 2.4)). During four years after the admission the use of psychiatric services was significantly higher than in the general population for nonspecific symptomatic conditions (observed/expected: abdominal pain 1.7, chest pain 2.0, and headache 4.2), cirrhosis of the liver (10.4), and fractures in road accidents and other fractures (1.3, 1.6). CONCLUSIONS--More patients with certain physical conditions used psychiatric services. Alternative methods of service delivery may be needed, especially for disabling chronic physical illness, alcohol related disorders, and non-specific symptomatic conditions.     

PSYCHIATRIC INPATIENT SERVICES IN GENERAL HOSPITALS

Traditional asylum care of psychiatric patients leads to the isolation, confinement, and restraint of the patients, and to isolation of psychiatric practice from the rest of medicine. Modern psychiatric advances have demonstrated the disadvantages to both patients and their families of such isolation, confinement and restraint. It is in the best interests of patients and professional workers that inpatient psychiatric services be continuous with, and contiguous to, other medical services and to rehabilitation services of all kinds.Examination of currently available information reveals a shortage of psychiatric beds in California, particularly for diagnosis and brief treatment. Thus, not only is there a need to develop psychiatric inpatient facilities, but also an opportunity to develop them along several different lines. Since both the Hill-Burton Act (federal) and the Short-Doyle Act (state) give financial assistance to only those psychiatric services established in general hospitals or affiliated with general hospitals, this requirement calls for examination in the light of experience with services so operated.At first, the Short-Doyle Act was perceived as a panacea for the psychiatric ills of the state. Now it is beginning to be recognized as one method of providing additional mental health resources, rather than the exclusive method. As more short-term cases are treated in local, tax-supported, psychiatric units in general hospitals, an impact can be expected on the state hospital program.In its administration of the Short-Doyle Act, the Department of Mental Hygiene attempts to respond to community needs as locally determined. It tries to insure local option and encourage local responsibility while furthering high standards of staffing and of service.     

A Survey of Health and Psychiatric Services on Canadian Campuses

The co-operation of the Canadian Union of Students was readily obtained for a survey of the facilities for health and psychiatric services currently available on Canadian campuses. A 100% response was obtained from the 49 campuses on the original list. Thirty-eight campuses had health services, but the staffing and facilities of these varied widely. Infirmary facilities were provided on 19 campuses. Student use of health services appeared to be heavy where they were provided. Carefully defined psychiatric services were present on 22 campuses, but here again the pattern of staffing varied widely. The percentage of the student body seen by the staff of these psychiatric services ranged from 1.4 to 10.3, with a mean of 2.9%. Only one Canadian university approaches the Recommended Standards of the American College Health Association—one physician and one nurse per 1000 students enrolled. Using the currently available figures on the expected incidence of emotional disturbance among university students and the average duration of psychiatric treatment, it was estimated that a psychiatric service needed .5 team member per 1000 students enrolled. The value of infirmary beds on the campus is also emphasized.     

Care of the Certified Psychiatric Patient in the General Hospital: The Saskatoon Project

The effect of admitting a random selection of 42 committed psychiatric patients to an ordinary, open general hospital psychiatric ward was studied. A control group of 44 regular psychiatric patients was formed for comparison purposes. Differences were studied by rating scales of behaviour and psychopathology and by nursing and medical observations. Though differences in ages and psychopathology were marked, the differences in behavioural problems were slight. The results are consistent with the belief that a well-trained staff can now manage practically all psychiatric admissions in a general hospital.     

A Survey of Psychiatric Units in General Hospitals in Canada

The Canadian Psychiatric Association recently recommended that all general hospitals over 200 beds should have psychiatric in-patient units. Questionnaires were sent to the administrators of the 52 existing general hospital psychiatric units in Canada. Most administrators expressed approval of these units, although some noted the existence of problems. Statistics are given on the staffing of the units. Although the number of beds was small, these facilities accounted for a very large number of admissions. Most had active teaching programs. The advantages of implementing the C.P.A. recommendation are many. General hospital psychiatric units should be encouraged to undertake comprehensive psychiatry, that is, to accept all types of psychiatric patients, and to retain responsibility for long-term care.     

Making access to health care more equal: the role of general medical services.

The Resource Allocation Working Party (RAWP) recognised the need to consider both health authority and primary care services in achieving its objective. RAWP and the subsequent Advisory Group on Resource Allocation (AGRA) found (but did not publish) considerable variation in resources used by both services but could not find a clear relation between them. Statistics provided by the DHSS were used to compare spending by 80 area health authorities in 1980-1 with expenditure per head on general medical services by their corresponding family practitioner committees. There was considerable variation in the provision of resources for both services and no clear relation between the variations in spending on each service. Only 40 of the 80 areas had both health authority and family practitioner committee spending levels within 10% of "target." Subregional inequalities in resources tend to be related to variations in admission rates, which in turn are related to general practitioners'' referral behaviour. These results emphasise the importance of finding out more about inequalities in the provision of general medical services and their relation to the use of hospital services. They also suggest that RAWP''s aim of equality of opportunity of access to health care resources may be achieved only if general medical services are brought into the equation as well.     

The center-satellite system for the wide-scale distribution of genetic counseling services.

A 6-year experience with a center-satellite system for the provision of comprehensive genetic counseling services to a large geographical area is described. A series of 12 satellite genetic clinics established throughout northern and central California have brought genetic counseling services to within a 2-hour drive for most patients. These satellite clinics are largely organized by local groups (such as National Foundation-March of Dimes chapters and county health departments) but are backed by the personnel and resources of the center at the University of California, San Francisco. Assistance is generally provided by county public health nurses who collect medical records from referring physicians and pedigrees from the family. Specimens for cytogenetic or special biochemical studies are brought back to the center, but, if possible, other laboratory determinations, radiological investigations, and specialty consultations are obtained locally. Follow-up counseling may be provided by the public health nurses, and a written summary is sent to each patient or family. The socioeconomic spectrum of the patients seen at the satellite clinics is much broader than at the central clinic, and the establishment of a satellite clinic results in a great increase in the number of cases seen from the area in which it is located. Physician time per patient and cost of services per patient are substantially the same in both central and satellite clinics. Based on population figures applicable to the state of California, it is estimated that approximately 60-70 comprehensive counseling centers, each with up to 15 satellites, could adequately provide for the foreseeable genetic counseling needs of the United States.     

Contribution of general practitioner hospitals in Scotland.

The results of a survey of 64 Scottish general practitioner hospitals showed that in 1980 these hospitals contained 3.3% of available staffed beds in Scotland; 13.6% of the resident population had access for initial hospital care, and 14.5% of Scottish general practitioners were on their staffs. During the year of the survey they discharged 1.8% of all non-surgical patients, treated almost 100 000 patients for accidents and emergencies and 140 000 outpatients, and 4.4% of all deliveries in Scotland were carried out in the hospitals surveyed. Most communities which are served by general practitioner hospitals in Scotland are rural and on average are more than 30 miles from their nearest district general hospital. The contribution that these small hospitals make to the overall hospital workload has not previously been estimated. It has been shown nationally to be small but not inconsiderable . In terms of the contribution to the health care of the communities they serve it cannot and should not be underestimated.     

Contribution of general practitioner hospitals in England and Wales.

A survey of a one-in-seven sample of general practitioner hospitals in England and Wales, performed to determine the contribution they make to overall hospital work load and the attitudes of the general practitioners working in them, showed that 3% of acute hospital beds in England and Wales were in general practitioner hospitals, which provided initial hospital care for up to 20% of the population. Altogether 16% of general practitioners and 22% of consultants were on the staffs, and they coped with more than 13% of all casualties, 6% of operations, and 4% of x-ray examinations. Nearly a million casualties were treated at no cost to the National Health Service. Twenty new district general hospitals would be needed to cope with the work load currently dealt with by general practitioner hospitals. The results of this survey indicate that these smaller hospitals deal efficiently and cheaply with their work load, and that morale is high. General practitioner hospitals could have an important part to play in providing certain types of care, but there are no financial incentives to enable general practitioners to realise this potential fully.     

Whither Psychiatric Day Care? A Study of Day Patients in Birmingham

A survey was made of the 647 patients attending the seven psychiatric day hospitals in Birmingham during a single census week, and of their patterns of attendance in day-care over the following 12 months. Marked differences were found between the day patients (583) attending the four large, traditional hospitals, and those (64) attending three small, relatively modern units. Patients attending the large hospitals were older, included the majority of schizophrenics, and carried a greater morbidity as measured by the frequency and duration of previous psychiatric care. At the end of the follow-up period 64% of patients attending the large hospitals were still in day care as against only 2 patients attending small hospital units.It is suggested that the results have important implications for the planning of future mental health services in that they highlight the extent to which different groups of patients have different requirements. A large proportion of the day hospital population had long-term needs which might be difficult to meet in the proposed general hospital units.     

The Development and Function of a Comprehensive Psychiatric Service in the Moose Jaw Union Hospital: (A Five-Year Study)

In the establishment of a comprehensive psychiatric service in a general hospital, two factors are of prime importance: (1) the integration of psychiatry with general medicine and (2) the therapeutic milieu established by the psychiatric staff. The application of these principles and the results obtained over a five-year period at the Psychiatric Department of the Moose Jaw Union Hospital are presented. Over that period of time, 1220 patients were admitted to the psychiatric ward and it was necessary to send only 80 patients of this total to a mental hospital. In the same period of time, 3194 outpatients were also treated. It is felt that a community-oriented psychiatric department in a general hospital can deal adequately with most types of psychiatric disabilities.     

Long-term outcome of patients with neurotic illness in general practice.

OBJECTIVE--To determine the 11 year outcome of neurotic disorder in general practice. DESIGN--Cohort study over 11 years. SETTING--Two general practices in Warwickshire England. SUBJECTS--100 patients selected to be representative of those identified nationally by general practitioners as having neurotic disorders. MAIN OUTCOME MEASURES--Mortality, morbidity, and use of health services. RESULTS--At 11 years 87 subjects were traced. The 11 year standardised mortality ratio was 173 (95% confidence interval 164 to 200). 47 were cases on the general health questionnaire, 32 had a relapsing or chronic psychiatric course, and 49 a relapsing or chronic physical course. Treatment for psychiatric illness was mainly drugs. The mean number of consultations per year was 10.8 (median 8.7). A persistent psychiatric diagnosis at one year follow up was associated with high attendance ( > 12 visits a year for 11 years) at follow up after age, sex, and physical illness were adjusted for. Severity of psychiatric illness (general health questionnaire score) at outset predicted general health questionnaire score at 11 year follow up, course of psychiatric illness, and high consultation rate. CONCLUSION--These data support the view that a neurotic illness can become chronic and is associated with raised mortality from all causes and high use of services. Such patients need effective intervention, particularly those with a more severe illness who do not recover within one year.     

Avian conservation practices strengthen ecosystem services in California vineyards

Insectivorous Western Bluebirds (Sialia mexicana) occupy vineyard nest boxes established by California winegrape growers who want to encourage avian conservation. Experimentally, the provision of available nest sites serves as an alternative to exclosure methods for isolating the potential ecosystem services provided by foraging birds. We compared the abundance and species richness of avian foragers and removal rates of sentinel prey in treatments with songbird nest boxes and controls without nest boxes. The average species richness of avian insectivores increased by over 50 percent compared to controls. Insectivorous bird density nearly quadrupled, primarily due to a tenfold increase in Western Bluebird abundance. In contrast, there was no significant difference in the abundance of omnivorous or granivorous bird species some of which opportunistically forage on grapes. In a sentinel prey experiment, 2.4 times more live beet armyworms (Spodoptera exigua) were removed in the nest box treatment than in the control. As an estimate of the maximum foraging services provided by insectivorous birds, we found that larval removal rates measured immediately below occupied boxes averaged 3.5 times greater than in the control. Consequently the presence of Western Bluebirds in vineyard nest boxes strengthened ecosystem services to winegrape growers, illustrating a benefit of agroecological conservation practices. Predator addition and sentinel prey experiments lack some disadvantages of predator exclusion experiments and were robust methodologies for detecting ecosystem services.     

MEDICAL GROUP PRACTICE IN CALIFORNIA

A 1950 study of group practice in California reveals 52 “true general medical groups” among 123 medical organizations surveyed, involving 634 full-time and 215 part-time physicians. The groups, in contrast to the national patterns, tend to be larger, younger and more urban. There is also a greater tendency toward unit hospital affiliation (30 groups) and operation of group prepayment plans (10 groups).In general similarity to the national scene, California groups are most frequently organized as private partnerships with a salary method of remuneration sometimes augmented by a share of net earnings. The range of medical and technical services offered varies widely with the size of the group.The combination of group prepayment, medical group practice, and coordinated medical-hospital centers seems to offer special opportunities for satisfactory practice and adequate medical care.     

Psychiatric reform revisited

The trend towards the establishment of community psychiatric services seems to be universal. However, before closing down a mental hospital, it is necessary to establish the appropriate alternative facilities in the community. Every de-institutionalization program should have a diachronic component, and cultural issues should be taken into consideration. Care for each patient has to be decided upon on the basis of the characteristics of that patient. Finally, de-institutionalization is just one aspect of psychiatric reform. Primary psychiatric prevention is equally or even more important     

The Development and Organization of a Children's Psychiatric Hospital

Thistletown Hospital is a children''s psychiatric hospital which was established by the Department of Health of the Province of Ontario. Special legislation permitting control of the admissions procedures was enacted. The administrative organization consists of a series of committees made up of the heads of hospital departments. An advisory board of distinguished psychiatrists and psychologists advises the Minister of Health directly on major policy changes or innovations envisaged for the hospital. Clinical organization is related to four functions: (1) service (treatment and assessment), (2) research, (3) training of staff, and (4) community education.The basic units of the hospital are related to the treatment or research design necessary in special diagnostic categories. A children''s psychiatric hospital should not be restricted to in-patient facilities but should consist of a totally community-oriented service.     

Psychiatric morbidity and the menopause; screening of general population sample.

A survey of 539 women from the general population indicated a high prevalence of minor psychiatric illness in women aged 40-55 years. There was evidence of an increase in psychiatric morbidity occurring before the menopause and lasting until about one year after menstrual periods had ended. Vasomotor symptoms increased dramatically when periods stopped and persisted up to five years after the menopause. Both these features seemed to have a clear relation to the menopause but not the same relation. The findings suggested that further investigation of the relation between perimenopausal hormonal changes and psychiatric morbidity should be directed towards premenopausal women. Environmental factors, particularly in relation to children, seemed to be associated with increased psychiatric morbidity at this time of life.