PSYCHIATRIC BEDS IN general hospitals (GHP beds) in Japan have progressively been decreasing in number. For example, 9.3% of GHP beds in Japan disappeared during the 3 years between 2002 and 2005.1 Under such circumstances, we are concerned that general hospitals may soon become unable to play the expected major roles, including treatment of medical comorbidities, provision of electroconvulsive therapy, determination of differential diagnoses using neuroimaging, and provision of emergency and acute-phase care. We thus examined whether GHP beds fulfill their expected roles, and whether such beds are running short, using a cross-sectional study provided to hospitals all over Tokyo.
In order to investigate the utility and sufficiency of psychiatric beds in general hospitals (GHP beds), a cross-sectional study was performed in general hospitals all over Tokyo. Reasons for admission were acute-phase treatment (43%), medical comorbidity (15%), electroconvulsive therapy (13%), differential diagnosis (12%), and others (17%). The number of patients who could not be admitted to GHP beds despite appropriate reasons for admission was estimated to be greater than that of inpatients without indispensable reasons for admission to GHP beds on the day of the survey. GHP beds played the expected roles, and were in short supply.
This cross-sectional study was performed all over Tokyo on 30 June 2008. Using the nationwide online Welfare and Medical Service Network System (WAM-NET) database (Japan Medical Press, Tokyo) on 19 May 2008, a list of all hospitals with a psychiatric department in Tokyo was obtained. A total of 214 hospitals were identified, and then psychiatric hospitals were excluded. Furthermore, the first author confirmed the information for each hospital by telephone. Some hospitals had already closed the psychiatric department because of resignation of the staff psychiatrist. Hospitals in which a psychiatrist worked only once a week were also excluded. The list of hospitals with psychiatric beds under control of the 1995 Law Concerning Mental Health and Welfare for the Mentally Disabled was provided by the Bureau of Social Welfare and Public Health of the Tokyo Metropolitan Government. Finally, identified hospitals were confirmed to show no differences from the reality of so-called ‘general hospitals’, as defined by Japanese medical law before the revision in 1997. The first author then asked the head psychiatrists of each hospital to respond to the survey, and sent a paper questionnaire. Eighteen (64%) of 28 general hospitals with psychiatric beds and 27 (68%) of 40 general hospitals without psychiatric beds participated in the study. The number of psychiatric beds among the participating institutions was 632. Rough sizes of participating general hospitals were as follows: <20 beds, n = 1; 20–39 beds, n = 12; 40–59 beds, n = 3; and 60–65 beds, n = 2.
All study protocols were approved by the institutional review board of Juntendo University School of Medicine. The approved protocol did not require informed consent from patients, as the data in this observational study remained anonymous and were analyzed in aggregate.
Information collected from GHP beds included the following numbers: (i) inpatients on the day of the survey; (ii) reservations for admissions; (iii) cases for consultation and liaison for psychiatry (CL cases) that should have been admitted to GHP beds; and (iv) outpatients or other hospital cases that could not be admitted to GHP beds despite requiring admissions. Reasons for each admission were also collected. Each respondent physician clinically decided whether a patient required admission to GHP beds.
Information collected from general hospitals without psychiatric beds included the following numbers: (i) CL cases that should have been admitted to GHP beds; and (ii) outpatients who could not be admitted despite requiring admission. Reasons for each admission were also collected.
To confirm the validity of this survey, we performed a comparison between respondent hospitals and non-respondent hospitals. No significant differences in the number of total beds were seen between respondent hospitals (mean [± standard deviation]: 787 ± 321 beds) and non-respondent hospitals (830 ± 262 beds; t = 0.36, P = 0.72). Likewise, there was no significant difference in the number of psychiatric beds between respondent hospitals (36.5 ± 12.1) and non-respondent hospitals (45.6 ± 9.7; t = 2.04, P = 0.052). Homogeneity between the groups seems tenable.
On the day of the survey, 542 inpatients were occupying 632 GHP beds (86%), suggesting that 14% of GHP beds were vacant. Reasons for admission were as follows: acute-phase treatment irrespective of psychiatric disorder, n = 233 (43%); medical comorbidity, n = 80 (15%); electroconvulsive therapy, n = 68 (13%); differential diagnosis using neuroimaging etc., because of evaluation for possible organic mental disorder, n = 65 (12%); stress care, n = 52 (10%); care for impulsiveness of borderline personality disorder (BPD), n = 23 (4%); and others, n = 21 (4%).
The number of reservations for admission to GHP beds was 99, corresponding to 16% of the 632 GHP beds. Reasons for admission were as follows: acute-phase treatment, n = 32 (32%); differential diagnosis, n = 19 (19%); electroconvulsive therapy, n = 16 (16%); medical comorbidity, n = 9 (9%); stress care, n = 8 (8%); and care for BPD, n = 3 (3%).
In general hospitals with psychiatric beds, numbers of CL cases that could not be admitted to GHP beds despite appropriate reasons for admission were as follows: medical comorbidity, n = 17; and acute-phase treatment, n = 13. In general hospitals without psychiatric beds, numbers of CL cases that could not be admitted to GHP beds despite appropriate reasons for admission were as follows: medical comorbidity, n = 39; differential diagnosis, n = 2; and acute-phase treatment, n = 6. Considering participation rates in the study, i.e. 64% for general hospitals with psychiatric beds and 68% for general hospitals without psychiatric beds, estimated numbers of subjects requiring GHP beds but who were unable to be admitted were 84 (17/0.64 + 39/0.68) for medical comorbidity, 29 (13/0.64 + 6/0.68) for acute-phase treatment, and three (2/0.68) for differential diagnosis. The total estimated number of subjects who could not be admitted to GHP beds despite appropriate reasons for admission was thus 116 cases (84 + 29 + 3).
Furthermore, numbers of outpatients or other hospital cases that could not be admitted to GHP beds despite appropriate reasons for admission were seven for general hospitals with psychiatric beds, and five for general hospitals without psychiatric beds. Considering the participation rates of each group in the study, 11 cases (7/0.64) for general hospitals with psychiatric beds, and seven cases (5/0.68) for general hospitals without psychiatric beds, could not be admitted to GHP beds. The total estimated number was 18 cases (11 + 7). The most frequent reason for refusal of admission was lack of an available private room (71%).
Do GHP beds fulfill their expected roles?
In general, GHP beds are expected to fulfill roles in the treatment of medical comorbidity, provision of electroconvulsive therapy, and determination of differential diagnoses using neuroimaging methods. Emergency and acute-phase patients should also preferably be cared for in GHP beds due to the high frequency of physical complications and abnormal physiological conditions. The present results showed that 83% of admissions to GHP beds were for one of these four reasons, and only 14% of admissions were due to stress care and care for BPD, for which GHP beds are not necessarily required. Similar results were observed in reservations for admissions to GHP beds. GHP beds thus, for the most part, seemed to fulfill their expected roles, at least on the day of the survey.
Although 14% of GHP beds appeared to be vacant on the day of the survey, reservations for admissions exceeded the number of vacancies (16%), suggesting that practically no vacancies were available.
Are GHP beds running short?
The number of CL cases that could not be admitted to GHP beds despite appropriate reasons and the number of outpatients or other hospital cases that could not be admitted to GHP beds despite appropriate reasons corresponded to 116 cases and 18 cases, respectively. These numbers can be considered as representing a lack of GHP beds on the day of the survey. Meanwhile, 75 patients were admitted to GHP beds on the day of the survey due to stress care and care for BPD. Considering the participation rate of general hospitals with psychiatry beds (64%), an estimated 117 cases (75/0.64) were admitted due to such reasons. Even if the 117 inpatients without indispensable reasons for admission to GHP beds had been transferred to psychiatric hospitals, the lack of GHP beds (116 + 18 = 134) would have exceeded the available number. In other words, a shortage of 17 beds (134–117) was seen in Tokyo on the day of the survey.
A policy regarding specialization of GHP beds thus seems warranted to induce efficient utilization of available beds. In addition, an increase in the number of private rooms or conversion from non-private rooms appears warranted, as 71% of refusals for admission were attributable to a lack of vacant private rooms.
Although various opinions about needs for GHP beds have been put forward, little evidence has been accumulated. One strength of this study was the cross-sectional design that covered the whole of Tokyo, and the relatively high participation rate. Despite the one-day nature of the survey, the results may be considered reliable, as the rate of medical comorbidity was consistent with a cross-sectional study performed in Tokyo during a 2-month period in 2007 (17.5%).2,3 One limitation was the possibility that admissions on Monday may have been high compared with other weekdays. Further regular population-based studies are needed to assess the quantity and quality of GHP beds.
This work was supported by a grant from the Ministry of Health, Labour and Welfare of the Japanese Government (Research on Psychiatric and Neurological Diseases and Mental Health, H19-009, and Intramural Research Grant for Neurological and Psychiatric Disorders of NCNP, 20B-8).