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A Comparison of Psychiatric Consultation–Liaison Services Between Hospitals in the United States and Japan

Received December 26, 2005; revised July 8, 2006; accepted July 13, 2006. From the Dept. of Psychiatry, Univ. of Minnesota; the Dept. of Psychiatry, Tokai University; the Dept. of Psychiatry, Saitama Medical Center, Saitama Medical School; the Dept. of Psychiatry, Saitama Psychiatric Center; the Dept. of Psychiatry, Nagoya City University; and the Dept. of Psychology, Woodland Centers. Send correspondence and reprint requests to Dr. Yasuhiro Kishi, Dept. of Psychiatry, Saitama Medical Center, 1981 Tsujido-machi, Kamoda, Kawagoe Saitama, 350-8550, Japan. e-mail (Dr. Thurber): steven_thurber{at}yahoo.com
© 2007 The Academy of Psychosomatic Medicine

ABSTRACT

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The authors investigated psychiatric consultation in two hospitals, one in the United States, the other in Japan. They examined similarities and differences, and drew inferences on possible cross-cultural values and/or temporary cultural conditions. As compared with the Japanese consultation patients, the Americans had more mood disorders, including anxiety and chemical-dependency problems, in respective diagnostic classifications. Patients in the United States also showed more acute as well as more serious chronic conditions. These differences may relate to disorder base-rates in the respective countries. In general, psychosocial problems emerged as ascendant in Japan, as compared with chemical-dependency difficulties among American patients. The results are discussed in terms of current conditions in Japan that affect the mental health professions, together with attempts by Japanese clinicians to protect collective mores by ascribing causation for disorders to the individual, rather than the societal conditions often invoked in the United States.

INTRODUCTION

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The aim of this study is to explore possible similarities and differences between two hospital consultation services, one in a major American city in Minnesota (catchment area: 3 million), the other in the central part of Kanagawa, Japan (catchment area: 1 million). Heretofore, investigations of consultation–liaison services have involved comparisons between the United States and countries in Europe. It was reasoned that the notable differences between the United States and Japan in areas such as cultural, healthcare systems, and political structures might be reflected in the nature of the patients referred for psychiatric consultation.

METHOD

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The participants included patients consecutively referred to the psychiatric consultation–liaison service of Fairview University Medical Center at the University of Minnesota (from January 1, 2001 through December 31, 2001) and the Psychiatric Service of Tokai University Hospital, Kanagawa, Japan. The Japanese referrals occurred from July 1, 2003 through June 30, 2004. This period was selected because of a major change in the Japanese system, from "fee-for-service" to a "lump-sum" payment system with the adoption of the Diagnostic Procedure Combination System.

The hospital in the United States is public, located in a catchment area of approximately 3 million people (with approximately 15% non-Caucasian minorities). During the study year, the hospital had 17,629 admissions. The average length of stay (LOS) was 5.7 days. The consultation team consisted of an attending psychiatrist, psychiatric residents, and medical and pharmacy students.

In Japan, the institution is a private, university hospital, located in the central part of Kanagawa, with a population of over 87 million. However, its catchment area has approximately 1 million persons. During the study year, the hospital had 16,903 admissions, with an average LOS of 15.7 days. The consultation team consisted of attending psychiatrists and psychiatric residents. Thus, in both hospitals, a monodisciplinary medical-consultant model was followed, consistent with those in larger university hospitals with restricted involvement of other psychosocial services.¹

The following information was recorded for each consultation both in the United States and Japan: patient demographics (Table 1), date of admission, date of consultation, referring specialty service, reason for referral (Table 2), and DSM–IV diagnosis,² on the basis of information gleaned from the consultation interview. The LOS for each patient was obtained from the hospital computer systems. Consultations were requested primarily by four specialty services: medicine, surgery, intensive-care unit, and family practice. Other medical services provided fewer referrals; these included ophthalmology, obstetrics and gynecology, radiology, and pediatrics.

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TABLE 1. Background Characteristics, N (Percent)

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TABLE 2. Reason for Referral, N (Percent)

Reasons for referral included suicidal ideation and/or suicidal behavior; depression; psychosis; substance abuse or dependency; requests for evaluation of psychotropic medications; or the assessment of unspecified mental conditions, competence, or refusal of treatment; behavioral problems; agitation; anxiety; confusion or delirium; somatic complaints (somatization, factitious disorder, or malingering); and conditions listed as "other." Corresponding DSM–IV psychiatric diagnoses are presented in Table 3.

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TABLE 3. Psychiatric Diagnosis, N (Percent)

Regarding the timing of consultation, it would be inappropriate to investigate the number of days from admission to consultation, since this would be confounded by the LOS itself. For example, patients who are in the hospital longer could have the potential for receiving a later psychiatric consultation. For this reason, several investigators have suggested transforming the timing of referral into one adjusted for LOS by use of the following formula:^3–5

Timing of Consultation=log (# days from admission to consultation)/log (LOS)

This means that the LOS is adjusted for the percentage of hospital stay occurring before consultation.

Statistical Analysis
Two-sample t-tests were computed, based on equal or unequal variances, using the Levene test. Chi-square tests were used to compare categorical data. When sample sizes were prohibitively small, we used Fisher’s exact test.

RESULTS

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Background characteristics of the United States and Japanese psychiatric-consultation patients are presented in Table 1. North American patients included a smaller percentage of men, and fewer who were married; there was a smaller percentage of employed patients, and they tended to be younger in age. They also included significantly more patients with a previous history of psychiatric illness. In the Minneapolis hospital, 541 patients (3.1%) were evaluated by the psychiatric consultation team, whereas, in Kanagawa, 399 patients (2.4%) were evaluated.

Reasons for referral and psychiatric diagnoses are presented in Tables 2 and 3, respectively. The American physicians more frequently requested evaluations for possible suicidal proclivities, depression, and chemical dependencies. Japanese physicians more frequently asked for evaluations for agitation, anxiety, delirium, general psychiatric issues, and, importantly, social adjustment topics. Concerning diagnoses, the Minneapolis patients received more mood-disorder, anxiety, and drug-dependency classifications. A significantly higher number of Japanese consultation referrals received no psychiatric diagnoses. Also, the American patients were in greater distress (i.e., with Axis IV designations) and evinced greater severity of presenting problems in terms of Global Assessment of Functioning (GAF) judgments. The difference in timing (using the above formula) was not significant between the two hospitals (+0.35/–0.50 and +0.30/–0.60; t[938]=1.5; p=0.13).

DISCUSSION

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To our knowledge, no previous studies have explored cross-national psychiatric consultation services comparing Western and Asian countries. Our investigation suggests that differences do exist between hospital consultations in urban Minnesota and Kanagawa, Japan. Referred patients in the former setting demonstrated more mood and anxiety disorders and chemical dependencies. One partial explanation involves prevalence rates of affective problems. Several cross-national studies have shown lower prevalence of mood and anxiety disorders among East Asian countries, including Japan, as compared with Western countries.^6–8 Moreover, 1-month prevalence of DSM–IV major depression is lower in China (2.5%) and Japan (1.6%) than in Western countries (4%–26%).⁶ There is nothing extant in the research literature to suggest that this lower prevalence in East Asian countries is culturally influenced.

Influences specific to a culture are of two types: The first involves stable, prevailing views regarding ingrained values, or "what ought or ought not to be." Such values may stem from historic and religious traditions, inculcated via child-rearing. The second refers to temporary conditions related to influences of changing economic and political forces in a culture during a particular epoch of time.⁹ In the United States, a core value seems to be that of individualism, such that Americans focus on explaining deviance relative to influences from group forces (peers, family, school, society). In Japan, a recognized core value is one in which more importance is placed on the collective society, as opposed to the individual. Japanese people place value on group over individual goals.¹⁰

Several cross-cultural surveys reveal that Japanese people experience greater shame and stigma relative to using mental health services than do people in Western countries.^11,12 Such stigmatization may be a component of an apparent core value of the Japanese culture: an emphasis on preservation of the collective even at the expense of the individual. Departures from normative expectations are attributed to the person; mental and emotional problems are a weakness for which the individual is responsible. Japanese physicians who accept such preconceptions may be reluctant to refer certain patients. This may, in particular, involve patients with symptoms of depression. In order to avoid stigmatization, nonpsychiatric physicians in Japan may attempt to treat ostensibly depressed patients on their own, without psychiatric input (see Ito et al.¹³). However, nonpsychiatric Japanese physicians may feel more "comfortable," attribute less stigmatization, or feel less competent to deal with, agitated or anxious patients, or those with delirium.

Of special note is the category related to "social issues." This was the single most frequent referral in the Tokai University Hospital. One hypothesis is that Japanese physicians view psychiatrists as an important resource for psychosocial management concerns. This is in the context of inadequate numbers of non-physician mental health professionals serving in Japanese general hospitals. For instance, there is a shortage of social workers in such settings (0.5 per 100 beds, including non-certified individuals, in hospitals in Japan.¹⁴) There is also a shortage of psychiatric nurses, along with a provider system in which a psychologist is classified as "non-medical" and not qualified for hospital reimbursement.¹⁵ Hence, there is a dearth of hospital mental health personnel who might share in providing for the psychosocial needs of patients. This would constitute a temporary economic or political issue in Japan, not a core characteristic, and one not shared with today’s American culture.

Another "social-issues" hypothesis is that the disproportionately high number of Japanese referrals in this area relates to Japan’s ostensible collective/individual cultural values. In Japan, more importance is placed on the collective as opposed to the individual well-being; Japanese people place value on group over individual goals. In contrast, in the United States, there appears to be an opposing core value, in which individual deviance is attributed to external deleterious factors in the family, school, or society-at-large, thus protecting the individual, rather than the group. Thus, physicians in America might not be inclined to refer patients with social difficulties for what amount to a group, and not an individual problem. As indicated above, Japanese clinicians may be predisposed to protect the collective and assign causal influence for interpersonal difficulties to the individual. Therefore, in Japan, apparent problems in the social domain are more likely to be perceived as a function of individual maladaptation, requiring intervention directly with the disturbed person. This observed difference between American and Japanese hospitals may thus involve a core-value disparity.

Referred patients in Minneapolis were more acute and serious in manifested symptoms, with a higher incidence of past psychiatric history, suicidal proclivities, depression, and chemical dependency, and lower, more severe GAF estimates. The lower severity rates among referred patients in the Tokai University Hospital may relate to the fact that Japan has more psychiatric beds per 10,000 people than other countries of the world (for example, Japan has 28.4 psychiatric beds, versus 7.7 for America in mental hospitals, and 20.6 versus 3.1 in general hospitals).¹⁶ Our data, therefore, may reflect the fact that, in Japan, patients with relatively low or moderate medical severity may be directly admitted to psychiatric beds in general or mental hospitals. Again, this may constitute a temporary cultural condition in Japan, not shared with the psychiatric community in America.

There were several important similarities shared between the two hospital consultation services. Both showed a low referral rate, 2.4% to 3.1%, results similar to those of other studies.¹⁷ Furthermore, both involved patients with longer hospital stays, as compared with non-consultation patients. Patients in both countries often obtained psychiatric consultations late in their hospital stay (i.e., on average, over 30% of hospital days passed before patients received consultation). This is unfortunate, since there are data showing that earlier consultation tends to reduce total LOS.^2,4,18,19 Our study adds emphasis to the problems encountered when psychiatric consultation relies on non-psychiatric physician referrals.

It is important to acknowledge limitations in our investigation. First, the study represents a retrospective analysis of consultation records. Standardized psychiatric scales and structured clinical interviews were not used. Second, the findings may not be applicable to patients outside university teaching hospitals. Third, since the American and Japanese hospitals were not randomly selected; the results may not generalize to cross-cultural comparisons of other teaching hospitals in the respective countries. Finally, it is important to note that in the absence of experimental or quasi-experimental controls, it cannot be definitively inferred that any consultation differences are in turn related to cross-cultural differences. It must be recognized that a comparison of consultation data between two randomly-selected university hospitals within either country might have yielded the same configuration of findings. Nevertheless, our data do suggest differences between hospitals in America and those in Japan that are consistent with known core-values or differences in contemporary cultural dynamics.

CONCLUSIONS

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In comparing consultation–liaison services in the two hospitals, differences, as well as similarities emerged; some of the differences may reflect indigenous values or current cultural conditions in the separate cultures in which the hospitals are embedded. Such values and conditions may affect the nature of physician referrals and psychiatric diagnoses, albeit other interpretations are possible. Nonetheless, the differences found in the current investigation exemplify the importance of tailoring psychiatric training and implementation of psychiatric consultation that conflate with the nature of patient referrals (e.g., more chemical-dependency management in Minnesota; more psychosocial problems in the Japanese hospital), case complexity, and the specific type of existing healthcare system. The INTERMED procedures developed by Huyse and colleagues constitute an exemplar of such an integrated approach.^20,21

REFERENCES

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Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Kishi, Y. Articles by Aoki, T. Search for Related Content PubMed Citation Articles by Kishi, Y. Articles by Aoki, T. Cross-Cultural Psychiatry Somatoform Disorders

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