INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 47(1) 65-74, 2014
DIAGNOSES OF PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS BY NON-PSYCHIATRIC PHYSICIANS IN JAPAN* YASUHIRO KISHI, MD Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan; Saitama Medical Center, Saitama, Japan; and Itasca Brain Behavioral Science Associations, Minnesota HISASHI KUROSAWA, MD Nippon Medical School, Tokyo, Japan NAOSHI HORIKAWA, MD Saitama Medical Center, Saitama, Japan KOTARO HATTA, MD Juntendo University Nerima Hospital, Tokyo, Japan WILLIAM MELLER, MD University of Minnesota Itasca Brain Behavioral Science Associations, Minnesota
ABSTRACT
Objective: This study was undertaken to investigate non-psychiatric physicians’ diagnoses of hypothetical patients in clinical scenarios with comorbid medical and psychiatric disease in Japan. Methods: The non-psychiatric physicians were asked to diagnose eight clinical scenarios describing several
*This work was supported by a grant from the Ministry of Health, Welfare, and Labor of the Japanese Government (Research on Psychiatric and Neurological Diseases and Mental Health, H19-009). This funding body had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. None has any conflict of interest to disclose. 65 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.47.1.f http://baywood.com
66 / KISHI ET AL.
typical behavioral health problems in the medical settings. Results: A total of 155 non-psychiatric physicians participated. Many physicians had problems correctly diagnosing depression and hypoactive delirium with medically ill patients. Conclusions: It is time to incorporate new efficient and effective approaches, such as collaborative care system and proactive delirium prevention programs, to improve overall behavioral health diagnosis and treatment, rather than relying on the rapid recognition of behavioral health problems in primary care/general medical settings. (Int’l. J. Psychiatry in Medicine 2014;47:65-74)
Key Words: diagnosis, primary healthcare, depression, delirium, mental disorders
INTRODUCTION Primary care physicians are continually challenged to accurately diagnose patients presenting with behavioral health complaints. Our previous study showed the family doctor (primary care physician) was recognized as a desirable provider for many behavioral health problems by the Japanese general population [1]. In fact, in a study of pathways to psychiatric care in Japan (n = 228), over 50% accessed mental health professionals via medical providers [2]. For example, the diagnosis and treatment of depression is now seen more often in the general medical sector than in the mental health sector [3-5]. It is consistently associated with increased medical service use [6], adversely impacts clinical outcomes of comorbid medical conditions, and is associated with increased mortality [7]. The same is true for anxiety disorders, substance related disorders, psychotic disorders, somatoform disorder, dementia, and delirium. Furthermore, reviews of prevalence studies of the comorbid patients of medical and psychiatric illness document increasing frequency as patients move from the community setting to the outpatient and inpatient medical setting [8]. Unfortunately, recognition and treatment of psychiatric disorders by primary care physicians varies, and is generally lacking [9-13]. There are few studies in Japan to examine this issue, and this study was undertaken to investigate non-psychiatric physicians’ diagnoses of hypothetical patients in standardized clinical scenarios involving comorbid medical and behavioral health problems. METHODS Data collection for the study occurred from October 2008 to November 2008. Data were collected using a cross-sectional mailed survey with a small financial incentive to participate (2,000 yen). First, a research company randomly contacted non-psychiatric physicians by telephone using several doctors’ lists until reaching 200 non-psychiatric physicians who agreed to participate in our
PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS /
67
survey research. The non-psychiatric physicians who agreed to participate in our research were then sent the questionnaires discussed below. This study was approved by the Institutional Review Board of Saitama Medical University, Saitama Medical Center. Questionnaire Eight typical clinical scenarios with patients suffering from behavioral health conditions in medical settings were described on the questionnaire. The scenarios included depression with cancer, delirium (hyperactive type), schizophrenia with diabetes mellitus, dementia with cancer, panic disorder, delirium (hypoactive type), alcohol withdrawal syndrome with bone fracture, and depression with unexplained somatic complaints. In the case of depression with cancer, the scenario developed by Okuyama et al. was used [14]. The other scenarios were developed by the research group; one of the eight scenarios is described here. Scenario
Mr. A is 65 years old. He learned of his cancer diagnosis about 6 months ago, and has been receiving anti-cancer treatment. Since he did not experience distressing symptoms such as pain after the treatment ended, he has gone back to the daily life at home. But since learning of his cancer diagnosis, he has been feeling unusually sad and miserable. Even though he is tired all the time, he has trouble sleeping nearly every night. He does not feel like eating and has lost weight. He cannot keep his mind on his work and puts off making any decisions. Even day-to-day tasks seem too much for him. This has come to the attention of Mr. A’s family members, who are concerned about his reduced activity. Question
In each case, the first question was to assess recognition of the problem in the clinical vignette. Participants were presented with a list of nine diagnoses (see Table 1) and asked to choose the most suitable diagnosis. Next, subjects were asked to rate how acceptable each intervention would be, scoring on a scale from 1 (“definitely not acceptable”) to 4 (“definitely acceptable”) (see Table 2). RESULTS A total of 155 non-psychiatric physicians returned the questionnaire. The majority of physicians’ specialty was internal medicine (92%). In Japan, internal medicine physicians play an important role in primary care, since Japan does not have a system of family doctors. The mean time in medical practice was 25.0 years (standard deviation (SD = 7.2).
41.3 40.6 0.0 0.0 0.0 0.0 0.0
Adjustment disorder
Depression
Dementia
Delirium
Schizophrenia
Personality disorder
Alcohol-related disorder
0.6
0.0
4.5
66.5
17.4
0.6
7.7
1.9
0.6
B
A: Depression with cancer B: Delirium (Hyperactive type) C: Schizophrenia with diabetes mellitus D: Dementia with cancer E: Panic disorder F: Delirium (Hypoactive type) G: Alcohol withdrawal syndrome with bone fractures H: Depression with unexplained somatic complaints
13.5
4.5
Anxiety disorder
No mental problems
A
0.0
2.6
78.7
5.8
0.6
1.9
4.5
5.8
0.0
C
0.0
0.6
0.0
0.6
98.1
0.6
0.0
0.0
0.0
D
0.0
0.0
0.0
0.0
0.0
0.0
4.5
95.5
0.0
E
0.0
0.6
1.3
12.3
19.4
4.5
54.2
1.3
6.5
F
97.4
0.0
0.0
0.0
0.0
0.0
0.0
1.9
0.0
G
Table 1. Percentage of Physicians Suggesting Diagnoses of Each Clinical Scenario Patient (The bold numbers show the correctly diagnosed percentages)
0.0
0.6
1.3
0.0
0.0
59.4
20.6
10.3
7.7
H
68 / KISHI ET AL.
26.5 28.4 6.5
Anxiolytics prescription
Sleeping pills prescription
Antipsychotics prescription
1.9
A: Depression with cancer B: Delirium (Hyperactive type) C: Schizophrenia with diabetes mellitus D: Dementia with cancer E: Panic disorder F: Delirium (Hypoactive type) G: Alcohol withdrawal syndrome with bone fractures H: Depression with unexplained somatic complaints
Alternative medicine
27.7
33.5
Antidepressants prescription
Psychotherapy (by psychiatrist)
14.2
Collaboration with social worker
20.0
35.5
Psychotherapy (by psychologist)
46.5
Collaboration with psychologist
2.6
Collaboration with psychiatrist
Wait and see
A
0
12.9
7.1
21.9
7.7
7.7
4.5
10.3
11.0
40.6
2.6
B
3.9
42.6
19.4
60.6
9.0
9.0
5.8
15.5
19.4
76.8
5.2
C
3.9
5.8
6.5
11.6
5.8
4.5
5.2
35.5
7.7
23.9
5.2
D
1.9
35.5
34.8
7.7
9.7
49.0
21.3
9.0
36.8
48.4
3.2
E
2.6
16.1
16.8
7.1
11.6
8.4
9.0
16.1
22.6
28.4
2.6
F
Table 2. Percentage of Physicians Who Rated “Definitely Acceptable” Intervention
3.2
37.4
27.1
11.0
12.9
9.7
3.9
36.8
32.3
56.1
1.9
G
0.6
28.4
19.4
6.5
31.0
16.8
44.5
9.0
24.5
45.2
3.2
H
PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS / 69
70 / KISHI ET AL.
Table 1 shows the percentage of physicians suggesting diagnoses of each clinical scenario. There were significant differences in the correctly detected diagnoses among the eight clinical scenarios (Chi-square = 472.3, df = 7, p < .001). Most physicians correctly detected diagnoses of schizophrenia (79%), dementia (98%), panic disorder (96%), and alcohol withdrawal syndrome (97%). The clinical scenarios that had low percentages of correct answers were depression with cancer (41%) and hypoactive type delirium (12%). Table 2 shows the percentage of physicians who rated intervention “definitely acceptable.” Not considering the patient scenarios with schizophrenia or alcohol withdrawal syndrome, less than 50% of Japanese physicians thought collaboration with psychiatrists or psychologists would be definitively acceptable. DISCUSSION This study found that Japanese physicians correctly diagnosed schizophrenia, dementia, panic disorder, and alcohol withdrawal syndrome in the hypothetical patients given in a clinical scenario. This study also found that 40-60% of physicians correctly diagnosed depression in clinical scenarios of depressed patients with cancer or somatic complaints. There are some limitations to this study that should be considered when contemplating the findings described below. As physicians were aware that they were being evaluated when responding to survey questions about a clinical scenario, their responses to these scenarios might differ from responses to actual patients. Because clinical scenarios provided enough information to justify a behavioral health diagnosis, and because a list of diagnoses was given, the rate of correct diagnosis might be lower in actual medical settings. However, a clinical scenario-based survey can be completed more quickly than a record review or standardized patient program and research has shown that clinical scenario-based surveys produce better measures of quality of care than medical record reviews [15, 16]. In our study, the rate of correctly identifying depressed patients with cancer was only 40%. It is consistent with research that found that fewer than half of physicians diagnosed depression in clinical scenarios [17, 18]. Physicians incorrectly identified depression with cancer more often than depression with unexplained somatic complaints. Depression occurring in the setting of a medical illness is often considered to be a psychological reaction. Depressed symptoms may still be seen by many physicians as inevitable consequences of the illness, when depression develops in the context of cancer. Depression co-existing with medical illnesses may impair recovery and rehabilitation, and increase morbidity and mortality [7]. Thus, recognition and appropriate treatment of depression comorbid with medical illnesses is essential for optimal patient outcomes. Screening is recommended for depression only when staff-assisted supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Caution is recommended when staff-assisted supports are not in place [19]. Providing
PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS /
71
primary care physicians with education about treatment of behavioral disorders that lead to improved patient outcome remains challenging. For example, although physician education is a necessary step to improve treatment of depression in the primary care setting, training alone is insufficient [20, 21]. Other than hypothetical patients with schizophrenia or alcohol withdrawal syndrome, less than 50% of Japanese physicians thought collaboration with psychiatrists or psychologists would be definitively acceptable. A summary of depression and panic disorder treatment studies in the primary care setting shows that “coordination of care with behavioral health specialists” is a critical component needed for outcome change [21-23]. This underscores the importance of collaborative care for depression and anxiety disorders in medical patients. The same can be said about dementia treatment in primary care settings. Challenges for primary care doctors that may reduce likelihood of appropriate referral for behavioral healthcare include: lack of time; poor access to expertise in dementia care and community resources; poor communication across medical, social, and community providers of care; the absence of an interdisciplinary dementia care team; and the difficulties of providing palliative care [24]. It is, therefore, essential that an efficient and effective system of collaboration between psychiatrists and family physicians is organized in Japan. Hypoactive type delirium was poorly diagnosed in this study. This is consistent with research that a hypoactive form of delirium is frequently misdiagnosed as depression, and emphasizes the importance for considering delirium in the differential diagnosis of the patient’s mood disturbance [25-29]. Delirium is a common mental disorder in medical and surgical patients. It is associated with higher mortality, longer lengths of hospital stay, poor functional recovery, and increased likelihood of nursing home placement [30-35]. The importance of rapid recognition and treatment of delirium cannot be overstated. Furthermore, we need to go beyond improving the ability of physicians to detect delirium correctly. In the management of delirium, studies show that delirium prevention in high-risk patients (i.e., multidisciplinary delirium prevention programs) leads to improved outcomes, rather than waiting for delirium to develop and then intervening [36-38]. New efficient and effective proactive approaches should be incorporated to improve overall delirium treatment rather than relying on the rapid recognition of delirium, starting with effective recognition of risk factors and diagnosis when the condition manifests. CONCLUSIONS This study showed that many physicians continue to have problems correctly diagnosing depression and hypoactive delirium. It is time to incorporate new efficient and effective approaches, such as a collaborative care system and proactive delirium prevention programs, to improve overall behavioral health treatment rather than relying on the rapid recognition of behavioral health problems, which appears unlikely to occur.
72 / KISHI ET AL.
REFERENCES 1. Kishi Y, Kurosawa H, Horikawa N, Hatta K, Meller W. Preferences of help regarding behavioral health problems among the Japanese general population. Psychiatry and Clinical Neuroscience 2012;66(5):460-461. 2. Fujisawa D, Hashimoto N, Masamune-Koizumi Y, Otsuka K, Tateno M, Okugawa G, Nakagawa A, Sato R, Kikuchi T, Tonai E, et al. Pathway to psychiatric care in Japan: A multicenter observational study. International Journal of Mental Health Systems 2008;2(1):14. 3. Fink P, Hansen MS, Sondergaard L, Frydenberg M. Mental illness in new neurological patients. Journal of Neurology and Neurosurgical Psychiatry 2003;74(6):817-819. 4. Hansen MS, Fink P, Frydenberg M, Oxhoj M, Sondergaard L, Munk-Jorgensen P. Mental disorders among internal medical inpatients: Prevalence, detection, and treatment status. Journal of Psychosomatic Research 2001;50(4):199-204. 5. Silverstone PH. Prevalence of psychiatric disorders in medical inpatients. Journal of Nervous and Mental Disease 1996;184(1):43-51. 6. Kathol RG, McAlpine D, Kishi Y, Spies R, Meller W, Bernhardt T, Eisenberg S, Folkert K, Gold W. General medical and pharmacy claims expenditures in users of behavioral health services. Journal of General Internal Medicine 2005;20(2):160-167. 7. Evans DL, Charney DS, Lewis L, Golden RN, Gorman JM, Krishnan KR, Nemeroff CB, Bremner JD, Carney RM, Coyne JC, et al. Mood disorders in the medically ill: Scientific review and recommendations. Biology and Psychiatry 2005;58(3):175-189. 8. Clarke DM. Psychological factors in illness and recovery. New Zealand Medical Journal 1998;111(1076):410-412. 9. Ormel J, Koeter MW, van den Brink W, van de Willige G. Recognition, management, and course of anxiety and depression in general practice. Archives of General Psychiatry 1991;48(8):700-706. 10. Friedmann PD, McCullough D, Chin MH, Saitz R. Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists. Journal of General Internal Medicine 2000;15(2):84-91. 11. Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Annals of Internal Medicine 1995; 122(6):422-429. 12. Turner S, Iliffe S, Downs M, Wilcock J, Bryans M, Levin E, Keady J, O’Carroll R. General practitioners’ knowledge, confidence and attitudes in the diagnosis and management of dementia. Age and Ageing 2004;33(5):461-467. 13. Yamada K, Maeno T, Waza K, Sato T. Under-diagnosis of alcohol-related problems and depression in a family practice in Japan. Asia Pacific Family Medicine 2008; 7(1):3. 14. Okuyama T, Nakane Y, Endo C, Seto T, Kato M, Seki N, Akechi T, Furukawa TA, Eguchi K, Hosaka T. Mental health literacy in Japanese cancer patients: Ability to recognize depression and preferences of treatments-comparison with Japanese lay public. Psychooncology 2007;16(9):834-842. 15. Veloski J, Tai S, Evans AS, Nash DB. Clinical vignette-based surveys: A tool for assessing physician practice variation. American Journal of Medical Qualification 2005;20(3):151-157. 16. Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: A prospective validation study of 3
PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS /
17. 18. 19.
20.
21. 22.
23.
24. 25. 26. 27. 28. 29. 30.
31.
32.
33. 34.
73
methods for measuring quality. Journal of the American Medical Association 2000; 283(13):1715-1722. Andersen SM, Harthorn BH. The recognition, diagnosis, and treatment of mental disorders by primary care physicians. Medical Care 1989;27(9):869-886. Simon GE. Evidence review: Efficacy and effectiveness of antidepressant treatment in primary care. General Hospital Psychiatry 2002;24(4):213-224. O’Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: A systematic evidence review. Annals of Internal Medicine 2009;151(11):793-803. Lin EH, Katon WJ, Simon GE, Von Korff M, Bush TM, Rutter CM, Saunders KW, Walker EA. Achieving guidelines for the treatment of depression in primary care: Is physician education enough? Medical Care 1997;35(8):831-842. Von Korff M, Goldberg D. Improving outcomes in depression. British Medical Journal 2001;323(7319):948-949. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: A systematic review. Journal of the American Medical Association 2003;289(23): 3145-3151. Katon WJ, Roy-Byrne P, Russo J, Cowley D. Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Archives of General Psychiatry 2002;59(12):1098-1104. England E. Survival after diagnosis of dementia in primary care. British Medical Journal 2010;341:c3530. Margolis RL. Nonpsychiatrist house staff frequently misdiagnose psychiatric disorders in general hospital inpatients. Psychosomatics 1994;35(5):485-491. Levine PM, Silberfarb PM, Lipowski ZJ. Mental disorders in cancer patients: A study of 100 psychiatric referrals. Cancer 1978;42(3):1385-1391. Trzepacz PT, Teague GB, Lipowski ZJ. Delirium and other organic mental disorders in a general hospital. General Hospital Psychiatry 1985;7(2):101-106. Nicholas LM, Lindsey BA. Delirium presenting with symptoms of depression. Psychosomatics 1995;36(5):471-479. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Archives of Internal Medicine 1995;155(22):2459-2464. Pitkala KH, Laurila JV, Strandberg TE, Tilvis RS. Prognostic significance of delirium in frail older people. Dementia and Geriatric Cognitive Disorder 2005;19(2-3): 158-163. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. Journal of the American Geriatric Society 2000;48(6):618-624. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. Journal of General Internal Medicine 1998;13(4):234-242. Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. Journal of the American Medical Association 1990;263(8):1097-1101. Schor JD, Levkoff SE, Lipsitz LA, Reilly CH, Cleary PD, Rowe JW, Evans DA. Risk factors for delirium in hospitalized elderly. Journal of the American Medical Association 1992;267(6):827-831.
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35. Kishi Y, Iwasaki Y, Takezawa K, Kurosawa H, Endo S. Delirium in critical care unit patients admitted through an emergency room. General Hospital Psychiatry 1995;17(5):371-379. 36. Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, Laplante J. Systematic detection and multidisciplinary care of delirium in older medical inpatients: A randomized trial. Canadian Medical Association Journal 2002; 167(7):753-759. 37. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 1999;340(9):669-676. 38. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatric Society 2001; 49(5):516-522.
Direct reprint requests to: Yasuhiro Kishi, MD Department of Psychiatry Nippon Medical School Musashikosugi Hospital 1-396 Kosugi-cho Kawasaki Kanagawa 211-8533 Japan e-mail: [email protected]
DIAGNOSES OF PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS BY NON-PSYCHIATRIC PHYSICIANS IN JAPAN* YASUHIRO KISHI, MD Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan; Saitama Medical Center, Saitama, Japan; and Itasca Brain Behavioral Science Associations, Minnesota HISASHI KUROSAWA, MD Nippon Medical School, Tokyo, Japan NAOSHI HORIKAWA, MD Saitama Medical Center, Saitama, Japan KOTARO HATTA, MD Juntendo University Nerima Hospital, Tokyo, Japan WILLIAM MELLER, MD University of Minnesota Itasca Brain Behavioral Science Associations, Minnesota
ABSTRACT
Objective: This study was undertaken to investigate non-psychiatric physicians’ diagnoses of hypothetical patients in clinical scenarios with comorbid medical and psychiatric disease in Japan. Methods: The non-psychiatric physicians were asked to diagnose eight clinical scenarios describing several
*This work was supported by a grant from the Ministry of Health, Welfare, and Labor of the Japanese Government (Research on Psychiatric and Neurological Diseases and Mental Health, H19-009). This funding body had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. None has any conflict of interest to disclose. 65 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.47.1.f http://baywood.com
66 / KISHI ET AL.
typical behavioral health problems in the medical settings. Results: A total of 155 non-psychiatric physicians participated. Many physicians had problems correctly diagnosing depression and hypoactive delirium with medically ill patients. Conclusions: It is time to incorporate new efficient and effective approaches, such as collaborative care system and proactive delirium prevention programs, to improve overall behavioral health diagnosis and treatment, rather than relying on the rapid recognition of behavioral health problems in primary care/general medical settings. (Int’l. J. Psychiatry in Medicine 2014;47:65-74)
Key Words: diagnosis, primary healthcare, depression, delirium, mental disorders
INTRODUCTION Primary care physicians are continually challenged to accurately diagnose patients presenting with behavioral health complaints. Our previous study showed the family doctor (primary care physician) was recognized as a desirable provider for many behavioral health problems by the Japanese general population [1]. In fact, in a study of pathways to psychiatric care in Japan (n = 228), over 50% accessed mental health professionals via medical providers [2]. For example, the diagnosis and treatment of depression is now seen more often in the general medical sector than in the mental health sector [3-5]. It is consistently associated with increased medical service use [6], adversely impacts clinical outcomes of comorbid medical conditions, and is associated with increased mortality [7]. The same is true for anxiety disorders, substance related disorders, psychotic disorders, somatoform disorder, dementia, and delirium. Furthermore, reviews of prevalence studies of the comorbid patients of medical and psychiatric illness document increasing frequency as patients move from the community setting to the outpatient and inpatient medical setting [8]. Unfortunately, recognition and treatment of psychiatric disorders by primary care physicians varies, and is generally lacking [9-13]. There are few studies in Japan to examine this issue, and this study was undertaken to investigate non-psychiatric physicians’ diagnoses of hypothetical patients in standardized clinical scenarios involving comorbid medical and behavioral health problems. METHODS Data collection for the study occurred from October 2008 to November 2008. Data were collected using a cross-sectional mailed survey with a small financial incentive to participate (2,000 yen). First, a research company randomly contacted non-psychiatric physicians by telephone using several doctors’ lists until reaching 200 non-psychiatric physicians who agreed to participate in our
PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS /
67
survey research. The non-psychiatric physicians who agreed to participate in our research were then sent the questionnaires discussed below. This study was approved by the Institutional Review Board of Saitama Medical University, Saitama Medical Center. Questionnaire Eight typical clinical scenarios with patients suffering from behavioral health conditions in medical settings were described on the questionnaire. The scenarios included depression with cancer, delirium (hyperactive type), schizophrenia with diabetes mellitus, dementia with cancer, panic disorder, delirium (hypoactive type), alcohol withdrawal syndrome with bone fracture, and depression with unexplained somatic complaints. In the case of depression with cancer, the scenario developed by Okuyama et al. was used [14]. The other scenarios were developed by the research group; one of the eight scenarios is described here. Scenario
Mr. A is 65 years old. He learned of his cancer diagnosis about 6 months ago, and has been receiving anti-cancer treatment. Since he did not experience distressing symptoms such as pain after the treatment ended, he has gone back to the daily life at home. But since learning of his cancer diagnosis, he has been feeling unusually sad and miserable. Even though he is tired all the time, he has trouble sleeping nearly every night. He does not feel like eating and has lost weight. He cannot keep his mind on his work and puts off making any decisions. Even day-to-day tasks seem too much for him. This has come to the attention of Mr. A’s family members, who are concerned about his reduced activity. Question
In each case, the first question was to assess recognition of the problem in the clinical vignette. Participants were presented with a list of nine diagnoses (see Table 1) and asked to choose the most suitable diagnosis. Next, subjects were asked to rate how acceptable each intervention would be, scoring on a scale from 1 (“definitely not acceptable”) to 4 (“definitely acceptable”) (see Table 2). RESULTS A total of 155 non-psychiatric physicians returned the questionnaire. The majority of physicians’ specialty was internal medicine (92%). In Japan, internal medicine physicians play an important role in primary care, since Japan does not have a system of family doctors. The mean time in medical practice was 25.0 years (standard deviation (SD = 7.2).
41.3 40.6 0.0 0.0 0.0 0.0 0.0
Adjustment disorder
Depression
Dementia
Delirium
Schizophrenia
Personality disorder
Alcohol-related disorder
0.6
0.0
4.5
66.5
17.4
0.6
7.7
1.9
0.6
B
A: Depression with cancer B: Delirium (Hyperactive type) C: Schizophrenia with diabetes mellitus D: Dementia with cancer E: Panic disorder F: Delirium (Hypoactive type) G: Alcohol withdrawal syndrome with bone fractures H: Depression with unexplained somatic complaints
13.5
4.5
Anxiety disorder
No mental problems
A
0.0
2.6
78.7
5.8
0.6
1.9
4.5
5.8
0.0
C
0.0
0.6
0.0
0.6
98.1
0.6
0.0
0.0
0.0
D
0.0
0.0
0.0
0.0
0.0
0.0
4.5
95.5
0.0
E
0.0
0.6
1.3
12.3
19.4
4.5
54.2
1.3
6.5
F
97.4
0.0
0.0
0.0
0.0
0.0
0.0
1.9
0.0
G
Table 1. Percentage of Physicians Suggesting Diagnoses of Each Clinical Scenario Patient (The bold numbers show the correctly diagnosed percentages)
0.0
0.6
1.3
0.0
0.0
59.4
20.6
10.3
7.7
H
68 / KISHI ET AL.
26.5 28.4 6.5
Anxiolytics prescription
Sleeping pills prescription
Antipsychotics prescription
1.9
A: Depression with cancer B: Delirium (Hyperactive type) C: Schizophrenia with diabetes mellitus D: Dementia with cancer E: Panic disorder F: Delirium (Hypoactive type) G: Alcohol withdrawal syndrome with bone fractures H: Depression with unexplained somatic complaints
Alternative medicine
27.7
33.5
Antidepressants prescription
Psychotherapy (by psychiatrist)
14.2
Collaboration with social worker
20.0
35.5
Psychotherapy (by psychologist)
46.5
Collaboration with psychologist
2.6
Collaboration with psychiatrist
Wait and see
A
0
12.9
7.1
21.9
7.7
7.7
4.5
10.3
11.0
40.6
2.6
B
3.9
42.6
19.4
60.6
9.0
9.0
5.8
15.5
19.4
76.8
5.2
C
3.9
5.8
6.5
11.6
5.8
4.5
5.2
35.5
7.7
23.9
5.2
D
1.9
35.5
34.8
7.7
9.7
49.0
21.3
9.0
36.8
48.4
3.2
E
2.6
16.1
16.8
7.1
11.6
8.4
9.0
16.1
22.6
28.4
2.6
F
Table 2. Percentage of Physicians Who Rated “Definitely Acceptable” Intervention
3.2
37.4
27.1
11.0
12.9
9.7
3.9
36.8
32.3
56.1
1.9
G
0.6
28.4
19.4
6.5
31.0
16.8
44.5
9.0
24.5
45.2
3.2
H
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Table 1 shows the percentage of physicians suggesting diagnoses of each clinical scenario. There were significant differences in the correctly detected diagnoses among the eight clinical scenarios (Chi-square = 472.3, df = 7, p < .001). Most physicians correctly detected diagnoses of schizophrenia (79%), dementia (98%), panic disorder (96%), and alcohol withdrawal syndrome (97%). The clinical scenarios that had low percentages of correct answers were depression with cancer (41%) and hypoactive type delirium (12%). Table 2 shows the percentage of physicians who rated intervention “definitely acceptable.” Not considering the patient scenarios with schizophrenia or alcohol withdrawal syndrome, less than 50% of Japanese physicians thought collaboration with psychiatrists or psychologists would be definitively acceptable. DISCUSSION This study found that Japanese physicians correctly diagnosed schizophrenia, dementia, panic disorder, and alcohol withdrawal syndrome in the hypothetical patients given in a clinical scenario. This study also found that 40-60% of physicians correctly diagnosed depression in clinical scenarios of depressed patients with cancer or somatic complaints. There are some limitations to this study that should be considered when contemplating the findings described below. As physicians were aware that they were being evaluated when responding to survey questions about a clinical scenario, their responses to these scenarios might differ from responses to actual patients. Because clinical scenarios provided enough information to justify a behavioral health diagnosis, and because a list of diagnoses was given, the rate of correct diagnosis might be lower in actual medical settings. However, a clinical scenario-based survey can be completed more quickly than a record review or standardized patient program and research has shown that clinical scenario-based surveys produce better measures of quality of care than medical record reviews [15, 16]. In our study, the rate of correctly identifying depressed patients with cancer was only 40%. It is consistent with research that found that fewer than half of physicians diagnosed depression in clinical scenarios [17, 18]. Physicians incorrectly identified depression with cancer more often than depression with unexplained somatic complaints. Depression occurring in the setting of a medical illness is often considered to be a psychological reaction. Depressed symptoms may still be seen by many physicians as inevitable consequences of the illness, when depression develops in the context of cancer. Depression co-existing with medical illnesses may impair recovery and rehabilitation, and increase morbidity and mortality [7]. Thus, recognition and appropriate treatment of depression comorbid with medical illnesses is essential for optimal patient outcomes. Screening is recommended for depression only when staff-assisted supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Caution is recommended when staff-assisted supports are not in place [19]. Providing
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primary care physicians with education about treatment of behavioral disorders that lead to improved patient outcome remains challenging. For example, although physician education is a necessary step to improve treatment of depression in the primary care setting, training alone is insufficient [20, 21]. Other than hypothetical patients with schizophrenia or alcohol withdrawal syndrome, less than 50% of Japanese physicians thought collaboration with psychiatrists or psychologists would be definitively acceptable. A summary of depression and panic disorder treatment studies in the primary care setting shows that “coordination of care with behavioral health specialists” is a critical component needed for outcome change [21-23]. This underscores the importance of collaborative care for depression and anxiety disorders in medical patients. The same can be said about dementia treatment in primary care settings. Challenges for primary care doctors that may reduce likelihood of appropriate referral for behavioral healthcare include: lack of time; poor access to expertise in dementia care and community resources; poor communication across medical, social, and community providers of care; the absence of an interdisciplinary dementia care team; and the difficulties of providing palliative care [24]. It is, therefore, essential that an efficient and effective system of collaboration between psychiatrists and family physicians is organized in Japan. Hypoactive type delirium was poorly diagnosed in this study. This is consistent with research that a hypoactive form of delirium is frequently misdiagnosed as depression, and emphasizes the importance for considering delirium in the differential diagnosis of the patient’s mood disturbance [25-29]. Delirium is a common mental disorder in medical and surgical patients. It is associated with higher mortality, longer lengths of hospital stay, poor functional recovery, and increased likelihood of nursing home placement [30-35]. The importance of rapid recognition and treatment of delirium cannot be overstated. Furthermore, we need to go beyond improving the ability of physicians to detect delirium correctly. In the management of delirium, studies show that delirium prevention in high-risk patients (i.e., multidisciplinary delirium prevention programs) leads to improved outcomes, rather than waiting for delirium to develop and then intervening [36-38]. New efficient and effective proactive approaches should be incorporated to improve overall delirium treatment rather than relying on the rapid recognition of delirium, starting with effective recognition of risk factors and diagnosis when the condition manifests. CONCLUSIONS This study showed that many physicians continue to have problems correctly diagnosing depression and hypoactive delirium. It is time to incorporate new efficient and effective approaches, such as a collaborative care system and proactive delirium prevention programs, to improve overall behavioral health treatment rather than relying on the rapid recognition of behavioral health problems, which appears unlikely to occur.
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REFERENCES 1. Kishi Y, Kurosawa H, Horikawa N, Hatta K, Meller W. Preferences of help regarding behavioral health problems among the Japanese general population. Psychiatry and Clinical Neuroscience 2012;66(5):460-461. 2. Fujisawa D, Hashimoto N, Masamune-Koizumi Y, Otsuka K, Tateno M, Okugawa G, Nakagawa A, Sato R, Kikuchi T, Tonai E, et al. Pathway to psychiatric care in Japan: A multicenter observational study. International Journal of Mental Health Systems 2008;2(1):14. 3. Fink P, Hansen MS, Sondergaard L, Frydenberg M. Mental illness in new neurological patients. Journal of Neurology and Neurosurgical Psychiatry 2003;74(6):817-819. 4. Hansen MS, Fink P, Frydenberg M, Oxhoj M, Sondergaard L, Munk-Jorgensen P. Mental disorders among internal medical inpatients: Prevalence, detection, and treatment status. Journal of Psychosomatic Research 2001;50(4):199-204. 5. Silverstone PH. Prevalence of psychiatric disorders in medical inpatients. Journal of Nervous and Mental Disease 1996;184(1):43-51. 6. Kathol RG, McAlpine D, Kishi Y, Spies R, Meller W, Bernhardt T, Eisenberg S, Folkert K, Gold W. General medical and pharmacy claims expenditures in users of behavioral health services. Journal of General Internal Medicine 2005;20(2):160-167. 7. Evans DL, Charney DS, Lewis L, Golden RN, Gorman JM, Krishnan KR, Nemeroff CB, Bremner JD, Carney RM, Coyne JC, et al. Mood disorders in the medically ill: Scientific review and recommendations. Biology and Psychiatry 2005;58(3):175-189. 8. Clarke DM. Psychological factors in illness and recovery. New Zealand Medical Journal 1998;111(1076):410-412. 9. Ormel J, Koeter MW, van den Brink W, van de Willige G. Recognition, management, and course of anxiety and depression in general practice. Archives of General Psychiatry 1991;48(8):700-706. 10. Friedmann PD, McCullough D, Chin MH, Saitz R. Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists. Journal of General Internal Medicine 2000;15(2):84-91. 11. Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Annals of Internal Medicine 1995; 122(6):422-429. 12. Turner S, Iliffe S, Downs M, Wilcock J, Bryans M, Levin E, Keady J, O’Carroll R. General practitioners’ knowledge, confidence and attitudes in the diagnosis and management of dementia. Age and Ageing 2004;33(5):461-467. 13. Yamada K, Maeno T, Waza K, Sato T. Under-diagnosis of alcohol-related problems and depression in a family practice in Japan. Asia Pacific Family Medicine 2008; 7(1):3. 14. Okuyama T, Nakane Y, Endo C, Seto T, Kato M, Seki N, Akechi T, Furukawa TA, Eguchi K, Hosaka T. Mental health literacy in Japanese cancer patients: Ability to recognize depression and preferences of treatments-comparison with Japanese lay public. Psychooncology 2007;16(9):834-842. 15. Veloski J, Tai S, Evans AS, Nash DB. Clinical vignette-based surveys: A tool for assessing physician practice variation. American Journal of Medical Qualification 2005;20(3):151-157. 16. Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: A prospective validation study of 3
PSYCHIATRIC DISORDERS IN HYPOTHETICAL PATIENTS /
17. 18. 19.
20.
21. 22.
23.
24. 25. 26. 27. 28. 29. 30.
31.
32.
33. 34.
73
methods for measuring quality. Journal of the American Medical Association 2000; 283(13):1715-1722. Andersen SM, Harthorn BH. The recognition, diagnosis, and treatment of mental disorders by primary care physicians. Medical Care 1989;27(9):869-886. Simon GE. Evidence review: Efficacy and effectiveness of antidepressant treatment in primary care. General Hospital Psychiatry 2002;24(4):213-224. O’Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: A systematic evidence review. Annals of Internal Medicine 2009;151(11):793-803. Lin EH, Katon WJ, Simon GE, Von Korff M, Bush TM, Rutter CM, Saunders KW, Walker EA. Achieving guidelines for the treatment of depression in primary care: Is physician education enough? Medical Care 1997;35(8):831-842. Von Korff M, Goldberg D. Improving outcomes in depression. British Medical Journal 2001;323(7319):948-949. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: A systematic review. Journal of the American Medical Association 2003;289(23): 3145-3151. Katon WJ, Roy-Byrne P, Russo J, Cowley D. Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Archives of General Psychiatry 2002;59(12):1098-1104. England E. Survival after diagnosis of dementia in primary care. British Medical Journal 2010;341:c3530. Margolis RL. Nonpsychiatrist house staff frequently misdiagnose psychiatric disorders in general hospital inpatients. Psychosomatics 1994;35(5):485-491. Levine PM, Silberfarb PM, Lipowski ZJ. Mental disorders in cancer patients: A study of 100 psychiatric referrals. Cancer 1978;42(3):1385-1391. Trzepacz PT, Teague GB, Lipowski ZJ. Delirium and other organic mental disorders in a general hospital. General Hospital Psychiatry 1985;7(2):101-106. Nicholas LM, Lindsey BA. Delirium presenting with symptoms of depression. Psychosomatics 1995;36(5):471-479. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Archives of Internal Medicine 1995;155(22):2459-2464. Pitkala KH, Laurila JV, Strandberg TE, Tilvis RS. Prognostic significance of delirium in frail older people. Dementia and Geriatric Cognitive Disorder 2005;19(2-3): 158-163. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. Journal of the American Geriatric Society 2000;48(6):618-624. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. Journal of General Internal Medicine 1998;13(4):234-242. Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. Journal of the American Medical Association 1990;263(8):1097-1101. Schor JD, Levkoff SE, Lipsitz LA, Reilly CH, Cleary PD, Rowe JW, Evans DA. Risk factors for delirium in hospitalized elderly. Journal of the American Medical Association 1992;267(6):827-831.
74 / KISHI ET AL.
35. Kishi Y, Iwasaki Y, Takezawa K, Kurosawa H, Endo S. Delirium in critical care unit patients admitted through an emergency room. General Hospital Psychiatry 1995;17(5):371-379. 36. Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, Laplante J. Systematic detection and multidisciplinary care of delirium in older medical inpatients: A randomized trial. Canadian Medical Association Journal 2002; 167(7):753-759. 37. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 1999;340(9):669-676. 38. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatric Society 2001; 49(5):516-522.
Direct reprint requests to: Yasuhiro Kishi, MD Department of Psychiatry Nippon Medical School Musashikosugi Hospital 1-396 Kosugi-cho Kawasaki Kanagawa 211-8533 Japan e-mail: [email protected]
