青少年 身, 心, 靈, 健康

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我是一名於醫院和急診室工作的精神科醫生。在來來往往的病人中，兒童和青少年患者可以說是屢見不鮮。正所謂醫者父母心，所以，每次 看到本應是活潑可愛的孩子，卻因為行為異常甚至失常而被警察帶到醫院給我診治時， 我心裏總是忍不住問： “ 到底是周遭的環境造成了他們的精神異常，還是他們的精神健康方面出了問題? 到底應該怎樣做才可以真正地幫到他們?”

無論是先天形成還是環境因素，都有機會導致兒童的精神問題。如果問題沒有及早被發現，當他們年紀愈大，問題將會更難處理。事實上，要察覺到青少年是否患有精神健康上的問題，比診斷身體本身的病痛要更爲困難。尤其是兒童精神問題方面的病徵往往會和我們所認為的“頑皮”、“好動” 的行爲相混淆。此時，只有放下我們的成見，用心去了解和仔細地觀察，才能真正找出問題的所在。

精神病，並不能單靠藥物治療和強行壓制，我漸漸地意識到，要真正的幫助精神病患者，首先我們要回到問題的起點。我們要問的是“為甚麼”而不單單是 “怎樣做“。

首先，讓我先簡略介紹我是怎樣確診青少年的精神異常。如果青少年患病的徵狀只是維持一段短時間 而且並不嚴重，醫生是不會隨便把他們 診斷成有精神問題的。同時，他們的年齡也是我斷診的其中一個考慮因素。因為在每一個年齡層，他們都有相應的行為，比如三歲的孩子普遍會黏著父母，或是十歲的孩子會比較反叛等等。相反，即使青少年表面上沒有什麽精神異常，也並不代表他的精神和心理是健康的。

那到底要怎樣判斷一個孩子有没有精神異常呢﹖一般來說，兒童的精神問題主要分爲四種。下面我會一一介紹每種精神異常的病徵，並且提供幾個案例給大家参考。

兒童的精神健康問題主要分為 ；

1)身心疾病，如語言障礙、緊張症
2)發展障礙，如自閉症
3)行為問題，如過度活躍症
4)情緒問題，如焦慮症、憂鬱症

1)身心疾病，如語言障礙和緊張症

「這個12歲病人失眠、動作遲滯、感到空虛、思考能力下降，出現尋死念頭，他一定是患有憂鬱症。」當我的醫學生對我這樣說的時候，我問他：「還有沒有其他的病因可能性?」醫學生卻堅持己見，說，「給他抗抑鬱藥，他就會病好。」儘管我十分想罵他，但我還是說：「剛剛病人才說他想死是因為他很孤獨，不是嗎?」當學生以為我在跟他探討病人的心理狀況，我卻提醒他，「記得，精神科急診室的金科玉律─ think medical (以醫學模式去思考)。」

學生很快就給我教科書上的標準答案「大約20%的憂鬱症病人有甲狀腺功能問題，而大多數甲狀腺功能低落的人都有憂鬱症症狀。」但實際上，這病人的憂鬱是由其他生理毛病所引起的。回想起昨天與病人的對話，(是的，主治醫生有時喜歡背著學生們去瞭解一下病人。) 當我要他介紹自已時，我等了很久，病人才斷斷續續的吐出四個字，「第.........一..次..我..」，他說話的嚴重遲滯，讓我意識到他有語言障礙，「你有口吃 (stuttering)嗎?」病人回答：「yes。」口吃是一種語言障礙，病因仍然成謎，但可以肯定的是，這和智力高低沒有直接關係。雖然口吃這生理毛病不像甲狀腺功能減退能夠直接導致情緒病，但口吃卻能導致焦慮、自信缺乏以及緊張等心理因素，更糟的是，焦慮是口吃惡化的主要原因，這種長期的惡性循環令患者缺乏自信，獨來獨往，不敢和其他人交往，久而久之，他們的孤獨與絕望感逐漸增加，導致病人最後極有可能走上不歸路。

在後來的治療中，我發現抗精神病藥物抗多巴胺類藥物 (antipsychotic) 不但能讓他的憂鬱症狀減輕，也改善了他的口吃! 但同時我也清楚，心理和環境等因素也可以造成很大的精神不平衡。所以我決定，在心理方面，要找語言治療師，對他施行口吃改變療法；在環境方面，我也希望能幫助他找到一些口吃者互助支持的團體。我等待，他的「第一次我…」終會有個美麗順暢的下一句。所以，健康的概念是包括整個人的身體、精神和社會心理狀況。精神健康對兒童的影響並不只限於心理上，而且還包括社交，甚至身體的發展等因素。

有一種精神疾病叫做緊張症 (catatonia)。儘管醫學界對此病仍然是一知半解，但這種病的病徵是很容易辨認的。在精神科急診室，有的病人大呼小叫，有的無法停止地跑來跑去，但緊張症的病人卻是身體局部或全身僵硬，躺在地板上一動也不動。有一次，我在急診室內看見一個12歲的小妹妹。自從經歷了讓她失去父母的車禍後，她已經5天不睡覺、不吃飯，和整天完全不動。當我把她的手扳到空中，她的手就這樣停在空中20分鐘。無論我問她什麼問題，她都不回答，好像一部關掉的電腦。我的醫學生問：「是不是可以使用Ativan（鎮定劑，用於治療焦慮，也可用於緊張症）治療她?」3分鐘後，小妹妹對我們微笑，學生們高興擊掌。但我知道，當我們重新啟動這「電腦」時，小妹妹的夢魘亦步步迫近。"Where is mom and dad?" (我的爸爸、媽媽在哪裏?) 在這女孩身上， 藥物是治標不治本的。我希望，她的門診治療師能真正打開她的心結，幫助她走出喪親的哀痛。其實人天生懂得自我保護，緊張症就好像電腦的Sleep Mode (休眠模式)，關閉了我們的感官，以切斷我們和外界接觸的渠道來保護我們的大腦，避免再受到進一步的傷害。

2)發展障礙，如自閉症

自閉症的病人通常不懂得跟人接觸，十分注重重覆的圖案和動作，並且只對死物有所反應。3歲大的喜禾 (化名) 雖然聽力正常，可就是不言不語，像聾子一樣。他只是在門診部不停地爬著， 目光從來不和任何人接觸，但當他發現 一個玩具，卻興高釆烈的玩個不停。醫師告訴媽媽：「喜禾可能有自閉症傾向，需要作進一步評估。」後來證實，十五歲的喜禾是一個高功能的自閉症患者 (Asperger's Syndrome)， 特別喜歡 畫畫，但他所畫的全都只是一條又一條的直線，就好像他的生命一般，只是孤獨的前行，和任何的人没有一絲的交集。

不少家長聽到「自閉症」幾個字已經大感可怕，更難以想象自己的孩子惹上這種麻煩病症。雖然自閉症不能根治，但越早接受治療，就能將所引起的問題及障礙減到最低。雖然自閉症不能根治，但我們能夠透過相關治療，包括： 特殊性教育、行為分析介入Applied Behavior Analysis(ABA) 和行為治療 來減低因為自閉症所引致的不良的行為。

讓我簡單介紹其中一項療法： 行為治療 。因為行為治療不單能夠幫助 自閉症孩子，它亦能促進 兒童的精神健康。首先家長 (或老師) 一定要 列出孩子所有的不良行為， 然後選擇 1至2樣 的行為不斷作重複的提醒和改正。經過一段時間後，孩子會慢慢明白甚麼是可以做和不可以做的，他的行為會因此而改善。要緊記的是，行為治療需要持之以恆，絕對不能操之過急。

另外，要治療自閉症也需要家長的共同配合。家長可以參加針對自閉症所提供的親屬訓練和諮詢。目標在於增進家長對此症的了解，協助家長接納和明白自閉症, 也持續地指導家長運用認知與行為管理技術改善孩子的表現等等。這有助於減少因自閉症而引起的問題，對其家人和孩子本身也會產生正面的效果。譬如形成一個正向循環，或者終止已經運行的惡性循環等等。而這種效果往往會出人意料的好！

3)行為問題，如過度活躍症

「這孩子注定要重複八年級! 」十三歲的大男孩只要沒人盯著就不會好好寫作業。在紀律方面，因缺乏自主控制能力而常常欠交功課、遺失作業…除了看電視打電動之外， 他沒有一刻能靜下來。帶他去餐廳時，他還四處奔走闖禍。 原本小孩就比大人好動、有些不專心和衝動不足為奇。事實上，年輕時的筆者我也曾經是這樣的！ 但是，如果男孩的表現帶給他自己的學習和人際關係上許多麻煩， 很大可能他已患上了過度活躍症 (ADHD)。根據統計，男童患上過度活躍症的機會率較女童高，一般男女比例為3:1至4:1。判斷是否患上過度活躍症的其中一個條件是要比較孩子在至少兩個以上的環境（學校、家中、課外活動）的表現 。家長需理解孩子在學校和家中的表現可以有較明顯的落差。所以家長應該多與學校和老師合作，了解孩子在校的表 現，才能夠及早發現，並為孩子作適當的治療。

要醫治過度活躍症，藥物治療 (methylphenidate (Ritalin中文名”利他能”)) 固然是 重要，但家長與 老師的角色亦是同等的重要。雖然筆者從來没有患過此症，但我小時候十分喜歡說話，即使是上課時候也說過不停，令我香港的老師們頭痛不已。最後我的班主任想到了一個辦法，她委任我作班長，我好像袐密警察般，專門“緝拿”於課堂上只顧聊天不專心上課的小孩子。我因為被賦予了這麼偉大神聖的任務，令我不得不作一個好的榜樣，留心上課。所以，各位老師的一點巧思絕對能夠化腐朽為神奇。當然，除了以靜制動，增加小孩子的運動量，家長多和孩子一起進行活動，好像一起打球，踏單車等都有助治療。現今愈來愈多小孩子有過度活躍症的症狀，不少的病例很可能是因為父母没有時間抽空陪伴他們，和他們一起玩一起成長。這不是十分悲哀的事嗎﹖

總括來說，過度活躍症的治法包括藥物、心理、社交訓練等方面，而其中仍以藥物為首選。雖然不少家長都擔心藥物有副作用，但其實最常見的只是胃口減少等等比較輕微的情況，加上藥物的效果確實比其他治療和訓練更快更明顯，所以家長可以考慮先嘗試讓孩子用藥一段時間，再觀察有否有所改善或有没有副作用，才考慮要否繼續療程。

4)情緒問題，如焦慮症、憂鬱症

從精神健康的角度來看，人的情緒是需要疏導和化解的，因為它不單單是讓我們感受到開心或不開心，它也是人生的一種推動力。譬如一個快樂的人會是積極的、做事 有建設性的；反之，內心充滿憤怒和仇恨的人，所想所做的便只是如何發洩和報復。

4A)情緒問題可以是環境造成

人生一定會經歷憂鬱和危機。 面對每一次新的挑戰時，不管是兒童或青少年，都可以藉着這樣的機會有更多的成長。在12 年前的一個冬天，當我從香港剛來到美國時，我不願意吃東西，總是眼淚汪汪，但我的媽媽工作十分忙碌，而我的爸爸亦在香港所以他們都没有留意到我情緒有異。直至我的姑姐問我「Ben，發生甚麼事﹖」我終於告訴她因為我不懂說英文，不能融入同儕當中。加上，常常受到同學的欺凌所以很難受。乘巴士上學途中，有些同學亂按下車鈴，但因為我不懂說英文，巴士司機以為是我亂按鈴，所以把我趕下車，我最後要走30分鐘的路才能回到家。後來，姑姐帶我回學校，把事情告訴校長，我才没有繼續受到欺凌。

現在每當我遇到遭受校園欺凌的孩子，回想這往事，我會做的事：
1） 我會告訴他／她，你並没有犯錯，然後用温柔、諒解的語氣讓他告訴我發生了甚麼事。
2） 當我知道事情的經過後，會立刻採取行動，就好像我姑姐會立刻聯絡校長，絕不能半點拖延。
3） 小孩子亦盡量應該結伴同行，因為多數的霸凌事件皆發生在兒童單獨的時候，所以有朋友同行會減少受到欺凌的機會。

我舉出以上的例子是想告訴大家，兒童和青少年時期的精神健康出了問題不一定是因為先天性的病，很多亦是因環境所致。曾經遭受虐待和 欺凌會令小孩子有極端的行為和反應。 這種童年的陰影、隱藏的心病就好像計時炸彈 般，一旦觸碰到一個引燃的事故，如失業失戀，喪失至愛，或學業遭挫，就會一發不可收拾。當然，聰明一點的孩子， 解決問題的能力也比較高。但要知道的是，情緒的波動往往會影響，甚至左右一個人的判斷力，尤其是因為兒時創傷後遺症，令他們在成人後會做出危害自已甚至社會的事。所以，現今的家長除了望子成龍、望女成鳳，更重要的是，應該多關心子女的情緒，堷養出身心健康的孩子才是為人父母最大的驕傲。

曾經作為一個新移民，我對新移民的孩子是感同身受，我猶記得12 歲那年，在我來美的飛機上，我邊流淚邊唱着這首歌：天空的飛鳥飛到那一方／只想有一個美夢寄他方／越過高山大海／又越過風與浪／還看遠岸／離別這海港
誰願孤孤單單到遠地／為了呼吸新鮮的空氣／無奈這裡個個卻顧著自己

那些年的點滴心情，我到今天仍然銘記。所以，我們真的要多關心新移民的孩子，因為他們所面對的衝擊是我們不能想像的巨大。有句話經常縈繞我心：「陪我長大，互相修補，分享每段人生路。」我希望能夠為將來我的孩子做到這一點。

4b)情緒問題需要親人的支持

父母對子女的愛，子女是感受得到 的，例如關心、讚賞、鼓勵等。箴言 19:18 “趁有指望、管教你的兒子．你的心不可任他死亡”。父母的一言一行亦對子女有相當大的影響力。我記得在我剛上中學時，我拿了UCLA的中學生獎學金，有機會於暑假到UCLA學習。 每天都要乘2小時巴士到UCLA上學放學。 眼見其他的孩子都有私家車接送，我覺得自已不比他們差，但是為甚麼生活的落差是這樣大呢﹖我心裹覺得太委屈，後來回家跟爸媽說。我爸爸對我說：「其實你比其他的孩子幸福得多了，你不但有專人司機 (巴士司機) 接送，還有40多個人 (其他乘客) 跟住你服侍你，你看你多威風。生活係苦係甜，係睇你點樣睇嘅。」就算父母未能花太時間陪伴孩子，亦要教導他們如何有一個正向的價值觀。即使面對挫折，也不要怨天尤人，相信明天會更好。

4c）從日常生活入手，改善情緒問題

孩童的情緒問題，很多時候因為不懂得面對生活的不如意事，我們應從日常生活入手來建立孩子的自信心。當年我初來美國，英文很爛，雖然我不是大懶蟲，但我真的不想上學，因為我害怕被其他同學嘲笑。那時候我的自信心很是低落。但是，我的數學很好，所以，每次我媽媽帶我到茶樓飲茶，她會讓我計算賬單，每次當我快速而準確無誤的把金額算出來，看到其他姨姨們讚嘆的眼光，我真的太開心了。從日常生活入手，建立自信心的機會一 定 有，所以千萬不要自我放棄。引用歌星李克勤的歌詞：「當歌手當司機當警察不緊要／只需要你似個鐵人／病痛少得不到金靴獎根本我不需要／我最想你似我面上懷著笑」
放手給孩子嘗試的空間，即使跌倒也無妨，這樣他們才會在風霜過後更茁壯。最重要的是，我們要對他們抱有信心，更要讓他們知道，我們作父母的深深的相信他們將來能鼎天立地。

4d)從小培養孩子自我控制的能力

一項針對1千名兒童的研究發現，挫折容忍度低、缺乏毅力、行為衝動、或難以專注的兒童，成年後 有生理問題，好像高膽固醇和高血壓的機會率較大。另外，他們亦有較大機會有社會問題，例如 財務和毒品問題，更可能成為單親父母；或有刑事犯罪記錄、酗酒、抽煙、吸毒等問題。個人自我控制的能力，具有其自己的影響力，與成長的環境無關。學會更好自我控制的孩子們比他們的同齡人成年時表現得更好。究人員說，證據顯示兒童改變行為並學習自制，成年後的表現更優良，意謂改變行為能有正面結果。希望家長能多關心孩子的日常生活情形：如同儕交游，尤其是使用電腦的社群網站；注意聯絡簿表現及聯絡事項；即時聯繫與處理孩子的突發狀況。品格教育與生活教育仍是四年級教學的重點：孩子又升上一個年級，待人接物、應對進退也要更加得體，不僅在言語上、動作與態度都應該舉止合宜，成為一個懂事的小孩。 對於作業完成與檢查，請加強錯誤的訂正。閱讀習慣的養成，除了在學校特別加強之外，也希望家長能撥空和孩子一起共讀，家庭的時間安排如果能有固定的閱讀時間，對固著孩子的閱讀習慣更易收效。 抽出一點點的時間陪陪孩子，您會發現孩子在學習與生活上的問題；也會驚覺孩子總是出乎意料的學習到令人驚訝的事! 「耶和華的靈必住在他身上，就是使他有智慧和聰明的靈，謀略和能力的靈，知識 和敬畏耶和華的靈。他必以敬畏耶和華為樂。」(賽11:2)

總括而言，兒童精神健康問題 早期的多方面治療是不可或缺的。但治療的意義並不是在於治療一個「病症」，而是將生活上的困境用合理的方式減到最低。最有效的療法，就是 讓 孩子重拾家庭溫暖和增加正面的人生經驗 。精神病並不是恐怖如蛇蠍，更不一定是不治之症，要預防和醫治兒童的精神異常，最需要的是，我們對他們用心的注視。我希望用我以前小學的校訓作為結語，希望能和各位家長，或是將成為家長的你共勉之﹣﹣ 箴言 22:6 教養孩童、 使他走當行的道、 就是到老他也不偏離。

身心相印 (之一) - 心臟病與憂鬱症

根據世界衛生組織 (WHO) 報告，心臟病與憂鬱症，是全球疾病負擔的主要元兇。憂鬱症與心臟病之間，互相影響，並存在一定的聯繫。雖然，心血管疾病能直接導致死亡，憂鬱症，卻能降低與健康相關的生活品質。這兩種常見的疾病，已經成為現代人群中的流行疾病。心臟學者研究證實，憂鬱症是心臟病發後常見的狀況，憂鬱症的發生更能增加心臟問題的復發和死亡率。

美國心臟協會(AHA)相信憂鬱症與心血管疾病的照護有重要關聯，並評估20％患者因罹患冠心病(acute coronary syndrome)而悲傷，對前景感到灰黯，也有研究認為憂鬱症會使他們死亡的風險加倍。2005年，研究追蹤311位罹患憂鬱症的心臟病患，及367位一般心臟病患。研究發現，罹患憂鬱症的心臟病患，死亡率為一般心臟病患的3倍！然而，憂鬱症為何增加死亡風險，仍是一個謎。

2003年研究顯示，心臟衰竭(congestive heart failure) 與憂鬱症也有關連。約30%的心臟衰竭病患同時罹患憂鬱症，較冠心病患的風險高1.5倍。2004年一項研究追蹤，沒有憂鬱症的心臟衰竭病人，發現21.2%的病患於一年後呈現憂鬱症。

憂鬱症本身，也是心血管與腦血管疾病的罪魁禍首。2011年，AHA的研究，對8萬名婦女進行6年追蹤調查，結果發現，有抑鬱症歷史的婦女，中風機率較沒有憂鬱症的婦女高23%。此外，現時罹患憂鬱症的婦女，中風的風險更高達41％！

正如癌症和心血管疾病的早期鑑定和干預一樣，及早發現和治療憂鬱症，可減少日後的發生率。美國心臟協會，呼籲所有心血管疾病患者，接受憂鬱症篩檢。治療心臟病患者的憂鬱症，可提高生活品質。認知行為治療(Cognitive Behavioral Therapy)，可幫助患者克服憂鬱症的負面健康行為 (如抽煙、缺乏運動和肥胖)。

角聲醫療中心，將為千多位低收入和沒有保險的華人，提供免費的憂鬱症篩檢，希望有助亞太裔社區降低憂鬱症的罹患率。

所以，憂鬱症防治與心血管疾病治療是相輔相成的。根據美國精神健康議會（National Advisory Mental Health Council）的報告說，如果憂鬱症獲得適當的治療，五個病人中有四個能改善病情。抗抑鬱病藥 (SSRI) ，能治療一般的憂鬱症和心臟病患的憂鬱症。認知行為治療，能改善心臟病患對前景的看法。更重要的是，要常常喜樂... 凡事謝恩！


◎胡啟贇醫師

Using a Chinese Radio Station to Disseminate Dementia Knowledge to Chinese Americans

Volume 60, Issue 11, pages 2175–2176, November 2012

Using a Chinese Radio Station to Disseminate Dementia Knowledge to Chinese Americans

Benjamin K. P. Woo, M. D. 

Although Chinese Americans are one of the fastest-growing minority groups in the country, they are not well represented in studies of dementia. Prior literature has highlighted that Asian Americans with dementia are particularly vulnerable to the stigma of chronic and severe mental illnesses.[1] Previous research has also suggested that Chinese Americans are likely to underuse mental health services.[2] There is a paucity of research on the knowledge of the Chinese-American general public about dementia, particularly in first-generation Chinese Americans.

Using ethnic minority radio stations to disseminate medical information may be a viable option to decrease stigma against dementia of Chinese Americans because many may be primarily Chinese speaking with low levels of education. In the greater Los Angeles metropolitan area, KMRB AM1430 is the only Cantonese station that broadcasts 24 hours a day. The program Rainbow Beneath the Sky broadcasts Monday through Friday from 7PM to 8PM. A psychiatrist fluent in Cantonese was asked to narrate the story of a Hong Kong Nobel Laureate, Charles Kao Kuen, who has had dementia. The program was aired on June 12, 2012, and the public was asked to call after the radio program to respond to a questionnaire. The survey consisted of three items about Chinese-Americans opinion about dementia. For each question, respondents were asked to answer yes or no in Chinese. Question 1 asked, “Is dementia a disease that affects the brain?” Question 2 asked, “Do all elderly adults develop dementia?” Question 3 asked, “Is dementia a mental illness?” The correct responses were yes, no, yes, respectively.

Twenty-two Chinese Americans participated in the survey. The sample consisted of 73% (n = 18) women, 36% (n = 8) with a high school degree or better, 45% (n = 10) with family history of dementia, and 59% (n = 13) who had immigrated to the United States more than 20 before. Seventy-seven percent (n = 17) were aged 40 to 64, and 23% (n = 5) were aged 65 and older. One hundred percent (n = 22), 64% (n = 14), and 14% (n = 3) responded with the correct answers for Questions 1, 2, and 3, respectively.

An ethnic radio program may be useful for Chinese Americans, especially for immigrants. Many of the respondents were primarily Chinese speaking, with low levels of education, so they were able to learn about mental health in their own language. As the survey identified, all Chinese Americans (100%) tend to view dementia as an illness that affects the brain. For example, one participant stated in Chinese, “Playing mah-jongg can eliminate dementia because it activates my brain!” but as Question 3 revealed, only 14% of Chinese Americans were able to conceptualize dementia as a mental disorder that can influence mood, thinking, and behavior. This is consistent with previous research that has showed that Asian Americans with dementia are particularly vulnerable to the stigma of chronic and severe mental illnesses.[1] Thus, it is critically important to develop culturally appropriate programs and services to ensure that Chinese Americans receive medical and mental health services for dementia when appropriate.

Forty-six percent of respondents believed that all elderly adults would have dementia. A previous study reported that, for Asian Americans, the aging mind and body as a machine is a culturally shaped metaphor that suggests the inevitability of deterioration.[3] The stereotype of dementia as part of normal aging may further delay Chinese Americans in seeking proper diagnostic evaluation and treatment. It is necessary to use ethnic media outlets to build public awareness against such stigma, as well as to highlight that successful aging is achievable.

In conclusion, from the program development perspective, we have the following recommendations to promote dementia awareness in ethnic minority: increase dementia information available in the Chinese language; raise public awareness through collaborating with media outlets, such as ethnic radio stations; present the medical background of dementia, and put a face on mental illness!

References

1. Liu D, Hinton L, Tran C et al. Reexamining the relationships among dementia, stigma, and aging in immigrant Chinese and Vietnamese family caregivers. J Cross Cult Gerontol 2008;23:283–299.
2. Woo BK, Lo TT. How often do Chinese Americans stay on treatment after transitioning from outpatient mental health to primary care setting? Gen Hosp Psychiatry 2011;33:e5–e6.
3. Hinton WL, Fox K, Levkoff S. Introduction: Exploring the relationships among aging, ethnicity, and family dementia caregiving. Cult Med Psychiatry 1999;23:403–413.

 

General Hospital Psychiatry

Available online 6 July 2012

Letter to the Editor

Are there race/ethnicity differences in disposition of older patients in psychiatric emergency service?

• Benjamin K.P. Woo, M.D. 

• Olive View–UCLA Medical Center, University of California, Los Angeles, CA

• Received 21 April 2012. Revised 31 May 2012. Accepted 1 June 2012. Available online 6 July 2012.

To the Editor,

The number of older patients with psychiatric disorders is rapidly increasing nationwide, yet little is known about the outcomes of care for geriatric patients with psychiatric emergencies [1]. This population is also increasing in diversity, and as a result, emergency room clinicians must expand their awareness of ethnicity and its effect on psychiatric emergencies among older patients. Few studies [2] and [3] have examined the utilization patterns of psychiatric emergency service (PES) by older patients, but little is known about the impact of race and ethnicity on PES clinical outcomes. To better understand the mental health needs of diverse, older patients in the PES, it is import to study the associations between ethnicity and PES disposition of this population.

This retrospective study utilized a PES database from a California county of 780,000 people. The PES database was extracted from the Mental Health Management Information System (MIS). Variables included age, gender, legal status, marital status, insurance status, ethnicity, previous psychiatric diagnoses, current psychiatric diagnosis and disposition [4]. There were 2591 PES evaluations in this 10-month study period (August 2005 to May 2006). Data were abstracted from the MIS in 2007. Older patients (aged ≥ 50) accounted for 438 (16.9%) evaluations. All patients who were identified as African Americans, Hispanics or Whites were included in the study. The sample size of older patients of other ethnic backgrounds was less than 11, insufficient for meaningful analyses. Thus, the final sample for this study was reduced to 427 older patients. One-way analysis of variance and χ² analyses were used to determine racial/ethnic group differences on sociodemographic and clinical factors for continuous variables and categorical variables, respectively.

The sample consisted of 6.8% (29) African Americans, 19.7% (84) Hispanics and 73.5% (314) Whites. The mean age±S.D. was 58.9±9.5, 59.8±10.5 and 57.4±8.0 for African Americans, Hispanics and Whites, respectively (F= 2.69, df=2, P=.07). Comparing among African Americans, Hispanics and Whites, there were 58.6% (17) vs. 45.9% (31) vs. 45.9% (144) males (χ²= 4.49, df=2, P=.11); 10.3% (3) vs. 19.1% (91) vs. 22.9% (72) married (χ²= 2.83, df=2, P=.24); 41.4% (12) vs. 23.8% (20) vs. 29.0% (91) uninsured (χ²= 3.26, df=2, P=.20); 44.8% (13) vs. 32.1% (27) vs. 45.9% (144) without previous psychiatric diagnoses (χ²= 5.12, df=2, P=.08); 58.6% (17) vs. 77.1% (62) vs. 77.1% (242) admitted on involuntary status (χ²= 4.95, df=2,P=.08), respectively. There were no statistically significant differences on any of the sociodemographic and clinical variables. Finally, 22.6% (71) of Whites compared to 24.1% (7) of African Americans and 19.0% (16) of Hispanics were discharged from the PES after evaluations. There were no ethnicity differences on PES dispositions (χ²=.57, df=2, P=.75).

These data present critical information on whether ethnicity plays a role in sociodemographic and clinical factors as well as dispositions of older patients presenting to a PES. Ethnic disparities in medical and mental health treatments have been well documented in numerous studies [5], [6], [7] and [8]. In the adult population, African Americans were overutilizing the PES compared to Whites [5]. Findings from an epidemiological study of a national sample also found ethnic differences in psychiatric treatment among older adults [6]. Clinical findings from the current study, however, demonstrate that among older patients of PES, minority populations have equal disposition rates compared with Whites. Nevertheless, this study is limited by its small sample of African Americans. Thus, multivariable logistic regression was not performed because of the small number of patients. The aggregate data for the PES utilization also did not permit us to infer correlation between race/ethnicity with clinical factors for older PES patients. The PES database also did not include relevant clinical information, such as acuity, comorbidity and severity.

Ethnic disparities in delivery of psychiatric emergency care would contribute to excess mortality among minorities. This study suggests that ethnicity may not play a role in PES disposition rates, despite multiple barriers that may exist for older adults to receive quality PES care. It is likely that, regardless of race, emergency room clinicians adhere to clinical necessity to determine inpatient admission or discharge from PES. Another possibility is that older minority patients presenting to the PES suffer greater acuity and comorbidity, thus restricting the likelihood of being discharged [9] and [10]. As older ethnic minorities are less likely to consult outpatient mental health services [11], PES may have become their last resort during psychiatric crises. Thus, the PES may also be providing care for a significant number of ethnic minorities who contribute a disproportionate share of disease burden. Further investigations should utilize structured interviews to determine whether racial disparities exist in clinical severities among ethnic minorities presenting to PESs. Future studies should investigate the impact of race and ethnicity on PESs nationwide. Given the high prevalence of psychiatric and medical conditions among older PES patients, future studies should also examine the effect of ethnicity on this comorbidity in the acute settings.

References

1. • [1]
   • B.K. Woo Utilization patterns of psychiatric emergency services by elderly patients J Am Geriatr Soc, 57 (1) (2009), pp. 182–183
2. • [2]
   • P.G. Walsh, G. Currier, M.N. Shah et al. Psychiatric emergency services for the U.S. elderly: 2008 and beyond Am J Geriatr Psychiatry, 16 (9) (2008), pp. 706–717
3. • [3]
   • B.K. Woo What role does ethnicity play in psychiatric emergency service? Gen Hosp Psychiatry, 33 (6) (2011), pp. 535–536
4. • [4]
   • T.T. Lo, B.K. Woo The impact of unemployment on utilization of psychiatric emergency services Gen Hosp Psychiatry, 33 (3) (2011), pp. e7–e8
5. • [5]
   • G.J. Unick, E. Kessell, E.K. Woodard et al. Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service Gen Hosp Psychiatry, 33 (6) (2011), pp. 618–625
6. • [6]
   • A. Akincigil, M. Olfson, J.T. Walkup et al. Diagnosis and treatment of depression in older community-dwelling adults: 1992–2005 J Am Geriatr Soc, 59 (6) (2011), pp. 1042–1051
7. • [7]
   • B.K. Woo, T.T. Lo How often do Chinese Americans stay on treatment after transitioning from outpatient mental health to primary care setting? Gen Hosp Psychiatry, 33 (1) (2011), pp. e5–e6
8. • [8]
   • K.J. August, H. Nguyen, Q. Ngo-Metzger et al. Language concordance and patient–physician communication regarding mental health needs J Am Geriatr Soc, 59 (12) (2011), pp. 2356–2362
9. • [9]
   • B.K. Woo, W. Chen Substance misuse among older patients in psychiatric emergency service
   • Gen Hosp Psychiatry, 32 (1) (2010), pp. 99–101
10. • [10]
    • B.K. Woo Unrecognized medical disorders among older patients in psychiatric emergency service Int J Geriatr Psychiatry, 26 (8) (2011), pp. 877–878
11. • [11]
    • D.H. Sorkin, E. Pham, Q. Ngo-Metzger Racial and ethnic differences in the mental health needs and access to care of older adults in California J Am Geriatr Soc, 57 (12) (2009), pp. 2311–2317

腦退化症知多少 (粵語健康講座)

Please click below for the links:

腦退化症知多少 (粵語健康講座), Part 1
腦退化症知多少 (粵語健康講座), Part 2
腦退化症知多少 (粵語健康講座), Part 3
腦退化症知多少 (粵語健康講座), Part 4
腦退化症知多少 (粵語健康講座), Part 5
腦退化症知多少 (粵語健康講座), Part 6
腦退化症知多少 (粵語健康講座), Part 7

From the front

From the back

你或你家人有没有... 剛做過的事轉頭即忘？ 腦退化症，前稱老人痴呆症，你到底知多少?認識腦退化症刻不容緩，齊來為身邊人提供身心支援。由胡啟贇醫生以粵語主講，胡醫生是洛杉磯加大醫學院臨床助理教授, 並洛杉磯華語廣播電台(AM1430)特約講員。

時間：2012 -- 6月16日 (星期六) 晚上七時正地點：羅省華人宣道會 (320 Cypress Ave, Alhambra, CA 91801)查詢：626-300-9078

2011-2012 Teaching Awards -- Outstanding Medical Student Teaching

2011-2012 Teaching Awards

The Psychiatry Teaching awards are presented annually during Psychiatry Grand Rounds.  Their purpose is to honor excellence in teaching, supervision, mentoring or related instructional activities in a number of categories.  Nominees for each award are selected for their ingenuity, clinical skill, innovation, availability, supportiveness, dedication, humanism, respect for diversity, improvement in the teaching process, and introduction of new important subjects.

Outstanding Medical Student Teaching

Eligible candidates are full-time faculty in the department who lecture, supervise or tutor in any of the courses for first or second year medical students or in any of the psychiatry clerkship or medical student electives (include those offered at our V.A. or affiliated medical programs).
Benjamin Woo, M.D.
Dr. Benjamin Woo is the site director for the third year Psychiatry clerkship at the Olive View Medical Center and works with the medical students that rotate through the inpatient psychiatry unit. One student that had begun their rotation with no particular interest in the field acknowledged that he had an epiphany about psychiatry while under the guidance of Dr. Woo, stating “I suppose that is what the truly great teachers do. They take something that may initially seem so foreign and unattractive and change it into the most interesting and fascinating thing in the world. This is indeed what Dr. Woo did for me in psychiatry. He undoubtedly planted an infectious desire to learn more about psychiatry and a new found drive to be instrumental in the treatment of the mentally ill. Subsequently, I have now decided to pursue a career in psychiatry.” A former student believes that the traits that Dr. Woo modeled early on have been indispensable in their development as a clinician and educator, adding that “Dr. Woo has been an invaluable part of my career, and I look forward to him inspiring future generations to come”. For his dedication to teaching students, Dr. Benjamin Woo is truly deserving of the 2012 Outstanding Medical Student Teaching Award.   

「腦退化症知多少?」 免費健康講座

你或你家人有没有... 剛做過的事轉頭即忘？ 腦退化症，前稱老人痴呆症，你到底知多少?認識腦退化症刻不容緩，齊來為身邊人提供身心支援。由胡啟贇醫生以粵語主講，胡醫生是洛杉磯加大醫學院臨床助理教授, 並洛杉磯華語廣播電台(AM1430)特約講員。

時間：2012 -- 6月16日 (星期六) 晚上七時正
地點：羅省華人宣道會 (320 Cypress Ave, Alhambra, CA 91801)
查詢：626-300-9078

Simple ways to test for Dementia (腦退化症)

畫鐘測驗 (CLOCK DRAWING TEST, aka CDT)

CDT is a simple method to detect whether you may be suffering from memory loss. Ask your loved one to draw a clock, point the hands to "10 after 11," and voila -- you are done! It is one of the ways to screen for dementia. Even if you have depression on top dementia, this simple test can still be useful (http://www.ncbi.nlm.nih.gov/pubmed/15533989)

畫鐘測驗是一個簡單的方法來檢測您是否患有記憶力減退。請你畫一個時鐘，指向 11:10. 畫鐘測驗也適用於同時患有抑鬱和腦退化患者.

If your clocks look like the above, please seek help immediately.

What role does ethnicity play in psychiatric emergency service?

Gen Hosp Psychiatry. 2011 Nov;33(6):535-6

Benjamin K.P. Woo M.D.a,

a. Olive View—UCLA Medical Center, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA 90024, USA

While patient entry into a psychiatric emergency service (PES) can be an important first step toward improved mental health, PESs have become increasingly more complex. Over the years, on top of providing triage and disposition, PES has become the place where psychiatric treatment may be rendered for patient safety. In times of economic recession, however, PESs may also have become de facto psychiatric wards [1].

Allen and Currier [2] have surveyed 51 psychiatric emergency services to assess the type and scope of services delivered. They found that psychiatrists initiating treatment with medications have become the norm, not the exception, in the PES. In comparison to the consultation model (in which psychiatrists are consultants to the emergency department), the PES model is found to be more timely, effective and safe [3]. As PES may act as a barometer of the overall mental health system, Boudreaux et al. [4] have developed and applied ten quality indicators to eight PESs across the nation. The study reinforced that even in the busy psychiatric emergency settings, benchmarking can ultimately improve quality of care.

Two years ago, in this Journal, an editorial [5] highlighted the importance of providing quality care in the PES. Optimal and appropriate care may be achieved only when safety, effectiveness, efficiency, timeliness, equity and patient-centeredness are actively promoted. The editorial explicitly called for future research to examine the relationship between quality of care and racial disparity. In this issue, Unick and colleagues [6] provide a timely report on whether ethnicity plays a role in clinical, demographic and service system characteristics in the PES and subsequent inpatient admission.

The authors reported on patients admitted to the only 24-h PES operating in San Francisco County in a 3-month period in 2005. Inpatient admissions from the PES were associated with delusions and deteriorated psychosocial functioning. Multiple previous PES visits in the past 2 years, as well as being admitted to PES on a Sunday, were associated with lower probability of inpatient admissions. These associations highlighted that despite inpatient admission should be strictly based on clinical necessity, other factors contribute to the algorithm of evaluation and disposition in the PES. Further studies should investigate the impact of clinical, demographic and service system characteristics on PESs nationwide.

Unick et al [6] noted that, in San Francisco County, African Americans were over-utilizing and Asians were under-utilizing the PES than adults in the population at large. The authors found that both Asians and blacks had higher levels of functional impairment on PES admission in comparison to other ethnicity groups. Not only that, Asian patients also had a higher probability of being admitted to the inpatient unit when compared to White patients. Clearly, ethnicity plays a role in PES utilization and inpatient admission.

What are the clinical implications of the growing emphasis on cultural emergency psychiatry? Asian Americans are one of the fastest growing groups in the US, particularly in the Los Angeles, New York, and San Francisco areas. Despite being labeled as a group of “model minorities,” multiple studies [7], [8] and [9] have shown that Asian Americans suffer from equal or higher rates of depression and suicides, but underutilize any type of mental health services, in comparison to the mainstream population. In the current study [6], the data confirm that few Asian Americans seek psychiatric emergency treatments. Not only that, many of them were sicker than others on PES admissions. Future studies should investigate whether limited access to care and cultural barriers contribute to the under-utilization of PES among different ethnicity groups.

While heterogeneity in mental health risk factors exist among different Asian subgroups, i.e., Chinese, Filipino, Korean, Vietnamese, etc., they are often aggregated in mental health services data collection. There are indeed numerous differences among different Asian ethnic sub-groups. For example, Southeast Asians are more likely to be refugees and immigrants from the Vietnam War. Thus, they may be under higher risk of loss, depression and post-traumatic stress disorders. Despite that PESs are exceedingly busy, clinicians should strike for providing culturally appropriate emergency psychiatric care. Furthermore, equity can only be achieved when cultural barriers are removed. Future studies should examine mental health disparities by ethnic subgroups among Asian Americans in the PES.

This study had a number of limitations. The main limitation of this study was its retrospective nature and the fact that it included only patients from a single PES. Second, the findings may not be applicable to other settings. However, this study represents a commendable effort to capture how clinical, demographic and service system characteristics are influencing decision making in the PES. This study also fills an important gap by providing a current snapshot of how cultural barriers may interfere with quality PES care.

The current health care costs have become increasingly unsustainable. Acute psychiatric hospitalization is the most expensive and restrictive level of care available in the mental health system. On top of providing culturally sensitive services, PES should strike for equity, efficiency and quality by removing cultural barriers and improving access to care. Providing cost-effective, timely, patient-centered health care in the PES would be a vital first step to ensure appropriate use of our scarce healthcare resources. To thrive in an era of healthcare reform, we must take up the unparalleled opportunities for system reform in all levels of psychiatric service to provide quality of care.

References
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[9] D.T. Takeuchi, R.C. Chung and K.M. Lin, et al. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese Americans in Los Angeles. Am J Psychiatry, 155 10 (1998), pp. 1407–1414.