Dissertation on A review on the trend of reduced hospital stays of the mentally-ill and its suitability in Hong Kong

Table of Contents

 TOC \o "1-3" \h \z \u Chapter 1. PAGEREF _Toc231860280 \h 2

Problem Statement and its Background. PAGEREF _Toc231860281 \h 2

1.0        Introduction. PAGEREF _Toc231860282 \h 2

1.1        Background of the Study. PAGEREF _Toc231860283 \h 4

1.2        Research Objective. PAGEREF _Toc231860284 \h 9

1.3        Research Questions. PAGEREF _Toc231860285 \h 9

1.4        Significance of the Study. PAGEREF _Toc231860286 \h 10

1.5        Scope and Limitation. PAGEREF _Toc231860287 \h 10

1.6        Definition of Terms. PAGEREF _Toc231860288 \h 11

Chapter 2. PAGEREF _Toc231860289 \h 16

Review of Relevant Literature. PAGEREF _Toc231860290 \h 16

2.0        Introduction. PAGEREF _Toc231860291 \h 16

2.1        Long-Term Hospital Stays. PAGEREF _Toc231860292 \h 18

2.2        Hong Kong Mental illness care. PAGEREF _Toc231860293 \h 28

2.3        Reduced Hospital Stays Studies. PAGEREF _Toc231860294 \h 30

Chapter 3. PAGEREF _Toc231860295 \h 33

Research Methodology. PAGEREF _Toc231860296 \h 33

3.0        Introduction. PAGEREF _Toc231860297 \h 33

3.1        Dissertation Design. PAGEREF _Toc231860298 \h 34

3.2        Method of Research to be used. PAGEREF _Toc231860299 \h 35

3.3        The Research Design. PAGEREF _Toc231860300 \h 40

3.4        Data Collection and Gathering. PAGEREF _Toc231860301 \h 43

3.5        Locating the Literature Utilized. PAGEREF _Toc231860302 \h 44

3.6        Evaluating Secondary Data Sources (Validation of the Data) PAGEREF _Toc231860303 \h 45

Chapter 4. PAGEREF _Toc231860304 \h 46

Data Analysis and Presentation. PAGEREF _Toc231860305 \h 46

4.0        Introduction. PAGEREF _Toc231860306 \h 46

4.1        Analysis of the Current Mental Health Policy in Hong Kong. PAGEREF _Toc231860307 \h 47

4.2        Capability of HK government for reduced Hospital stays of Mentally-ill PAGEREF _Toc231860308 \h 56

Chapter 5. PAGEREF _Toc231860309 \h 62

Summary, conclusions and recommendation. PAGEREF _Toc231860310 \h 62

 

 

 

Chapter 1 Problem Statement and its Background

 

1.0 Introduction

Accordingly, mental health is the capacity of an individual, the group and the environment to interact with each other in a manner which promotes subjective wellness, the optimal development and use of mental abilities including cognitive, affective and relational aspects, and also the attainment and preservation of condition of underlying equality (Durlak & Wells, 1997). Mental health definition reflects number of themes which include social and psychological harmony and integration, general wellness and quality of life, growth and self-actualization, effective personal adaptation, and the mutual influences of the individual, the group, and the environment. In addition, it also give emphasis on the social context of mental health by explicitly indicating the importance of social justice and equality.  

On the other hand, mental disorder refers to a recognized, medically diagnosable illness which results in a significant impairment of the individual's cognitive, affective or relational abilities (Conn, 2002). Characterized by disturbances in a person’s thoughts, emotions or behavior, mental illness can refer to a wide variety of disorders, which can range from mild distress to severe impairment of a person’s ability to function. At times, mental health professionals used the terms psychiatric disorder or psychopathology to refer to mental illness (Microsoft Encarta Online Encyclopedia, 2004). 

Throughout the years, healthcare professionals have attempted to comprehend the causes of mental illnesses. This urge started in the latter part of 19th centuries and continued in the early 20th centuries, in which the contemporary era of psychiatry has witnessed sharp debate between the psychological and biological aspects of mental illness.  In terms of biological perspective, mental illness is viewed as bodily processes while the psychological aspects give focus on the roles of the individual upbringing and the environment.

Mental health disorders are a common problem worldwide and numerous surveys and studies had been made regarding the matter. Some studies have dealt with specific disorders such as depression, dementia, delirium and anxiety disorders.  With the realization of the government and healthcare authorities to help individuals with this kind of problem, areas like Hong Kong has been able to consider various approaches to solve the issue for mental illness. Most of the individuals with mental illness are seeking the help from healthcare professionals. Most of them are rehabilitated in mental institutions to help them recover from such illness. However, contemporary healthcare services are considering the planned short-termed or reduced hospital stays of mentally-ill for immediate recovery.  Primarily, the main goal of this dissertation is to investigate the suitability of this contemporary approach for providing healthcare service for mentally ill in Hong Kong patients. Furthermore, this will provide various literatures and evidences on the effectiveness of this approach for mentally ill patients.

1.1  Background of the Study

Mental disorders come in various forms and healthcare authorities are trying to provide proper care with each mental disorders. Mental health services are provided by a variety of mental health professionals including psychiatrists, psychologists, clinical social workers, clinical nurse specialists, other therapists and counselors including marriage, family, and child counselors, and allied health professional. Services offered by mental health professionals include: case management, partial hospitalization, inpatient treatment, vocational rehabilitation, and a variety of residential programs. On the other hand, addiction treatment is provided by a diverse group of practitioners, including physicians, psychiatrists, psychologists, other therapists, counselors, and recovering therapists. In typical addiction treatment, medications are used to treat the complications of addiction, such as overdose and withdrawal (Anthenelli & Schuckit, 1993). The provision of healthcare services for mentally ill individuals is now categorized into two: the standard care and the planned shorter hospital stay for mentally ill.  Accordingly, hospitalization of mentally ill is now aiming on stabilizing individuals to ensure which they are not longer a danger to themselves, rather than long-term treatment to actually help them recover (Sperling cited at Seeman, 2002). In a study conducted by Johnstone & Zolese (1999) they attempted to determine the effectiveness of reduced hospitals stays against standard care for people with mental illness. In this research, systematic review of all randomized controlled trials have considered to compare effectiveness of  reduced hospital stays versus long-termed hospital stay for people with mental illness which considered four trials with 628 patients.   The result of this study shows which patients who have considered planned short-termed or reduced hospital stays had far lower rate of  readmissions, defaulted follow up, and more successful discharges on time than those patients which considered long-termed hospital stays or standard care. 

 

In this study, it has also been noted which patients with reduced hospital stay have the chance to leave the hospital in an earlier state and also have greater opportunities for being employed than those patients allocated for longer term care. In this research, it has been concluded which effectiveness of healthcare in mental hospitals is essential to carers, patients and policy makers. Despite data inadequacies, this study recommends which reduced hospital stays do not encourage “revolving door” pattern of care for individuals with serious mental illness and may be more effective than the long term hospital stay or standard care. In addition, pragmatic trials are required on the most effective organization and delivery of healthcare in mental hospitals. With the growing evidence of the effectiveness of planned short-termed or reduced hospital stays or reduced hospital stays, this dissertation will be conducted to analyze whether Hong Kong health care system has the capability to consider reduced hospital stays of mentally ill patient and investigate its effectiveness as an alternative medical care for these patients

 

1.2  Research Objective

As mentioned, this research study aims on investigating the suitability of reduced hospital stay for mentally ill in Hong Kong and will critically analyze the effectiveness of this approach to help these individuals recovered easily. Specifically this paper aims on achieving the following objectives

1.1.1     Assess the current mental health policy of Hong Kong to know whether it is suitable for reduced hospital stays of mentally ill practice.

1.1.2     Critically analyze the capability of Hong Kong health care system to adapt the approach of reduced hospital stay for mentally ill patients

1.1.3     Identify whether planned short hospital stays are effective in reducing relapse in people who have severe mental illness

1.3  Research Questions

 

Given the objectives and purpose of this research study, this paper attempt to answer the following queries:

1.3.1     What is the current mental health policy to know whether it is suitable for reduced hospital stays of mentally ill practice.

1.3.2     Does Hong Kong government have the capability to consider reduced hospital stay for mentally ill individuals?

1.3.3     Are planned short hospital stays effective in reducing relapse in people who have severe mental illness?

 

1.4  Significance of the Study

Generally, the purpose of the study is to conduct a critical analysis to determine whether the reduced hospital stays of the mentally ill is effective and whether it is suitable for Hong Kong setting.  The research will specifically determine the capabilities of the Hong Kong government to consider partial reduced or planned short-termed or reduced hospital stays of mentally ill to help people recover from their illness.  Moreover, this study will review relevant literature on the same topic.  Based on the preliminary review of literature, the researcher assumed which Hong Kong healthcare authorities and government have the capability of facilitating planned short-termed or reduced hospital stays for mentally ill individuals. In addition, this is study will be conducted to contribute to the researches made about hospitalization of mentally ill individuals.

 

1.5  Scope and Limitation

This research will be conducted to cover the population study for Hong Kong healthcare authorities and their adherence to the reduced hospital stay as an alternative approach for caring patients with mental illness. This study will attempt to determine if reduced hospital stay will be effective in helping the patient to recover from mental illness. In order to achieve the objective of this study, review of relevant literature and analysis of the data gathered will be considered. The outcome of this study will be limited only to the data gathered from books and journals on prevalence of mental disorders and from the data gathered from the result of the screening of the recent studies which will be conducted by the researcher. As the research was completed in a relatively short period of time other factors and variables are not considered. This might have an impact on the results of the study.

 

1.6  Definition of Terms

For the purpose of understanding this study, some terms have been defined as they are used in the research:

1. Anxiety Disorder – a cover term for a variety of mental disorders in which severe anxiety is a salient symptom.

2. Delirium – is a state of violent mental agitation, usually a brief state of excitement and mental confusion often accompanied by hallucinations.

3. Dementia - mental deterioration of organic or functional origin.

4. Depression -   a mental state characterized by a pessimistic sense of inadequacy and despondent lack of activity.

5. DSM-IV ­- Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association; it is the primary system used to classify and diagnose mental disorders in the United States. For this study, the following criteria will be used:

Depression:

For the past two weeks, the patient must had 5 or more of the following symptoms, which are a definite change from usual functioning.

·         Mood. For most of nearly every day, the patient reports depressed mood or appears depressed to others.

·         Interests. For most of nearly every day, interest or pleasure is markedly decreased in nearly all activities (noted by the patient or by others).

·         Eating and weight. Although not dieting, there is a marked loss or gain of weight (such as five percent in one month) or appetite is markedly decreased or increased nearly every day.

·         Sleep. Nearly every day the patient sleeps excessively or not enough.

·         Motor activity. Nearly every day others can see which the patient's activity is agitated or retarded.

·         Fatigue. Nearly every day there is fatigue or loss of energy.

·         Self-worth. Nearly every day the patient feels worthless or inappropriately guilty. These feelings are not just about being sick; they may be delusional.

·         Concentration. Noted by the patient or by others, nearly every day the patient is indecisive or has trouble thinking or concentrating.

·         Death. The patient has had repeated thoughts about death (other than the fear of dying), suicide (with or without a plan) or has made a suicide attempt.

General Anxiety Disorder:

For more than half the days in at least 6 months, the patient experiences excessive anxiety and worry about several events or activities. The patient has trouble controlling these feelings. Associated with this anxiety and worry, the patient has 3 or more of the following symptoms, some of which are present for over half the days in the past 6 months:

·         Feels restless, edgy, keyed up

·         Tires easily

·         Trouble concentrating

·         Irritability

·         Increased muscle tension

·         Trouble sleeping (initial insomnia or restless, unrefreshing sleep)

Dementia:

• The patient has developed deficits of thinking as shown by both of:

• Impaired memory (can't learn new information or can't recall information previously learned) plus
• One or more of:

Ø  Aphasia (problems using language)

Ø  Apraxia (trouble carrying out motor activity, despite intact motor functioning)

Ø  Agnosia (despite intact sensory functioning, the patient fails to recognize or identify objects presented)

Ø  Impaired executive functioning (problems abstracting, organizing, planning or sequencing information)

• Each of these symptoms materially impairs work, social or personal functioning.

• These symptoms don't occur solely during a delirium.

• These impairments have more than one cause, as judged by history, physical examination or laboratory data.

Delirium:

• The patient has a reduced level of consciousness and difficulty focusing, shifting or sustaining attention.
• There has been a cognitive change (deficit of language, memory, orientation, perception) which a dementia cannot better explain.
• These symptoms develop rapidly (hours to days) and tend to fluctuate during the day.
• These symptoms have more than one cause, as judged by history, physical examination or laboratory data.

6. Magnetic Resonance Imaging (MRI) - noninvasive diagnostic technique which uses nuclear magnet resonance to produce cross-sectional images of organs and other internal body structures. It is used in the diagnosis of brain tumors and disorders, spinal disorders, multiple sclerosis, and cardiovascular disease.

7. White Matter - the part of the brain which contains myelinated nerve fibers. The white matter is white because it is the color of myelin, the insulation covering the nerve fibers.

6. Mental Illness - is referred as a psychiatric disorder which results in a disruption in a person’s thinking, feeling, moods and ability to relate to others; a broad range of mental and emotional conditions.  The most common forms of mental disorders or mental illness are anxiety disorders, depressive disorders and schizophrenia.

7. Schizophrenia - referred as psychiatric diagnosis denoting a persistent, often chronic, mental illness, variously affecting the behavior, thinking and emotion of an individual.

 

 

Chapter 2 Review of Relevant Literature

 

2.0       Introduction

            The public health effects of mental disorders are considered to be profound (Murray & Lopez, 1996; World Health Organization, 2001a). Accordingly, the estimated disability-adjusted life-years in 2000 linked with mental disorders represents 11.6% of total disability in the globe – more than double the level of disability which is caused by different types of cancer (5.3%) and higher than the level of disability because of the cardiovascular disease (10.3%).  Customarily, the response of various mental health services from one nation to another can be seen in three periods: the existence of the asylum, the fall of the asylum and the transformation of mental health services (Thornicroft & Tansella, 1999).

In the last period, community-based and hospital-based services typically aims on providing treatment and care which are close to home, which include acute hospital-care and long-term residential facilities in the community;  respond to disabilities  and also the symptoms  and offering treatment and care specific to the diagnosis and requirements of each patient; are consistent with international conventions on human rights, relevant and associated with the priorities of service users themselves; coordinated between mental health professions and agencies; and are mobile rather than static. It is said which the mental service can be considered as the ‘balanced care’ approach (Thornicroft & Tansella, 2002).

This part of the paper will provide relevant literature reviews about the reduced hospital stays of the mentally-ill trends.  The discussion will include countries which have considered this trend and identify if it is effective and efficient.  in addition, this will also conduct literature on the current status of this concept in Hong Kong setting.

The current health care arena requires hospitals with diverse levels of preparation to provide comprehensive, high quality and cost effective health care services. Authorities have imposed many changes in order to bring quality service to different individuals who are seeking care regarding their health. These rapid changes in society and the health care system over the past decade have sparked dialogue about how best to conceptualize and label the advanced practice domains of hospitals. Initially, debate focused identifying whether reduced hospital stays of the mentally ill could help a nation in solving the hospital problems relating to the mentally-ill individuals.  The review will also include the difference between reduced hospital stay and long-term hospital stay for mentally ill people in terms of immediate recovery, (symptoms and social functioning), suicide risk, readmissions, unemployment at follow up; and symptom reduction.

2.1  Long-Term Hospital Stays

 

With the emergence of different mental health problems in different countries, each of them tries to provide Mental Healthcare alternatives which will  be able to handle and control the problems brought by mental illness and mental disorder towards their societies.           Mental Healthcare alternatives, like considering shorter or reduced hospital stats have not been implemented exactly in the same way for all countries.  While trends have swept through some countries, they may have come much later or not at all to other countries.  In addition, culture, religion, and politics have clearly played a significant role in the development of Mental Healthcare alternatives across nations.

Mental Healthcare programs had been an arduous and ambivalent struggle of different nations to care for those who experience the anguish of mental illness. It has been marked by periods of idealistic policy development aimed at the widespread prevention and cure of mental illness, as well as by periodic retreats to containment, control, and avoidance of mutual responsibility.  Hence, the main objective of the Mental Healthcare alternatives or Program imposed is to provide proper mental health care system to different people who suffers from mental illnesses and disorders may it be brought by biological means or external factors such as drugs, alcohols and others.

The ultimate goal of the Mental Healthcare alternatives is to provide a high and uniform standard of mental health care, and a wide array of integrated services, especially in those regions which were seriously underserved. In this case, the Mental Healthcare alternatives needs a general public law which mandates the construction of Community Mental Health Care required each of the  participating state to initiate a state plan based on a needs assessment and evaluation of existing services. Additionally, America needs a specific state agency which should be responsible for assessing how community mental health centers would affect the delivery of services to already existing patients, as well as to unsaved and underserved populations (Murphy & Vega, 1990).

Hospitals and healthcare authorities basically attached to the definition which they have given to mental health because this means a new definition of mental health much broader than traditional definitions. The 1988 definition of the mental health reflects a number of themes, which compromises their objectives. This includes their objective of including psychological and social harmony and integration, quality of life and general well-being, self-actualization and growth, effective personal adaptation, and the mutual influences of the individual and the group of individuals with mental health problems.

Hence, the Mental Healthcare alternatives of Hospitals and healthcare authority’s needs to emphasize the social context of mental health by explicitly indicate the importance of social justice and equality to mental well- being. The definition also recognizes which all individuals possess a capacity for mental health, whether or not they have a mental disorder (Lakaski et al, 1990). This approach emphasizes the common needs of all and focuses on solidarity among those with mental disorders rather than emphasizing the growing divisions among mental health constituencies. This broad- based approach stresses the importance of social, psychological, and biological issues. Other countries also recognize the need for this broad approach to mental health.

Hospitals and healthcare authorities focuses on health promotion through healthy fostering, adaptive behaviors such as parenting practices, social skills development, and lifelong learning, and on the prevention of maladaptive behaviors such as alcohol and drug use, suicide, and child abuse. It also seeks the elimination of discrimination. Creating environments and policies which support these approaches is a high priority (Lakaski et al, 1990).  Since the return of democracy in 1984, Argentina also has focused on primary and secondary prevention (Kemp, 1993).

            Hospital care encompasses differences in terms of the forms of benefits which their program produces. In order to provide their objectives and goals to the patients, the Hospital care had imposed many beneficial subprograms which will support and continue its services to different kinds of people with mental health problems.  One of which is the consumer rights movement.  This program has played a significant task in the adoption of a wide range of laws which defines the rights of mental patients. In line with this, new commitment laws have restricted both the criteria and procedures by which a person can be forced to enter a mental hospital (Starr, 1995). One of the forms of benefits given by the program is the protection of the rights of the patients. Although laws vary in each of the fifty states, in most, psychiatric commitment requires evidence which the person is imminently dangerous to himself or herself or others by reason of mental illness. He or she has a right to due process, to representation by counsel, to call and interrogate witnesses, and to a decision based on the existence of "clear and convincing" evidence. If detained on an emergency basis, patients have the right to examination by a psychiatrist typically within twenty-four hours and, at all times, the right to confidential communication with an attorney or court officials (Starr, 1995).

Patients have rights to visitors and other communications; however, these can be modified based on clinical considerations. Voluntary patients can sign a request for discharge, which must be honored typically within five days, or commitment proceedings must be initiated. Most states have strict laws and regulations governing the use of restraints, seclusion rooms, and invasive treatments such as psychosurgery and ECT.  Both the mental patients’ rights and the larger anti-psychiatry movements have been decisive forces in defining Hospital care in the United States, specifically in propelling the deinstitutionalization of public mental health facilities (Murphy & Vega, 1990).

In this literature review, the researcher attempted to organize the results in line with the level of resources available, as noted by the World Health Organizations Health Report (World Health Organization, 2001a: pp. 112–115). The table below shows which nations or nations with a low level of resources must present most of their mental health care in primary health care programs, delivered by primary care health care professionals, with specialist back-up to give training, consultation for complicated conditions, and in-patient evaluation, evaluation and treatment of conditions which cannot be handled primary care (Saxena & Maulik, 2003).

Some low-resource nations may in fact be in a pre-asylum phase (Njenga, 2002) in which apparent community care in fact delegate widespread neglect of patients with mental illness. Where asylums do exist, health care authorities and face preferences about whether to improve the quality of care offered (Njenga, 2002) or to utilize the resources of the larger hospitals to generate de-centralized services instead (Alem, 2002) or consider the aspect of shorter hospital stays for patients with mental illness.

Discrepancies in mental health services between low-resource and high-resource nations are vast. For instance, in Europe, there are 5.5–20.0 psychiatrists per 100 000 population, while the figure is 0.05 per 100 000 in African nations (Njenga, 2002); the average number of psychiatric beds is 8.70 in the European countries and 0.34 in Africa (Alem, 2002). About 5–10% of the total health budget is being providing on mental health in European nations (Becker & Vázquez-Barquero, 2001), while in the African continent 80% of nations spend less than 1% of their limited total health budget on mental health programmes. These and other related comparative information are available from the WHO Project Atlas website (World Health Organization, 2001b) and from the World Bank (2002). Like for instance, although health care services spending delegates some 7.9% of global GDP, with an average expenditure expressed in international dollars (based on purchasing power parities) of $523 on health services, this average significantly differs among nations and regions, ranging from $82 per person in Africa to $2078 in the Organization for Economic Cooperation and Considerment (OECD) nations (Poullier et al, 2002). Further, for both European and African regions, there are also considerable as well as often growing variations both between nations and between regions within each nation not only in health expenditure however also in accordance with social care. As a consequence the types of service provision related to low-resource nations will be very different from those relevant to medium- and high-resource nations.

Nations with a medium level of resources may first generate the service components shown in column 2 of table above, and later, as resources permits, choose to add some of the wider variations of more differentiated services as shown in the last column. The preferences of which of these more specialized services to consider first depends upon local factors, which include service traditions and specific situations and circumstances; consumer, caregiver and health care professionals preferences; existing service strengths and weaknesses; and the manner in which evidence is interpreted and utilized. This stepped care model also shows which the forms of care relevant and affordable in nations with a high level of resources will include elements from column 3, furthermore, to the components in columns 1 and 2 which will typically already be present. Hence, the model can be considered as both additive and sequential, in those new resources permits extra levels of service to be given and presented over time, in terms of mixtures of the compositions within each step, when the provision of the components in the previous step is already complete.

Decisions in terms of planning as well as investment of funds to enhance mental health will require consisting wide range of stakeholders, often bringing divergent or even conflicting aspects to this task. It is now increasingly common in many nations for service users or patients and family members or caregivers to participate routinely in such decision-making.

Primary care mental health with specialist back-up

Mental disorders and mental illnesses are very common in general health care and primary health care programmes in every nation, and cause disability which is usually in proportion to the number of symptoms present in the entire nation (Ormel et al, 1994). In nations which low level of resources (Table 1, column 1), the large majority of conditions of mental disorder or mental illness should be considered and treated within primary health care (Desjarlais et al, 1995). The World Health Organization has shown which the integration of essential or significant mental health treatments within primary health care in these nations is plausible (World Health Organization, 2001a).

Mainstream mental health care

Mainstream mental health care refers to a range of service components, which may be essential in nations which can have more than a primary care-based system with specialist back-up. Nonetheless, the recognition as well as the treatment of the majority of patients with mental illnesses, specifically depression and anxiety-related disorders, still remains a responsibility which falls mostly to primary care. Von Korff & Goldberg (2001) reviewed 12 different randomized controlled trials of improved care for major depression in primary care programmes. They found which interventions which have been solely directed with training and supporting general practitioners have not been indicated to be effective (Von Korff & Goldberg, 2001).

There is surprisingly little proof on any of these key characteristics of out-patient care (Becker, 2001), however, there is a strong clinical consensus in many nations which such type of mental care or clinics are a relatively efficient manner of organizing the provision of evaluation and treatment, presented which the clinics are accessible to local populations or residents. Nonetheless, these clinics are simply systems of arranging clinical contact among between health care professionals as well as patients, and so the key issue is the content of the clinical interventions: namely, to deliver treatments which are known to be evidence-based approach (Roth & Fonagy, 1996; Nathan & Gorman, 2002; BMJ Publishing Group, 2003).

Community mental health teams (CMHTs)

Community mental health teams are considered as the basic building block for community mental health services.  Accordingly, the simplest form or model of provision of community care is for generic (non-specialized) teams to present the full range of interventions (which include the contributions of psychiatrists, social workers, community psychiatric nurses, psychologists as well as occupational therapists), prioritizing elderly patients with severe mental illness, for a local defined geographical catchment region (Thornicroft et al, 1999; Department of Health, 2002).

Different studies and investigations has been done to compare community mental health teams with a variety of local usual services and these studies have recommended which there are transparent and clear benefits to the introduction of generic, community-based multidisciplinary teams: they can improve engagement with services, enhance user satisfaction, enhance the provision of needs and improve adherence to mental illness treatment, although they do not improve symptoms or social function (Tyrer et al, 1995, 1998, 2003; Thornicroft et al, 1998; Burns, 2001; Simmonds et al, 2001). Furthermore, continuity of care and service flexibility has been shown to be more considered where a community mental health team model is in place (Sytema et al, 1997).

 

Case management

Within community mental health teams, there are systems or approaches which can be considered and this includes the case management. Accordingly, case management is a system or approach of delivering care, rather than being a clinical intervention in its own right, and at this phase the evidence recommends which it can most usefully be initiated within the aspect of the community mental health team (Hollomanner & Carson, 2001). It is a style of working which has been characterized as the ‘coordination, integration and allocation of individualized care within limited resources’ (Thornicroft, 1991). There is now a considerable literature to show which this style of working can be moderately efficient in enhancing continuity of care, quality of life and patient satisfaction, however there is conflicting evidence as to whether it has any effect on the use of in-patient services (Saarento et al, 1996; Hansson et al, 1998; Mueser et al, 1998; Ziguras & Stuart, 2000; Ziguras et al, 2002). Case management requires to be carefully classified from the much more specific and more intensive assertive community treatment.

 

Acute in-patient care

There is no evidence which a balanced system of mental health care can be present without acute beds.  Some services which include home treatment teams, crisis house as well as acute day hospital care may be able to provide realistic alternative care for some voluntary mentally ill patients. Nonetheless, patients who need immediate medical evaluation, or those with severe and co-morbid medical and psychiatric situations and cases, or those who are experiencing severe psychiatric relapse as well as behavioral disturbance, or those with high levels of suicidality or assaultativeness, or with an acute neuropsychiatric condition, or elderly patients with concomitant severe physical disorders, will typically needs or demands high-intensity urgent support in acute in-patient hospital units.

 

2.2  Hong Kong Mental illness care

             In Hong Kong, the Hospital Authority provides different programs and approaches in helping people with mental illness. Accordingly, Hong Kong has an estimated 232,000 psychiatric out-patients and in-patients under the care of mental health institutions and services in 1990 (HK Government, 1990 cited in Yip, 2003).  In Hong Kong, the Hospital Authority established the long-stay care home in 1990. Overcrowding of mental hospitals has been a major problem in this city. In an attempt to solve this issues. Castle Peak Hospital, the oldest and largest mental hospital, opened since 1961, expanded and is now able to  accommodates 1242 patients and had 1933 beds in 1990 (Ng and Leung, 2000). In a study conducted by Ng and Leung (2000), they have investigated the multiple psychosocial aspects of chronic psychotic patients after 5 years of re-settlement in the community.  In this study, they have used a retrospective cross-sectional survey of a group of chronic psychotic patients who are discharged from a rehabilitation unit in a psychiatric hospital in the community. Herein, assessment of their physical, social and psychiatric well-being of the discharged patients has been considered. In this research, the result showed which only two-thirds of patients remained in the communication and 10% of the patients have died because of medical problems. In the study, the authors have found out which patients frequently changed their place of residents and there was no incidence of major violence in the community where patients with psychiatric problems live. The study also found which only 30% of the patients remained in their competitive employment whole most had multiple and severe social disabilities. To be able to help these patients to fully re-incorporate in the community, the research proposed which measures must be considered to alleviate social disabilities. This research concluded which patients enjoyed freedom and autonomy in the community. But many patients still have sub-standard quality of life after their resettlement in the community.

Accordingly, the significant proportion of patients at CPH was long-stay patients who had risen in number of years.  In a study conducted by Cheung (2001), he investigated the cost-effectiveness of the first psychiatric long-stay care home in the city. In order to achieve the objective of this research, the researcher have used cohort study of the first 43 patients discharged to the long-stay care home from the Castle peak Hospital, who have been followed-up for 2 years. In this study, the result shows which the patients who have stayed long outside the Castle Peak Hospital has been able to improve in terms of social and community skills while remaining symptomatically and behaviorally stable. According to the study, the long-stay case home have been able to provide a less restricted environment than Castle Peak Hospital and patients satisfaction has marked high.   In this research, it shows which the long-stay care home is a cost effective means of rehabilitating successfully a group of long-stay hospital in-patients who do not qualify for halfway houses but only needs minimal nursing care which is less than 2.5 hours a week (Cheung, 2001).

           

2.3  Reduced Hospital Stays Studies

            With the longing to provide effective approach in helping people with mental illness, healthcare authorities are trying to consider various approaches and strategies and one of the known strategies which has been done in different parts of the world is the reduced or short-term hospital stays of people with mental illness in the hospital. Mental health care had been conventionally confinement mainly to large mental hospitals in which patients were put into custody for longer term unless they are able to recover.  Long-term hospital stays in 1950s along with its adverse effects were better considered. Accordingly, mentally ill patients were reported to be adapted to the hospital environment with their total dependency on the staffs and healthcare providers which discharging  from hospital to independent living in a particular community which is deemed to be difficult for the patients to adjust to. In some studies, some psychiatric symptoms which include social including social withdrawal and poverty of speech in patients were revealed to be correlated with the level of provision of services in the hospital. Along with these findings was the transition of attitude from the previous stand of putting the mentally ill individuals under the custodial care to care in the community, in other term, from isolation to reintegration with the community. Such transition of focus of care from the hospital to the community has also been facilitated by the enhancement of major tranquillizers around the same period of time. It is revealed which psychotic symptoms as well as disturbing behavior in large number of patients could be managed with drug treatment, permitting them to be well enough to be admitted in the community.

Various studies have been conducted to know its effectiveness in solving the issue for mental illness.  In a qualitative study by Umansky and colleagues (2003), they investigated how chronic mental patients with reduced hospital stay movement from a mental hospital to a hostel in the community helps in improving the lives of these patients. The result of this study shows which although there are some cases which shows positive result, the observation has not been generalized because the observation which changes in patients’ Quality of life are evaluated differently by staff and patients. Hence, result varies.

            Different studies have been conducted to assess the significance of reduced hospital stays by patients with chronic illness. Accordingly, those patients who were discharged usually stays in the community-based psychiatric care. In a study by Sytema, Burgess and Tansella (2002), they investigated the nation which community care decrease length of stay and risk of rehospitalisation in new patients with schizophrenic disorders. This study is a comparative study of the cases in Groningen, the Netherlands, Australia; Victoria, Australia and South-Verona, Italy. Accordingly, this study is a long-term follow-up research of defined cohorts of new patients who met ICD 10 criteria for schizophrenia and relevant disorders. In this research, three mental health service systems with psychiatric case registers were compared. In this study, it has been found which the three psychiatric service systems do not have a difference in terms of their level of care in the community but Groningen has been noted to have a far greater supply of beds. This study give emphasis on new patients with schizophrenic disorders who were entering the psychiatric case for the first time rather than on long-termed hospital patients moving to community settings. Patients at their first psychiatric contact are a more homogenous group with less severe illness as compared with longer term patients, whose further pattern of care with services may be biased by their previous psychiatric . Accordingly, the result of this study cannot be extrapolated to the entire patients with schizophrenia.

   

 

Chapter 3 Research Methodology

 

3.0  Introduction

This part of the paper discusses the methods which have been used for this dissertation.  This detailed the steps the researcher took in order to accomplish the study.  The said steps then include the collection procedure of the data which is required in the delivery and completion of the dissertation.  It also presents the manner in which these data will be utilized and integrated in the study and at the same time, detail how the dissertation proceed to answer the aims and objectives in order to reach to the conclusion.

In this manner, this part of the paper justifies the means in which the study will be performed.  It also emphasizes its credibility by making mention of widely accepted scientific methodologies. Through the methods mentioned in this paper, a plausible conclusion will be obtained.

Looking back to the aims and objectives of the study, the study intends to determine whether reduced hospital stay for mentally-ill can be adapted to Hong Kong healthcare setting. In order to achieve this objective, the study’s methodology was focused on collecting both primary and secondary data through related literature dissertation.

As the dissertation intends to discover the general consensus of healthcare professionals with regards to reduced hospital stays of mentally ill, the immediate dissertation methodology in mind is the descriptive dissertation design.  The dissertation are taken from various data sources which is integral in identifying issues of  reduced or shorten hospital stay of individuals with mental illness.

 

3.1  Dissertation Design

To achieve the objective of this study, the researcher opted to use descriptive method of dissertation was utilized. The purpose of employing the descriptive method is to describe the nature of a condition, as it takes place during the time of the study and to explore the cause or causes of a particular condition. The researcher opted to use this kind of dissertation considering the desire to acquire first hand data from the respondents so as to formulate rational and sound conclusions and recommendations for the study.

According to Creswell (1994), the descriptive method of dissertation is to collect information or data regarding the present existing situation or phenomenon.  Descriptive dissertation has as its purpose developing a better understanding of a phenomenon in detail. Descriptive studies usually have as their purpose the first two aims of normal science as described by Kuhn (1970, pp. 25-26): “attempts to increase the accuracy and scope with which facts are known” or “determination of those facts which can be compared directly with the predictions from theory”. The aim of descriptive dissertation is to clarify the nature of a phenomenon in a specified, static context while viewed from a specific, fixed perspective.

Descriptive dissertation design, then, is directed toward clarifying a phenomenon's appearance or nature. In other words, it describes a particular phenomenon, focusing upon the issue of what is happening, rather than why it is happening.  Two types of data were used: the primary and the secondary data.

 

3.2  Method of Research to be used

There are three types of research processes which the research can be considered in this research design; correlational, experimental and descriptive (Walliman and Baiche, 2001). Accordingly, the correlational type of research approach is utilising because of ethical problems with experiments. Furthermore, it is also utilized due to practical problems with experiments. In addition, inferring causality from correlation is not just actually impossible, but very difficult. This mode of research design is widely applicable, cheap, and usually ethical. Nevertheless, there exist some "third variable" issues and measurement problems. The correlational research refers to studies in which the objective is to discover relationships between variables by the use of correlational statistics (r). The square of a correlation coefficient yields the explained variance (r-squared). A correlational relationship between two variables is typically the result of an outside source, so we have to be careful and remember which correlation does not really tell us about cause and effect. If a strong relationship is found between two variables, utilizing an experimental approach can test causality.

On the other hand, the experimental approach is the only approach which can be utilized to generate cause-and-effect relationships (Creswell, 1994). That is, it is the only one which can be utilized to explain the bases of behavior and mental procedures. In this approach, the subjects are split into two (or more) groups. One group, called the experimental group gets the treatment which the researcher believes will cause something to happen (this treatment is formally called the independent variable). The experimental and control groups are compared on some variable which is presumed to reflect the effects of the treatment, or output. This is formally referred to as the dependent variable.

And lastly, the descriptive research approach utilizes observation and surveys. In this approach, it is possible which the research design would be cheap and quick. It could also suggest unanticipated hypotheses. Nevertheless, it would be very hard to rule out alternative explanations and especially infer causations. Hence, this research design or approach will utilize the descriptive approach.  This descriptive type of research will use observations in the research design.

To illustrate the descriptive type of research, Creswell (1994) will guide the researcher when he stated: Descriptive approach of research is use to gather information about the present existing situation or circumstances.  The objective of employing this approach is to describe the nature of a situation, as it exists at the time of the research design and to explore the cause/s of specific phenomena. The researcher opted to utilize this type of research considering the desire of the researcher to gather first hand pertinent information or data from the respondents so as to formulate rational and sound conclusions and recommendations for the research design.

 

The researcher shall undertake the research procedure ‘onion’ so as to come up with the most appropriate research approaches and research strategies for this research design. While it is not uncommon for a researcher to first consider whether one should, for instance, administer a questionnaire or conduct interviews, thoughts on this question accordingly belong to the centre of the research ‘onion’, wherein, so as to come to the central issue of how to collect the pertinent information or data requires to answer ones research questions, there are significant layers of the onion which requires to be peeled away: the first layer raises the question of the research context to adopt, the second considers the subject of research approach which flows from the research context, the third examines the research method most applicable, the fourth layer refers to the time horizon a researcher applies to his research, and the fifth layer is the pertinent information or data collection processes to be utilized. (Saunders et al, 2003)

Figure 1 shows how the researcher conceptualized the research approach to be applied in this research design so as to come up with the pertinent information or data required to answer the research questions stated in the first chapter, as well as to arrive to the fulfillment of this research undertaking’s objectives.

 

 

As shown in Figure 1, the research context which is reflected in this research design is positivism. With this research context, a researcher opted to work with an observable social realism so as to come up with law-like generalizations which is very similar to those generated by the physical and natural scientists (Remenyi et al, 1998), and in this tradition, the researcher becomes an objective analyst, coolly making detached interpretations about those pertinent information or data which have been collected in an apparently value-free manner (Saunders et al, 2003). In addition, the focus is on a highly structured approachology to facilitate replication (Gill & Johnson, 1997).

 

Meanwhile, the researcher deduced which the research approach most applicable is the multiple processes (multi-processes) approach, or the integration of the various research approaches and strategies available. Accordingly, there are two major advantages in the application of multi-processes: first, various approaches can be utilized for various objectives in the research design so as to gain more confidence which one is addressing the most significant issues, and the second advantage is which it enables triangulation, or the utilize of various pertinent information or data collection processes within one research design so as to ensure which the pertinent information or data are clear, valid and reliable. (Saunders et al, 2003).

 

On the other hand, case research design is defined as a method for doing research which includes an empirical investigation of a specific modern phenomenon within the realm of life  aspects with the use of various sources of evidence, and in this method, one has the considerable ability to establish and produce answers for the questions “why?”, “what?” and “how?”, where pertinent information or data collection processes applicable with such approach include questionnaires, interviews, observation, and documentary analysis. (Robson, 2002; Saunders et al, 2003)

 

Another significant layer shown in Figure 1 is the time horizon layer, which answers an significant question: “Do I want my research to be a “snapshot” taken at a specific time (cross-sectional studies) or do I want it to be more akin to a “diary” and be a representation of events over a given period (longitudinal studies)?” (Saunders et al, 2003, p. 95) In this case, this research is longitudinal, whose main strength is the capacity it has to research design change and development.  (Saunders et al, 2003).

 

 According to Adams and Schvaneveldt (1991), by observing events or individuals over time, a researcher has been able to learn to use measure of control and management over variables being studied, provided which they are not influenced by the research procedure itself. Even with time constraints or restrictions it is still possible to introduce a longitudinal element to one’s research, as there is a massive amount of published pertinent information or data collected over time which could give powerful insight into a subject or are just basically waiting to be analyzed. (Saunders et al, 2003, p. 96) With longitudinal studies, the basic question is “Has there been any change over a period of time” (Bouma and Atkinson, 1995).

3.3  The Research Design

 

Basically, this research design, as a whole, can be classified as a descriptive research which will focus on the review of relevant literature whose aims is to have accurate profile of persons, events or situations, and may be an extension or a forerunner to a piece of exploratory study, an approach which attempts to generate causal relationship between variables (Robson, 2002; Saunders et al, 2003). As has been mentioned, with the descriptive research, it is essential to have a clear picture of the phenomena on which a researcher wishes to collect pertinent information or data prior to the collection of the pertinent information or data. (Saunders et al, 2003)

            Further, even if many adviser are often wary for research studies which are too descriptive, and they will want a researcher to go further and draw conclusions from the pertinent information or data gathered, description in some type of research has a very clear place, although, it should not be thought of as an end in itself, but only as a means to an end. (Saunders et al, 2003).

The research described in this dissertation is solely based on the analysis of the relevant literature collated by the researcher. This enables an iterative and flexible method and design. During pertinent information or data gathering the selection as well as the design of the research processes are simultaneously modified, based on ongoing analysis. This enables investigation of significant new issues and questions as they arise, and allows the investigators to drop unproductive areas of research from the original research plan.

Accordingly, qualitative approach or research designs more able than traditional or conventional models to express states of incomplete knowledge about continuous mechanisms (Benjamin, 1994). Qualitative simulation guarantees to find all possible behaviors consistent with the knowledge in the model. This expressive power and coverage are significant in problem solving for diagnosis, design, monitoring, and explanation.

Qualitative evaluation pertinent information or data usually refers to raw, descriptive information about: programs/products and the people who participate in/utilize them or are affected by them and; programs/products and the people who develop or utilize them (Patton, 1987). Three pertinent information or data gathering strategies typically characterize qualitative approachology: in-depth, open-ended interviews; direct observation; and written documents (including program records, personal diaries, logs, etc.).

This research design basically intends to investigate the issues on the investigation of the suitability of the reduced hospital stays of mentally ill in Hong Kong setting. Specifically, this research design will be conducted so as to introduce the approach to the healthcare providers in Hong Kong and the capabilities of Hong Kong to adapt this approach. .  

The main approach which the researcher will employ in this dissertation will be based on qualitative research approach, since this research aims on finding and building theories which would explain the relationship of one variable (reduced hospital stays of mentally ill) with another variable (suitability in Hong Kong setting) by qualitative elements in research. These qualitative elements does not have standard measures, rather they are behavior, attitudes, opinions, and beliefs. 

In addition, qualitative research is also regarded as a multi method in focus, which involves interpretative, naturalistic approach to its topic or the subject matter. This indicates which qualitative researchers design things in their natural settings, trying to make sense of, or interpret situation or happenings in terms of the meanings people bring to them. Accordingly, qualitative researchers deploy a wide range of interconnected processes, hoping always to get a better fix on the subject matter at hand.

3.4  Data Collection and Gathering

The primary source of pertinent information or data will come from published articles journals and magazines, theses and related studies on the effect of reduced hospital stays of mentally ill with regards to its suitability in Hong Kong setting.  The pertinent information or data will solely come from healthcare journals which discusses the reduced hospital stays of mentally ill in relation to the Hong Kong situation.

 

Furthermore, the sources of pertinent information or data came from published articles in the healthcare journals and medical journals, information via internet resources, articles, and books relating to reduced hospital stays of mentally ill specifically, Hong Kong setting. This served as the basis of the researchers’ assumptions and comparative pertinent information or data in the discussion or findings.  Afterwards, the researcher summarized all the information, made a conclusion based on the null hypotheses posited and provided insightful recommendations on the dealing with reduced hospital stays.

Furthermore, an independent variable is one which influences the dependent variable in either a positive or a negative way. As a result the researcher will utilize a systematic explanatory and exploratory research and focus on those dependent variables. The relationships of the variables will be designed in detail, based on the understanding the independent variables of the Hong Kong journals and other related studies.  For this research, the method that will be considered is literature review.

Accordingly, a literature review is known to be the compilation of available published and unpublished documents, to effectively collate evidences and proofs which has been found in line with the pre-defined eligibility criteria and standards to be given emphasis on research objectives an questions (Higgins and Green, 2008, 1.2.2).

Searching the relevant literature and documents are essential in various projects (Hart, 2004 and by a crucial appraisal the present state of knowledge can be identified and new substantial evidence have been established (Carnwell and Daly, 2001, p.57; Aveyard, 2007. Such permits as much as practical and intellectual value as collating first hand data (Hart, 2004).  In this research, the literature review conducted was based on an organized approach and method. This method includes the following:

• A visibly and plainly stated set of objectives and aims with pre-defined eligibility criteria;
• An explicit, reproducible methodology;
• A systematic and organized search to determine all studies that meet the criteria;
• An assessment of the validity of the findings;
• A systematic presentation, and synthesis, of the findings. (Higgins and Green, 2008, 1.2.2

 

For this research, literature review is considered as the most suitable research approach to meet the objective of the study. In this regard, an initial search of literature into the context of reduced hospital stays of mentally ill individuals revealed the essentialities of the issue in the current healthcare policies as well as showed that there is a sufficient literature available to create or establish a comprehensive review. In particular, literature review is appropriate for this project since it is easily accessible and available.

 Herein, no ethical approval and consent is required to carry out a literature review, which provide benefits in terms of the time limits of the research (Aveyard, 2007).  In addition, it permits a synthesis of available data so that journals are not seen in isolation enabling the reader a succinct concise overview of the entire subject matter (Aveyard, 2007). Herein, the review of literature aims on collating data in line with reduced hospital stays and Hong Kong policies for mental illness.  It can be said that literature review can consider data from a range of sources to investigate the available research and establish conclusions. This will permit a wider and more comprehensive knowledge of the present condition than any new information drawn from an undergraduate research (Hart, 1998).

 

3.5  Locating the Relevant Literature

            Accordingly, finding relevant literature involves two interlinked phases. The first phase is identifying whether or not the pertinent information or data which a researcher looks for are available as literature, while the second phase is finding the precise pertinent information or data which is requires for the research design. (Saunders et al, 2003)

            For this research design, the researcher was able to establish which the pertinent information or data requires for the fulfillment of this research’s objectives are available by the literature review previously conducted. Because of the review, the researcher was able to gather full references to the sources of the requires pertinent information or data. Tertiary literature (like indexes and pertinent information or data archive catalogues) also helped especially those on-line indexes and catalogues of Universities, organizations (hospitals and health departments) and Governments (such as the Government of Hong Kong).

             After determining the availability of the pertinent information or data, the next step for the researcher was to locate them. As a result, the researcher had gone to several libraries within the researcher’s area of vicinity so as to locate the books, journals and magazines which are requires. But more significantly, the researcher utilized the Internet, as it will not be feasible for the researcher to go to different places because of the big distance between the regions, as well as the large budget requires for such travel. By the Internet, the researcher was able to gather the websites of numerous organizations and institutions which have provided the pertinent literature required. The keywords utilized for the search include the reduced hospital stay of mentally ill and hospital settings of Hong Kong.

3.6  Evaluating Secondary Data Sources (Validation of the Data)

 

According to Stewart and Kamins (1993), the utilization of literature is advantageous for a researcher since one can already evaluate the suitability of pertinent information or data as it is already in existence, hence, much time can be saved. Needless to say, an evaluation of potential literature is very significant before one incorporates it in his/her research design. In this research design, the researcher adopted the three-phase procedure devised by Saunders et al (2003, p. 205):

 

The first phase is evaluating the overall suitability of pertinent information or data to the aims and objectives of the research. In this phase, the researcher paid specific focus to measurement validity which means measuring or estimating whether the secondary or relevant data will result to a valid answer to the research questions as well as research objectives and coverage which consists of ensuring if the pertinent information or data is wanted and can be included or not, as well as making sure which sufficient pertinent information or data remain for analyses to be undertaken once unwanted pertinent information or data have been excluded).

 

The second phase is evaluating precisely the suitability of pertinent information or data for analyses requires to answer and meet the research questions and objectives. In this phase, the researcher made sure of the validity and reliability of the literature by evaluating how it was previously gathered, who are its sources, and the likes. Also, the researcher was cautious not to commit measurement bias (which can occur due to deliberate distortion of pertinent information or data or changes in the way pertinent information or data are collected) had been paid close focus.  Finally, the researcher judged whether to utilize pertinent information or data based on an assessment of costs and benefits in comparison with alternative sources.

 

 

 

Chapter 4 Data Analysis and Presentation

 

 

4.0  Introduction

This part of the paper provides discussion of the qualitative analysis of the data gathered from secondary literature review. As mentioned above, the main goal of this paper is to assess whether reduced hospital stays on mentally-ill will be suitable for Hong Kong setting. To be able to achieve the objective of this study, qualitative analysis has been considered in which secondary data relevant to the topic were gathered and analysed systematically.  This part will be divided on sections to answer the queries of this dissertation.

 

4.1  Analysis of the Current Mental Health Policy in Hong Kong  

In Hong Kong, Mental health services have been considered as one of the debatable issue for the public. There is a constant increasing demand as well as the present setting of the mental health services is no longer able to adjust in the increasing need. A more intensive review of the formulation and service of Mental Health policy deemed significant to avoid further deterioration of public mental health and to create a system which can meet the requirements and need of the local population.  Accordingly, in Hong Kong there was no comprehensive mental health policy to direct or guide the development of mental health services in HK.  In addition, those enhancements are only done on bit and piece which is mainly drive by tragic incidents. In a study conducted by Kwong (2007), the author has noted which investment in mental health care in Hong Kong is considered to be in low side as compared with other high income nations.  The Hong Kong mental health is said to index favorable as compared with those of most developed nations. The study also show which the existing community consensus shows which the current mental health services system in the country is no long sustainable because of the increasing number of patients and the higher expectation from the community as well as increase in expenses in modern treatment methods or models.  In this study, it has also been revealed which the public perceived which the local mental health services have no consistency policy, lack of funding and under resources which also resulted in under staff, limited budget for drugs and medicine in which only a small proportion of patients on newer medications are provides, long waiting time of 2-3 years, short consultation time for patients.  In addition, Hong Kong mental health services has also found to have splitting of treatment (health) and social (rehabilitation) services and inadequate public mental health education and unsatisfactory specialist for primary care and public private cooperation. And lastly, it has also been found which most of the mental health treatment as well as rehabilitation are located in institutes and not scattered or spread around in the community.

The following data has been collected to show how big the problem is faced by the mental health services in Hong Kong.  First, there is no intensive data in terms prevalence of mental disorders in the country. Because of the lack of data, the government has not been able to establish proactive planning of the service based on scientific evidence. In addition, there is also no convincing data or information on mental disorder made known to the general public, hence the effect of the mental health issues and problems has been under-estimated and has not been given proper attention or consideration. In a study conducted worldwide, the study indicated which 1 individual out of 6 had some sort of mental problems in the country which include mild to moderate depression or general anxiety disorders at any given period time (SEU 2004). In addition, it also shows which 20% of the total population had a mental illness in the previous year (Offord DR et al 1996) and 3% out of the population affected by severe mental illness (McEwan & Golder, 2000). The study also revealed which 1 individual in 100 people developed severe mental disorders which include schizophrenia, bipolar affective disorders and others at any given time (SEU 2004). The research also shows which one third of the GP consultation are relevant to the mental health issues of the patients (SEU, 2004) while 91% of the total population who has mental problem have been treated entirely in primary healthcare provider  (Hague & Cohen 2005).

The world Health Organization also revealed which prevalence or the emergence of various mental disorders is more or less the same in various area and countries and it has been revealed which by 2020 depression will be one of the most significant causes of mental illness overall, 340 million individuals will suffer from depression and patients suffering from this as well as anxiety related problems are on the rising trend. Data gathered also revealed which 19% of the local population attending public health services in Hong Kong had some sort of mental health issues while 3.5% if the local population attending public healthcare services are suffering from severe mental illness/disorders which might result in marginal social independence.

In most studies, depression is the most common psychiatric disorder in the elderly population. The prevalence is from 8 to 10 percent in geriatric medical outpatients. Primary care physicians accurately recognize less than one half of patients with depression, resulting in potentially decreased function and increased length of hospitalization. Meldon and associates (Sadovsky, 1998) conducted a cross-sectional observational survey to determine the prevalence of depression in elderly patients presenting to the emergency department and to assess the recognition of depression by emergency physicians. A total of 259 patients older than 65 years of age who presented to the emergency department of a large urban public hospital over a three-month period and who gave oral consent were included in the study. Each patient completed a verbally administered Koenig Scale to identify depression.

This scale requires simple yes/no responses to 11 questions. A predetermined cutoff score of 4 was used to identify depression. Demographic data were also collected for each patient. Recognition of depression by the emergency physician was assessed by means of retrospective chart review. The patients' charts were also reviewed for any notation indicating which the emergency department physician recognized depression.            Seventy of the 259 patients (27 percent) who were tested scored at or above the cutoff score for depression. Demographic data correlating with depression included patients who categorized their health as poor and patients living in nursing homes. Emergency physicians failed to recognize depression in all 70 patients.

Estimates of the prevalence of depression in the elderly vary widely depending on the definition of depression and the study population (Mulsant and Ganguli, 1999). The prevalence of major depression appears to be 1% to 2% in the community-dwelling elderly, while the prevalence of significant depressive symptoms has been estimated to be between 13% and 27% in the same population (Lebowitz et al., 1997). In a study of an elderly community sample in Utah, the prevalence of clinically significant episodes of depression was 4.3% (3.2% in men; 5.1% in women), and the prevalence of subclinical symptoms of depression was 1.1% (0.7% in men; 1.3% in women). The study authors credited the low prevalence of subclinical depressive disorders to residence in a community with high rates of religious involvement, prohibition of alcohol or tobacco use, and low rates of cardiovascular disease (Steffens et al., 2000).

In another study, the prevalence of major depressive disorder has been shown to be approximately 10% to 12% in primary care patients, with the prevalence of depressive symptoms approximately 20% in this group (Schulberg, 1992). Ten percent to 15% of elderly acute care medical inpatients have major depressive disorder, with between 20% and 25% displaying significant depressive symptoms (Koenig, 1993). In nursing homes, the prevalence of major depressive disorder in the elderly is 12% to 16%, with the prevalence of depressive symptoms being 30% to 40% (Mulsant and Ganguli, 1999). It has been reported which the prevalence of significant depressive symptoms in the medically ill elderly and nursing home residents may be as high as 50% (Lebowitz et al., 1997). Furthermore, 13% of nursing home residents experience a new episode of major depression annually (NIH Consensus Development Panel on Depression in Late Life, 1992). Estimates of prevalence for depressive disorders in patients with Alzheimer’s disease have varied widely, from 0% to 86% (Katz, 1998).

Accordingly, in a study conducted in Hong Kong, mental disorders or illness contribute to 16% inpatient bed days or equivalent to 1.1 million population, 7% specialist out-patient attendance with 600,000 individuals and 8.7%of the public health budget or 2.3 billion people.  It has been mentioned which the demand is growing for 80-90% increase in psychiatric out-patient attendance in a decade (Solomon, 2006). Table 1 shows the public psychiatric service in Hong Kong (Tsang, 2007). In this table it shows which public psychiatric service in the country from 1998-2006.  The table provided information regarding the psychiatric beds used during those years and the attendance of the out-patients and the doctors in psychiatry for public primary care.

Based on this table, it shows which the population of patients with mental disorders is decreasing while the psychiatric beds decreased from 5133 in 1998-1999 down to 4666 in 2005-2006 and the outpatient attendance also increases.  From 1998-2002, there are no doctors in psychiatry available and it only started on 2003 with 254 psychiatrists including their trainees From 2004-2006 there are 258 psychiatrists available with their trainees.

 

Table 1

Public Psychiatric Service in Hong Kong

The next table shows the mental health funding of Hong Kong as of 2005 according to World health Organizations (2005).  In this table, the spending of Hong Kong on mental health services which is 0.2436% us just a 1/3 to 1/4 of which of the US and the Australian mental health care.  This shows which the investment of Hong Kong to mental health service is not adequate or good enough to ensure which they are able to provide quality service for the mentally ill and it is also not good enough to ensure having community psychiatric service and hence patients are kept in hospital and outpatients department are congested and over-crowded with extremely long waiting list.

 

 

Table 2

Mental Health Funding (WHO Mental health Atlas, 2005)

 

 

Some studies have also been able to compare Hong Kong’s mental health policy with other nations. In this regard, the report has compared the specialist ratio of major specialties in Hong Kong compared to UK, New Zealand, and the United States of America (USA).  The specialty ration compares includes internal medicine, general surgery, pediatrics, orthopedics and traumatology, obstetrics and gynecology and psychiatry, the comparison also includes sub-specialties (See Table 3).

 

Table 3

Population to Specialist Ration of Major Specialties in Hong Kong

Table 4

Population Psychiatrist Ration

            The table above shows the population psychiatrists ratio of Hong Kong as compared to other countries.  Based on the table, it shows which Hong Kong has a small population psychiatrist’s ratio as compared to Australia and USA. This shows the lack and inadequate resource for mental health care in the country,

 

4.2  Capability of HK government for reduced Hospital stays of Mentally-ill

 

Basically, people with intellectual disability may be limited not only in their cognitive and adaptive behavior skills, but also by emotional and behavioral disorders which further limit their ability to learn new skills, adapt to changing environments and develop appropriate social interaction skills. According to Einfeld & Tonge, (1996), when these disorders are of a sufficient severity and intensity, they may constitute a diagnosable psychiatric disorder. Hence, Bongiorno, (1996) believes which when intellectual disability is complicated by mental illness, the common clinical term "dual diagnosis" is used to describe these individuals. Actually, the term "dual diagnosis" indicating a co-existence of intellectual disability and mental illness is relatively new and has only recently been acknowledged in the field (Parmenter, 2001).

According to Health and Welfare Canada (1988), mental health is broadly defined as the capacity of the individual to promote subjective well-being, to develop and use mental abilities, to achieve individual and collective goals consistent with justice and to attain and preserve conditions of fundamental equality. On the other hand, mental disorder refers to recognized, medically diagnosable illnesses which result in a significant impairment of the individual's cognitive, affective or relational abilities (Conn, 2002). Individuals with intellectual disability and mental illness present several challenges to both community and health services in terms of the difficult behaviors they present, the complexities of diagnoses and treatment, and the complex service needs they require (Dudley, Ahlgrim-Delzell & Calhoun, 1999).

The awareness of Hong Kong Government in the increase of mental health problems has lead them to consider reforms in terms of the services and to meet the expectation of the people with regards to a better quality of care.  In this regard, long waiting time for patients with mental illness and short consultation time is no longer acceptable by the public. In this regard, the Hong Kong government perceived which the trend is for having community car and reduced hospital stays among patients with mental illness.

In this regard, it is said which Hong Kong government can be adaptable and capable of the reduced hospital stays for mentally ill if Hong Kong government will be able to change their policies. Firsty, mentally ill patients, patient advocates as well as relative groups should be willing or eager to take part in the decision of treatment mode and health care policy for mentally ill. In addition, Hong Kong government should allocate more funding to hire more mental health professionals/ psychiatrist and this is deemed mandatory. Other essential or significant matter to consider includes the having mental health policy which aims at tackling immediate issues and to establish long-term plan, in line with the population dynamics as well as scientific evidences with the people involved.  In addition, this will also be applicable for Hong Kong with the government should be more committed and the citizen supports the decision of having a reduced hospital stays programme for the mentally ill.

            Based on the analysis, one of the problems which can be considered as a hindrance for adapting reduced hospital stays is the inadequacy and lack of funds. In this regard, Hong Kong setting can adapt reduced hospital stays for mentally ill if they have enough funding and investment to provide for community programmes to help mentally ill patients.  Along with this is the enhancement in terms of having additional healthcare professionals which will monitor the situation or condition of mentally ill individuals in the community and to ensure balanced hospital-community based mental health service.  Aside from this, reduced hospital stays can be adaptable to Hong Kong setting if the government and healthcare department will increase the number of psychiatrists/doctors under training to shorten waiting time immediately and to provide a more ideal contact time for follow-up appointment for the patients.

            Studies have been shown which the trend now is for having community psychiatric treatment or short term hospital stays of patients with mental illness is the trend and there is tons of evidence which this type of arrangement is very humane as it enables the preservation of the dignity of patients, with better quality of life as weak as it also able to avoid secondary impairment resulted from

prolonged hospitalization. Hence, it can be said which Hong Kong can be adaptable to this kind of setting if and only if they have financial and enough healthcare resources.  In doing so, Hong Kong healthcare system should be able to convert inpatient treatment to community mode of treatment.  Although, Hong Kong can be capable of this setting, there are still other factors to consider to ensure which proper health care of mentally ill are provided effectively.

 

4.3  Reduced hospital stay effective in helping and assessing mentally ill individuals for immediate recovery

With the aim of healthcare providers to provide excellent healthcare service among mentally ill, they are able to adopt various approaches and treatment. In this regard, different studies have been conducted to analyze the effectiveness of short-term or reduced hospital stay of patients with mental illness. Accordingly, different nations are reviewing short-term community care whether it is effective or not. In some cases, reduced hospital stays deemed to be effective for patients to easily recover from their illness; however, most of the studies are still favoring more hospital care for people with serious mental illness. Studies have shown which short-termed or reduced length of stay in hospital is cited as one of the major reasons for failure of providing excellent community care as well as the existence of “revolving door” and “new long-termed hospital” mentally ill patients.  However, there are still studies which show which short termed or reduced hospital stays seem to be as efficient as long-termed hospital stays for several essential or significant and significant reasons.

First, patients allocated short-termed or reduced hospital stay is able to experience no more readmission as well as no more losses to follow-up and in addition, mentally ill patients were more likely to be discharged on time than those patients who were allocated with long termed hospital stay. Moreover, those allocated to short-termed or reduced hospital stay care have been noted to have lower rates of unemployment, although these information or data should be interpreted with caution as well as warrant further investigation and studies for proof.

As mentioned there are various reasons why short-termed or reduced hospital stay care seem as successful as longer stay care. In the theory of Goffman's in terms of institutionalization, the author has been able to explain why patients allocated long-termed hospital stay had negative results or outcome.  Accordingly, longer hospitalization ca result to difficulties for patients in going back to the “real world” or adapting to the real world environment. Furthermore, short-termed or reduced hospital stay  are with discharge planning as well as a date for discharge may have provided a drive or motivation for having managed care which was both focused as well as coordinated as compared with standard care and this is similar to the care given in stroke units. Herein, those patients may also prefer short-termed or reduced hospital stays (which may help enhance engagement in treatment), even though this should also be investigated.

Other essential or significant outcomes were not evaluated in the original trials or could not be summated, which include deaths, violence, criminal offence or imprisonment, as well as continuous data or information on mental state, patient’s social functioning, and family burden. Various studies have not been able to reveal patient satisfaction as  result, possibly because these views were not considered essential or significant in the 1960s and 1970s. Economic data were also considered as very poor and difficult to interpret during this period. If the mean actual length of hospital stay was utilized as a measure of resources consumed, then it can be perceived that the average costs for short-termed or reduced hospital stay were more than three times cheaper or less expensive than those for long-termed hospital stay, and this suggests that short-termed or reduced hospital stay care offered the same or better outcomes for less resources.

            Based on the analysis, it has also been founded that three lower quality quasirandomised trials launched heterogeneity to most outcomes, hence supporting the consideration of Cochrane criteria for inclusion of methodologically or progressively rigorous trials in reviews.  Several studies were concerned about the randomization approach utilized which could have led to unequal opportunities of being randomized into the short-termed or reduced hospital stay group from a hospital cohort. The researcher, nevertheless, have given sole aftercare which include counseling and continuous personal access through telephone.  Finally, it can be said that short-termed or reduced hospital stays are effective for mentally ill because planners has the ability to evaluate the extent of inpatient provisions on the basis of national and international comparisons rather than on their efficacy. In this regard, the review has been able to show even on the basis of limited data so far, that commissioning short-termed or reduced hospital stay policies seem to be an appropriate use of resource irrespective of the quantity as well as the quality of care after discharge and the provision of newer antipsychotics. In addition, pragmatic trials are demanded to fill essential or significant gaps in knowledge, strengthen existing evidence, and permits greater generalisability to other care cultures.

 

Chapter 5 Summary, conclusions and recommendation

 

5.1 Summary

This part of the study will provide the discussion of the conclusion and recommendation based on the results presented in the previous chapters. The focus of the study is to determine in detail the researcher’s findings on the analysis of the on the suitability of short-termed or reduced hospital stays of mentally ill in Hong Kong setting, the current mental health service policy of Hong Kong and the effectiveness of reduced hospital stays. Specifically, the study will focus on evaluating short-termed or reduced hospital stays of mentally ill through the use of qualitative and content analysis..

The result of the study shows that short-termed or reduced hospital stays of mentally ill is suitable for Hong Kong setting if Hong Kong healthcare department will be reformed and change to support this practice.  The secondary information or data gathered have been able to provide reasons of agreeing or disagreeing on the initiation of short-termed or reduced hospital stays of mentally ill in Hong Kong. One of the reasons is the belief that short-termed or reduced hospital stays of mentally ill will help in the improvement of Hong Kong mental health service. In addition, secondary information or data gathered have noted that Hong Kong should be effectively promoted by the consideration of short-termed or reduced hospital stays of mentally ill. Further, data agreed also revealed and perceived that short-termed or reduced hospital stays of mentally ill is a new source if practice for mental health service for patients. However, those data that revealed on considering the idea of putting an short-termed or reduced hospital stays of mentally ill, suggest that the this approach should be opened only to those patients who have serious mental disorders. Other reasons for the hindrance of the idea of considering short-termed or reduced hospital stays of mentally ill include the context of the financial resources of Hong Kong in the World Health organization and that Hong Kong still need to do some transformations before healthcare providers and authorities in Hong Kong can cope with short-termed or reduced hospital stays of mentally ill.

One of the aims of this research is to determine the current situation of the mental health service of Hong Kong with regards to short-termed or reduced hospital stays. The analysis revealed that secondary information or data gathered have expressed that short-termed or reduced hospital stays revealed that although Hong Kong government have some shortcomings, there are still other factors which can help them in having a successfully planned reduced or short termed hospital stays among mentally ill patients. Herein, the analysis revealed that the secondary information or data gathered agreed that short-termed or reduced hospital stays in Hong Kong may provide mental health service gain through the enhancement of the policy, less expenses, and revenues for the public sector, increase investment, and infrastructure in the community which will help them in providing quality living among mentally ill patients.

In line with the data gathered about the consideration of the project in the short-termed or reduced hospital stays of mentally ill, the secondary information or data gathered revealed that Hong Kong government is aware of the need to consider this approach and that healthcare providers and authorities in Hong Kong also notes that they are aware of the possible impact of short-termed or reduced hospital stays of mentally ill to the community and the entire healthcare sectors of the country.

 

5.2 Conclusions

The primary source of data comes from qualitative data regarding the healthcare system of Hong Kong, specifically mental health service, reduced or short-term hospital stays for mentally ill, and the current literature regarding its effectiveness.  In this study, the following queries can be concluded:

1.    The secondary information or data gathered used in this study has been able to provide relevant literature to meet or achieve the objective of this study in knowing whether reduced hospital stays of mentally ill is suitable for Hong Kong setting.

2.    The study identified that the major premises that can affect the initiation of reduced hospital stays for mentally ill include:

·         Consistency of the mental health service policy.

·         Adequate funding for mental health service in Hong Kong

·         Sufficient and effective planning for reduced hospitals stays for patients

·         Building new community healthcare that will cater to the needs of mentally ill patients.

1.     The research have discovered that based on the analysis, it can be said that most of the secondary information or data gathered revealed adequate information on concluding that adaptation of reduced hospital stays for mentally ill can be suitable in the healthcare setting of Hong Kong. However, it can be said that short-termed or reduced hospital stays of mentally ill approach for mentally ill of Hong Kong has a long way to go in proving its competitiveness and effectiveness.

2.     In addition, the secondary information or data gathered believed that there is a need for a more comprehensive planning for having an effective short-termed or reduced hospital stays of mentally ill that would meet the needs of the locals of the country.

 

5.3 Recommendation

Competitiveness of healthcare services has become increasingly importance for countries as healthcare providers and authorities in Hong Kong are striving for bigger and better healthcare provisions. The issue is especially crucial for many patients, specifically mentally ill, which rely heavily on help of the government for them to have a better or quality living.. Moreover, the role of healthcare providers in most countries also tends to increase overtime, further highlighting the importance of optimal health promotion industry in the economy. In order for Hong Kong to ensure the effectiveness of the initiation of short-termed or reduced hospital stays of mentally ill to adhere on the competition and satisfy the needs of the patients, it is recommended that the health department and government of Hong Kong focus on the following issues in short-termed or reduced hospital stays of mentally ill effort to develop this practices in making a better healthcare service for mentally ill patients.

 

5.4 Future Research

The study conducted for short-termed or reduced hospital stays of mentally ill initiation or suitability in Hong Kong analysis, herein, this research can be enhanced further through the following future research recommendations:

1.    Future researchers using a similar topic may consider the use of quantitative approach from Hong Kong healthcare providers. This could be helpful in making the findings more applicable in general.

2.    Other methods of research and data-gathering such as meta-analysis or regression analysis may be used in the future to determine the connection between the factors that may affect the effective initiation of short-termed or reduced hospital stays of mentally ill in Hong Kong.

  

Reference

"Anxiety in the People", (1995) Anxiety Disorder Association of America. Available at [http://library.adoption.com/] Accessed [17/04/04].

"Mental Health and the People Position Statement", (1993) Mental Health American Geriatrics Society (AGS). Available at [http://www.americangeriatrics.org/] Accessed [17/04/04].

"Mental Health of the People", American Psychiatric Association. Available at [http://www.psych.org] Accessed [17/04/04].

"Mental Illness", (2004) Microsoft® Encarta® Online Encyclopedia  Availabe at [http://encarta.msn.com] Accessed 17/04/04.

“Alzheimer's Disease”. The Columbia Encyclopedia, Sixth Edition. Publisher: Columbia University Press. Place of Publication: New York. Publication Year: 2000.

“Dementia”. The Columbia Encyclopedia, Sixth Edition. Columbia University Press. New York. 2000.

“Depression in the People”, (2004) Cleveland Clinic Health System. Available at [http://www.cchs.net/] Accessed 18/04/04.

Alagiakrishnan, Kannayiram MD. (2002) "Delirium", eMedicine. Available at [http://www.emedicine.com] Accessed [17/04/04].

Alexopoulos, GS. “Depression and Other Mood Disorders”. Clinical Geriatrics. October 2000.

American Geriatrics Society. (1993) Mental Health and the People Position Statement. Available at [http://www.americangeriatrics.org/] Accessed [19/08/04].

American Psychiatric Association. Practice Guideline for the Treatment of Patients with Delirium. Washington, DC: American Psychiatric Association; 2000:31-68.

Andersen, U. A. et al. (2000) “Contacts to the health care system prior to suicide: A comprehensive analysis using registers for general and psychiatric hospital admissions, contacts to general practitioners and practicing specialists and drug prescriptions." Acta Psychiatrica Scandinavica, 102, no. 2, p. 126-34.

Auchus AP. “Demographic and clinical features of Alzheimer disease in Black Americans: Preliminary observations on an outpatient sample in Atlanta, Georgia”. Alzheimer Dis Assoc Disorders 1997;11:38-46.

Aveyard, H. (2007). Doing a Literature Review in Health and Social Care: A Practical Guide. Maidenhead: Open University Press (McGraw Hill)

Benjamin K. (1994) Qualitative Reasoning: Modeling and Simulation with  Incomplete Knowledge. Cambridge, MA: MIT Press.

Blazer, D., L. K. George and D. Hughes. (1991) “The epidemiology of anxiety disorders: an age comparison”. In C. Salzman and B. D. Lebowitz (eds.), Anxiety in the People. New York, US: Springer.

Bouma, G. and Atkinson, G. (1995). A Handbook of Social Science Research:      A Comprehensive and Practical Guide for Students, 2nd Ed. Oxford:      Oxford University Press.

Bryman, A. (1989). Research Methods and Organization Studies. London:             Unwin Hyman.

Butler, R., Lewis, M., & Sunderland, T. (1998). Aging and mental health: Positive psychosocial and biomedical approaches. Boston: Allyn & Bacon.

Carnwell, R., and Daly, W. (2001). Strategies for the construction of a critical review of the literature [Electronic Version]. Nurse Education in Practice, 1, 57-63.

Conn, D. K. (2002) “An overview of common mental disorders among seniors”. Health Canada. Available at [http://www.hc-sc.gc.ca]. Accessed [21/10/03].

Creswell, J.W. (1994) Research design. Qualitative and quantitative approaches.  Thousand Oaks, California: Sage.

De la Monte SM, Hutchins GM, Moore GW. “Racial differences in the etiology of dementia and frequency of Alzheimer lesions in the brain”. J Natl Med Assoc 1989;81:644- 652.

Edwards, Joanne. "Dementia and Depression in Older People", International Pschogeriatric Association Bulletin. Volume 19, Number 2. 2003.

Flint, Alastair. "Anxiety disorders", Clinical Geriatrics. October 2001.

Francis, J. “Delirium in older patients”. J Am Geriatr Soc. 1992;40(8):829-838.

Fry, P.S. (1993). “Mediators of depression in community-based elders”, In P. Cappeliez & R. J. Flynn (Eds.), Depression and the social environment: Research and interventions with neglected populations (pp. 369-394). Montreal: McGill-Queen's University Press.

Gill, J. and Johnson, P. (1997). Research Methods for Managers. London:             Paul Chapman.

Hakim, C. (2000). Research Designs: Successful Designs for Social and    economic Research. London: Routledge.

Hart, C. (1998). Doing a literature review: Releasing the social science research imagination. London: Sage.

Hart, C. (2004). Doing A Literature Search: A Comprehensive Guide for the Social Sciences. London: Sage Publication

Health and Welfare Canada (1988) Mental Health for Canadians: Striking a Balance. Ottawa: Health and Welfare Canada.

Hendrie HC, et al. “Prevalence of Alzheimer's disease and dementia in two communities: Nigerian Africans and African Americans”. Am J Psychiatry 1995;152:1485- 1492.

Heyman A, Fillenbaum G, Prosnitz B, Raiford K, Burchett B, Clark C. “Estimated prevalence of dementia among people black and white residents”. Arch Neurol 1991;48:594-598.

Higgins, J.P.T., and Green, S (Eds.). (2008) Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]. The Cochrane Collaboration

Johnstone P, Zolese G. Systematic review of the effectiveness of planned short-termed or reduced hospital stays for mental health care. BMJ. 1999;318:1387–1390. . (22 May

Katz IR. “Diagnosis and treatment of depression in patients with Alzheimer’s disease and other dementias”. J Clin Psychiatry. 1998;59(suppl 9):38-44.

Koenig HG, Cohen HJ, Blazer DG, et al. “Profile of depressive symptoms in younger and older medical inpatients with major depression”. J Am Geriatr Soc 1993;41(11):1169-1176.

Lebowitz, BD, Pearson JL, Schneider LS, et al. “Diagnosis and treatment of depression in late life: Consensus statement update”. JAMA 1997;278(16):1186-1190.

Lipowski J. “Update on delirium”. Psychiatr Clin North Am 1992;15(2):335-346.

Lyness, Jeffrey M. MD et al., “Psychiatric Disorders in Older Primary Care Patients”, Journal of General Internal Medicine Volume 14 Issue 4.  April 1999.

Morrison, James. DSM-IV Made Easy: The Clinicians Guide to Diagnosis. Available at [http://www.geocities.com/morrison94/] Accessed [19/04/04].

Mulrow CD, Chiodo LK, Gerety MB, Lee S, Basu S, Nelson D. “Function and medical comorbidity South Texas nursing home residents: Variations by ethnic group”. J Am Geriatr Soc 1996;44:279-284.

Mulsant, BH, Ganguli M. “Epidemiology and diagnosis of depression in late life”. J Clin Psychiatry 1999;60(suppl 20):9-15.

National Institutes of Health. (1991). Diagnosis and treatment of depression in late life “NIH Consensus Development Conference Consensus Statement”. Bethesda, MD: National Library of  Medicine.

NIH Consensus Development Panel on Depression in Late Life. “Diagnosis and treatment of depression”. JAMA 1992;268: 1018-1024.

Ólafsdóttir, María, Jan Marcusson and Ingmar Skoog. “Mental disorders among people in primary care: the Linköping study”, Acta Psychiatrica Scandinavica. Volume 104 Issue 1. July 2001.

O'Neill, John V. "Report Examines People's Mental Health", NASW NEWS. October 2001.

Patton, M. (1990). Qualitative evaluation methods. Beverly Hills, CA: Sage

Patton, M. Q. (1987). How to use qualitative methods in evaluation. Thousand       Oaks, CA: SAGE Publications.

Remenyi, D., Williams, B., and Swartz, E. (1998). Doing Research in Business     Management: An Introduction to Process and Method. London: Sage

Robson, C. (2002). Real World Research, 2nd Ed. Oxford: Blackwell.

Sadovsky, Richard. "Prevalence and recognition of depression in people patients", American Family Physician. March 1, 1998.

SAGE Publications

Saunders, M., Lewis, P. and Thornhill, A. (2003). Research Methods for     Business Students, 3rd Ed. London: Prentice Hall Financial Times.

Schoenberg BS, Anderson DW, Haerer AF. “Severe dementia: Prevalence and clinical features in a biracial US population”. Arch Neurol 1985;42:740-743.

Schulberg HC, Mulsant B, Schulz R, et al. “Characteristics and course of major depression in older primary care patients”. Int J Psychiatry Med 1992;28(4):421-436.

Sekaran, Uma. (2000) Research Methods for Business. John Wiley & Sons, Inc.

Shua-Haim, Joshua R. M.D., M. R. Sabo, M.D., and Joel S. Ross, M.D. (2003) “Delirium in the People”, Clinical Geriatrics. Available at [http://www.mmhc.com/] Accessed 17/04/04.

 

Solomon, S (2006). Key future directions for Hospital Authority’s mental health services, Conference of the Institute of Mental Health, Castle Peak Hospital. Steffens DC, Skoog I, Norton MC, et al. “Prevalence of depression and its treatment in an people population: The Cache County Study”. Arch Gen Psychiatry 2000;57(6):601-607.

Strickland, Tony L. Ph.D., Paul Longobardi, Ph.D., and Gregory E. Gray, M.D. ”Dementia in Minority People”, Clinical Geriatrics. October 1999.
 Tiemey. M. C. and Charles, J. (2002) “The care and treatment of people with dementia and cognitive impairment: an update”. Health Canada. Available at [http://www.hc-sc.gc.ca]. Accessed [21/10/03].

Walliman, Nicholas and Bousmaha Baiche (2001). Your research project.

Yates William R. MD. (2004) "Anxiety Disorders", eMedicine. Available at [http://www.emedicine.com/] Accessed [17/04/04].

 

 

 

 

 

 

http://researchkorner.blogspot.com/2014/02/dissertation-on-review-on-trend-of.html