Current status of general hospital psychiatry without bed is reported. In May 2013, the number of hospital without bed for psychiatry holding full-time psychiatrists is 260. The number increased a little compared to 2008-2009. The increase may be due to the involvement of palliative care and psycho-oncology. 60% of 260 hospitals hold only one doctor. Clinical psychologists are employed by 50% of those hospitals. 66% of those hospitals have palliative care teams. Doctors who work in general hospital psychiatry without bed should design their own job in terms of diversity and sustainability.

In order to realize the development of psychiatry in general hospitals without psychiatric wards, it is crucial to increase the importance of psychiatry through consultation liaison activities. It is also important to emphasize an educational and collaborative system that enriches the capacity of primary care teams. We need to attempt new projects, such as outpatient management, in order to cope with the annually increasing demand and the limited number of psychiatrists, and also in order to maintain our physical and mental health. Such attempts will make it possible for general hospital psychiatry to play a central role in the local medical community. We can build the attractive and sustainable status by such a system.

The purpose of our psychiatry liaison team is, from a patient-centric perspective, to improve patients' psychoneurotic status, conduct a psychiatric evaluation of the treatment environment, and examine patients as a part of joined-up care. From a staff-centric perspective, we support the mental and physical health of hospital staff and attempt to improve motivation while working and to prevent burnout. In this report, we introduce the process of our psychiatry liaison team activity. We work with patients, their families, medical staff, and regional alliances. In case of an incident, we report on the present conditions and on the actions our team takes. We want to think about the functions and potential of psychiatry liaison teams at general hospitals without a specialized psychiatry inpatient unit and also about the future prospects of such teams. In our hospital, we conduct liaison team rounds and liaison team conferences to reduce patients' stress during hospitalization. We develop brochures to improve patient and family awareness of their emotions during hospitalization. We also develop programs a) to train the staff in preventing falls, particularly those triggered by delirium, b) to provide mental support after suicide and attempted suicide, and c) to deal with violent language or physical violence at the workplace. We are also responsible for five pocket guides, which are compiled into a compact manual. Outside the hospital, we treat patients with physical diseases in 12 mental hospitals in Kobe city, in cooperation with these hospitals. Since June 2012, we have helped develop certification for collaboration in dementia treatment, in cooperation with Nagata-ku Medical Association. Through liaison team rounds and conferences, we plan early remedial intervention and care, and develop a system of collaboration with the necessary specialists. Medical staffs except psychiatrists cooperate with us. Initial remedial intervention is conducted at an early stage by developing a pocket guide of a correspondence manual and guidelines. We attempt to improve the staff's sensitivity and the care for their own mental well-being, by offering cooperative mental support. We share our expertise with the local medical staff, and cooperation with them gradually increases as we spread awareness of mental care. Through the system that handles physical complications, patients of local mental hospitals who also have physical complications are treated.

A second palliative care team (PCT) was established at the Cancer Institute Hospital of the Japanese Foundation for Cancer Research on June 1, 2012. Known as the Liaison PCT, this team took over consultation-liaison psychiatry services. Of the 228 consecutive referrals to the Liaison PCT from its establishment until February 28, 2013, 97 (43%) were men, and the mean (SD) age was 60.1 years (13.7). Their psychiatric diagnoses included adjustment disorder (59 patients; 25.9%), delirium (52; 22.8%), alcoholism (29; 12.7%), mood disorders (28; 12.3%), acute stress disorder (20; 8.8%), other anxiety disorders (10; 4.4%), dementia (8; 3.5%), schizophrenia (5; 2.2%), and other disorders (17; 7.5%) (e.g., sleep disorder and akathisia). Symptom evaluation in patients with cancer is often difficult, as appetite loss, apathy, insomnia, fatigue, and depression are common effects of the cancer, its treatment (e.g., chemotherapy and radiation therapy), and mental illnesses such as mood or cognitive disorders. If depression with suicidal ideation were present in cancer patients, it would be crucial for clinicians to be skilled in appropriately assessing and relieving uncontrolled suffering. PCTs are required to solve such heterogeneous problems, especially delirium. General hospitals have an advantage in that they can conduct multidisciplinary, collaborative team care with symptom management as the common goal. PCTs trained in treating pain, depression, and delirium will be essential in caring for the super-aging population of Japan, as this care will require a psychosomatic approach.

In this article, we introduced the role of psychiatry division in national center hospital. The mission of national center hospital is not only providing good clinical practice, but also has research, educational activity, and policy recommendation. The psychiatry division also has important role of the area. It is exciting to participate in a big project with colleagues who are experts on other area.

In general hospital the activity of psychiatric department must be performed not only in ambulatory section but also in inpatient section and outside of the hospital. Consultation liaison psychiatry for inpatients consists of collaborative care with physical doctors and paramedical staffs, cancer palliative care, prevention of child abuse and so on. Outside of hospital, the cooperation with regional psychiatric activities and industrial mental health team etc. is also important. The significance of psychiatric department in general hospital does not consist in economical profits but in its existence itself.

The Confusion Assessment Method (CAM) is a simple screening tool for delirium used worldwide. We made the CAM Japanese version and validated usefulness for 53 cases, which became orthopedics hospitalization by femoral neck fracture from January 1, 2012 to July 31. Twelve patients (22.6%) met the criteria for delirium. The CAM positivity was 11 subjects (10 delirium, 1 non-delirium), and the CAM negativity was 42 subjects (2 delirium, 40 non-delirium). It seemed that CAM Japanese version had a sensitivity of 83.3%, specificity of 97.6%, Cohen's kappa coefficient of 0.83, and Phi value of 0.78. We considered the CAM Japanese version to be a useful screening tool for delirium. The Japanese-translation of the CAM is a copyrighted instrument, which can be found at: [http://www.hospitalelderlifeprogram.org/private/cam-disclaimer.php?pageid=01.08.00]

To clarify the current state of and issues concerning medical care for dementia, we conducted a questionnaire survey of members of the JSGHP (Japanese Society of General Hospital Psychiatry) in March 2012. As a result, we obtained responses from 87 centers (42 general hospitals, 24 university hospitals, 8 psychiatric hospitals, and 13 psychiatric clinics). The main departments that provided medical care for dementia were: psychiatric departments (86.2%), departments of neurology (44.8%), departments of neurosurgery (5.7%), and departments of internal medicine (5.7%). The proportions of patients aged 65 years or older among the new out-patients in 2011 were 45.2, 37.3, 32.9, and 15.5% in general hospitals, university hospitals, psychiatric hospitals, and psychiatric clinics, respectively. This suggested that medical care for dementia is provided daily regardless of the type of medical center or doctors' specialty. In addition, it was indicated that 40% or more of the patients in consultations in university and general hospitals had dementia. A wide range of current limitations and tasks were pointed out, such as the promotion of community cooperation, skewed distribution of specialized medical centers (general hospitals), treatment of physical complications and BPSD (behavioral and psychological symptoms of dementia), and provision of dementia education.