Psychiatric Knowledge and Skills Required of Occupational Physicians

Journal of Occupational Health

J Occup Health 2011; 53: 371–376

Field Study

Psychiatric Knowledge and Skills Required of Occupational Physicians: Priorities in the Japanese Setting Akizumi Tsutsumi, Takashi Maruyama and Masako Nagata Occupational Health Training Center, University of Occupational Health and Environmental Health, Japan Abstract: Psychiatric Knowledge and Skills Required of Occupational Physicians: Priorities in the Japanese Setting: Akizumi T sutsumi , et al. Occupational Health Training Center, University of Occupational Health and Environmental Health, Japan—Objective: To prioritize the educational content in psychiatry teaching materials for occupational physicians. Methods: A preparatory investigation was performed that included interviews with 13 psychiatrists who were well acquainted with occupational health and practices. Brainstorming among the psychiatrists and 12 occupational physicians was used to develop a list of educational content related to psychiatric issues that should be required for occupational physicians. Using a questionnaire survey constructed based on the preparatory investigations, 135 specialists with extensive experience in occupational medicine were asked to prioritize the selected items. Results: A total of 67 specialists responded to the questionnaire. The following were recommended as high educational priorities for occupational physicians to master: awareness and diagnosis of mood disorders, being able to appropriately deal with depressed workers, screening for depression, understanding cases that should be referred for special treatment, appropriate action for a suicidal person, understanding symptoms that require cooperation in an emergency with a specialist, acquisition of the attitude and skills used in active listening and awareness of diseases such as alcohol dependence, adjustment disorders and schizophrenia. Conclusions: What has been presented here is a consensus view of specialists in this field. The items included were those obtained from sitting in on the discussions of psychiatrists and occupational physicians. They represent indicators for the development of teaching materials. (J Occup Health 2011; 53: 371–376) Received Jan 28, 2011; Accepted Jun 21, 2011 Published online in J-STAGE Aug 5, 2011 Correspondence to: A. Tsutsumi, Occupational Health Training Center, University of Occupational Health and Environmental Health, Japan, 1–1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan (e-mail: [email protected])

Key words: Lifelong education, Occupational medicine, Occupational physician, Psychiatry, Training

A panel of the American College of Occupational and Environmental Medicine (ACOEM) has defined competencies in occupational and environmental medicine related to mental health1). The comprehensive “menu” of competencies includes the following: taking a psychiatric and psychosocial history and performing a mental status examination; identifying troubled or psychologically impaired employees and managing/referring appropriately to community resources, including employee assistance programs; and identifying and interpreting danger signs in violent, homicidal or suicidal employees, managing the situation and appropriately referring patients for treatment with a specialist. However, ACOEM points out that it is not practical to define a “core” set of competencies for this field of medicine, as occupational and environmental physicians vary in the nature of their practices and their practice settings. Although there seem to be some SPH (School of Public Health) courses for occupational mental health2), to our knowledge, there is no systematic curriculum in psychiatry for occupational physicians in Japan, and the relevant subjects have been chosen empirically. To develop curricula in psychiatry for occupational physicians in a Japanese setting, we aimed to identify the psychiatric knowledge and skills that occupational physicians need to master.

Methods First, items necessary in psychiatric teaching materials were listed during interviews with occupational physicians and psychiatrists who had experience working as occupational physicians, and consequent brainstorming by the two groups was based on the respective results. Then, to extract the high priority educational items from those on the list, a questionnaire survey was conducted for specialists in psychiatry and psychosomatic medicine who knew occupational health well. The respondents were asked to indicate the relative importance or priority of the

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items and to add other necessary items to the list where appropriate. Preparatory investigation A total of 13 psychiatrists who were staff or residents of the Department of Psychiatry at the University of Occupational and Environmental Health and 12 occupational physicians who belonged to the Occupational Health Training Center of the University of Occupational and Environmental Health participated in the preparatory investigation. Most of the psychiatrists were either teachers or postgraduate alumni of the University of Occupational and Environmental Health, which was established for the purpose of promoting occupational and environmental health and training excellent occupational physicians. The Occupational Health Training Center is a facility for training occupational physicians and other health care specialists in acquiring knowledge and technical know-how related to the practice of occupational health. Participants enumerated psychiatric knowledge and skills that occupational physicians should acquire, and concrete educational content was listed by each group separately. Then, through discussion, the two groups reached consensus on what items are minimum requirements of knowledge and skills in psychiatry for occupational physicians. These items were then allocated frequency scores used to rank them from high to low priority. Main enumeration Potential study participants were derived from two groups. The first group involved 13 specialists in psychiatry or psychosomatic medicine. This group held periodic meetings with occupational physicians to discuss efficient coordination between the two specialist groups in treating workers suffering from mental health problems. The second group consisted of 122 psychiatrists who were fellow members of the Department of Psychiatry of the University of Occupational and Environmental Health. Most of them were currently working or used to work as occupational physicians, so they were well informed about both occupational health and psychiatry as well as current related issues. A self-administered questionnaire was mailed to participants asking their views on which psychiatric knowledge or skills should be required for occupational physicians. The survey was conducted from the middle to the end of January 2010 by mail, and a small remuneration was presented to the respondents.

Results Preparatory investigation The psychiatrists listed several psychiatric disorders of which respective symptoms should be known to the extent that the illness can be noticed. The list of disorders was enumerated in order of frequency experienced in the

J Occup Health, Vol. 53, 2011

workplace. These items were considered basic but of high priority in this group. Cooperation with specialists was an item with a high priority level. There was a comment that occupational physicians need to become acquainted with two or three psychiatrists who can be easily consulted. Judgment related to work reinstatement was considered a high priority and an indispensable item, though such judgments are difficult. There was an opinion that it is important for occupational physicians to identify cases through consultations with supervisors and to consult specialists when appropriate, even when a worker does not come to an occupational physician as a case. In the group work of the occupational physicians, a concern was difficulty in communicating with specialists on the basis of a medical certificate. The importance of conveying accurate information on what happens at the workplace from the occupational physician to the psychiatrist was discussed. The priority of knowledge and skills related to psychiatric emergencies, such as identifying suicidal ideation and managing a suicidal person, was high. A moderate priority was awareness of psychotic manifestations or diagnostic norms and knowledge concerning treatment methods. Interviewing techniques using an appropriate attitude as well as listening and specific response skills (active listening) 3) were considered a priority to a moderate degree. In addition, physicians reported that skill was needed in how to refer workers for medical treatment who are not aware of their illness. The psychiatrists and occupational physicians came to a consensus that it is not necessary to diagnose, but it is necessary to understand symptoms to the extent that some of the psychiatric disorders can be recognized. However, they agreed that there are some psychiatric diseases for which diagnoses should be understood, with the necessity of a diagnosis for each disorder indicated in the main enumeration. As for interviewing techniques, they agreed upon the necessity of mastering an appropriate attitude as well as specific listening and response skills (active listening). The questionnaire for the main enumeration was made based on the discussions of the occupational physicians and psychiatrists in preparatory investigations. Main enumeration A total of 7 out of 13 specialists in psychiatry or psychosomatic medicine and 60 out of 122 fellow members of the Department of Psychiatry at the University of Occupational and Environmental Health responded to the questionnaire (see Table 1). More than half of the specialists answered that the following items were knowledge and skills necessary for the occupational physician: understanding cases that had to be referred for special treatment, such as those with serious depressive symptoms; appropriately managing

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Table 1. Prioritization ranking and concrete content and action targets for psychiatric knowledge and skills that occupational physicians should be required to master (frequencies of ranking scores given by 67 specialists) Category: Cooperation with specialist Understanding of the state that should be entrusted to special treatment Able to manage suicidal workers appropriately (correspondence in emergency) Understanding of symptoms that requires cooperation with specialist in an emergency Able to tell a specialist about a worker without insight into disorders Able to consult specialists on the base of understanding psychiatric state Able to provide specialists with useful/necessary information for psychiatric diagnosis Category: Case management Able to manage a worker in the state of depression appropriately Able to provide appropriate life guidance for workers according to respective disorders Able to provide appropriate support and counseling for families of workers according to respective disorders Category: Awareness of illness Able to notice the possibility of the appearance of mood disorders in the workplace Able to notice the possibility of the appearance of alcoholic dependence in the workplace Able to notice the possibility of the appearance of an adjustment disorder in the workplace Able to notice the possibility of the appearance of schizophrenia in the workplace Able to notice the possibility of the appearance of sleep disturbance in the workplace Able to notice the possibility of the appearance of anxiety disorders in the workplace Able to notice the possibility of the appearance of personality disorders in the workplace Able to notice the possibility of the appearance of dissociative disorders in the workplace Able to notice the possibility of the appearance of eating disorders in the workplace Category: Diagnosis Understanding the diagnostic norm of mood disorders Understanding the diagnostic norm of schizophrenia Understanding the diagnostic norm of alcohol dependence Understanding the diagnostic norm of adjustment disorders Understanding the diagnostic norm of sleep disturbance Understanding the diagnostic norm of personality disorders Understanding the diagnostic norm of anxiety disorders Understanding the diagnostic norm of dissociative disorders Understanding the diagnostic norm of eating disorders Category: Interview technique Master of the attitude and skill of active listening Able to assess suicidal risk (i.e., suicidal intention) Able to scrutinize structured interviews (i.e., M.I.N.I.) Category: Understanding of psychiatric treatment and psychotropic medication Understand the standard psychotropic medication and able to assess the current state of workers treated with a particular medication Understand the application and side effects of psychotropic medication and whether a worker is fit for a specific job Category: Tests Understand and able to implement depression screening appropriately Understand and able to implement stress surveillance in the workplace appropriately Understand and able to implement alcohol abuse screening (CAGE, etc.) appropriately Understand and able to implement sleeping disorder screening appropriately Category: Regulations and systems Understanding the Mental Health and Welfare Law Understanding hospital systems and related procedures Understanding the Law for Employment Promotion of the Disabled

(49) (37) (34) (28) (24) (20) (46) (23) (9) (51) (33) (32) (30) (16) (14) (6) (4) (4) (30) (15) (14) (13) (9) (7) (5) (3) (2) (44) (24) (2) (28) (17) (29) (23) (9) (4) (11) (10) (8)

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workers who are in a state of depression; acquiring the attitude and skills of active listening; and being able to conduct appropriate management of a suicidal person. Relative to the category, the item concerning cooperation with specialists was ranked comparatively high. Fifty-one out of 67 specialists pointed out that recognizing mood disorders was an item with the highest priority. Forty percent of the specialists answered that the diagnosis of mood disorders was a high priority. Other than mood disorders, alcohol dependence, adjustment disorders and schizophrenia were given a high ranking as illnesses that should be noticed. Awareness of the symptoms of anxiety disorders, personality disorders, dissociative disorders and eating disorders was ranked as a low priority. About 20–40% of respondents answered that an understanding of psychiatric treatment was a high priority. As for interviewing techniques, mastering the attitude and skills involved in active listening was considered a high priority (44 respondents; 66%). However, being able to conduct a scrutinizing interview (e.g., Mini-International Neuropsychiatric Interview; M.I.N.I.) was considered a low priority. Although priority was low for investigation and inspection, screening for depression was considered a high priority. About 30% supported stress surveillance at the office. It was considered a moderate priority related to the risk of suicide (thoughts of suicide) (24 people; 36%). Awareness of regulations and system issues was supported by up to 16% of respondents. There were some additional items pointed out as important: “Understanding of a phased reinstatement,” “Able to decrease the recurrence of depression” and “High-functioning pervasive developmental disorder” (awareness of the disorder). In addition, “Understanding of Occupational health and safety laws” and “Safety considerations” as well as “Well informed about starting work rules in the company and master and servant contracts, especially leave-taking, reinstatement and retirement” gave weight to work considerations. “Able to cooperate with a specialist and advise/arrange work considerations according to the worker’s condition and psychotropic medication” was an item related to cooperation with a specialist. There was an opinion that the ability to coordinate others in the workplace was considered high priority; this was illustrated by items such as “Able to excellently communicate with human affairs and health care staff” and “Able to coordinate views between workplace personnel and patients.”

Discussion To develop educational programs and teaching materials for psychiatric issues so that Japanese occupational physicians can provide mental health measures effectively, a two-step investigation was conducted of specialists with significant achievements in occupational medicine. The following were considered psychiatric skills that


occupational physicians should be required to master: awareness of the appearance of mood disorders, being able to screen for depression, understanding cases that should be referred for special treatment, appropriately managing workers in a state of depression, acquiring the attitude and skills involved in active listening, being able to manage a suicidal person appropriately and understanding symptoms that require cooperating in an emergency with a specialist. In addition, understanding the diagnostic norms for mood disorders, understanding psychotic manifestations and being able to recognize the possibility of adjustment disorders, alcoholic dependence and schizophrenia in the workplace were also considered important. Items were concordant with the “core competencies for occupational physician specialists” advocated by the WHO4). However, they were more specific for psychiatric issues and indicated priorities that may help to develop efficient educational curricula in the current Japanese setting. To elucidate further insight from the obtained data, we tried factor analysis and reliability analysis for the studied items. The factor analysis did not support our prior categorization nor extract any meaningful factor matrices (data not shown). The reliability analysis revealed moderate internal consistencies among the categories of ‘awareness and diagnosis of illnesses’ (alpha=0.64, and 0.77, respectively) and low internal consistencies for other categories (between 0.18 and 0.45). Scrutinizing the findings of the two analyses, moderate internal consistencies in the categories of “awareness and diagnosis of illnesses” were found to be derived from the similar response patterns of the specialists—the affirmative selections for mood disorders, alcoholic dependence, adjustment disorder and schizophrenia on one hand and the negative selections for dissociative disorders and eating disorders on the other. Sleep disturbance, anxiety disorders and personality disorders were in between. Still, the indefinite factor pattern and relatively low reliabilities suggest that the educational contents were prioritized depending on the respective experiences of each specialist and/or their perspectives on occupational health. The item concerning cooperation with specialists was comparatively high in rank. This is understandable because occupational physicians need to have acquired basic knowledge regarding psychiatry and psychosomatic medicine so that more detailed information can be collected and they can smoothly communicate with the physician in charge5). Discussions with psychiatrists and occupational physicians in the preparatory investigation revealed the following about knowledge concerning psychiatric disorders: “It is not necessary to diagnose; however, symptoms should be understood to the extent that they are noticed.” Similar answers were obtained in the main enumeration. Therefore, in developing psychiatric teaching materials for occupational physicians, inclusion

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of information on recognizing symptoms in the workplace is important. However, an understanding of diagnostic norms was requested for mood disorders. This finding is concordant with recent facts: mood disorders have increased in the office and become a major problem in the workplace; depressive symptoms are important as an expression of many types of psychiatric disorders; and difficult cases, such as bipolar disorder, are a problem. It is necessary to allot significant weight to education about mood disorders, including diagnosis and screening. Awareness of diseases such as alcohol dependence, adjustment disorders and schizophrenia was given a high rank. Although it is presumed that the frequency of alcohol dependence and the forerunner—problem drinking—is not low6), several reasons may explain the high priority concerning awareness of the disease. For example, although the problem of alcohol is not recognized easily because of a Japanese culture generous with alcohol, management of such cases is difficult. Adjustment disorders are a high educational priority because they are often the earliest sign of many disorders, and most chances for awareness of these disorders are in the workplace. In addition, the removal of stressors can be an effective remedy in managing workers with these disorders. Although the frequency of managing workers with schizophrenia is less in the office compared with mood disorders7), there is great confusion both in the office and in the family when schizophrenia develops or relapses. There is a problem with decrease in work ability, and the effectiveness of intervention at an early stage has been pointed out8, 9). Therefore, schizophrenia should be recognized at an early stage. Twenty to 40 percent of the specialists answered that understanding psychotropic medications was a high priority. An additional item involved the importance of following workers, in cooperation with a specialist, who return to the office after a diagnosis of a disease and was illustrated be comments such as “a stepwise phased reinstatement (quality and amount of work) can be understood” and “able to decrease the recurrence of depression.” The side effects of medications should be known when it is confirmed that medicine is being taken, given that some side effects are considered easier to notice in a work setting than in a clinical session10). Mastering the attitude and skills of active listening was ranked as a high priority and concordant with the occupational physician’s needs. It is necessary to include knowledge as well as practice, such as role playing, when developing teaching materials related to these skills11). There were opinions regarding occupational physicians’ basic abilities and those relating to regulations, including opinions about such things as “Understanding of occupational health and safety laws” and “Safety considerations,” being “Well informed about starting work rules and labor contracts, especially leave-taking,

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reinstatement and retirement” and being “Able to communicate excellently with human affairs and the health care staff.” It seems that a lack of respect for these abilities was experienced by the reported specialists. The awareness of anxiety disorders, personality disorders, dissociative disorders and eating disorders was placed at a low position in relation to education priority. The priority for mastering awareness of these particular disorders may be low because cases are comparatively clear when the typical symptoms emerge. The priority of being well informed regarding regulations and systems was considered low, though these are important matters. Limitations The obtained data were not from a representative sample of related specialties (psychiatric and occupational), but were relevant expert opinions. While the prioritization was not intended to be conclusive, it nevertheless provides a good basis for further development and refinement of likely education priorities. Many shortcomings of the technique in prioritizing areas of occupational medicine have been outlined elsewhere12). These include the requirement for respondents to prioritize lists of topic areas that they think are of equal importance. Although the participants did not enumerate additional disorders or symptoms, the items listed in our table may not cover all the important psychiatric fields that occupational physicians should learn. The questionnaire was developed based on certain disorders and did not ask the symptoms or subtypes of psychiatric disorders. This procedure had a limitation in that it could not elucidate important clinical features such as subtypes as well as several constellations of symptoms. Although occupational physicians cannot diagnose all specific types of psychiatric disorders practically, it would be fruitful to educate them on the psychiatric symptomatology for early detection of the disorders13). This is a challenging theme which is related to how to teach psychiatry. The education method could be approached in a future study.

Conclusions The following psychiatric items were suggested as having high educational priority for Japanese occupational physicians to master based on the investigation of specialists with extensive experience in occupational medicine: awareness and diagnosis of mood disorders, screening for depression, understanding cases that should be referred for special treatment, ability to appropriately manage workers in a state of depression, acquisition of the attitude and skills of active listening, appropriate action for a suicidal person, understanding of symptoms that require emergency cooperation with a specialist and awareness of diseases such as alcohol dependence, adjustment disorders and schizophrenia. What has been presented here is a consensus view of specialists in this

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field. The items were obtained from the discussions of psychiatrists and occupational physicians. The items that assumed low priority are not necessarily unimportant. We consider these items to be indicators that can be used in the development of teaching materials. Acknowledgments: This study was partly supported by Health and Labour Sciences Research Grants, Research on Occupational Safety and Health (No. 20320201, principal investigator: Prof. Kazuhito Yokoyama), from the Japan Ministry of Health, Labour and Welfare. Thanks are due to Drs Kouji Hayashida, Eiichiro Gotoh, Susumu Oda, Jun Nakamura, Takahiro Shinkai, Yuichiro Nakano, Tatsuya Okamoto, Hikaru Hori, Kenji Hayashi, Kenji Yamada, Miyuki Inoue, Dan Kamata, Kiyokazu Atake, Maiko Waki, Asuka Katsuki, Koji Mori, Kotaro Kayashima, Seiichiro Tateishi, Tomohisa Nagata, Aki Matsui, Sho Kondo, Makiko Kuroishi, Nana Tamayose, Kumi Hasegawa and Nozomi Kuroiwa for offering their valuable comments.

References 1) ACOEM Panel to Define the Competencies of Occupational and Environmental Medicine. Occupational and environmental medicine competencies, version 1.0. J Occup Environ Med 1998; 40: 427–40. 2) University of Tokyo, School of Public Health: syllabus 2010. [Online]. 2010 [cited 2010 Apr 3]; Available from: URL: http://www.m.u-tokyo.ac.jp/sph/SPH2010.pdf 3) Rogers C, Farson R. Active listening. Chicago (IL): The Industrial Relations Center of the University of Chicago; 1955.


4) World Health Organization. Occupational medicine in Europe: Scope and competencies. Bilthoven: WHO European Centre for Environment and Health; 2000. 5) Ministry of Health Labour and Welfare. Guide to help workers who leave because of mental health problems return to work, revised. 2009 (in Japanese). 6) Osaki Y, Matsushita S, Shirasaka T, Hiro H, Higuchi S. Nationwide survey of alcohol drinking and alcoholism among Japanese adults. Jpn J Alcohol & Drug Dependence 2005; 40: 455–70 (in Japanese). 7) Nakagawa KS. In: Japanese Society for Occupational Mental Health, editor. Manual of Occupational Mental Health. Tokyo: Nakayama Shoten; 2007. p. 312–6 (in Japanese). 8) Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 2005; 62: 975–83. 9) Perkins DO, Gu H, Boteva K, Lieberman JA. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry 2005; 162: 1785–804. 10) Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA 2004; 292: 338–43. 11) Kubota S, Mishima N, Nagata S. A study of the effects of active listening on listening attitudes of middle managers. J Occup Health 2004; 46: 60–7. 12) Iavicoli S, Rondinone B, Marinaccio A, Fingerhut M. Identification of research priorities in occupational health. Occup Environ Med 2005; 62: 71–2. 13) Hamada H. Sémiologie psychiatrique, 2nd edition. Tokyo: Kobun-do; 2009 (in Japanese).