O R I G I N A L P A P E R
Needs and Demands for Community Psychiatric Rehabilitation Programs from the Perspectives of Patients and Caregivers
Ling-Ling Yeh•Shi-Kai Liu •Hai-Gwo Hwu
Received: 14 November 2009 / Accepted: 26 June 2010 / Published online: 7 July 2010 Ó Springer Science+Business Media, LLC 2010
Abstract This study interviewed 182 pairs of patients and caregivers to explore the needs and demands for community programs for patients with chronic mental ill- ness and to detect the factors associated with them. The most needed and demanded programs were structured day services (69.2 vs. 78.6%), club house (71.4 vs. 74.2%), and caregiver support (72.5 vs. 74.7%). The needs and demands perceived by both patients and caregivers ranged from 3.3 to 31.9%, while those perceived by either patients or caregivers ranged from 25.8 to 72.5%. Needs and demands for individual programs were higher in caregivers (67, 65.9%) than in patients (41.2, 42.9%) and the proportion of demand (42.3–78.6%) for the eight programs was greater
than the need (25.8–72.5%) for programs. The results showed that married and younger caregivers needed and demanded active community programs and the patients with a higher level of education favored a club house with high autonomy.
Keywords Community psychiatric rehabilitation Need Demand Chronic mental illness Caregiver
Introduction
Community psychiatric rehabilitation has been advocated as an important and integral part of psychiatric care for people with chronic mental illness (American Psychiatric Associ- ation2004), and diverse community psychiatric rehabilita- tion programs have been established in different countries.
These include assertive community treatment (ACT) pro- grams and clubhouses in the United States (Baronet and Gerber1998; Macias et al.2001), integrated psychological therapy (IPT) in Switzerland (Roder et al.2001), care pro- gram approach (CPA) in the United Kingdom (Holloway et al. 2002), ACT and supported employment in Canada (Latimer2005). However, there are still substantial barriers for people with mental illness to access community psy- chiatric services, which is reflected in the magnitude of the unmet needs and shortage of resources (Anderson and Lyon 2001; Higgins et al. 2007; Lemaire and Mallik 2005).
Considering that the needs and demands for psychiatric community rehabilitation have been dominated by unilateral professional psychiatric opinions (Anderson and Lyon2001;
Higgins et al. 2007; Lecomte et al. 2005) without inputs from patient’s perspective, there might be overt mismatch between needs and demands; patients may need community programs but may not demand them; they may not use L.-L. Yeh (&)
Department of Healthcare Administration, College of Health Science, Asia University, 500, Lioufeng Rd., Wufong, Taichung 413, Taiwan
e-mail: yehll.sophia@msa.hinet.net S.-K. Liu
Center for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada S.-K. Liu
Department of Psychiatry, Far Eastern Memorial Hospital, Taipei, Taiwan
H.-G. Hwu
Department of Psychiatry, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
H.-G. Hwu
Department of Psychology, College of Science, National Taiwan University, Taipei, Taiwan
H.-G. Hwu
Institute of Epidemiology, College of Public Health, National Taiwan University, Taipei, Taiwan DOI 10.1007/s10597-010-9336-y
programs they need; and they may use services they don’t need. Unfortunately, most past studies on community psy- chiatric rehabilitation have focused solely on the need for skills training (e.g., vocational rehabilitation, shopping, paying bills) (Anderson and Lyon2001; Kersten et al.2000;
Lecomte et al.2005; Nieves2002; Pinkney et al.1991) and few studies have examined the needs for community psy- chiatric rehabilitation programs. Exploring the needs and demands for community programs should provide a com- prehensive framework for constructing psychiatric care systems.
Needs and demands data provided by patients them- selves may be misleading as they might not be able to adequately express these needs and demands. Since patients often depend heavily on caregivers for activities of daily living, caregivers should be important participants and opinion providers in health care planning. In this regard, research addressing the needs and demands issue from the perspectives of both patients and caregivers could prove informative in providing a balanced view. This will be especially important for planning community programs, since in Taiwan near 90% of people with chronic mental illness live with their families (Hwu et al.1995) and com- munity psychiatric rehabilitation programs are still highly needed (Department of Health 2006). Considering that different community rehabilitation programs vary in their service population, goals of rehabilitation, and allocated resources and operations, diverse psychiatric rehabilita- tion programs such as drop-in services, accommodations, club houses, home care, respite services and caregiver support, are needed to meet individualized and multi-level needs. Currently, only structured day service and residential rehabilitation are available and covered by the National Health Insurance in Taiwan and they have to serve multi- purpose functions and might not fit the needs of individual patients.
The purpose of this study was hence to explore the needs and demands for these different community psychiatric rehabilitation programs in Taiwan, from both patients’ and caregivers’ perspectives. Besides currently available pro- grams, the survey covered all possible modalities of com- munity rehabilitation. Since socio-demographic, clinical characteristics of patients and caregivers might influence the needs and demands for individual community program, multivariate statistics were used to explore the extent of impacts of these individual characteristic on needs and demands for each community treatment modality. The scopes of the study included the following: (1) to assess and describe the needs and demands for these community psychiatric rehabilitation programs; (2) to explore the factors related to needs and demands for individual com- munity programs in terms of the characteristics of patients and caregivers.
Methods Study Design
The current study was conducted in seven psychiatric hospitals in Taiwan between October 15, 2007 and February 15, 2008. The seven participating psychiatric hospitals were the core mental hospitals responsible for their respective regional mental health care networks and were selected after balancing the geographic distribution.
Subjects were screened and recruited from those attending outpatient clinics in the seven psychiatric hos- pitals when they met the following inclusion criteria: (1) an ICD9-CM diagnosis of either schizophrenia (295) or affective disorder (296); (2) a duration of illness over 2 years; (3) age less than 50 years old; (4) regular visits to psychiatric clinics; (5) unemployed; (6) never used com- munity psychiatric rehabilitation or having used it for less than 1 month. Those who fulfilled the inclusion criteria were assumed to be in need of community psychiat- ric rehabilitation. After a complete description of the study, written informed consent was obtained. In-person interviews with patients and their caregivers were con- ducted by four trained graduate research assistants, using the structured questionnaire of the Inventory of Needs and Demands for Community Psychiatric Rehabil- itation (INDCPR). The protocol and questionnaires were approved by the institutional research boards of all seven participating hospitals.
In addition to demographic and clinical information about patients and caregivers, the INDCPR assesses the needs and demands for the eight community psychiatric rehabilitation programs: structured day service, drop-in service, residential rehabilitation, accommodation, club house, home care, respite service and caregiver support.
Briefly, the structured day service provides a daily schedule of activities directed by professionals, and all consumers receive aggressive rehabilitation activities in order to improve their daily living, social and vocational skills. The drop-in service provides unstructured day services with less active interventions and users are free to participate or not.
The residential rehabilitation program emphasizes proac- tive interventions for improving daily living, social and vocational skills, and independent living in the community, whereas accommodation offers only residential service.
The main function of a club house is a meeting place, and all activities are initiated and organized by members of the club house. Home care operates by professionals delivering psychiatric rehabilitation or nursing care in consumer’s home. In contrast to the preceding programs which provide services for patients, respite service and caregiver support target the caregivers of patients with chronic mentally illness.
The content of individual community program was described in detail to the interviewees, and interviewer made sure that the interviewee understood the content of the programs, before inquiring whether a specific program was needed or not. When interviewers inquired about the needs and demands for these community programs, they had to remind the interviewees that not all the eight pro- grams were currently operating in Taiwan and they could respond by solely following what they perceived to be a need or not. No matter the patients and caregivers felt they were in need of a certain community program or not, the interviewers inquired further as to whether or not the interviewees would use the program if it existed in the healthcare system. The ratings of the need/demand were: 1 need/demand; 2 no need/demand; and 3 unknown.
The validity and inter-rater reliability of the INDCPR was assessed before the field work. Six senior psychiatric professionals were invited to examine the content validity, including two psychiatrists, one psychiatric nurse, two occupation therapists, and one psychiatric social worker.
Two graduate level research assistants interviewed 15 pairs
of patients and caregivers to collect data for inter-rater reliability. The kappa statistics and inter-class coefficient (ICC) reliability were calculated. 325 (92.3%) of a total of 352 items in the questionnaire for patients had a kappa or ICC greater than 0.9. Only seven items (2.0%) ranged from 0.5 to 0.6. The rest of the items ranged from 0.7 to 0.8. In the questionnaire for caregivers, 311 (89.4%) of a total of 348 items had a kappa or ICC greater than 0.9. Only nine items (2.6%) ranged from 0.5 to 0.6. The other items ranged from 0.7 to 0.8.
The characteristics assessed in the study included gen- der, marriage (single, married and living with spouse, married and living without spouse), education level (B9, 10–12, C13 years), religion (belief, no belief), and age of patients and caregivers, duration of illness, diagnosis, and kinship of caregiver with patients. The job status of care- givers was categorized as unemployed, full-time job, part- time job, or retirement.
The need for a certain community rehabilitation pro- gram was coded as present when the patient and/or care- giver perceived that such program was needed. If the
Table 1 The variable information in multiple logistic regression analysis
# b/a: a as reference category to examine the effect of the categories of the independent variable on dependent variable in contrast to the category b of this specific variable
? Represents continuous variables in multiple logistic regression analysis
Variables Variables in
patient group
Variables in caregiver group
Categories b/a#
Dependent variable
Need status Yes Yes No need or need
Demand status Yes Yes No demand or demand
Independent variables
Gender Yes Yes Male a
Female b
Marriage Yes Yes Single a
Living with spouse b Living without spouse b
Education level Yes Yes B9 Years a
10–12 Years b
C13 Years b
Religion Yes Yes Belief a
No belief b
Job status No Yes Unemployed a
Full-time job b
Part-time job b
Retirement b
Yes Yes Age c?
Yes No Duration of illness c?
Diagnosis Yes No Schizophrenia a
Affective disorder b
Kinship with patients No Yes Parents a
Children b
Spouses b
Siblings b
Others b
patient and/or caregiver stated that they wanted to use such a program, it was further defined as a demand for that program. The needs and demands of patients and care- givers were further classified into 4 subcategories: need/
demand of patient only, need/demand of caregiver only, need/demand of both patients and caregivers, and no need/
demand. Further in regression analysis, the four subcate- gories of need/demand status were changed into a binary variable (need vs. no need; demand vs. no demand) by collapsing the three subcategories of need/demand of patient only, caregiver only, and both of patients and caregivers into a single category.
Data Analysis
Descriptive statistics were used to delineate the needs and demands for the eight community psychiatric rehabilitation programs. The factors associated with the need and demand for a specific individual program were explored by multiple logistic regression analysis, in which the status of need (need vs. no need) and demand (demand vs. no demand) was the dependent variable and the independent variables included gender, marital status, education level, religion, and age of patients and caregivers, duration of illness, diagnosis, kinship of caregiver with patients, and job status of caregivers. Since some of the categorical independent variables were with more than two categories, they were transformed into dummy variables. For example, since the variable of ‘‘marital status’’ had three categories, it was substituted by three binary dummy variables (present or not present) that represented each of the three categories. And the first category in these variables is set as the reference category. All variable information is demonstrated in Table1, such as dependent variables, independent vari- ables, categories in each independent variable, and the reference category in categorical variables. The odds ratio of an event in logistic regression is defined as the ratio of the probability that an event occurs to the probability that it fails to occur. For example, the odds ratio (OR) is 10.93 in the category of married and living without spouse of care- giver’s marital status, which means the probability of caregivers married and living without spouse need a certain service are 10.93 times of the probability in the reference category of single caregivers, controlling the other inde- pendent variables. Statistical analyses were performed with SPSS 12.0 (SPSS Inc.2000). Significance for all procedures was determined at the 0.05 probability level (two-tail test).
Results
A total of 182 pairs of patients and caregivers participated in the study. The patients with chronic mental illness were
more likely to be males (51.1%) and single (73.6%), while the caregivers were more likely to be females (57.1%), married and living with spouse (71.1%), and employed (60.0%). The mean ages of patients and caregivers were 36.2 (SD 7.7) and 55.2 (SD 13.5), respectively. The majority of patients (83.0%) were diagnosed as schizo- phrenia. The mean duration of illness was 13.0 (SD 8.9) years. Among the patients, 27.4, 48.4, and 24.2% had years of education less than 10, 10–12, and more than 12, respectively. The majority of the caregivers were parents of the patients (67.1%), and 60.3% of them had less than 10 years of education (Table2).
Table3 shows the three most needed community pro- grams by either patient or caregiver to be caregiver support (72.5%), club house (71.4%) and structured day services
Table 2 Characteristics of patients with chronic mental illness and caregivers
Patient Caregiver
N % N %
Gender
Male 93 51.1 78 42.9
Female 89 48.9 104 57.1
Marriage
Single 134 73.6 15 8.2
Married and living with spouse 31 17.0 128 71.1 Married and living without spouse 17 9.4 37 20.6 Education level
B9 Years 50 27.4 109 60.3
10–12 Years 88 48.4 52 28.7
C13 Years 44 24.2 20 11.0
Religion
Belief 65 35.7 61 33.7
No belief 117 64.3 120 66.3
Job status
Unemployed 72 40.0
Full-time job 62 34.4
Part-time job 21 11.7
Retirement 25 13.9
Age (Mean, SD) 36.2 7.7 55.2 13.5
Duration of illness (Mean, SD) 13.0 8.9 Diagnosis
Schizophrenia 151 83.0
Affective disorder 31 17.0
Kinship with patients
Parents 122 67.1
Children 4 2.2
Spouses 22 12.1
Siblings 25 13.7
Others 9 4.9
(69.2%), while those needs shared by both patients and caregivers were caregiver support (31.9%), club house (26.9%) and structured day services (19.2%). In general, the proportions of needs for specific community programs were higher in caregivers than in patients. The proportions in need of any one of the community programs in the subcategories of patient only, caregiver only, and patient and caregiver were 41.2, 67.0, and 54.9%, respectively.
The three most demanded community programs by either patient or caregiver were structured day services (78.6%), caregiver support (74.7%), and club house (74.2%). The community programs most demanded by patients and caregivers were caregiver support (33.0%), structured day services (29.1%) and club house (28.6%).
The proportions of demands for any one of eight commu- nity programs in the subcategories of patient only, care- giver only, and patient and caregiver were 42.9, 65.9, and 59.3%, respectively. In general, the proportions of demands for the eight community programs were higher than those of needs for community programs.
After multiple logistic regressions analysis, independent variables achieving statistical significance in any of com- munity psychiatric rehabilitation programs are illustrated in Tables4 and 5. The study results shows that caregivers
who were married and lived without spouses (OR 10.93), had 10–12 years of education (OR 3.4), were younger (OR 0.92), and were parents of patients (OR 0.09) had higher probabilities of being in need of structured day service than those who were single, had B9 years of education, were older, and were sibling of patients. Caregivers as parents of patients had a higher probability of being in need of drop-in services than did caregivers as sibling of patients. The major factors associated with a need for residential reha- bilitation and accommodation were the marital status of patients (single patients had a higher probability than patients who were married and living with a spouse).
Patients with 10–12 years of education (OR 3.14) and caregivers with religious beliefs (OR 2.96) had a higher probability of being in need for a club house than patients with less than 10 years’ education and caregivers with no religious belief (Table4).
Caregivers who were younger (OR 0.92) and married (living with/without a spouse) (OR 16.83, 30.28) had a higher probability of demanding structured day services than did caregivers who were older and single. Patients who were single (OR 0.15) and with 10–12 years of edu- cation (OR 3.13)had a higher probability of demanding a club house than were patients who were married and living Table 3 Needs and demands for community psychiatric rehabilitation programs from the perspectives of patients and caregivers
Need/demand No need/demand
Patient only Caregiver only Patient and caregiver Totala N %
N % N % N % N %
Need
Structured day service 12 6.6 79 43.4 35 19.2 126 69.2 56 30.8
Drop-in service 16 8.8 68 37.4 27 14.8 111 61.0 71 39.0
Residential rehabilitation 15 8.2 42 23.1 12 6.6 69 37.9 113 62.1
Accommodation 12 6.6 29 15.9 6 3.3 47 25.8 135 74.2
Club house 23 12.6 58 31.9 49 26.9 130 71.4 52 28.6
Home care 23 12.6 29 15.9 26 14.3 78 42.9 104 57.1
Respite service 17 9.3 44 24.2 8 4.4 69 37.9 113 62.1
Caregiver support 28 15.4 46 25.3 58 31.9 132 72.5 50 27.5
Any of above 75 41.2 122 67.0 100 54.9
Demand
Structured day service 18 9.9 72 39.6 53 29.1 143 78.6 39 21.4
Drop-in service 18 9.9 66 36.3 36 19.8 120 65.9 62 34.1
Residential rehabilitation 17 9.3 54 29.7 28 15.4 99 54.4 83 45.6
Accommodation 13 7.1 44 24.2 20 11.0 77 42.3 105 57.7
Club house 25 13.7 58 31.9 52 28.6 135 74.2 47 25.8
Home care 29 15.9 35 19.2 33 18.1 97 53.3 85 46.7
Respite service 21 11.5 57 31.3 21 11.5 99 54.4 83 45.6
Caregiver support 29 15.9 47 25.8 60 33.0 136 74.7 46 25.3
Any of above 78 42.9 120 65.9 108 59.3
a Denoted the need/demand perceived by either patients or caregivers
Table4Factorsrelatedtoneedsforeachspecificcommunitypsychiatricrehabilitationprogram Structuredday serviceDrop-inserviceResidential rehabilitationAccommodationClubhouseHomecare OR95%CIOR95%CIOR95%CIOR95%CIOR95%CIOR95%CI Patients Marriage(ref:single) LivingwithspouseNSNS0.10(0.01,0.75)0.05(0.00,0.74)NSNS LivingwithoutspouseNSNSNSNSNSNS Educationlevel(ref:B9) 10–12YearsNSNSNSNS3.14(1.24,7.97)NS C13YearsNSNSNSNSNSNS AgeNSNS1.10(1.02,1.20)NSNS1.11(1.02,1.21) Caregivers Marriage(ref:single) LivingwithspouseNSNSNSNSNSNS Livingwithoutspouse10.93(1.14,104.95)NSNSNSNSNS Educationlevel(ref:B9) 10–12Years3.40(1.10,10.58)NSNSNSNSNS C13YearsNSNSNSNSNSNS Religion(ref:no)NSNSNSNS2.96(1.15,7.65)NS Age0.92(0.86,0.99)NSNSNSNS0.92(0.86,0.98) Kinship(ref:parents) ChildrenNSNSNSNSNSNS SpousesNSNSNSNSNSNS Siblings0.09(0.01,0.76)0.11(0.02,0.77)NSNSNS0.09(0.01,0.70) OthersNSNSNSNSNS0.04(0.00,0.56) ORoddsratio,CIconfidenceinterval,refreferencecategory,NSnotsignificant
with a spouse, and had B9 years of education. Caregivers who were older (OR 0.92) and were parents of patients had a higher probability of demanding home care, whereas patients with a longer duration of illness (OR 1.09) and caregivers as spouses (OR 11.92) had a higher probability of demanding respite services (Table5).
Discussion
This study assesses the needs and demands for community psychiatric rehabilitation programs from the perspectives of patients and caregivers and provides important infor- mation for a developing community mental healthcare system. Based on the quantity of healthcare resources, the care planners could adopt the needs perceived by both patients and caregivers or choose the needs perceived by either patients or caregivers. The research results suggest that the needs and demands perceived by both patients and caregivers range from 3.3 to 31.9% and those perceived by either patients or caregivers range from 25.8 to 72.5% for the eight community programs. The demands for commu- nity programs are greater than the needs for corresponding programs, implying that those who will use services (demand) in the future might not now feel themselves in need of those services (need). Offering needed services is a high priority in healthcare policy and the care systems ought to avoid providing services for in which there is no
need. The psychiatric care system should develop an edu- cational campaign to balance the needs and demands for community psychiatric rehabilitation services and to pro- vide services for those who perceive the need.
Based on health statistics (Department of Health 2006, 2007), the proportion of patients using the two existing community programs (structured day services and resi- dential rehabilitation) are only 3.1 and 3.6%, respectively.
The current study points out the extreme shortage of these two programs. For those six community programs that do not exist in Taiwan, over 25% of study subjects needed or demanded them, indicating that these facilities serve spe- cific functions that are not covered by current programs. It is notable that the club house is among the most needed and demanded programs. This suggests that from the patients’
perspective, autonomy might be one important factor determining their choice of programs, since club house is distinct in that professional supervision is absent and activities are initiated by members. The high need and demand for caregiver support might have reflected the great burden upon caregivers under the current mental healthcare system. Accordingly, providing more programs for caregiver support is likely to diminish the needs and demands for psychiatric services, through fostering the care potential of caregivers and their families.
The results of multivariate analyses reflect the individ- uality of programs and the target populations they are supposed to serve an important reference for care planners Table 5 Factors related to demands for each specific community psychiatric rehabilitation program
Structured day service Drop-in service Club house Home care Respite service
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Patients
Marriage (ref: single)
Living with spouse NS NS 0.15 (0.03, 0.91) NS NS
Living without spouse NS NS NS NS NS
Education level (ref: B9)
10–12 Years NS NS 3.13 (1.20, 8.18) NS NS
C13 Years NS NS NS NS NS
Duration of illness NS NS NS NS 1.09 (1.03, 1.16)
Caregivers
Marriage (ref: single)
Living with spouse 16.83 (1.56, 181.95) 10.54 (1.46, 76.24) NS NS NS
Living without spouse 30.28 (1.87, 490.53) 19.47 (1.92, 197.89) NS NS NS
Age 0.92 (0.86, 0.99) NS NS 0.92 (0.87, 0.98) NS
Kinship (ref: parents)
Children NS NS NS 0.01 (0.00, 0.66) NS
Spouses NS NS NS NS 11.92 (1.22, 116.45)
Siblings NS NS NS 0.11 (0.02, 0.81) NS
Others 0.10 (0.01, 0.74) NS NS 0.03 (0.00, 0.36) NS
OR odds ratio, CI confidence interval, ref reference category, NS not significant
in improving the efficiency of community programs. The results indicate that caregivers’ factors dominated over all related factors of needs and demands for these community programs, implying that the advocates of community psy- chiatric rehabilitation must emphasize the importance of communications with caregivers. For example, married and younger caregivers might favor structured day services because they have little time to care for the patients, and they might more easily accept modern community pro- grams. Single patients were in need of residential rehabil- itation and accommodation. In the Oriental culture of Taiwan, parents represent the majority of caregivers (70.1%) (Hwu et al. 1995) and are usually devoted to taking care of their children with schizophrenia (Yeh et al.
2008). It is plausible that, once their parents pass away, single patients who have no spouse to take care of them will be anxious about the possibility of being homeless, hence their need for residential rehabilitation and accom- modation. In this regard, it is important to offer assistance to parents and spouses in order to enhance their capacity as caregivers. This might, in turn, decrease the need for res- idential rehabilitation and accommodation services.
Although club house is not available in Taiwan, patients with a higher level of education and caregivers having religious faith were keen to have this kind of service and it turned out to be the most needed and demanded of the community programs. This finding might reflect a concern for autonomy in the better educated patients and might be further incorporated into the current psychiatric healthcare system.
It should be cautioned that the need and demand for individual community programs may be overestimated in the current study, since patients and caregivers could have multiple options among the eight programs of community psychiatric rehabilitation. Although they may choose multiple community programs according to their needs and demands, in reality, they could not receive all these ser- vices at the same time. However, data exploring the needs and demands for community programs are especially informative for those countries with a shortage of com- munity psychiatric care resources. Finally, considering that, for individual patients, the course of disease and family support will change over time, patients should be provided with various services to meet their needs across disease stages and life cycles. In this regard, the patients need and demand for more than one community program.
Another statistical issue might be reminded, that more independent variables in multiple logistic regression anal- ysis might cause more OR’s tests achieving statistical significance. Since this potential error, the implication of the research results of the multivariate analyses might be taken conservatively.
From the policy-making perspective, information about the needs and demands for service programs supports recommendations for changes in the design of community psychiatric healthcare systems. The multi-level needs and demands for community programs require that policy makers oversee the development of community care sys- tems step by step.
Acknowledgments This study was supported by a grant from the Department of Health in Taiwan (No. DOH96-TD-M-113-045b). We thank Chiao-Chicy Chen, Chang-Jer Tsai (Taipei City Hospital);
Joseph Jror-Serk Cheng (Bali Psychiatric Center); Happy Kuy-Lok Tan (Taoyuan Mental Hospital); Hong Chen (Tsaotun Psychiatric center); Ta-Jen Chang (Jianan Mental Hospital); Frank Huang-Chih Chou (Kaohsiung Kai-Suan Psychiatric Hospital); Chih-Yuan Lin (Yuli Veterans Hospital) in seven psychiatric hospitals.
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