FREQUENCY OF PSYCHIATRIC DISORDERS IN REFERRED HOSPITALIZED PATIENTS OF OTHER MEDICAL DISCIPLINES A HOSPITAL BASED STUDY.
Objective: To asses the frequency of psychiatric disorders in the admitted patients of other medical disciplines at PNS Shifa Karachi. Study Design: Cross sectional study. Place and duration of study: The study was conducted at PNS Shifa Karachi from April 2007 to Oct 2007. Patients and Methods: Total of 427 hospitalized patients in other medical disciplines at PNS Shifa Karachi; a tertiary care hospital, referred for psychiatric consultation in sequence were studied. Results: The age of the patients ranged from 13 to 97 years, with the mean age being 43.22 years. Sixty four percent patients of the studied individuals were males. Forty nine percent patients were diagnosed to be suffering from Depression/Dysthymia. Twelve percent patients qualified the diagnosis of Anxiety disorder and Reaction to severe stress and adjustment disorders each.
Seventeen percent patients suffered from Dementia, Delirium, Psychoactive substance abuse, Acute and transient Psychotic disorder, Schizophrenia, Bipolar affective disorder/Mood disorder and Puerperal depression. Conclusion: A considerable proportion of psychiatrically ill patients require psychiatric intervention either because of their primary psychiatric disorder or secondary psychological reactions to physical morbidity. Such intervention in time not only improves the quality of patient's life but also saves the heavy portion of the budget utilized for medical services in these patients later on if not diagnosed earlier.
INTRODUCTION All illnesses have both psychological and physical dimensions. This may seem a startling claim, but on reflection it is uncontroversial. Disease doesn't come to doctors; patients do; and the processes by which patients detect, describe and ponder their symptoms are all eminently psychological1. The relative prevalence of specific psychiatric disorders encountered in medical setting is very different from that found in specialist psychiatric services. Neurosis, somatoform disorders and alcohol problems are most commonly seen in primary care2. All intensive care units (ICUs) deal mainly with anxiety, depression and delirium. Delirium occurs in 15-30 % of hospitalized patients3,4. In recent years, there has been an increasing awareness of the importance of the psychological factors in the causation of various physical illnesses. Effective psychiatric treatments both pharmacological and psychological have been developed and the psychiatric units in the general hospitals have been established.
Because of these advances as the psychiatry re-enters the mainstream of medicine, it is linked to other medical disciplines by consultation and liaison psychiatry, which involve the practical application of all psychiatric knowledge, ideas and techniques when they may be helpful to other specialists in the care and understanding of their patients. Epidemiological studies have shown high percentage of psychiatric symptoms in medical and surgical in-patients i.e. 30-65%5, much of it unrecognized and untreated; for an example persistent depression was not recognized in nearly 40 % patients hospitalized with heart failure6. Psychiatric disorder is not only a cause of suffering to medical patients but also affects the prognosis and treatment of their medical conditions, complicates management, leads to poorer outcome and increases the consumption of general medical resources and is a common reason why non psychiatric doctors find it difficult to help with the application of standard medical approaches5,6.
Since psychiatric disorders are responsible for considerable distress and can be persistent, particularly in in-patients and can also predispose to greater morbidity due to physical illness, it is important that these should be detected and treated as early as possible .This can be achieved by establishment, improvement and better utilization of consultation and liaison services in general hospitals. In a few North American general hospitals with large Consultation-Liaison services, up to 5 % of all admissions are referred to a psychiatrist7.This trend of establishing psychiatric units in general hospitals and collaboration of psychiatry with other medical disciplines has continued in Pakistan but we are still lagging behind in this field. Due to little research work in this all-important area we have no reliable statistics in this field. Therefore this effort was carried out to add to this vital aspect of psychiatry.
PATIENTS AND METHODS A total of 427 hospitalized patients in other medical disciplines at PNS Shifa Naval hospital; tertiary care hospitals, referred for psychiatric consultation, from April 2007 to Oct 2007 were studied; (an extension of dissertation based study). The outdoor cases and the patients who were seen by a psychiatrist at emergency department were not included. Informed consent was obtained from all the hospitalized patients/caregivers of the patients in case patients themselves were unable to do so. The patients were interviewed in detail. Clinical examination was carried out including mental state examination by two psychiatrists. All relevant information was recorded on the semi-structured proforma. The Minimental state examination was the part of proforma. The Psychiatric diagnosis was made according to the International Classification of Diseases (ICD) - 10 diagnostic criteria. After the clinical diagnosis of psychiatric illness different rating scales were used according to the diagnosis.
All the data collected in the study was analyzed using SPSS Version 10.0. Relevant descriptive statistics, like frequency, percentage, gender, locality, education level and diagnosis was computed for qualitative output response. Mean and Standard deviation were computed for quantitative variables like the age of the patient. RESULTS No patient included in study was dropped. The age of the patients in this study ranged from 13 to 97 years. The mean age of the patients being 43.22 years (SD= 19.05). Eight percent (34) cases of the studied population was below the age of 20 years, twenty percent (86) above 60 years, forty one percent (175) between 21 and 40 years; while thirty one percent (132) belonged to age group of 41 to 60 years. There were sixty four percent (273) males and thirty six percent (154) females. The maximum number of the patients was either illiterate or below Matric i.e. forty seven percent (201).
The seventy four percent (316) were married, fifteen percent (64) were unmarried, while eleven percent (47) were widows. The thirty two percent (137) of referrals were housewives by profession, followed by sailors/soldiers of Armed forces, who made twenty five percent (107) of the studied group. In about sixty two percent (265) cases there was no history of any psychiatric illness/consultation in the past; thirty eight percent (162) had earlier remained under care of psychiatrist either as an indoor or outdoor patients. Thirty seven percent (158) of patients had no history of previous medical and surgical illness, while sixty three percent (269) had remained under treatment of different medical and allied and surgical and allied specialties. Fifty two percent (222) denied any stress, while thirty seven percent (158) narrated family/marital/financial stress and eleven percent (47) reportedly faced work stress.
Depending on the clinical diagnostic impression, different rating scales were applied to sixty nine percent patients while in 31% cases no rating scale was applied either because of their prediagnosed illness or deteriorated cognitive state (Table-1). Fifty eight percent (248) were referred on account of diagnostic difficulties; thirty two percent (136) because of genuine psychiatric illness and ten percent (43) because of management problems.
Maximum number of cases i.e. seventy percent (299) were referred by physicians; followed by Surgeons who referred thirty percent (128) cases (Table-2). Out of 427studied cases ten percent (43) were diagnosed not to be suffering from any psychiatric illness, while forty nine percent (209) suffered from depression, twelve percent (51) from anxiety, twelve percent (51) from reaction to severe stress and adjustment disorder, five percent (21) from functional psychoses, seven percent (30) from organic disorders including delirium and dementia and three percent (13) from psychoactive substance abuse. One percent each was diagnosed to be suffering from puerperal depression (4) and organic mood disorder (5) (Table-3) DISCUSSION Liaison psychiatry in bridging the gap between psychiatry and general medicine and providing clear picture of the disorders occurring in hospital practice and the task of psychiatrist in such situation was studied.
The liaison psychiatrist must be aware of the effects of medical drugs and the interaction between medical and psychotropic drugs and must know how to stay abreast of these reactions7-9. Epidemiological studies have shown that the psychiatric problems are present in almost all branches of medicine10. The prevalence of depression in the general population in Pakistan has been reported to be from 10-25 % in males and 25-66 % in females11,12. Between 10 and 20 million American youth are having a disproportionate burden of psychiatric co-morbidities particularly depression13. Studies also have shown 2 to 3 fold increased risk of future cardiac event in patients with coronary artery disease and depression14 ,about 30-50% patients of dementia also have depression as co-morbid condition15 and higher prevalence of hepatitis C virus has been reported in psychiatric patients in public sector16. Cardiac neurosis is a frequently encountered form of Somatization particularly in Armed forces personnel and females17.
Another local study found 34.11% psychiatric morbidity in attendees of dermatology clinic18. Up to 45 % of medical in-patients have psychiatric disorder. Prevalence of depression in medical in-patients in Pakistan has been reported up to30.5 %19 to 39.26 %20 in different studies. The most frequent psychiatric diagnoses in medical in-patients have been depression and anxiety21,22. This is also reflected in our study as a group but with little variation in individual disorders. The most common psychiatric diagnosis in this study was depression. Unlike previous studies the diagnosis of organic brain disorders was much less e.g. in one study it was 32%21. About 10 % of patients did not qualify any psychiatric diagnosis22. About 70% were referred by medical and allied specialties, a finding consistent with study done by Ali23.
But unlike that study, where the maximum referrals were because of management and behavioral problems, maximum referrals in our study were because of diagnostic problems followed by genuine psychiatric illness and management problems. The first consideration should be given to organic mental disorders in evaluation of sudden onset of abnormal behavior, changes in mood, thoughts, or cognitive functions. In its most typical form, physicians can easily diagnose delirium while it is not uncommon for them to mistakenly ascribe even gross organic delirium to some psychological illness and visual hallucinations to schizophrenia. The early correct diagnosis of organic disorders is insisted as its failure may lead to misdiagnosis and permanent functional loss21.
Benefits of liaison Psychiatry to general hospital patients include comprehensive physical and psychological care including less need for investigations, shorter in-patients stay, better quality of life, less distress and decreased rate of deliberate self harm9. In our study total 08% (35) cases suffered from organic mental disorders due to one or other cause. These patients often are troublesome for the physicians in management, needing frequent psychiatric consultations. 10% (43) patients in this study had no clinical evidence of psychiatric problems and therefore most of these cases were referred back to consulting specialists either for management of their underlying physical illness or for further investigations. Most of the cases diagnosed to be suffering from psychiatric illness in present study were suffering from co-morbid medical or surgical disease(s). In such cases info-care sessions and psychotherapy were helpful along with pharmacotherapy in deserving cases.
Little research work has been done on the subject, particularly in our country. Not only further replication is required to be carried out but also required is improved liaison between psychiatrists and other clinicians for better patient management as these aspects of liaison psychiatry are almost absent in our hospitals. It will not only give more insight into the psychiatric morbidity of indoor medical patients but will also improve the role/image of psychiatrist in the eye of other specialists and will also help to reduce stigma of psychiatric Illness. CONCLUSION A proportion of psychiatrically ill hospitalized patients of other medical disciplines require psychiatric intervention either because of their primary psychiatric illness or secondary psychological reactions to physical morbidity. Such timely intervention not only improves the quality of patient's life but also cut down the heavy budget utilized for medical services in these patients.
There is an urgent extreme need to increase the insight into psychiatric disorders in these patients and to improve the liaison between the psychiatrists and other consultants. Furthermore, more research is required in this vital field of psychiatry.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Sep 30, 2010|
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