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Psychiatric referral pattern in general hospital.
Correspondence Address:
Here we have tried to analyse the psychiatric referral pattern in general hospital setting. In one year period, 20.20% of the total new cases in psychiatry O.P.D. were referred cases. Majority of the patients were referred at O.P.D. level. Males were more than females. Physicians referred maximum cases than surgeons and gynaecologist. Neurosis was the common diagnosis amongst the referred cases. As one of the senior psychiatrists has mentioned 'lack of referral's by the non-psychiatrists has been an unfortunate negative factor for the growth of psychiatry.
Psychiatric disorders carried social stigma in the past, on account of its association with mental hospitals. There were only three psychiatric units attached to the general hospital in the country before independence. With the passage of time, almost every major hospital has psychiatric facilities. Today, psychiatry units have been functioning independently of mental hospitals. However, psychiatry still receives step motherly attitude and treatment from other branches of medicine. The tendency still continues to consider that, psychiatry treatment is the last resort, a wastepaper basket for dumping cases as functional. Physicians refer the cases to psychiatry only when the positive findings cannot be elicited on clinical examination or laboratory investigations. Even in urban setting, the psychological factors in the care of patients are ignored. This is in spite of the fact that more than 50% of all the illnesses have roots in psychological factors, which needs attention and treatment. The current study was done in a general hospital on the pattern of psychiatric referral to assess the awareness and attitude of other departments towards this speciality.
The study was carried out in the Psychiatry Department in General Hospital in one-year period. The department runs O.P.D. on all the days of the week. The separate registration is maintained by clerk for each and every new cases where the special mention is made for the referred cases either from O.P.D. or indoor. Original case papers are kept in the department itself. Data has been collected from the registration books and O.P.D. papers. The referred cases were segregated and analysed. In majority of the cases, provisional diagnosis was made which was confirmed in subsequent visits. 1) Total number of new cases 2) Socio-demographic data 3) Total number of referred cases 4) Source of reference 5) Diagnosis Whatever cases came to casualty after routine O.P.D. hours were excluded from the study.
Out of the total 4,688 new cases seen in one-year period, 994 were referred cases. Ten cases were referred from institutes outside the hospital campus and 37 cases original case papers could not be traced. So only 947 cases have been analysed. Thus the percentage of the reference works out to be 20.20%. [Table - 1]. Largest number of patients was in the age group of 16 to 45 years i.e. 83.64% of the total population. [Table - 2]. Males were 71.26% and females were 28.70%. [Table - 3]. As it is seen in the Table 3, 69.01% references were at O.P.D. level and 30.99% were referred as indoor patients. The main source of reference was Medicine Department. [Table - 4]. Neurosis was found to be the most frequent disorder (51.95%), psychosis was found in 14.15% of the cases. Alcoholism, drug addictions and other personality disorders were found in 12.1% of the cases. Organic brain syndrome was present in 8.1% of the cases. Sexual disorders were found in 2.12% of the cases. Mental retardation was found in 5.04% of the cases. 0.98% cases were kept under observation and no psychiatry abnormality was found in 2.25% of the cases [Table - 4].
Only 20.20% cases were referred that means majority of the patients i.e. 78.80% came on their own or brought by the relations or directly referred by outside agencies to psychiatry department. The number of referrals is quite low as compared to Kollen et al[3] study where 2/3rd i.e. 66.66% of the total new patients were referred from the other department in one of the teaching hospitals in London. But this British study was carried out nearly 20 years back, when going to psychiatrist directly was a rare phenomenon. The R. C. Jindral and D. M. Hemrajani's[2] study carried out in 1980 shows referral rate to be 30%. The above findings reflect that awareness of psychiatric problems has definitely increased considerably over last two decades. Majority of the patients belong to younger and middle age group, which is in agreement with many other studies. [1] In the study by Kollen et al[3] study majority belonged to the age groups of 20-49 years. It is well accepted that middle age causes lot of tensions and hence neurosis, these cases usually seek help from non- psychiatrist first and then get referred to psychiatry. The age of the youngest patient in our study was 13 years. The number of children referred in our study were less because the child guidance clinic is under Pediatric department. A senior psychiatrist from our department attends to these cases in Child Guidance Clinic (C.G.C.) every day. The oldest patient seen in our study was 80 years old who was referred for dementia. Less number of females was referred though neurotic disorders are supposed to be more common in females. However, the pattern of sex representation in our study was identical to the ratio M: F in the total attendance of the hospital and the total new patients in the department. One reason could be that, because of social customs the females are brought to the hospital only in serious condition while male population attends even for minor problems. The percentage of OPD reference was more because only after tight scrutiny patients get admitted. The ratio of OPD: Indoor references were 2.2:1. It is comparable to other studies[3],[4]. The main source of reference was medicine including all the branches of Medicine. But 90% of these references were from General Medicine. This is understandable as the Psychiatry is a branch of Medicine and physicians have to deal with the illnesses having psychological component, and they are more psychiatrically oriented. In our study there were many references from Skin and V. D. Dept. This requires special mention because majority of them had sex anxiety or what is commonly known as 'Dhatu Syndrome'. Less number of patients was referred by surgeon as the surgical patients have short pre-operative stay in the hospital and surgeons usually like to concentrate only on the physical aspect or only the organ where they have to operate. This is also in agreement with other studies[1],[3]. Only 1.36% cases were referred from Gynaecology and Obstetric Department. Low reference rate from Gynaecology might be due to their acceptance of emotional disturbances in relation to menstruation, sex, pregnancy, etc. as normal and even if they are aware of the psychological factors some how they don't seek psychiatric help. Routinely they refer cases where there is obvious psychosis after delivery or other controversial issue of tube ligation and hysterectomy in mentally retarded girls, where they want psychiatrist to share legal and moral responsibilities. Neurosis was the commonest diagnosis, which is in agreement with Western studies[4]. Neurotics always like to consult the physician rather than psychiatrist for their somatic symptoms, since they are not willing to accept the symptom as functional. One reason might be that social stigma is still attached to psychiatry and wrong notion by people that functional means malingering. Among neurosis, anxiety reaction had highest prevalence i.e. 28.87% followed by neurotic depression 13.2% and hysteria 7.06%. Prevalence of anxiety was less and hysteria was more[1]. In the present study anxiety was diagnosed more frequently in outdoor cases. Sex anxiety was really high which requires special mention. Amongst indoor references percentage of hysteria was more. Psychosis was found in only 14.15% of the cases, which is expected because this disorder can be easily identified by family members or general practitioner and they are brought to the Psychiatry Department directly. A few referred cases had typical schizophrenia, mania, etc. Usually chronic psychotics, admitted in other wards for some other medical problems were referred for revaluation and treatment. Alcoholism, drug addiction and other personality disorders were diagnosed in 12.1% of the cases. Amongst these 90% were suffering from alcoholism and drug addiction. Usually patients were admitted to medicine side for somatic problems like malnourishment, cirrhosis, peripheral neuropathy, hypoglycaemia or some time in withdrawal. Whenever patients expressed the desire to give up alcohol or drug, they were referred to psychiatry. In Anstee's, study alcoholism and drug addiction was found in 11% of the cases[1] and in other study personality disorder was found in 4% of cases[4]. Organic brain syndrome was found in 8.10% of the cases. Majority were referred from General Medicine or Neurology. Provisional diagnosis made by referring doctor was hysteria in majority of the cases. Here patients may be showing psychotic or neurotic symptoms but underlying there was an organic cause. Hysterical cases require long-term follow up. These are the cases where psychiatrist's knowledge is challenged and they keep him in touch with other branches of medicine. Sexual disorders were found in 2.12% of the cases, which includes premature ejaculation, impotency, sterility, transsexuals, homosexual, etc., though premature ejaculation and impotency were the commonest. Epilepsy was diagnosed in 2.25% of the cases. Epileptics were referred for behavioural problems, personality deterioration or psychosis. Mental retardation was found in 5.04% of the cases, they were referred mainly for behavioural problems, scholastic backwardness or abnormal behaviour. But in many of these cases it turned out to be induced aggression or uninhibited behaviour and not a real psychosis. No psychiatry abnormality was found in 2.25% of the cases. In Anstee's study, it was 1%. In 0.98% cases diagnosis was not definite and they were kept under observation. Psychosomatic disorder was found in 1.05% of the cases like broncheal asthma, peptic ulcer which is definitely low. But majority of these cases must have got included in anxiety or depression.
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