Psychiatric referrals in two general hospitals.DR Doongaji, RP Nadkarni, ML Bhatawdekar
A prospective study was undertaken to compare the patterns of psychiatric referrals in two general hospitals in Bombay viz. the King Edward Memorial Hospital (64 cases) and the Jaslok Hospital and Research Centre (62 cases). It was observed that depressive symptoms were the most common presenting symptoms in these patients attending either of the hospitals. Similarly, the commonest diagnoses were depression and organic mental disorder. Attempted suicide with organophosphorous compounds was the commonest reason for hospitalization at K.E.M. Hospital (p less than 0.001). A significant number of these patients were females (p less than 0.05). The psychiatric referrals at Jaslok had been hospitalized mainly for suspected medical or neurological illness (p less than 0.001). These patients belonged to higher economic strata and hence had a better paying capacity compared to patients at KEM hospital, a significant number of whom were unemployed (p less than 0.001). The duration of pre-referred illness of patients and their stay at Jaslok hospital were longer as compared to those at KEM Hospital (p less than 0.01). The number of non-relevant special investigations carried out on patients in Jaslok was more (p less than 0.01). Further analysis of diagnoses revealed that a significant number of patients at KEM Hospital were admitted as primary psychiatric illness (p less than 0.05).
Keywords: Delirium, Dementia, Amnestic, Cognitive Disorders, Depression, Hospitals, General, Human, India, Referral and Consultation,
Physical symptoms which cannot be understood medically, or which are present without sufficient medical cause, are frequent reasons for referring patients to a psychiatric inpatient service in a general hospital.
There is an increasing awareness that medical and psychiatric problems may coexist. This had led to a revival of interest in psychiatric units in general hospitals. This report describes and compares the pattern of psychiatric referrals in two general hospitals in Bombay.
This study was conducted in the inpatient services of the Department of Psychiatry, King Edward Memorial Hospital (K.E.M.H.), and the Jaslok Hospital and Research Centre, Bombay (J.H.). The K.E.M.H. is a teaching general hospital where the majority of services is available free of cost or at nominal cost to patients from the poorer and the lower middle social classes. The J.H. is managed by a private charitable trust and has restricted number of services available free of cost to the public. It was decided to study an approximately equal number of patients at both hospitals.
All patients (n = 62) referred for psychiatric consultation during a six-month period at the J.H. were included in the study.
At the K.E.M.H., 64 consecutive cases referred for consultation to the participating psychiatric unit during the initial two months of this period of time, were included in the study.
The referred patients were interviewed in depth. Details of the medical history, clinical examination, mental status examination and laboratory investigations with results were recorded on a proforma. At the time of discharge, the patients' medical charts were re-examined and further ongoing information including the total length of stay in the hospital, further investigations and progress, and the date of discharge were recorded.
[Table - 1]shows the bed strength, the staffing pattern and the number of referrals at both the hospitals.
The two groups of patients differed in so far as the primary reason for hospitalisation of the patients under study was concerned [Table - 2] Attempted suicide with organophosphorus compounds was the commonest primary reason for hospitalisation at the K.E.M.H. (p < 0.001). Suspected medical or neurological illness was the commonest primary reason for hospitalisation at the J.H.
The sociodemographic data was similar in both the groups of patients as far as age; marital status, type of family and educational level were concerned. More male patients were referred at the J.H. while more female patients were referred at the K.E.M.H. (p < 0. 05). There was a large preponderance of patients belonging to the Muslim community (p < 0.02) at the J.H. The J.H. had a larger number of patients who were professionals while there was a large number of unemployed patients at the K.E.M.H. (p < 0.001). The patients at J.H. belonged to higher economic status (p < 0.01) and had more paying capacity (p < 0.001).
The number of patients with a past history of psychiatric or other illness was similar in both the groups. However, more patients at the J.H. had prior consultations with psychiatrists or other specialities, had longer duration of pre-referred illness (p < 0.01), had been hospitalised more often in the past (p < 0.001) and had a longer duration of in-patient stay at the J.H. (mean duration-40 days) as compared to the K.E.M.H. (mean duration-10 days), (p < 0.01).
[Table - 3]demonstrates that there was no significant difference between psychiatric referral groups at both the hospitals regarding presenting complaint, mood disturbance being the commonest presentation in both.
[Table - 4]gives the details of final psychiatric diagnosis at the two hospitals. [Table - 5]shows that a significantly greater number of patients at the K.E.M.H. belonged to category 1, i.e. primary psychiatric illness.
Finally the patterns of investigations carried out in the referred patients by the referring clinicians were compared. For want of a more precise classification, haemogram, urinalysis, stool analysis, and X-ray chest were labelled as "routine" investigations, while detailed blood investigations, ECG, echo cardiogram, X-ray skull, CT scan, angiogram etc. were labelled as "special" investigations. There was no difference in the patterns of "routine" investigations advised for both the groups. The "special" investigations were advised more frequently at the J.H.
An investigation (routine or special) was termed "relevant" if it had influenced either the diagnosis or the subsequent management of the patients in the light of the final diagnosis, while it was termed "non-relevant" if it had not. The number of non-relevant special investigations carried out in the J.H. group (n = 36) was significantly more as compared to the K.E.M.H. group (n = 3) (p < 0.01).
There are some similarities and some differences in the patterns of psychiatric referrals and their prevalence as described in this study when compared with studies in Western countries.
The reported prevalence of psychiatric consultations in the West varies between 2% and 10% of the general hospital population depending upon whether the patients studied were in-patients or out-patients, the screening methods, the criteria used for defining the morbidity, and the presence or absence of a psychiatric unit in the general hospital.
Studies in the West have variously reported a psychiatric morbidity prevalence in medical out-patients ranging from 30% to 83%.,, Indian studies have reported a prevalence rate in medical out-patients ranging between 33.4% and 50%., The prevalence rate reported in our study [Table - 1]approximates the prevalence rate (0.74%) in a study carried out on Chinese in-patients.
The low prevalence rate may reflect the prevailing referral practice. There are many possible reasons for the discrepancy between the rate of liaison referral and the level of psychiatric morbidity. These include failure to recognise psychiatric disorders, the physician's reluctance to refer patients to psychiarists because of the stigma attached to a psychiatric label; a high prevalence of transient, self-limiting psychiatric disorders; low priority of treatment of psychiatric disorders compared with physical disorders; and poor access to or dissatisfaction with psychiatric services.
The number of patients referred for psychiatric consultation with suspected medical problems were not very different in the two hospitals. The patients admitted for attempted suicide (most of them young females) were referred more frequently at the K.E.M.H. as compared with the J.H. Until 1982, attempted suicide was a cognisable offence, and patients with suspected medicolegal problems are frequently admitted in general hospitals rather than private hospitals.
The differences in some of the socio-demographic variables reported in our study, namely, economic status, paying capacity and occupation were not chance occurrence, as the K.E.M.H. administers medical care free of cost or at nominal cost which is not the case at the J.H. The referred patients at the J.H. had longer duration of stay as compared with the K.E.M.H. group probably because of bed availability and also probably because they had more paying capacity.
In our study more female patients were referred for consultation than male patients at the K.E.M.H. Similar findings have been reported elsewhere.,,,, The greater prevalence of female patients referred for psychiatric evaluation in our study can be explained by the fact that maximum number of referrals were for patients who had attempted suicides and who were young females.
In the West, depression is the most frequent diagnosis in psychiatric consultation-liaison services.,,, A prevalence in the range of 33% to 56% has been variously reported in Western studies carried out on in-patients., , ,  Out-patient studies in the West report a prevalence of 12-36%. Indians studies carried out on out-patients report figures varying from 33.4% to 54%., The severity of medical illness is probably responsible for depressive symptoms and depressive syndromes. Organic brain syndrome was the commonest final diagnosis in the Chinese study referred to earlier. As compared with some of these studies which used a retrospective design, our study provides more diagnostic reliability and validity since we used a prospective design with a structured proforma.
A significantly greater number of patients at the K.E.M.H. belonged to category 1 [Table - 5]. As there are no psychiatric inpatient units at the J.H., patients with both medical and psychiatric diagnoses are likely to be admitted under medical units and are then referred for psychiatric evaluation. In the K.E.M.H. however, there are psychiatric units which admit patients with a primary psychiatric illness. It should be noted that these categories may not always be mutually exclusive, e.g., for a patient with malignancy and depression it may be difficult to state whether the depression is reactive to the effects of malignancy, or it is a manifestation of organic mental changes which complicate the malignancy, or that the depression is a complication of treatment with chemotherapeutic drugs. In the first instance the patient would belong to category 6, while in the second instance he or she would be classified either as category 1 or category 5, and in the third instance the classification would be category 4. Diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III)4 also requires, apart from the diagnosis of the primary psychiatric disorder, an assessment of the level of psychosocial stressors and the highest level of adoptation in the past one year. This assessment may be difficult in patients such as the one cited above.
A large number of special investigations which were carried out in patients at the J.H. was not relevant in 36 out of 51. Detecting a disease in patients who have no known or clinically apparent medical illness is a vexing clinical problem. Recently, a series of articles has been commissioned by the Blue Cross-Blue Shield Medical Necessity Project in the USA.,,,, In this series many authors have expressed doubts regarding the utility of investigations in enhancing patient care. The investigations cited include ESR, leucocyte count, chest X-ray, E.C.G. biochemical tests etc. Critical evaluation of these diagnostic tests has shown that the rationale for subjecting patients to an exhaustive battery of investigations is more apparent than real, as they do not substantially influence either the diagnosis or the subsequent management.
The authors thank Dr. G. B. Parulkar, Dean, K.E.M. Hospital, and Dr. N. H. Keswani, Medical Director, Jaslok Hospital and Research Centre for permission to conduct and publish this study. Grateful acknowledgement is made to the consultant staff at both the hospitals for their kind referrals.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]