|Year : 2017 | Volume
| Issue : 1 | Page : 45-49
Sociodemographic profile and psychiatric diagnosis of patients referred to consultation-liaison psychiatric services of general hospital psychiatric unit at a Tertiary Care Center
Shri Gopal Goyal1, Rajesh Sagar2, Pratap Sharan2
1 Department of Psychiatry, DIMHANS, PBM Hospital, SP Medical College, Bikaner, Rajasthan, India
2 Department of Psychiatry, AIIMS, New Delhi, India
|Date of Web Publication||14-Jul-2017|
Shri Gopal Goyal
Goyallo ka Mohalla, Napasar, Bikaner - 334 201, Rajasthan
Source of Support: None, Conflict of Interest: None
Context: Previous studies have reported high psychiatric comorbidity with physical illness. However, referral rate to consultation-liaison (C-L) psychiatry from other departments is very low. There is a paucity of literature from India in this subspecialty of psychiatry. Aims: This study was conducted to assess the sociodemographic profile and psychiatric diagnosis of patients referred to C-L psychiatric services at a tertiary care center. Settings and Design: This was a descriptive cross-sectional study conducted in a tertiary care multispecialty teaching institution. Patients and Methods: The study population comprised all the patients who were referred for psychiatric consultation from other departments to C-L services of psychiatry department for 2 months. Information was collected using semi-structured pro forma, and diagnosis was made based on the International Classification of Diseases-10 criteria. Results: A total of 160 patients were referred for C-L psychiatric services. Majority of the patients were in the age group of 31–45 years, married, educated matriculation or beyond, belonged to Hindu religion, nuclear family, and residing in urban area. The maximum referrals were from internal medicine department (17.5) followed by nephrology (15.0%) and neurology (10.6%). The most common psychiatric diagnosis was depression (12%) followed by delirium (8%). The most common reason for seeking psychiatric consultation was psychiatric clearance of prospective kidney donor and bone marrow transplant/stem cell transplant recipient. Conclusions: Psychiatric comorbidity may present with chronic physical illness. The C-L psychiatry would play a major role in the management of psychiatric comorbidity.
Keywords: Consultation-liaison, general hospital psychiatry unit, psychiatric diagnosis
|How to cite this article:|
Goyal SG, Sagar R, Sharan P. Sociodemographic profile and psychiatric diagnosis of patients referred to consultation-liaison psychiatric services of general hospital psychiatric unit at a Tertiary Care Center. J Mental Health Hum Behav 2017;22:45-9
|How to cite this URL:|
Goyal SG, Sagar R, Sharan P. Sociodemographic profile and psychiatric diagnosis of patients referred to consultation-liaison psychiatric services of general hospital psychiatric unit at a Tertiary Care Center. J Mental Health Hum Behav [serial online] 2017 [cited 2019 Nov 14];22:45-9. Available from: http://www.jmhhb.org/text.asp?2017/22/1/45/210709
| Introduction|| |
Consultation-liaison (C-L) psychiatry is defined as the area of clinical psychiatry that encompasses clinical, teaching, and research activities of psychiatrists and allied mental health professionals in the nonpsychiatric divisions of a general hospital. C-L psychiatry encompasses a broad spectrum of activities. It includes consultation in which a medical specialist provides information of diagnosis and treatment of medical illness, and a psychiatrist assesses and manages the current psychiatric symptoms. Liaison interaction, whereby the psychiatrist becomes an integral part of a medical-surgical team, helps in the recognition of psychological morbidity at an early stage and in the comprehensive management of the patients on the site. C-L psychiatrists treat mainly four types of patients: comorbid psychiatric-medical illnesses; psychiatric disorders directly resulting from a primary medical condition or its treatment, such as delirium; complex illness behavior such as somatoform and functional disorders; and acute psychopathology admitted to medical-surgical units, such as attempted suicides.
Currently, the C-L services in India follow the consultation model, wherein a psychiatrist evaluates and manages the patient referred from a physician/surgeon. C-L psychiatry referral rates from other specialties in India are very low (0.06%–3.6%). Previous studies have reported a high psychiatric comorbidity with physical illness (18.42%–53.7%). Studies conducted in India and Nepal report internal medicine to be the most common department seeking consultation from psychiatrists. Studies on inpatient referrals report organic brain syndrome to be the most common diagnosis,, while those on outpatient referrals report neurotic, stress-related, and somatoform disorders., Still, there is a dearth of studies which have focused on C-L psychiatry in India. Our center is having the maximum specialties in India. Hence, this study was conducted to assess the sociodemographic profile and psychiatric diagnosis of patients referred to C-L psychiatric services at a tertiary care center.
| Patients and Methods|| |
The present study was a descriptive cross-sectional study conducted in a tertiary care multi-specialty teaching institution providing services to a major part of North India. It is having the maximum number of specialties in India. The study population comprised all the patients who were referred for psychiatric consultation from other departments (mainly inpatient) to C-L services of the department of psychiatry for 2 months, from April 2009 to May 2009. All the referred cases are initially evaluated by a detailed clinical interview by a junior resident, supervised by a senior resident, and subsequently reviewed by a consultant psychiatrist. The cases were evaluated for psychiatric illness, diagnoses were made as per the International Classification of Diseases-10 (ICD-10) criteria, and an appropriate treatment plan was formulated and carried out. The semi-structured pro forma was made to document the information regarding sociodemographic data, source of referral, diagnosis of the physical condition, reason for psychiatry referrals, psychiatric diagnosis, and management done. Informed verbal consent was taken from patients/key informant. Data were analyzed using descriptive statistical methods.
| Results|| |
A total of 160 patients were referred for psychiatric consultation from various departments during the study period. The total number of patients referred from outpatient department (OPD) was 20 (13%) and the remaining was referred from inpatient department. However, the total number of patients admitted in various departments of our institution during this period was approximately 25,000. Therefore, referral rate (0.006) was very low in comparison to the number of admission.
The mean age of patients was 40.69 years (standard deviation-16.40), with a range of 7–80 years. A majority of the patients belonged to the age group of 31–45 years (n = 47, 29.4%) followed by the age group of 16–30 (n = 46, 28.8%) and 46–60 (n = 40, 25.6%) years. The number of patients in the age groups of 1–15 years and above 60 years was 5 (3.1%) and 21 (13.1%), respectively. Females (n = 82, 51.2%) were slightly more in number than males (n = 78, 48.8%). Majority of the patients were married (n = 109, 68.1%), educated matriculation or beyond (n = 126, 78.8%), belonged to Hindu religion (n = 137, 85.6%), nuclear family (n = 124, 77.5%), and residing in urban area (n = 122, 76.3%). About 50% of the patients (n = 79) were currently employed before hospitalization. About 40% of the patients (n = 64) were homemaker followed by 13% of the patients (n = 21) who were self-employed.
Source of referral
Psychiatry C-L was most commonly sought by the departments of internal medicine (n = 28, 17.5%), nephrology (n = 24, 15.0%), and neurology (n = 17, 10.6%). Referrals were also sought by the department of medical oncology (n = 15, 9.4%), surgery (n = 13, 8.1%), hematology (n = 8, 5%), orthopedics (n = 7, 4.4%), gastroenterology (n = 7, 4.4%), and endocrinology (n = 5, 3.1%). When data were analyzed based on broad medical and surgical specialties, maximum referrals were sought by medical specialties (n = 114, 71.3%) compared to surgical specialties (n = 46, 28.8%) [Table 1].
Reason for consultation
The most common reason for seeking psychiatric consultation was psychiatric clearance of prospective kidney donor and bone marrow transplant (BMT)/stem cell transplant recipients (n = 37, 23.1%) followed by the assessment of suicidal behavior (n = 27, 16.9%) and altered behavior (n = 23, 14.4%). The other major reasons for consultation were assessment of psychiatric illness (n = 16, 10%), assessment of addiction (n = 13, 8.1%), assessment of depressive symptoms (n = 11, 6.9%), and assessment of somatic complaint (n = 11, 6.9%).
A significant number of patients also received nil psychiatric illness diagnosis (n = 56, 35%). The most common psychiatric diagnosis was depressive disorder (n = 22, 13.8%) followed by delirium (n = 14, 8.7%), substance use disorder (n = 14, 8.7%), psychotic disorder (n = 10, 6.2%), bipolar disorder (n = 7, 4.4%), and emotionally unstable personality disorder (n = 6, 3.8%). When data were analyzed based on broad ICD-10 categories, the most common category was mood disorder (F30-F39) (n = 29, 18.1%) followed by organic including, symptomatic mental disorders (F00-F09) (n = 22, 13.8%) and neurotic, stress-related, and somatoform disorders (F40-F48) (n = 17, 10.6%) [Table 2].
When psychiatric diagnoses were compared based on gender, nil psychiatric diagnosis and mood disorder (F30-F39) were significantly more among females (n = 33, 40.2%; n = 20, 24.4%) compared to males (n = 23, 29.5%; n = 9, 11.5%), respectively. However, males (n = 12, 15.4%) were significantly more diagnosed with mental and behavioral disorders due to psychoactive substance use (F10-F19) compared to females (n = 2, 2.4%). Similarly, when psychiatric diagnoses were compared based on the broad specialties, nil psychiatric diagnosis and mood disorder (F30-F39) were significantly more in medicine specialties (n = 46, 40.4%; n = 24, 21.1%) compared to surgical specialties (n = 10, 21.7%; n = 5, 10.9%), respectively [Table 3].
Referral based on medical illness
When data were analyzed on specific medical illness, the most common medical illnesses in patients seeking psychiatric consultation were malignancy (n = 25, 15.6%), diabetes mellitus (n = 14, 8.8%), and tuberculosis (n = 11, 6.9%). The other major medical illnesses were gastrointestinal stenosis (n = 6, 3.8%), multiple myeloma (n = 6, 3.8%), and seizure (n = 6, 3.8%).
| Discussion|| |
C-L services are the integral part of general hospital psychiatry unit. It bridges the gap between psychiatry and other medical and surgical specialties. Every physical disorder has psychological and social component according to biopsychosocial theory. Therefore, its significance is considered in terms of holistic care approach that looks upon both the psychological and physical components of any illness. This collaborative approach would not only reduce hospital stay but also improve the quality of life of patient and reduces the burden of physical illness.
Referral rate was very low (0.006) in our study compared to other studies conducted in a general hospital psychiatry unit in India and Nepal with referral rate ranging from 1.4% to 3.78%., However, a recent review reported referral rate in India to be 0.15%–3.6%. The reason for low referral in our study could be that mainly inpatients were included in the study. Majority of patients (58.2%) belonged to age range between 15 and 45 years, similar results (59.8%–70%) were found in various previous studies.,,, The referred patients in the age group more than 60 years was 13%. This was more than a previous study conducted in India, ranging between 3.3% and 8.8%; however, this proportion was less than European countries (30%). The reasons for lower proportion than Western countries were lower proportion of elderly population in India due to less life expectancy than Western countries, preference of other means of treatment for psychological problems (spiritual), and less recognition of psychological symptoms in elderly population by physician; they would consider psychological symptoms as part of aging process. We received female patients' referral slightly more than male patients. The finding from the previous study has not been conclusive in this aspect. Some studies have shown similar results to our study,,, while others have reported male preponderance., The maximum number of patients were married, homemaker, belonged to nuclear family, and residing in urban areas. This was explained on the basis that our center in New Delhi and rapid urbanization in metro cities lead to change in the structure of family organization into nuclear type.
The majority of patients were referred from the department of medicine. This is consistent with previous studies which have shown that maximum patients were referred from the department of medicine.,,,, However, the number is less compared to other studies as our institution has multiple super-specialty wards, which leads to overall decrease in the proportion of department of medicine. We also got the second highest consultation from the department of nephrology. This could be explained by our institution having renal transplant facility which seeks psychiatric clearance of prospective kidney donors. When we analyzed the data dividing into two broad specialties, medical specialties comprised three-fourth shares of all consultations.
When the reasons for referral were analyzed, it was found that psychiatric clearance of prospective kidney donor and BMT/stem cell transplant recipients was the most common reason. These results were not reported in earlier studies from India as few centers are having such facilities. The second most common reason was assessment of suicidal behavior. This can be explained by legal mandate of psychiatric assessment of suicidal-attempted patients. Similarly, many studies reported high referral for self-harm/suicidal attempt ranging from 9.7% to 33.14%., The other common reason for referral in our study was assessment of altered behavior. Most of the cases referred for altered behavior were diagnosed as delirium. Referral for addiction contributed 8.1% of the total referrals. This was similar to the findings of a study conducted by Singh et al. and Keertish et al. which showed that 11.3%–14.5% of the referrals were sought for substance use. Few referrals were sent for the assessment of somatic complaints. In contrast, previous studies found medically unexplained somatic complaints were the most common reason.,, The major reason for this contrast finding in our study was that only admitted patients seen by consultation liaison team were included. However, outpatient referred cases for somatic complaints from other departments were seen in psychiatry OPD.
Detailed psychiatric evaluation of these referred cases revealed depression, delirium, and substance use to be the most common diagnoses. However, when data were analyzed on the basis of broad ICD-10 categories, it was found that mood disorder was the most common followed by organic mental disorder and neurotic, stress-related, and somatoform disorders (includes panic disorder, generalized anxiety disorder, adjustment disorder, dissociative disorder, and somatoform disorder). This finding was consistent with other similar studies done at various centers in India and abroad which also showed depression to be the most common psychiatric diagnosis in referred patients ,,, although other studies reported neurotic, stress-related, and somatoform disorders to be the most common diagnoses in referred patients.,,
C-L psychiatry service utilization depends on the kind of services provided by the hospital as we provide BMT and renal transplant which mandate psychiatry clearance; we had higher proportion of nil psychiatric diagnosis. The reason for more females having nil psychiatric diagnosis in our study was that most of the prospective kidney donors were females. A higher proportion of females were diagnosed to have mood disorder that reflects the higher prevalence of depression among females in general population. A higher proportion of males were diagnosed as having mental and a behavioral problem due to psychoactive substance use which reflects higher prevalence of psychoactive substance use among males compared to females in India.
The common group of medical illness for seeking psychiatric consultations was malignancy followed by diabetes mellitus and tuberculosis. This indicates that certain groups of illness were having more chances of developing psychiatric illness considering their poor prognosis, underlying psycho-physiological mechanism, and side effects of medication used for treatment.
| Conclusions|| |
Psychiatric comorbidity may present in chronic physical illness. The C-L psychiatry would play a major role in the management of psychiatric comorbidity; however, the growth of this subspecialty of psychiatry is at its infant stage. This is evident from low referral rate reported in our study and only consultation is the predominant component of C-L psychiatry. The internal medicine was the main department for referring patients. However, referral from other specialties was comparatively lower, this could be due to lack of awareness of specialist for psychiatric symptoms or underreporting of psychiatric symptoms by patients due to attached stigma and sometimes specialist would consider these symptoms as part of physical illness. Therefore, it may be necessary to conduct a short training session for recognition of psychiatric symptoms in physically ill patients among specialists. This may improve referral rates.
This study was conducted only for a limited period of 2 months. The study findings cannot be generalized to other hospitals. It may serve as a platform to conduct major studies in this field.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grover S. State of consultation-liaison psychiatry in India: Current status and vision for future. Indian J Psychiatry 2011;53:202-13.
] [Full text]
Avasthi A, Sharan P, Kulhara P, Malhotra S, Varma VK. Psychiatric profiles in medical-surgical populations: Need for a focused approach to consultation-liaison psychiatry in developing countries. Indian J Psychiatry 1998;40:224-30.
] [Full text]
Levenson JL. Consultation-liaison psychiatry: The crucial interface between psychiatry and the rest of medicine. J Ment Health Human Behav 2012;17:i-ii.
Malhotra S. Liaison psychiatry in general hospitals. Indian J Psychiatry 1984;26:264-73.
] [Full text]
Grover S, Subodh BN, Avasthi A, Chakrabarti S, Kumar S, Sharan P, et al.
Prevalence and clinical profile of delirium: A study from a tertiary-care hospital in north India. Gen Hosp Psychiatry 2009;31:25-9.
Bhogale GS, Katte RM, Heble SP, Sinha UK, Patil BA. Psychiatric referrals in multispeciality hospital. Indian J Psychiatry 2000;42:188-94.
] [Full text]
Goyal A, Bhojak MM, Verma KK, Singhal A, Jhirwal OP, Bhojak M. Psychiatric morbidity among patients attending cardiac OPD. Indian J Psychiatry 2001;43:335-9.
] [Full text]
Singh PM, Vaidya L, Shrestha DM, Tajhya R, Shakya S. Consultation liaison psychiatry at Nepal Medical College and Teaching Hospital. Nepal Med Coll J 2009;11:272-4.
Risal A, Sharma PP. Psychiatric morbidity patterns in referred inpatients of other specialties. JNMA J Nepal Med Assoc 2013;52:238-44.
Keertish N, Sathyanarayana MT, Kumar BG, Singh N, Udagave K. Pattern of psychiatric referrals in a tertiary care teaching hospital in Southern India. J Clin Diagn Res 2013;7:1689-91.
Aghanwa H. Consultation-liaison psychiatry in Fiji. Pac Health Dialog 2002;9:21-8.
Huyse FJ, Herzog T, Lobo A, Malt UF, Opmeer BC, Stein B, et al.
Consultation-liaison psychiatric service delivery: Results from a European study. Gen Hosp Psychiatry 2001;23:124-32.
Creed F, Guthrie E, Black D, Tranmer M. Psychiatric referrals within the general hospital: Comparison with referrals to general practitioners. Br J Psychiatry 1993;162:204-11.
Arbabi M, Laghayeepoor R, Golestan B, Mahdanian A, Nejatisafa A, Tavakkoli A, et al.
Diagnoses, requests and timing of 503 psychiatric consultations in two general hospitals. Acta Med Iran 2012;50:53-60.
Michalon M. Consultation-liaison psychiatry: A prospective study in a general hospital milieu. Can J Psychiatry 1993;38:168-74.
Srinivasan K, Babu RK, Appaya P, Subrahmanyam HS. A study of inpatient referral patterns to a general hospital psychiatry unit in India. Gen Hosp Psychiatry 1987;9:372-5.
Lipowski ZJ, Wolston EJ. Liaison psychiatry: Referral patterns and their stability over time. Am J Psychiatry 1981;138:1608-11.
Rosen DH, Gregory RJ, Pollock D, Schiffmann A. Depression in patients referred for psychiatric consultation. A need for a new diagnosis. Gen Hosp Psychiatry 1987;9:391-7.
[Table 1], [Table 2], [Table 3]