Profile of adolescents who came only once to outpatient psychiatric services

Jasmin Garg; Priti Arun; Chandrabala Mankotia

doi:10.4103/0971-8990.193433

BRIEF COMMUNICATION

Year : 2016 | Volume : 21 | Issue : 2 | Page : 125-128

Profile of adolescents who came only once to outpatient psychiatric services

Jasmin Garg, Priti Arun, Chandrabala Mankotia
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication

4-Nov-2016

Correspondence Address:
Jasmin Garg
Department of Psychiatry, 5th Level, D-Block, Government Medical College and Hospital, Sector 32, Chandigarh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0971-8990.193433

Abstract

Background: Disengagement of patients from psychiatric care is a known and a serious issue worldwide. However, very limited data are available on dropout of adolescent patients with mental health disorders. Aim: This study was planned to look into the profile and diagnosis of adolescents with single visit to psychiatry outpatient department (OPD). Materials and Methods: A retrospective chart review of cases in the age group of 12-18 years reporting to Psychiatry OPD of a tertiary care hospital of India was carried out. Diagnosis and profile of those who came only once were noted and analyzed for the present study. Results: From 2008 to 2011, a total of 2006 adolescents were registered which included 560 cases with mental retardation, epilepsy, and nil psychiatry. From the remaining 1446 adolescents, 659 (45.57%) did not come after the first visit. The rate of dropout at the single visit was significantly higher in females and in the age group of 16-18 years. It was highest in those with borderline intelligence, adjustment disorders, anxiety disorders, dissociative and somatoform disorders, and substance use disorders. Conclusions: There is huge dropout rate at single visit itself in adolescents. Adolescents do not present themselves to psychiatric services in India. Parental understanding of mental disorders needs to be improved to prevent early dropout.

Keywords: Adolescents, dropout, mental disorders

How to cite this article:
Garg J, Arun P, Mankotia C. Profile of adolescents who came only once to outpatient psychiatric services. J Mental Health Hum Behav 2016;21:125-8

How to cite this URL:
Garg J, Arun P, Mankotia C. Profile of adolescents who came only once to outpatient psychiatric services. J Mental Health Hum Behav [serial online] 2016 [cited 2023 Jun 2];21:125-8. Available from: https://www.jmhhb.org/text.asp?2016/21/2/125/193433

Introduction

Most mental health disorders begin in the young age. Approximately 10% of children and adolescents of India have a diagnosable mental health disorder. It is estimated that there are up to 20 million adolescents with severe mental health disorders and around 90% of them are not currently receiving any specialist service. ^[1] Even those who seek help, a substantial proportion of them drop out early from the treatment.

Dropout from psychiatric care is more common globally. Rates of disengagement from mental health services vary from 4% to 46% overall. ^[2] The World Mental Health Survey Initiative reported an average dropout rate of 21.3% after collecting data from both low- and high-income countries. ^[3] A few studies have specifically focused on dropout of adolescent patients with mental health problems. ^[4],[5],[6] Hence, this study was planned with the aim of assessing the prevalence and pattern of dropout of adolescent patients from psychiatry outpatient department (OPD).

Materials and Methods

This analysis was conducted in the Department of Psychiatry of a Tertiary Care Hospital of North India. The department provides services to patients presenting themselves, brought by family members and those referred from other departments, relatives, schools, and other institutions/hospitals. A structured walk-in pro forma is filled up for the patients who came for the first time in the psychiatry OPD. On an average, 25 new patients are seen daily in the psychiatry OPD. A psychiatry social works notes the sociodemographic details and source of referral of the patient in the walk-in pro forma. New patient is then seen by the psychiatry senior resident. Patients with diagnostic difficulty are discussed with consultant psychiatrist. Furthermore, some new patients are seen directly by the consultants. Patient's complaints, important history, examination findings, provisional diagnosis according to the International Classification of Disease-10, and proposed management are noted down in the walk-in pro forma. An appointment for detailed workup is given for coming week for those patients where some diagnostic difficulty is there, or more information is required for management of the case; however, all cases are not given appointment for workup due to inadequate number of junior residents. The patients requiring psychological testing, psychotherapy, or those with suspected intellectual disability are referred to the Psychology Department for getting appointment for required services. If the testing or counseling session is not feasible same day, the appointment is given for another day within a week or 2 weeks. The patients presenting with nil psychiatric diagnosis are referred to other OPDs according to their presenting complaints and are advised to review in psychiatry OPD in case any need arises. The patients whose intelligence quotient (IQ) testing reveals mental retardation are referred to the Government Institute for Mentally Retarded Children for treatment and training. In addition, patients presenting with the epilepsy are referred to medicine/pediatrics OPD for the management. Pharmacotherapy is started on the first visit for the rest of patients, and they are advised to revisit within 2 weeks. All patients are seen by a consultant psychiatrist from the second visit onward. For all patients coming to psychiatry OPD, record is maintained in the department. Whenever a patient revisits, his/her respective file is taken out to record progress, examination findings, and treatment advised by the consultant psychiatrist. A retrospective chart review of all adolescent patients of age group 12-18 years which presented to the psychiatry OPD from January 2008 to December 2011 was carried out. The sociodemographic data and diagnosis of adolescents who failed to turn up after the first visit were analyzed for the study. For statistical analysis, Chi-square test was performed. P < 0.05 was considered statistically significant.

Results

From 2008 to 2011, a total of 2006 adolescents were registered in psychiatry OPD, of which a total of 560 cases were excluded as mental retardation was diagnosed in 274 cases, seizure disorder was in 197 cases, and 89 cases did not receive any diagnosis. From remaining 1446 adolescent patients registered, 659 (45.57%) did not come after the first visit.

In this cohort, there were total 855 males from which 352 (41.16%) came only once and there were 591 females from which 307 (51.94%) came only once. The dropout at the first visit was significantly higher in females (P < 0.001, χ² = 16.4).

The diagnostic distribution of the adolescent patients was analyzed along with the number of patients who came only once in respective diagnosis [Table 1]. Adolescents most commonly presented with depressive disorders, dissociative disorders, anxiety disorders, and psychotic disorders in decreasing order. Almost equal number of attention deficit hyperactivity disorder (ADHD) (n = 83), adjustment disorder (n = 79), and substance use disorder (n = 73) were seen. Cases reporting with academic difficulty and diagnosed with borderline intelligence were 92.

Table 1: Pattern of adolescent patients registered and dropped out after single visit

Click here to view

The data were also analyzed age-wise. In the age group of 12-15 years, a total of 663 patients were registered, of which 276 (41.6%) came only once, and in the age group 16-18 years, total 783 patients registered, of which 383 (48.91%) came only once. This rate was significantly higher in the 16-18 years age group (P = 0.006, χ² = 7.68). Some disorders were more common in the age group of 16-18 years which were substance use disorders, psychotic disorder, depressive disorders, and anxiety disorders. While in the age group of 12-15 years, specific learning disorder, ADHD, and conduct disorder were more commonly seen. There were more females diagnosed as conversion, somatoform disorder, and other neurotic disorder (n = 221). Substance use disorder was seen in males only and was diagnosed in 12-15 years age group and 46.6% of them dropped out after the first visit. High dropout rates after the single visit were also seen in borderline intelligence (80%), adjustment disorders (62%), dissociative and somatoform disorders (60%), and anxiety disorders (53%).

Discussion

In this retrospective chart review, adolescents most commonly presented with mental retardation, seizure disorder, depressive disorders, dissociative and somatoform disorders, anxiety disorders, and psychotic disorders. This was similar to the findings of earlier studies from India which evaluated the diagnosis of children and adolescents presenting with mental health problems. ^[7],[8],[9] Yet, there were more cases of psychotic disorders in this study as compared to the previous studies. In this study, substance use disorder was seen exclusively in males. In females, dissociative and somatoform disorders were more commonly seen compared to males. It was concordant with earlier research where it has been reported that women tend to somatize and develop fits more often than males. ^[10] Furthermore, alcohol and substance abuse is commoner in males as compared to females. ^[11]

In this study, higher percentage of patients who came only once in the age group of 16-18 years was concordant with the findings of an earlier study, in which dropout was higher in older adolescents compared to younger adolescents. ^[6] It was also seen that lesser number of females presented to psychiatry OPD than males, and from them, significantly higher proportion came only once as compared to males. The earlier studies which evaluated the profile of children and adolescents visiting psychiatry OPD from India have also reported that more males are brought to OPD as compared to females. ^[7],[8] However, in Western countries, no gender difference has been found in rate of presentation or dropout of adolescents from psychiatry OPD. ^[6],[12] In Indian culture, girls are considered subordinate to boys and they are at disadvantaged position with regard to health care. Their access to health care is poorer compared to males. ^[13] More preference being given to boys could be the reason why more males were brought and more of them continued the treatment in this study. Another possible reason for this difference could be that bringing girls to the psychiatry OPD carries more stigma as it leads to difficulty in finding match for marriage in case the label of mental illness is attached to a girl.

The dropout rate of 45.5% after the single visit found in the present study was much higher than that reported in the previous studies. The dropout rate of adolescent patients has been reported from 11% to 16% after the first contact in studies from other countries. ^[4],[6] Another study from Hong Kong reported a 1 year dropout rate of 27% in adolescent patients. ^[5] The authors could not find any published research which focused on adolescent dropout from India. However, an earlier study from India analyzed the rate of dropout in children with ADHD and found that 45.8% patients dropped after the first visit. ^[14] A prior study from this department, which focused on dropouts from adult patients with psychiatric problems, reported a dropout rate of 26%. ^[15] It shows that dropout of adolescents was much more than that of adult patients. This dropout after the first visit represents those adolescents who failed to show up even before some intervention was initiated in many of them.

Adolescent patients do not tend to seek help for mental health problems themselves. A large proportion of those who present to mental health facility are referrals from school counselors or physicians/pediatricians. ^[16] It has been reported that the education sector plays a central role as a point of entry into the mental health system. ^[12] However, parents act as gatekeepers for presentation to mental health facility. ^[17] The parental perception of the severity of problem in adolescents brings them to mental health care. The high dropout rate observed in the present study can be explained by the fact that though parents brought their children to psychiatry OPD on school's recommendation once, they did not acknowledge the severity of problem or need for continuing the treatment for mental health problems. Commonly, at the first visit to psychiatry OPD, detailed assessment is carried out in adolescents and treatment may or may not be instituted at the first visit. Hence, dropout after the first visit represents those whose parents had not made up their mind for getting their children treated. It has been reported that parents find it appropriate to discuss concerns about psychiatric problems to physicians, and even if referred to a psychiatrist, very few of them think of bringing their children to psychiatrists. ^[17],[18]

In this study, there was high proportion of patients with borderline intelligence who came only once. Those with academic problems are mainly referred from school and many of them are diagnosed with borderline intelligence. They often fail to come once IQ testing is done, leading to high rate of dropout at the single visit. Most of the patients with adjustment disorders, anxiety disorders, and dissociative disorders came only once. High dropout in adjustment disorder was also reported by another study on adolescent dropout. ^[6] However, patients with psychotic disorders or bipolar disorders were less likely to come only once. This finding is concordant with the findings of earlier studies on dropout from adult patients with mental disorders that patients with severe mental illness or psychotic disorders tend to continue the treatment as compared to neurotic or anxiety disorders which drop out early. ^[19]

The percentage of patients with ADHD (26.5%) and conduct disorder (20%) who came only once was less as compared to other disorders. However, earlier research has indicated that children with externalizing disorders drop out more as compared to other disorder. ^[6] In this study, the overall percentage of patients with ADHD and conduct disorders was less, and higher dropout was seen after the single visit in other disorders compared to these disorders. In addition, almost half of the adolescents with substance abuse came only once (46.6%). This carries significance because adolescence is the age of experimentation and several adolescents experiment with drugs of abuse at this age. ^[20] Higher number of those who came only once in this category could be because adolescents are forcibly brought by parents on detection and the patients might not wish to quit substances. Many times, parents bring patients on suspicion of drug use.

Fifty percent of patients whose diagnosis was deferred did not come for the second visit. The possible reason for this could be that treatment is usually not started when diagnosis is deferred. The high rate of the patients who came only once was also observed in nonorganic enuresis (86.1%), but the overall frequency of patients with this disorder was low.

The inclusion of a larger sample size than that of the previous studies describing dropout is the strength of the present study. ^[4],[5],[6] Records of around 99% patients were traceable in the department. However, this study was limited by being retrospective in nature and the reasons of dropout could not be evaluated and only the pattern of dropout was described. It is also not known whether the cases had genuinely dropped the psychiatric treatment or had continued their treatment from elsewhere. Furthermore, data of the patients who dropped later on were not analyzed in the study. Yet, it shows that adolescent dropout is very high after the first visit. There is a huge treatment gap in adolescents with mental disorders. Dropping out after initial visit to psychiatric services adds to it. A higher dropout in adolescents is of concern because most of the adult psychiatric disorders begin during the adolescence. ^[21] As parents are important if adolescents need to follow up, an effort should be made to improve their understanding of illness and address their concerns on visiting psychiatric care. Hence, the findings of this study signify that at the first visit, focus is needed not only on diagnostic evaluation and treatment initiation but also on patient engagement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Shastri PC. Promotion and prevention in child mental health. Indian J Psychiatry 2009;51:88-95. [PUBMED]
2.	O'Brien A, Fahmy R, Singh SP. Disengagement from mental health services. A literature review. Soc Psychiatry Psychiatr Epidemiol 2009;44:558-68. [PUBMED]
3.	Wells JE, Browne MO, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Angermeyer MC, et al. Drop out from out-patient mental healthcare in the World Health Organization's World Mental Health Survey initiative. Br J Psychiatry 2013;202:42-9. [PUBMED]
4.	Cottrell D, Hill P, Walk D, Dearnaley J, Ierotheou A. Factors influencing non-attendance at child psychiatry out-patient appointments. Br J Psychiatry 1988;152:201-4. [PUBMED]
5.	Lai KY, Pang AH, Wong CK, Lum F, Lo MK. Characteristics of dropouts from a child psychiatry clinic in Hong Kong. Soc Psychiatry Psychiatr Epidemiol 1998;33:45-8. [PUBMED]
6.	Pelkonen M, Marttunen M, Laippala P, Lönnqvist J. Factors associated with early dropout from adolescent psychiatric outpatient treatment. J Am Acad Child Adolesc Psychiatry 2000;39:329-36.
7.	Malhotra S, Biswas S, Sharan P, Grover S. Characteristics of patients visiting the child and adolescent psychiatric clinic; A 26-year study from North India. J Indian Assoc Child Adolesc Ment Health 2007;3:53-60.
8.	Jayaprakash R. Clinical profile of children and adolescents attending the behavioural paediatrics unit OPD in a tertiary care set up. J Indian Assoc Child Adolesc Ment Health 2012;8:51-66.
9.	Khairkar P, Pathak C, Lakhkar B, Sarode R, Vagha J, Jagzape T, et al. A 5-year hospital prevalence of child and adolescent psychiatric disorders from central India. Indian J Pediatr 2013;80:826-31.
10.	Malik SC. Women and mental health. Indian J Psychiatry 1993;35:3-10. [PUBMED]
11.	Afifi M. Gender differences in mental health. Singapore Med J 2007;48:385-91. [PUBMED]
12.	Farmer EM, Burns BJ, Phillips SD, Angold A, Costello EJ. Pathways into and through mental health services for children and adolescents. Psychiatr Serv 2003;54:60-6. [PUBMED]
13.	Fikree FF, Pasha O. Role of gender in health disparity: The South Asian context. BMJ 2004;328:823-6. [PUBMED]
14.	Sitholey P, Agarwal V, Chamoli S. A preliminary study of factors affecting adherence to medication in clinic children with attention-deficit/hyperactivity disorder. Indian J Psychiatry 2011;53:41-4. [PUBMED]
15.	Kaur J, Chavan BS, Sharma A, Raj L, Chandrabala. Study of factors associated with drop out. J Ment Health Hum Behav 2009;14:87-94.
16.	Rickwood DJ, Deane FP, Wilson CJ. When and how do young people seek professional help for mental health problems? Med J Aust 2007;187 7 Suppl:S35-9.
17.	Sayal K. Annotation: Pathways to care for children with mental health problems. J Child Psychol Psychiatry 2006;47:649-59. [PUBMED]
18.	Sayal K, Tischler V, Coope C, Robotham S, Ashworth M, Day C, et al. Parental help-seeking in primary care for child and adolescent mental health concerns: Qualitative study. Br J Psychiatry 2010;197:476-81. [PUBMED]
19.	Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome. Br J Psychiatry 2000;176:160-5. [PUBMED]
20.	Sagar R. Child and adolescent mental health: Need for a public health approach. J Men Health Hum Behav 2011;16:1-4.
21.	Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602. [PUBMED]