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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 129-135

A study of psychiatric referrals from other specialties at a tertiary care center


1 Senior Resident in Department of Psychiatry, Mamata Medical College, Khammam, Telangana, India
2 Associate Professor, Department of Psychiatry, Mamata Medical College, Khammam, Telangana, India
3 Post Graduate in Department of Psychiatry, Department of Psychiatry, Mamata Medical College, Khammam, Telangana, India
4 Professor, HOD, Department of Psychiatry, Mamata Medical College, Khammam, Telangana, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Raghuram Macharapu
Department of Psychiatry, Mamata Medical College, Khammam, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_30_18

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  Abstract 


Objective: The objective was to study the reasons for referral, to study diagnostic categories of psychiatric referrals, and to study the associations if any between reasons for referral and diagnostic categories of psychiatric referrals.
Materials and Methods: The present study was conducted at the Department of Psychiatry, Mamata General Hospital, Khammam. The present study consists of 112 psychiatric referrals; 12 referrals were excluded from the study as they are not willing to give consent, so the study was conducted on 100 psychiatric referrals. The study protocol was approved by the Institutional Ethics Committee.
Results: In the present study, based on the sources of referrals, it was found that majority of the patients were from the Department of General Medicine (38%). In the present study, the most common reason stated for referral was suicidal/self-harm act by 29% of the sample. The most common psychiatric disorder diagnosed in the present study was found to be substance use disorder which is seen in 33% of the sample. On evaluation of diagnostic categories with reference to reasons for referral, it is found that most of the referrals with a history of excessive alcohol intake were diagnosed as substance use disorders (91.6%). Majority of referrals with a history of suicidal attempts were diagnosed as intentional self-harm (58.6%). Referrals with a history of altered sensorium were diagnosed with organic mental disorders (50%), substance use disorder (37.5%), and 12.5% had no psychopathology.
Conclusion: Suicidal attempts are most commonly diagnosed to have intentional self-harm. Substance use disorder came to be high in referrals which are referred for excessive alcohol intake. Regarding referrals to psychiatry department, majority of the patients were from the Department of General Medicine. The most common reason stated for referral to psychiatry was suicidal/self-harm.

Keywords: Psychiatry referrals, referrals from other specialties, study of psychiatric referrals


How to cite this article:
Gurram S, Macharapu R, Kumar M V, Reddy PM. A study of psychiatric referrals from other specialties at a tertiary care center. Arch Ment Health 2018;19:129-35

How to cite this URL:
Gurram S, Macharapu R, Kumar M V, Reddy PM. A study of psychiatric referrals from other specialties at a tertiary care center. Arch Ment Health [serial online] 2018 [cited 2019 Mar 25];19:129-35. Available from: http://www.amhonline.org/text.asp?2018/19/2/129/248885




  Introduction Top


“Consultation-liaison psychiatry (CLP) provides a fit vantage point for watching the changes that permit prediction of future directions in psychiatry as a medical discipline. The kind of psychiatry that the consultants practice and the type of training, skills, and professional attitudes that their work requires represent a model that is likely to prevail in psychiatry in the coming years.”[1]

The heart of consultation psychiatry is the provision of psychiatric consultation to hospitalized medical and surgical patients who are thought by their primary caretakers to have a psychiatric problem. Implied in this task is the education of the consultee, nurses, and medical students about common affective, behavioral, and cognitive disorders in the general hospital. In liaising, CLP promotes integration of care rather than integrated care by a single clinician.[2]

Consultation refers to the provision of expert opinion about the diagnosis and advice on management regarding a patient's mental state and behavior by a psychiatrist.[3] Liaison psychiatry specializes in bridging psychiatric services to other specialties and it has been actively intervening in prevention of the communication gaps between the various specialties in many health-care setups and thereby providing them the ability to convey understanding of the complexity in treating patients with physical and psychiatric co-morbidities. Quality of health care is strongly influenced by efficient communication between different levels of care. Hence, CLP services can be regarded as a linchpin between psychiatry and the other medical specialties.[3]

CLP as a subspecialty has been 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.”[3],[4] Over the past several decades, physicians across specialties and countries are realizing the increasing need to recognize, diagnose, and treat psychiatric symptoms and disorders which affect treatment outcome of physical illnesses.

Co-existence of physical and psychiatric morbidity negatively affects the course and outcome of both conditions resulting in increased overall burden of disease.[5] Chronic suffering, deterioration of physical and psychiatric condition, morbidity and even mortality has been documented by many studies.[6] Timely identification and intervention of such patients not only enhances recovery and prognosis but also helps to avoid wastage of resources and unnecessary investigations.[7]

Current literature also indicates that, in spite of high rates of psychiatric morbidity in Indian patients attending various nonpsychiatric departments of a general hospital, psychiatric referral rates remain low.[8]

In India, CLP is still being considered as part of general psychiatry which is in contrast to the USA and Europe where CLP is a subspecialty.[9]

The percentage of patients receiving psychiatric consultation varies from 1% to 10% in Western countries.[10] The referral rates in India are much lower (0.15%–3.6%).[11] Hence, there is an urgent need to improve CLP services and training to provide best and optimal care to the patients and provide best education to the trainees.


  Materials and Methods Top


Aims and objectives of the study

  • To study the reasons for referral
  • To study diagnostic categories of psychiatric referrals
  • To study the associations if any between sociodemographic variables, reasons for referral, and diagnostic categories of psychiatric referrals.


Place of study

The study was conducted in Mamata General Hospital, Khammam, Telangana.

Study period

The study was undertaken from January 2018 to June 2018 at the Department of Psychiatry following the college's Ethical Committee approval.

Study sample

The study sample consists of 100 referrals to psychiatry department from various other specialties of Mamata General Hospital.

Study design

This is a cross–sectional study.

Inclusion criteria

  1. Psychiatric referrals sent for evaluation from other specialties
  2. Psychiatric referrals who (patients or caregivers) gave consent to participate in the study
  3. Psychiatric referrals between the age group of 18 and 65 years.


Exclusion criteria

  1. Psychiatric referrals sent for disability assessment
  2. Nonconsenting individuals.


Materials

  • International Classification of Diseases (ICD)-10 Diagnostic Criteria for research:


  • ICD 10th revision, Diagnostic Criteria for Research is devised by the World Health Organization with an aim to standardize diagnosis and classification of mental disorders. The diagnosis is based on clinical interview and other available information.

  • Modified Kuppuswamy's Socioeconomic Scale:


  • The most widely used scale for socioeconomic data collection is Kuppuswamy's Socioeconomic Scale, which was devised by Kuppuswamy in 1976. Kuppuswamy scale is a composite score of education and occupation of the head of the family along with monthly income of the family, which yields a score of 3–29. This scale classifies the study populations into high, middle, and low socioeconomic status.

  • Mini International Neuropsychiatric Interview- Plus (Mini-Plus):


  • It is a short structured diagnostic interview, developed by Sheehan et al.[12] and in the United States and Europe, for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and ICD-10 psychiatric disorders. It consists of questions with “yes” or “no” answers to detect present and past DSM-IV-Text Revision and ICD-10 disorders. With an administration time of approximately 15 min, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies, and to be used as a first step in outcome tracking in nonresearch clinical settings. It explores 26 disorders and is a more detailed version of the MINI, which details 17 psychiatric disorders.


Statistical analysis

The statistical analysis of data was performed using Statistical Package for the Social Science for Windows (version 21) and Microsoft Excel 2010. Categorical variables were analyzed with the Chi-square test. Significance levels for all analyses were set at P = 0.05.


  Results Top


[Figure 1] shows referrals from department of General Medicine (38%) followed by 13% referrals from Causality, 12% from General Surgery, 11% from Dermatology, 10% from Orthopaedics, 7% from Neurosurgery, 5% from Obstetrics and Gynaecology, 2% from Ophthalmology and ENT each.
Figure 1: Referrals from department of General Medicine (38%) followed by 13% referrals from Causality, 12% from General Surgery, 11% from Dermatology, 10% from Orthopaedics, 7% from Neurosurgery, 5% from Obstetrics and Gynaecology, 2% from Ophthalmology and ENT each

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[Figure 2] shows that 29% of referrals were referred for suicidal attempts, 16% for altered sensorium, 12% for excessive alcohol intake, 10% aggression and irritability, 8% fearfulness, 7% each of anxiety and multiple somatic complaints and others 8%.
Figure 2: 29% of referrals were referred for suicidal attempts, 16% for altered sensorium, 12% for excessive alcohol intake, 10% aggression and irritability, 8% fearfulness, 7% each of anxiety and multiple somatic complaints and others 8%

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[Figure 3] shows that 33% of referrals had substance use disorders, 17% had intentional self-harm (ISH), 15% organic mental disorders, 14% neurotic disorders, 7% mood disorders, 3% psychotic disorders, 3% Behavioral syndromes, 2% personality disorders and 6% did not have any psychopathology.
Figure 3: Thirty-three percent of referrals had substance use disorders, 17% had intentional self-harm, 15% organic mental disorders, 14% neurotic disorders, 7% mood disorders, 3% psychotic disorders, 3% Behavioral syndromes, 2% personality disorders and 6% did not have any psychopathology

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In the present study, based on the sources of referrals, it was found that majority of the patients were from the department of General Medicine (38%) followed by 13% referrals from Causality, 12% from General Surgery, 11% from Dermatology, 10% from Orthopedics, 7% from Neurosurgery, 5% from Obstetrics and Gynecology, 2% from Ophthalmology and 2% from ENT department [Table 1].
Table 1: Distribution of patients according to the referrals from various departments

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[Table 2] shows that 29% of referrals were referred for suicidal attempts, 16% for altered sensorium, 12% for excessive alcohol intake, 10% aggression and irritability, 8% fearfulness, 7% each of anxiety and multiple somatic complaints and others 8%.
Table 2: Reasons for referral of psychiatric referrals

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[Table 3] showed that 33% of referrals had substance use disorders, 17% had intentional self harm (ISH), 15% organic mental disorders, 14% neurotic disorders, 7% mood disorders, 3% psychotic disorders,3% Behavioural syndromes, 2% personality disorders and 6% did not have any psychopathology.
Table 3: Diagnostic categories of the psychiatric referrals

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On evaluation of diagnostic categories with reference to reasons for referral it is found that most of the referrals with a history of excessive alcohol intake were diagnosed as substance use disorders (91.6%) and 8.4% were diagnosed as neurotic disorders. Referrals with a history ofsuicidal attempts were diagnosed as ISH (58.6%), mood disorder (10.3%), Personality disorder (6.8%), substance use disorder (13.7%), organic mental disorder (3.4%) and 3.4% had no psychopathology. Referrals with a history of altered sensorium were diagnosed with organic mental disorders (50%), substance use disorder (37.5%) and 12.5% had no psychopathology as shown in [Table 4].
Table 4: Most common psychiatric diagnosis for common reasons of referrals

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Suicidal attempts are most commonly diagnosed to have ISH, Substance use disorder came to be high in referrals which are referred for excessive alcohol intake as shown in [Table 5].
Table 5: Association between reasons for referral and diagnostic categories

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  Discussion Top


In the present study, based on the sources of referrals, it was found that majority of the patients were from the department of General Medicine similar results were observed in study conducted by Reddy[13] a descriptive cross-sectional study in a 1000 bedded multispecialty rural teaching hospital, reported 37.8% of referrals were from outpatient and 62.2% from inpatient services, General Medicine department accounted for the highest number (65.7%) of referrals which are similar to our study.

Present study results were in accordance with the findings of the studies conducted by Ajagallay et al.[14] and Holikatti[15] which showed that the referral rate from department of medicine was 40% and 38.2%, respectively.

Most of the general medical conditions like hypothyroidism in which patients commonly present with symptoms of depression, diabetes mellitus where there is multiple somatic pains needs sometimes psychiatric consultation, hypertension in which patients most commonly present with anxiety symptoms such as palpitations, fearfulness which leads to referring the patient to psychiatry department. Ignorance about the psychiatric origin of somatic symptoms and the stigma which is associated with psychiatric consultations are other factors which may result in patients visiting physicians instead of psychiatrists[16] for psychiatry problems which in turn leads to referral to psychiatry from physician, thus showing higher referral rates from general medicine.

Referral rates from surgical units in Creed et al.[17] study was 14% which is in accordance with our study having overall 12% referral from surgical department. But the observed referral rate was quite low when compared with the general medicine department. Co morbid psychiatric problem is usually neglected because of urgency of treatment of primary surgical conditions as well as lack of experience in the field of psychiatry. In addition, there is a lot of stigma not only among the patients, but also among the health-care professionals about mental illness and its treatment.[18]

Only 5% cases were referred from Gynecology and Obstetrics Department and this rate was similar with the studies conducted by of Kumar et al.[19] and Dhavale and Barve[20] where referral rate from of obstetrics and gynecology department reported to be 6.4% and 1.36%, respectively, which may be due appearance of emotional disturbance during menstruation period, postpartum depression, postpartum psychosis, hormonal effects during pregnancy which leads to psychiatric problems.

In our study, lower percentage, i.e., 4% of the patients was referred from Ophthalmology and ENT departments, which is attributed to less outpatient and inpatients rate in the study area of those departments and most of the cases treated are not relevant with the psychiatric symptomatology.

In our study 29% were referred for suicidal/self-harm act, 16% were referred for altered sensorium and irrelevant talk, 12% for excessive alcohol intake, 10% for aggressive and abnormal behavior, 8% for fearfulness, disturbed sleep and irritability, 7% for multiple somatic complaints, 7% for anxiety and restlessness, 5% for crying spells and easy fatigability, 3% for crawling sensations all over the body and 3% for not taking baby care.

In the present study, the most common reasons stated for referral was suicidal/self-harm act is 29%, which is in accordance with the Indian study done by Manabendra and Uttam[18] where referral rate for suicidal/self-harm act is 30.3%. In developing countries like India, there is gradual increase in suicidal/self-harm act, most of the families are doing farming, in which due to climate changes there is less yielding in cultivation leading to financial crisis, which reflected to have higher prevalence of suicidal/self-harm act in farmers. The present study area comes under Telangana district, which ranked second in farmers suicide rate in India, which may be the reason that there is highest number of referrals sent was with the reason of suicidal/self-harm act.

The second common reason for referrals was altered sensorium and irrelevant talk (16%) which is in accordance with the studies done by Singh et al.[21] Most of the delirium and organic mental disorders patients present with altered sensorium and irrelevant talk, in the present study there is 15% of the patients were diagnosed to have organic mental disorders and substance use disorders which is highest diagnosed condition in this study are also sometimes presents with altered sensorium and irrelevant talk which reflected to cite the altered sensorium and irrelevant talk as the second common reason for referral in the present study.

In the present study, we found that 33% had substance-related disorders, 17% had ISH, 15% diagnosed to have organic mental disorders, 14% had neurotic disorders, 7% had mood disorders, 3% had psychotic disorders, 3% of them have behavioral syndromes, 2% had personality disorders and 6% of the sample did not have any psychopathology. Among the neurotic disorders 71.5% were diagnosed as adjustment disorders. 14.3% were somatoform disorders, and 7.1% were dissociative disorders and 7.1% eating disorders. Among the mood disorders, 85.7% were diagnosed as depressive disorders and 14.3% were bipolar disorders.

The most common psychiatric disorder diagnosed in the present study was found to be substance use disorder which is seen in 33% of the sample; these included various substance-related conditions such as intoxication, dependence, withdrawal syndromes and substance-induced mental disorders. Lyne et al.,[22] done a survey of referral reasons and diagnoses on all patients presenting to a Dublin-based inpatient liaison psychiatry consultation service over 1-year period. Alcohol-related disorders were the common diagnosis with 19.7% of all referrals, while depressive disorders were diagnosed in 16.6%. These results are in accordance with the present study. Reasons for the high rate of alcohol referrals and diagnoses in our study could be due to higher rates of alcohol misuse in study area, however this should be interpret with caution, as this study is merely a proportion of the referrals within the area of the study.

Analyzing the physical (medical/surgical) diagnoses of the referred sample, in the current study the second most common group belonged to ISH by fracture/poisoning/hanging (ISH – 17%). The current study findings are in accordance with the study of Christodoulou et al.,[23] who reported that both in their cases and control group the most common physical illness was of injuries and poisoning. Undoubtedly, a suicide attempt is a major concern which alarm and sensitize physicians on medical and surgical wards. A recent suicide attempt, or a suicide attempt that takes place within a hospital ward, alerts the physicians and makes them very sensitive to any thought or action that could be considered self-destructive, even months after the attempt.

The finding of alcohol dependence syndrome (ADS) and ISH as the most common diagnosis in our study may reflect the increased awareness among general physician of this medical college regarding the need for psychiatry consultation in every cases of ISH and also the awareness of ADS as a disorder to be treated by psychiatrists.

On evaluation of diagnostic categories with reference to reasons for referral, it is found that most of the referrals with excessive alcohol intake were diagnosed as substance use disorders (91.6%) and 8.4% were diagnosed as neurotic disorders. Referrals with a history of suicidal attempts/self-harm acts were diagnosed as ISH (58.6%), mood disorder (10.3%), personality disorder (6.8%), substance use disorder (13.7%), organic mental disorder (3.4%) and 3.4% had no psychopathology. Referrals with a history of altered sensorium were diagnosed with organic mental disorders (50%), substance use disorder (37.5%) and 12.5% had no psychopathology.


  Conclusion Top


  • Referrals from department of General Medicine (38%) followed by 13% referrals from Causality, 12% from General Surgery, 11% from Dermatology, 10% from Orthopedics, 7% from Neurosurgery, 5% from Obstetrics and Gynaecology, 2% from Ophthalmology and ENT each
  • The most common reasons for referral were suicidal attempts (29%) followed by 16% for altered sensorium, 12% for excessive alcohol intake, 10% aggression and irritability, 8% fearfulness, 7% each of anxiety and multiple somatic complaints and others 8%
  • According to the ICD-10 Diagnostic Criteria for Research, the most common diagnostic categories were substance-related disorders (33%), 17% had ISH, 15% organic mental disorders, 14% neurotic disorders, 7% mood disorders, 3% psychotic disorders, 3% behavioral syndromes, 2% personality disorders and 6% did not have any psychopathology
  • These findings have important implications for mental health services, training of medical health professionals, research and policy making in the Indian setting.


Limitations

There are few limitations to our study which needs to be considered while interpreting the result. The study was done among patients referred for consultation-liaison within a period of 6 months period, so may not represent overall psychiatric referral. The results of this clinic-based study cannot be generalized to community settings as the sample size of the study is less. Also we recruited patients on consecutive basis instead of using any sampling technique for the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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