Psychiatric disorder in a South African general hospital

ELSEVIER

Psychiatric Disorder General Hospital Prevalence in Medical,

in a South African Surgical, and Gynecological

Wards

Margaret G. Nair, M.B., Ch.B., M.Med, EC. Psych (S.A.) and Srinivasan S. Pillay, M.D., Ch.B. Abstract: The aim was to elicit the individual and comparative prevalence of psychiatric disorder in medical, surgical, and gynecological wards in a South African hospital comprising a predominantly Third World patient population. Results indicated that 21%, 95% coltfidence interval (16;26) of the total sample of 230 patients had a DSM-111-R psychiatric disorder. Fifty-six percent had a diagnosis of substance dependence and 33% were found to have depressive disorders. Comparative analysis between disciplines indicated that the highest prevalence was in surgical wards. There was a statistically signifcant difference between the sexes. The variables associated with the presence of a psychiatric disorder and implications for better 0 1997 Elsevier recognition and treatment are discussed. Science, Inc.

Introduction Psychiatric disorder in general hospital inpatients has a substantial impact on hospital resources, finances, and the eventual management of patients. This is well illustrated by the statement by Mayou et al. [l] “. . . improved recognition of psychiatric disorder during hospital admission could result in better overall care of medical patients’ psychiatric and social difficulties and more effective use of medical resources.” Though there have been studies of psychiatric disorder in general hospitals, none has presented a comparative account of psychiatric disorder among the three major disciplines, i.e., medical, surgical, and gynecological, particularly in an underdevelDepartment of Psychiatry, Faculty of Medicine, University of Natal, Congella, South Africa Address reprint requests to: Dr. Margaret G. Nair, Deputy Head, Department of Psychiatry, Faculty of Medicine, University of Natal, PO Box 17039, Congella 4013, South Africa.

144 ISSN 0163~8343/97/$17.00 PII SO163-8343(97)00147-S

oped population. This study was conducted to highlight and address this deficiency. The study was conducted at King Edward VIII Hospital, a 2000 bed academic general hospital in Durban, South Africa. The hospital services an ill-defined catchment area which includes a proportion of migratory laborers and “informal settlements.” As King Edward VIII Hospital is a tertiary/quetenary teaching hospital, patients are referred from all areas in the province of Kwazulu-Natal. Patients are also admitted directly to the hospital as self- or family referrals as well as being referred from general practioners. The different type of referrals are all admitted through the same system as there is no formal “emergency room” (ER) facility. Patients attending the hospital are mainly of Zulu extraction and usually come from a lower income bracket.

Method At the time of the study there were approximately 1000 general medical, general surgical, and gynecological patients within the hospital. The study was a prospective one, and a statistically predetermined representative sample consisting of 230 patients were randomly selected for interview. Of the 230 subjects, a statistically proportionate selection included 120 from general medical wards, 60 from general surgical wards, and 50 from gynecological wards. Patient selection was based on standardized “random tables.” Written informed consent was obtained from all subjects. Exclusion criteria included patients unwilling to participate in the study, patients younger than 18 years of age, and patients who were too physically

General 655 Avenue

Hospital

Psychiatry 19,144-148, 1997 0 1997 Elsevier Science Inc. of the Americas, New York, NY 10010

Psychiatric Disorder in a S. African

Chtwi

Hi>spital

ill to be interviewed. The last mentioned criterion is a shortcoming of the study as inclusion of these patients may have increased the overall psychiatric morbidity, especially in the diagnostic category of the organic mental syndromes. Of the 246 patients approached, 3 refused to participate in the study, 5 were younger than 18 years of age, and 8 were too ill to be interviewed.

The administration of the questionnaires and the mental state examination was personally conducted by the first author, an experienced registered psychiatrist. A trained professional nurse assisted in the translation into the Zulu language where this was necessary.

Instruments/Assessment

The results are presented as descriptive and analytical statistics. CI of 95% was set. The Chi-square test was used to assess the significance of associations between psychiatric disorders and all categorical variables. Students’ unpaired t-test was used to compare mean ages between patients with and without psychiatric disorders. Significance level of 0.05 was used.

Procedure

A formal psychiatric mental state examination was conducted on all patients. Three questionnaires were administered: Demographic Inventory. The data recorded included age, sex, marital status, employment status, education, past psychiatric history, duration of current hospitalization, and severity of the physical disorder. The 30-item General Health Questionnaire (GHQ) [Z]. The verbal format of this screening instrument was administered in order to screen patients with possible psychiatric disorder. The questionnaire has been validated in hospital inpatients by Maguire et al. [3]. The GHQ threshold cutoff score used was 11/12. The reason for raising the threshold from 4/5 was that in a pilot study of the first 30 patients, the GHQ 4/5 cutoff yielded an 88% false-positive rate for subsequent definitive psychiatric diagnosis. Responses to certain questions are affected by physical illness and all the study patients were physically ill. Goldberg 141 recommended an 11/12 threshold for inpatients, and this was then implemented. The score was still lower than the 15/16 cutoff recommended by Benjamin et al. [51. The authors did not feel that the raised cutoff score reduced possible “caseness” as other factors viz, an abnormal psychiatric mental state examination, history of past psychiatric disorder, as well as history of substance abuse were used as additional screeners prior to administering the definitive diagnostic questionnaire, i.e., The Structured Clinical Interview. 3. The Structured Clinical Interview for the DSMIII-R (SCID) 151. The aim of administering the SCID was to obtain a validated DSM-III-R diagnosis. The SCID was administered only to those patients who obtained a score of greater than 11 on the GHQ, had a significant history of substance abuse or a past psychiatric history, and those who had an abnormal psychiatric mental state examination.

Statistical

Analysis

Results Demographic

Data

For the purpose of simplicity, only significant aspects of the demographic data will be presented. The mean age of patients was 40 years with a range between 18 and 82 years. Forty-three percent of the sample were male and 57% female. Thirtynine percent of subjects were in legal or commonlaw marriages. Analysis of level of education revealed that a high proportion of subjects were illiterate (30%) or semiliterate (14%), i.e., lower primary school education. Employment status revealed that 34% of patients were unemployed and a further 14% were in receipt of either a medical disability grant or old-age pension. Only 28% of patients were in full-time employment. Seventy-one percent had a previous admission for medical problems, most had previously been admitted once or twice. As the patients had widely differing medical diagnoses, their disease processes were graded into mild, moderate, severe, lifethreatening, and terminal categories. Analysis revealed that 47% of patients were mild to moderately ill, 25% were severely ill, and 28% had a lifethreatening or terminal illness. Discipline-specific analysis illustrated that in the general medical wards 39% of patients were mild to moderately ill, 33% were severely ill, and 28% had a lifethreatening or terminal illness. By comparison 53% of surgical and 60% of gynecological patients were mild to moderately ill, 23% of surgical and 6% of

145

M. G. Nair and S. S. Pillay

Table 1. Psychiatric diagnoses (DSM-III-R) sample (N = 230)

Substancedependence Depressivedisorders Adjustment disorders Organic mood disorders Posttraumatic stressdisorder Simple phobia Male erectile disorder Antisocial personality disorder V Code: uncomplicated bereavement

in total

N

%

27 16 5 2 1

12 7 2 1

1 1

gynecological were severely ill, and 23% of surgical and 34% of gynecological patients had a lifethreatening or terminal illness.

Psychiatric Morbidity The SCID was administered to 33% of subjects based on the criteria that 13% of the sample had a GHQ score greater than 11 points; 14% had a significant history of substance abuse; 4% a combination of the first two criteria; and the remaining 2% an abnormal psychiatric mental state examination in the absence of a high GHQ score. Of the 17% of patients who had above-threshold GHQ scores, 67% were identified by the SCID as having a psychiatric diagnosis, a statistically significant finding (p < 0.0001). These results yielded a sensitivity of 54% and a specificity of 93% for the GHQ using the 11/12 threshold. Results obtained from the SCID showed that 21% of patients, 95% CI: (16;26), had a psychiatric disorder. Table 1 illustrates the subtypes of psychiatric disorder that were present in the total sample (N = 230) and Table 2 illustrates the specific psychiatric disorders present in the psychiatrically ill sample (N = 48). Seven of these patients had dual psychiatric diagnoses yielding 55 diagnostic categories. The second diagnosis in six of the patients was substance dependence and in the seventh it was male erectile disorder. Of the six substance dependence patients, three had major depression, one dysthymia, one organic mood disorder, and one antisocial personality disorder as the principal diagnosis (first diagnosis). It is clear that alcohol dependence (46%) and major depression (25%) were the most prevalent disorders. For convenience, similar type disorders have been grouped together.

146

Table 2. Distribution of psychiatric diagnoses (DSM-III-R) (A! = 48)’

Alcohol dependence Major depression Adjustment disorders Dysthymia Polysubstancedependence Organic mood syndrome Cannabisdependence Post traumatic stressdisorder Simple phobia Male erectile disorder Antisocial personality disorder V Code: uncomplicated bereavement

N

‘!A0

23

48

12

25

5 4 3 2

10

1 1 1 1 1 1

8 6 4 2 2 2 2 2 2

“55 diagnosticcategories.

The distribution of psychiatric disorder in the different disciplines revealed interesting results. Thirty percent of general surgical patients, 21% of general medical patients, and 12% of gynecological patients had a psychiatric disorder (p = 0.071). Figure 1 illustrates the subtypes of psychiatric disorder in the different disciplines. A high prevalence of substance dependence in the surgical wards is apparent.

Psychiatric Disorder Compared with Other Variables Gender differences were statistically significant. Thirty-five percent of males compared with 11% of females of the total sample (N = 230) had a psychiatric disorder (p < 0.0001). The psychiatrically disordered group (N = 48) comprised 71% males and 29% females. Males were 3.25 times more likely than females to have a psychiatric disorder, 95% CI: (1.85; 5.70). Substance dependence was more prevalent in males and depressive disorders (major depression and dysthymia) were more common in females (Table 3). Of particular note is that no statistically significant difference existed between the presence or absence of psychiatric disorder when factors of age of patient, marital status, past psychiatric treatment, employment status, previous admissions for medical problems, and duration of current hospitalization were taken into account. Interestingly there was also no significant difference between presence of psychiatric disorder and whether the patient had a medical, surgical, or gynecological illness. There

Psychiatric Disorder in a 5. African

Ckvwrctl Hospital

Table 3. Prevalence of psychiatric disorder according to gender’

---- - ..-- __. Males Females iN -= 13) (N = 35) __-I-

AM

Adi

Per

PSY

vcode

Figure 1. Comparative psychiatric diagnosesin medical, surgical, and gynecological wards

Substancedependence Depressiondisorders Anxiety disorders Adjustment disorders V Codes Organic mental disorders Antisocial personality Psychosexual “55 diagnostic

was also no statistical difference between severity of physical disorder (axis III) and the presence of psychiatric disorder. The nonsignificant variables were the same across all three disciplines.

Discussion Maguire et al. [3] obtained a psychiatric diagnosis in 23% of patients studied in general medical wards whereas Despande et al. 171reported figures of 34% in a similar setting. Bridges and Goldberg’s [Sl study in neurology wards yielded a psychiatric diagnosis in 39% of patients. Leung et al. 191demonstrated an overall psychiatric morbidity of 24% in a Chinese general hospital. The present study’s psychiatric morbidity rate of 21% is similar to studies worldwide. A surprising finding was the higher prevalence of psychiatric disorders in males. The Mayou et al. ill study showed a higher prevalence for females whereas other studies [lO,lll showed no gender differences. Possible explanations for differences include the high prevalence of substance dependence in the disordered sample (56%) with males (66%) having more than double the female (31%) figures. Cultural factors may also have played a role. The population studied is largely male dominated with a patriarchal family system. It is also possible that stressors might be perceived as more burdensome by males, especially those forced to live away from families, thus resulting in a higher prevalence of psychiatric disorder, especially substance dependence. Another unexpected finding was the higher prevalence of psychiatric disorder in surgical wards. Clarke et al. [lo] showed a higher preva-

dysfunction

23

66

4

10

29

h

0 5 0 :!

!! 14

2 0

31 46 15 0

0 h

I I)

8 0

1

i

0

0

I

?

0 _--.-.--I_-

iI

-_-,

categories.

lence in medical compared with surgical wards. The present study’s findings could be accounted for by the high prevalence of substance abuse in the surgical wards (Figure 1). The surgical wards in the hospital studied have among the highest rates of trauma in the world. Related to this are prevailing sociopolitical problems in the surrounding catchment area of Kwazulu-Natal. The relationship between trauma and substance abuse IS well recognixed . With the exception of one patient who had attempted suicide and was thus routinely referred to the psychiatric department, none of the remaining patients were identified by their treating doctors as requiring psychiatric attention. Possible reasons for this include the high prevalence of substance dependence. Its association with the high trauma prevalence may engender negative countertransferase issues in the doctors, who although recognizing the problem, do not refer patients for psychiatric treatment. Another important reason for nonreferral is the high patient turnover and the constant pressure placed upon doctors to have beds available for the numerous seriously ill, new patients requiring admission.

Conclusion With the exception of gender differemes, the findings in the current study are similar to worldwide studies, thus reinforcing the current trend in psychiatry that similarities and not differences are important when comparing different- population groups. Interesting results were obtained by com-

147

M. G. Nair and S. S. Pillay paring general medical, general surgical, and gynecological wards. The failure to recognize psychiatric disorders by our colleagues in the other disciplines is a source of concern. An ongoing process of education for psychiatrists to train nonpsychiatrist physicians to increase their awareness of psychopathology in physically ill patients and to enhance their diagnostic skills is required. Specifically designed substance abuse programs should be introduced as part of hospital policy. In order to improve quality of patient care in a general hospital, the burden of responsibility for bridging the gap between psychiatry and other disciplines probably lies with psychiatrists.

References 1. Mayou R, Hawton K, Feldman E: What happens to medical patients with psychiatric disorder? J Psychosom Res 32:541-549,1988 2. Goldberg D: Manual of the General Health Questionnaire. Windsor, Berks, NFER-Nelson Publishing Company, 1978 3. Maguire GP, Julier DL, Hawton KE, Bancroft JHJ:

148

4. 5.

6. 7. 8.

9. 10. 11.

Psychiatric morbidity and referral on two general medical wards. Br Med J 1:268-270, 1974 Goldberg D: Identifying psychiatric illness among general medical patients. Br Med J 291:161-162,1985 Benjamin J, Maoz B, Shiber A, Antonovsky H, Mark M: Prevalence of psychiatric disorders in three primary-care clinics in Beersheba, Israel. Gen Hosp Psychiatry 14:307-314, 1992 Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-III-R. Washington, DC, American Psychiatric Press, 1990 Deshpande SN, Sundaram KR, Wig NN: Psychiatric disorders among medical inpatients in an Indian hospital. Br J Psychiatry 154:504-509, 1989 Bridges KW, Goldberg DP: Psychiatric illness in inpatients with neurological disorders: patients’ views on discussion of emotional problems with neurologists. Br Med J 289:656-658, 1984 Leung CM, Chan KK, Cheng KK: Psychiatric morbidity in a general medical ward: Hong Kong’s experience. Gen Hosp Psychiatry 14:196-200,1992 Clarke D, Minas IH, Stuart GW: The prevalence of psychiatric morbidity in general hospital inpatients. Aust NZ J Psychiatry 25:322-329, 1991 Feldman E, Mayou R, Hawton K, Ardern E, Smith EBO: Psychiatric disorder in medical in-patients. Q J Med 63(241):405412, 1987