Liaison psychiatry in an Indian general hospital

Liaison Psychiatry in an Indian General Hospital Savita Malhotra, Anil Malhotra,

M.D. Ph.D.

Department of Psychiatry,

Postgraduate

Institute of Medical Education and Research,

Abstract: Patterns and the “dynamics” of the psychiatric referral process in a postgraduate teaching general hospital in lndia have been studied and compared with the trends in the West. The overall referral rate was 1.48%. On the whole, it is not simply the problem of “‘organic” versus “functional” diagnosis or abnormal behavior that are referred for psychiatric opinion. A large variety of other clinical problems are referred as well, Most of these problems could be tackled by simple measures like advice to the treating team, use of drugs, and supportive psychotherapy in the respective wards.

Introduction Liaison psychiatry has flourished more vigorously in the United States than anywhere else in the world, and the current resurgence of interest is also largely an American phenomenon. In Britain as well as in India, liaison psychiatry is not a full-time assignment. In most teaching centers in India, well organized liaison services do not exist. However, there is ample evidence based on epidemiologic data that positive correlation exists between physical and psychiatric disorders. According to Lipowski [2], “physical illness is the major cause of psychiatric morbidity.” Thirty percent to sixty percent of inpatients and 50-80% of outpatients suffer from psychic distress or disorder [3]. Rosen et al. [4] in his study on patients seen in several general medical clinics in Monroe county, New York, found that emotional disorder was diagnosed in 9%-23% of patients with various groups of somatic diagnosis. Incidence of depression has been variously reported to be 20% [5] of medical inpatients, 64% of hospitalized cardiac patients [6], 20% of severely ill medical inpatients [7], 29% of inpatients hospitalized for acute myocardial infarction [8]. Similarly, in the psychiatric population, 266 ISSN 0163-8343/84/$3.00

Chandigarh,

India

higher incidence of organic diseases has been reported [g-11]. These facts and figures undoubtedly address the importance, the need, and the scope of consultation-liaison work. Apart from the positive impact on the quality of patient care, there are important teaching and research implications. Systematic analysis of liaison work has not been reported from India. The present study was carried out at the Psychiatry Department of the Postgraduate Institute of Medical Education and Research, Chandigarh with the aim to study (1) the patterns and “dynamics” of the psychiatric referral process in the available setting and to compare it with other reports in the literature; (2) the common grounds on which nonpsychiatric physicians and psychiatrists come faceto-face most frequently.

Organizational Aspects The Department of Psychiatry at the P.G.I.M.E.R., Chandigarh, provides systematic exposure to consultation-liaison work to all its postgraduate trainees. Each resident during his MD training in psychiatry gets a full time rotational posting for 3 months at which he attends to all the inpatient referrals under the supervision of consultants. All the referral slips are received in a centralized location and the cases are assigned treatment within the following 24 hours depending upon the urgency indicated on the referral slip. After the detailed evaluation, the resident takes the consultant to the bedside of the patient where, upon review, the treatment is formulated. Apart from that, there are weekly psychosomatic case conferences in rotation with the departments of Internal Medicine, General Hospital Psych&y 6, 266-270, 1984 0 Elsevier Science Publishing Co., Inc. 1984 52 Vanderbilt Avenue, New York, NY 10017

Liaison Psychiatry in Indian General Hospital

General Surgery, Neurology, and Pediatrics, attended by the joint faculty and residents.

Methodology All the cases referred during one year (1978-1979) were used for the study. The author was the consulTable 1. Reasons for referral (Why) No.

Percentage

95

28.27

74 56

22.02 16.66

41 11 56 3

12.20 3.27 16.66 0.89

1. Mental symptoms coexisting

with physical problem 2. Abnormal behavior 3. Organic illness insufficient to explain symptoms 4. No physical illness detected 5. Past history of mental illness 6. Others 7. Not known

Table 2. Purpose of referral (What?)

No. 1. Help in management along

2. 3.

4. 5.

(336)

Percentage

177

52.67

98

29.16

44

13.09

9 8

2.68 2.38

with medical management Diagnosis (“organic” versus “functional”) Evaluation prior to special procedures (renal transplant, MTP, etc.) Crisis intervention Not clear

tant in charge of the referral service during that period and saw all the patients. A specially designed proforma was used for data collection on the following clinical variables: physical diagnosis, reasons that prompted the referrals, purpose for which it was referred, psychiatric diagnosis, and treatment advised. Information was gathered from the referral note, the patient’s case notes, discussion with the referring physician and the patient and his relatives.

Results Three hundred thirty-six patients were referred during 1 year of the study period, which formed about 1.48% of the total admissions to the hospital during that time. The majority (58%) were referred from Medicine and allied specialities and 31% from Surgery and allied specialities. Table 1 gives the most prominent reason for referral, meaning thereby why it was thought to send

for the consultation. Theoretically these categories are not mutually exclusive, but here the most prominent single reason has been taken. In the majority of cases (28%) it was the existence of certain mental symptoms along with physical illness that led to psychiatric referral. Table 2 shows in which area the assistance was expected. In about 53% it was in management assistance and in about 29%, help was sought to clarify the diagnosis generally between “organic” versus “functional” disorder. Table 3 gives the breakdown of the psychiatric diagnosis according to ICD-9. The most common diagnosis was neurosis (31%), followed by organic

Table 3. Psychiatric diagnosis

Organic psychoses Functional psychosesb Neurosesb Personality disorder Drug dependency and alcohol Psychosomatic disease Others No psychiatric diagnosis Diagnosis deferred Depression of all kinds

Taylor and Doody

Fava and Paven

N

Percent

(1979) (%)

(1980) (%)

Torem et al. (1979) (%)

65 23 105 3 6 7 27 85 15

19.34 6.84 31.25 0.89 1.78 2.08 8.02 25.29 4.46

18.8 4.5 14.2 11 5 3.7 3.7 2.3

1.6~ 3.2 19.8

17.7 6.4 42.5

18.4 6 3.2 10.8

4.3 2.1 16.3 4.3 6.4

36.8

37

apatients of organic psychoses were managed by the Neurology Department. bIncludes cases of MDP depression (4) and Reactive depression (51) respectively.

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S. Malhotraand A. Malhotra

Discussion

Table 4. Medical diagnosis (ICD-9) N

Infections and parasitic diseases

(336)

Percent

19

5.65 6.54 2.97 1.19 7.43 8.03 2.97 11.90 13.98 5.35 12.20 6.25 2.38 13.09

22 10 4 25 27 10 40 47 18 41 21 8 44

Neoplasms Endocrine, nutritional, and metabolic Blood and blood forming organs Nervous system and sense organs Disorders of CVS Disorders of RS Disorders of GIT Disorders of GUT Pregnancy and childbirth Injury and poisoning Others Physical diagnosis deferred No physical disease

psychoses (19%). On comparing these data with other studies [12,13], it is noteworthy that there is an under-representation of drug dependence and alcoholism and a greater frequency of “no psychiatric illness” category in our study. The number of psychosomatic disorders is uniformally low in all the studies. Table 4 indicates the distribution of medical diagnoses according to ICD-9. The largest group was of the disorders of the genitourinary tract. The following most common group was injury and poisoning (12.2%) and disorders of gastrointestinal tract (11.9%). However, in 13% of the cases physical disease was not found. Table 5 indicates that, in most cases, more than one treatment method was used. In about 40%, drugs were prescribed and in about 30%, active advice to the treatment team was given in terms of handling the patient or relatives.

Table 5. Treatment

Dnw

Adviceto treating team Supportive psychotherapy Investigations Family and social case work up

NIL Special

268

No.

Percent

134

39.88

101

30.06 16.66 2.08 0.89

56 7 3

65

19.34

The findings of our study when compared with reported literature will bring forth certain similarities as well as differences. Looking at the referral rates, American figures range between the 0.5% reported by Keamey [15] and the 10% reported by Hackett [16]. Komfeld and Feldman [17] reported 9%-13%. Figures reported from the United Kingdom are lower, that is 0.7% [18] to 2.8% [19]. Indian figures are comparable to British figures, that is, 0.66% [20], 1.4% [21], 1.17% [22], and 1.48% in the present study. However, when compared with the prevalence of psychiatric morbidity on general medical and surgical wards, these referral rates are very low, comprising only 20% of the total. Reasons for this discrepancy could be the following 1. Psychiatrists are not identified as members of the medical community. 2. Furthermore, it may be argued that physicians and surgeons are able to manage the psychiatric aspects of their patients as well. This does not seem very true because various studies have shown that a large amount of psychiatric morbidity in general medical wards goes undetected, particularly if the psychiatric problem is unobtrusive [ 23-261. It is suggested that the joint meetings and teaching sessions will enhance awareness in medical colleagues and increase the referral rates. In a study by Torem et al. [14], the use of an “active” liaison approach increased the referral rate from 2% to 20%. It is encouraging to note that it is not simply the presence of abnormal behavior that prompted psychiatric consultation; it is also that organic illness seemed insufficient to explain the symptoms existing with the physical problem and a positive past history (Table 1). This positive trend in our liaison work reflects the sensitivity and awareness of our medical colleagues and also the common teaching and service opportunities that are responsible. Assistance sought for the management of cases was reported in 38.6% of cases by Taylor and Doody [12], 40.3% by Fava and Pavan [13], and 52.67% in our sample (Table 2). The subsequent most common assistance sought was in diagnosis: 17% by Torem et al. [14], 27.7% by Taylor and Doody [12], 32.4% by Fava and Pavan 1131, and 29.16% in our study. This shows a remarkable similarity in the purpose of referral across various centers. On examination of the pattern of psychiatric ill-

Liaison Psychiatry in Indian General Hospital

nesses seen in referral work, the incidence of neuroses is highest (Table 3). The most common varieties of neuroses encountered were of depressive and anxiety types. In about 17% of cases, it was only a neurotic disorder that gave rise to physical complaints and in 13% there was no physical disease (Table 4), which shows that in India, somatic symptoms are common manifestations of psychiatric problems to the extent that many of them are admitted to the general medical and surgical wards. This ubiquitous tendency for somatization has been reported by other Indian workers as well. One explanation put forth is that conditions with only physical distress are considered illnesses needing medical intervention. Secondly, in Indian religiophilosophic tradition, free verbal expression of emotions is not encouraged, and this factor may be acting as an unconscious force behind somatization. Lower representation of alcohol and drug dependence and personality disorders in our study is perhaps a reflection of the distribution of these disorders in the general public. Psychosomatic disorders are uniformly fewer in most of the studies when compared with their actual prevalence in the general medical and surgical wards. It is possible that our colleagues are efficiently able to manage these conditions in totality, but what is more likely is that they are unaware of the kind of help psychiatrists can provide in the long-term care of these patients. This area needs further attention on the part of the psychiatrists in order to increase awareness in the medical colleagues of intervention strategies by psychiatrists and to enhance the quality of patient care. The incidence of depression in our study was found to be about 16% (N = 55, Table 3), which is relatively lower than the figures reported from other centers [5-S]. It is likely that depression, unless severe, is not recognized as a clinical entity in our setting both by the physician and the patient. On the whole, it was found that a wide variety of clinical problems are referred for psychiatric opinion and not simply the problem of “organic” versus “functional” diagnosis. Most of these issues could be tackled by simple measures such as advice to the treatment team, use of psychotropic drugs, and supportive psychotherapy done in the respective ward (Table 5). It is evident that in India there is a need and scope for the expansion of liaison psychiatry. Perhaps, the present state is a reflection of manpower and organizational problems.

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Savita Malhotra, M.D. Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh - 160012 India