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Psychiatric morbidity in a general medical ward
Psychiatric Morbidity in a General Medical Ward Hong Kong’s Experience C. M. Leung, K. K. Chan and K. K. Cheng
Abstract: The psychiatric
morbidity of a general hospital’s male medical ward in Hong Kong was studied using a onestage single-rater method. Medical diagnoses were made according to ICD-9 on 91.5% of patients and 24% were diagnosed with DSM-Ill. The most common mental disorders included substance use disorder, dementia, and delirium. Of all the patients, 8.5% were not medically diagnosable and 5.3% were given only psychiatric diagnoses, the majority of which were substance use disorders.
Introduction Although the development of consultation-liaison (C-L) psychiatry has met resistance despite early optimism [l], C-L psychiatrists have succeeded in defining their expertise, theoretical framework, and subspecialty status in North America [2-41. In the United Kingdom, C-L psychiatry is not recognized as a subspecialty, but only as a “special interest,” due to financial constraints and other theoretical issues [5]. Nevertheless, since the pioneering work by Maguire et al. [6], different liaison groups have flourished, and the study of psychiatric morbidity in different specialties and settings has provided data essential for the planning and organization of C-L service [7]. Data in Hong Kong are scanty [8,9]; therefore, the current study was conducted in an attempt to look into the From the Department of Psychiatry, The Chinese University of Hong Kong (CML), the Department of Medicine, Kwong Wah Hospitil, Ho& Kong (KKChan), and the Department of-Cornmunitv Medicine, Universitv of Hone: Konp. (KKChena). Address reprint requests to: Dr. ?.M. Eeung, De&tment of Psychiatry, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
196 ISSN 0X3+3343/92/$5.00
size and features of the problem so as to provide a basis for further research and planning. The hospital where the study was conducted, a regional hospital in Hong Kong with a total bed number of 1,560, is situated in west Kowloon and serves a population of 400,000, mostly of social class IV and V. It provides a full range of specialty services except radiotherapy and psychiatry. The Accident and Emergency (A&E) Department works independently with no input from other specialties, i.e., no secondary screening by liaison psychiatrists is available. Only patients with physical problems, including those with deliberate selfharm, are admitted. Those with primary psychiatric problems with no organic basis are referred to mental hospitals or other psychiatric services. The overall admission rate is 30%.
Method This was a prospective study. Two of the authors (CML and KKChan) were the chief clinical staff on a male medical ward at the hospital studied. All patients admitted between September and December 1987 through the A&E department were interviewed and assessed for psychiatric morbidity by one of the authors (CML) using DSM-III [lo] criteria. The psychiatric assessment was conducted on the ward on a continuous basis after admission when physical condition allowed. Relatives were seen whenever possible to assist in ascertaining the diagnosis. Patients readmitted within the studied period, those admitted through the outpatient clinic, those transferred out soon after admission, and nonlocal citizens were excluded. Case notes for those who discharged themselves before asGeneral Hospital Psychiatry 14, 196-200, 1992 0 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Psychiatric Morbidity in a Hong Kong Hospital
sessment were traced for further study. The results were analyzed using the SPSS + package [ 111.
Table 1. Axis I and II diagnoses of patients according to DSM. III criteria Axis I, excluding tobacco dependence
Results During the period studied, 898 patients were admitted and 569 (63.3%) were formally assessed. The mean duration of hospital stay was 8.30 (SD 11.15) days. One-hundred (11%) patients were discharged before they could be adequately examined, and another 106 (12%) patients were transferred out for administrative reasons (they belonged to other medical units). There were 40 readmissions, 29 admissions through the outpatient clinic and three nonlocal citizen admissions. Sixteen patients died shortly after admission, and four were not accessible because of poor physical status. Fortyone records were lost.
Substance use disorder Dementia, primary degenerative of Alzheimer type, senile onset Dementia, multi-infarct Delirium (associated with Axis III physical disorder/etiology unknown) Dysthymia Schizophrenia Adjustment disorder Substance-induced organic disorder Generalized anxiety disorder Major depression Paranoid disorder Somatozation disorder Total Axis II Diagnoses Personality disorder Mental retardation Total
No. % 61 (45) 19 (14) 13 (9.5) 13 (9.5) 7 (5) 6 (4.5) 6 (4.5) 4 3 1 1 1 135
(3) (2) (1) (1) (1) (100)
10 2 12
Demographic Data All patients were male with a mean age of 54.5 years. The fiftieth percentile stood at 59 (range 1299 years); 37.4% were age 65 or above. Fifty-five percent were married or cohabiting. Over 70% came from Mainland China with an average stay of 34.5 years in Hong Kong. Twenty-nine percent lived alone, 33% occupied a bed space or cubicle, and 2% had no fixed abode. The percentage of unemployed was 11.8%, and 42.6% had retired. The percentage of skilled and unskilled workers was 14.1 and 23.6, respectively. Less than 1% belonged to social classes IV and V. Social security benefits from the government were received by 12.7%. Fifty percent had not finished primary education.
Medical Problems The major medical diagnoses were chronic obstructive pulmonary disease (18.5%), diabetes mellitus (lo%), hypertension (9.5%), gastroenteritis (6%), asthma (5%), pneumonia (5%), peptic ulcer (5%), acute cerebrovascular disease (4%), and ischemic heart disease (4%). There were two cases of selfpoisoning, one with sleeping pills and the other with a corrosive. No medical diagnosis was made in 8.5% of patients.
Psychiatric morbidity The total number of patients receiving psychiatric diagnosis according to DSM-III (excluding tobacco dependence) was 134 (23.5%). The axis I and II diagnoses are shown in Table 1. Sixty-one (10.7%) patients were found to have psychoactive substance dependence/abuse, including opiates (4.9%), alcohol (3.9%), benzodiazepines (I%), cough mixture (0.2%), and multiple drugs (0.7%). There were 13 patients with delirium, the causes of which included hypoxia/CO, retention (2), postictal state (2), uremia (2), anemia (l), gastrointestinal bleeding (l), hepatic failure (l), cerebral infarction (l), and subdural hematoma (1). The cause in two patients remained unknown despite extensive search. Among the 48 (8.5%) patients in whom no medical diagnosis could be made, 30 (5.3%) received psychiatric labeling. The range of diagnoses is shown in Table 2. The remaining 18 (3.2%) patients were not diagnosed either medically or psychiatrically. Of the 100 patients who were discharged before adequate psychiatric assessment, 62 discharged themselves against medical advice (DAMA). Case notes of 47 DAMA patients were traceable for scru-
197
C.
M. Leung et al.
Table 2. Psychiatric diagnoses in the absence of
medical diagnosis
Alcohol abuse/dependence Benzodiazepine abuse/dependence Heroin abuse/dependence Dysthymialdepression Adjustment disorder Somatization disorder Scizophrenia
11 9 5 3 2 1 1
Total
32
tiny. Eight (17%) were admitted because of drugrelated problems (no statistically significant difference when compared with the assessed sample, X2 = 1.23, df = 1, p = ~0.1).
Discussion Excluding tobacco dependence, the overall psychiatric morbidity of our sample patients is 24%; substance use disorder makes up nearly half of this figure (10.7%), mainly because opiate and alcohol dependence have remained a predominantly male activity among the local lower social class [12], a fact often overlooked in a clinical setting and in most inpatient studies [13]. Drug-dependent patients are frequently hospitalized not because of their drug habits, but for associated problems, e.g., chest infections or chronic obstructive pulmonary disease. Occasionally, they malinger in order to avoid court hearings for various offenses. But though most opiate users readily admit using illicit drugs in order to obtain substitutes such as methadone, alcohol users tend to hide their drinking habits and underreport their consumption even on direct confrontation [14]. Though nonnarcotic substance use is relatively inconspicuous in the current study, the local prevalence has been rising rapidly in recent years. In 1990, cannabis, benzodiazepine, and cough mixture abuse were found in 70% of the newly reported drug cases [12]. New legislation is being prepared to deal with the problem. The low prevalence of mood disorders (dysthymia 1.2%, major depression 0.2%) reflects their uncommon occurrence among aged men in our society as compared with the West [15]. This is in agreement with the local epidemiological study by Chen et al. [16]. Studies on Taiwan Chinese showed similar findings [17]. Both biological and social factors are thought to be responsible for the
198
cross-cultural differences, which require further clarification. It is often claimed that in certain cultures, including the local Chinese, the tendency to somatize and keep feelings to oneself may make detection difficult [l&J].However, in our study, only one diagnosis of somatization disorder was made. This probably reflects the genuine rarity of somatization disorder among the hospitalized male patients, as somatization is more commonly found among females at the primary health care level. Only two cases of self-poisoning were collected in the current study. The low figure can be misleading as it refers only to male patients. However, even when this is taken into account, inpatient data for self-poisoning can still be highly deceptive as many clients discharge themselves from the A&E
Department or soon after admission. A recent local study found that poisoning made up only 0.19% of the total A&E presentations, a very low figure compared with findings in the United States [19,20]. The diluting effect due to A&E visits for minor complaints was the main explanation for the low incidence observed. The same study revealed a female predominance of 71% . Of those assessed, 3.2% were given neither a physical nor a psychiatric diagnosis. These patients commonly presented with vague symptoms such as dizzy spells or headaches. Lack of diagnosis could reflect genuine absence of pathology. On the other hand, it may represent subtle, undetected illness--physical, psychological, or both. It is evident from the above that the prevalence of psychiatric morbidity among general hospital patients depends on a large number of interrelated factors. Different physical diseases or mental illnesses affect different patient populations, depending on age, sex, smoking and drinking habits, occupation, and social class, as shown in this study. A young surgical sample is obviously different from an aged medical population. The source of referral and efficiency of the screening process at the A&E Department are other significant variables. Efficient scrutiny by competent A&E physicians and liaison psychiatrists would filter out a significant number of the psychiatric patients who would otherwise be admitted to nonpsychiatric wards. This would undoubtedly ease the burden on nonpsychiatrist physicians, though there is no evidence that they provide inferior service to psychiatric patients [21]. Thus, the importance of many factors, including geographical location of the hospital, social class of the population it serves,
Psychiatric Morbidity in a Hong Kong Hospital
admission policy, and provision of various specialty services, in determining the psychiatric morbidity among medical inpatients cannot be overemphasized. In future studies, the confounding factors listed above should be described in detail to make comparison meaningful. In Hong Kong, with a total population of 5.7 million, only one university general hospital provides a full 24-hour psychiatric liaison service at its A&E Department due to shortage of help 191. Furthermore, half of the regional hospitals lack an inpatient psychiatric service. Where there is no such support, as in our case, all patients with deliberate self-harm are admitted to general wards for observation, even when found to be physically fit. Thus, the provision of such basic “holding” facilities is the prerequisite for developing a psychiatric liaison service of any magnitude. Our study, though sex biased, suggests that organic conditions such as substance use disorder, dementia, and delirium predominate, a fact that liaison psychiatrists should be aware of in the planning of clinical service, training, and research.
Shortcoming of the Present Study Most recent studies of psychiatric morbidity in the general hospital employ a two-stage method: screening with a health questionnaire followed by a structured interview of suspected cases [22-251. This saves time and expertise but suffers from problems of sensitivity, reliability, and flexibility [26]. We attempted to overcome these difficulties by personally interviewing every patient included in the study. This was possible because one author (CML), the psychiatric assessor, was working as a registrar in medicine at the time. Our one-stage, single-rater method, however, is extremely labor intensive. Also, without a structured interview, personal biases are unchecked. Furthermore, the use of DSM-III criteria in general medical patients is limited [27,28]. Finally, as only the male ward was surveyed, further exploration of the psychiatric morbidity among female patients, likely to be different from male ones, is warranted.
References SA: Future directions in consultationliaison psychiatry. Psychother Psychosom 48168-77,
1. Cavanaugh
1988 2. Lipowski ZJ: Holistic-medical
foundations
of Amer-
ican psychiatry: a bicentennial. Am J Psychiatry 138:888-895, 1981 psychiatry: the 3. Lipowski ZJ: Consultation-liaison first half century. Gen Hosp Psychiatry 8:305-315, 1986 psychiatry: prog4. Pasnau RO: Consultation-liaison ress, problems and prospects. Psychosomatics 29:515, 1988 5. Maguire GP, Julier DL, Hawton KE, Bancroft JHJ: Psychiatric morbidity and referral on two general medical wards. BMJ 1:268-270, 1974 6. Mayou R: A British view of liaison psychiatry. Gen Hosp Psychiatry 918-24, 1987 7. Mayou R: The present state of consultation and liaison psychiatry. Psych Bull 14:321-325, 1990 8. Lai B, Tsoi TK: The psychiatrist in a general hospital: the role in consultation psychiatry. Hong Kong J Ment Health 14:9-21, 1984 psychia9. Leung CM, Lee S: The consultation-liaison try at Prince of Wales Hospital-a new look. J Hong Kong College Psychiatrists 1:57-60, 1990 10. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder, 3rd ed. Washington, DC, APA, 1980 11. Norusis MJ: SPSS/PC + V2.0 Chicago:SPSS Inc, 1988 12. Central Registry of Drug Abuse, Hong Kong Government, 1981-1990 13. Mayou R, Hawton K: Psychiatric disorder in the general hospital. Br J Psychiatry 149:172-190, 1986 14. Midanik L: The validity of self-reported alcohol consumption and alcohol problems: a literature review. Br J Addiction 77~357-382, 1982 15. Myers JK, Weissman MM, Tischler GL: Six-month prevalence of psychiatric disorders in three communities. Arch Gen Psychiatry 41:959-967, 1984 16. Chen CN, Wong-M J, Lee N, Chan-Ho MW: Mental health morbidity in a Hong Kong community. Presented at the 4th Scientific Meeting of the Pacific Rim College of Psychiatrists, Dee 1988, Hong Kong 17. Yeh EK, Hwu HG, Chang LY, Yeh YL: Lifetime prevalence of mental disorders in a Chinese metropolis and 2 townships. In Yeh EK, Rin H, Yeh CC, Hwu HG (eds), Prevalence of Mental Disorders. Proc Int Symp on Psychiatric Epidemiology, April 26-28. Taipei, Department of Health, ROC, 1985, pp 175197 18. Tseng WS: The nature of somatic complaints among psychiatric patients: the Chinese case. Compr Psychiatry 16:237-245, 1975 epidemiolog19. Yeung KC, Wong TW: Poisoning-an ical study (in press) 20. Guzzardi LJ: Role of the emergency physician in treatment of the poisoned patient. Emerg Med Clin North Am 2:3-21, 1984 21. Hendryx M, Bootzin RR: Psychiatric episodes in general hospitals without psychiatric units. Hosp Community Psychiatry 37:1025-1029, 1986 22. Goldberg DP: The detection of psychiatric illness by questionnaire. Maudsley Monograph No. 21, London, Oxford University Press, 1972 23. Harding TW, de Arango MV, Baltazar J, et al: Mental disorders in primary health care: a study of their
199
C. M. Leung et al.
frequency and diagnosis in four developing countries. Psycho1 Med 10:231-241, 1980 24. Wing JK, Cooper J, Sartorius N: The measurement and classification of psychiatric symptoms. Cambridge, Cambridge University Press, 1974 25. American Psychiatric Association: Structured clinical interview for DSM-III-R: patient edition (with psychotic screen). Washington DC, APA, 1990
200
26. Goldberg D, Huxley P: Mental Illness in the Community. London, Tavistock, 1980 27. Leigh H, Price L, Ciarcia J, Mirassou, MM: DSM-III and consultation-liaison psychiatry: toward a comprehensive medical model of the patient. Gen Hosp Psychiatry 4283-289, 1982 28. Mackenzie TB, Popkin MK, Callies AL: Clinical applications of DSM-III in consultation-liaison psychiatry. Hosp Community Psychiatry 34:628-631, 1983
Abstract: The psychiatric
morbidity of a general hospital’s male medical ward in Hong Kong was studied using a onestage single-rater method. Medical diagnoses were made according to ICD-9 on 91.5% of patients and 24% were diagnosed with DSM-Ill. The most common mental disorders included substance use disorder, dementia, and delirium. Of all the patients, 8.5% were not medically diagnosable and 5.3% were given only psychiatric diagnoses, the majority of which were substance use disorders.
Introduction Although the development of consultation-liaison (C-L) psychiatry has met resistance despite early optimism [l], C-L psychiatrists have succeeded in defining their expertise, theoretical framework, and subspecialty status in North America [2-41. In the United Kingdom, C-L psychiatry is not recognized as a subspecialty, but only as a “special interest,” due to financial constraints and other theoretical issues [5]. Nevertheless, since the pioneering work by Maguire et al. [6], different liaison groups have flourished, and the study of psychiatric morbidity in different specialties and settings has provided data essential for the planning and organization of C-L service [7]. Data in Hong Kong are scanty [8,9]; therefore, the current study was conducted in an attempt to look into the From the Department of Psychiatry, The Chinese University of Hong Kong (CML), the Department of Medicine, Kwong Wah Hospitil, Ho& Kong (KKChan), and the Department of-Cornmunitv Medicine, Universitv of Hone: Konp. (KKChena). Address reprint requests to: Dr. ?.M. Eeung, De&tment of Psychiatry, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
196 ISSN 0X3+3343/92/$5.00
size and features of the problem so as to provide a basis for further research and planning. The hospital where the study was conducted, a regional hospital in Hong Kong with a total bed number of 1,560, is situated in west Kowloon and serves a population of 400,000, mostly of social class IV and V. It provides a full range of specialty services except radiotherapy and psychiatry. The Accident and Emergency (A&E) Department works independently with no input from other specialties, i.e., no secondary screening by liaison psychiatrists is available. Only patients with physical problems, including those with deliberate selfharm, are admitted. Those with primary psychiatric problems with no organic basis are referred to mental hospitals or other psychiatric services. The overall admission rate is 30%.
Method This was a prospective study. Two of the authors (CML and KKChan) were the chief clinical staff on a male medical ward at the hospital studied. All patients admitted between September and December 1987 through the A&E department were interviewed and assessed for psychiatric morbidity by one of the authors (CML) using DSM-III [lo] criteria. The psychiatric assessment was conducted on the ward on a continuous basis after admission when physical condition allowed. Relatives were seen whenever possible to assist in ascertaining the diagnosis. Patients readmitted within the studied period, those admitted through the outpatient clinic, those transferred out soon after admission, and nonlocal citizens were excluded. Case notes for those who discharged themselves before asGeneral Hospital Psychiatry 14, 196-200, 1992 0 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Psychiatric Morbidity in a Hong Kong Hospital
sessment were traced for further study. The results were analyzed using the SPSS + package [ 111.
Table 1. Axis I and II diagnoses of patients according to DSM. III criteria Axis I, excluding tobacco dependence
Results During the period studied, 898 patients were admitted and 569 (63.3%) were formally assessed. The mean duration of hospital stay was 8.30 (SD 11.15) days. One-hundred (11%) patients were discharged before they could be adequately examined, and another 106 (12%) patients were transferred out for administrative reasons (they belonged to other medical units). There were 40 readmissions, 29 admissions through the outpatient clinic and three nonlocal citizen admissions. Sixteen patients died shortly after admission, and four were not accessible because of poor physical status. Fortyone records were lost.
Substance use disorder Dementia, primary degenerative of Alzheimer type, senile onset Dementia, multi-infarct Delirium (associated with Axis III physical disorder/etiology unknown) Dysthymia Schizophrenia Adjustment disorder Substance-induced organic disorder Generalized anxiety disorder Major depression Paranoid disorder Somatozation disorder Total Axis II Diagnoses Personality disorder Mental retardation Total
No. % 61 (45) 19 (14) 13 (9.5) 13 (9.5) 7 (5) 6 (4.5) 6 (4.5) 4 3 1 1 1 135
(3) (2) (1) (1) (1) (100)
10 2 12
Demographic Data All patients were male with a mean age of 54.5 years. The fiftieth percentile stood at 59 (range 1299 years); 37.4% were age 65 or above. Fifty-five percent were married or cohabiting. Over 70% came from Mainland China with an average stay of 34.5 years in Hong Kong. Twenty-nine percent lived alone, 33% occupied a bed space or cubicle, and 2% had no fixed abode. The percentage of unemployed was 11.8%, and 42.6% had retired. The percentage of skilled and unskilled workers was 14.1 and 23.6, respectively. Less than 1% belonged to social classes IV and V. Social security benefits from the government were received by 12.7%. Fifty percent had not finished primary education.
Medical Problems The major medical diagnoses were chronic obstructive pulmonary disease (18.5%), diabetes mellitus (lo%), hypertension (9.5%), gastroenteritis (6%), asthma (5%), pneumonia (5%), peptic ulcer (5%), acute cerebrovascular disease (4%), and ischemic heart disease (4%). There were two cases of selfpoisoning, one with sleeping pills and the other with a corrosive. No medical diagnosis was made in 8.5% of patients.
Psychiatric morbidity The total number of patients receiving psychiatric diagnosis according to DSM-III (excluding tobacco dependence) was 134 (23.5%). The axis I and II diagnoses are shown in Table 1. Sixty-one (10.7%) patients were found to have psychoactive substance dependence/abuse, including opiates (4.9%), alcohol (3.9%), benzodiazepines (I%), cough mixture (0.2%), and multiple drugs (0.7%). There were 13 patients with delirium, the causes of which included hypoxia/CO, retention (2), postictal state (2), uremia (2), anemia (l), gastrointestinal bleeding (l), hepatic failure (l), cerebral infarction (l), and subdural hematoma (1). The cause in two patients remained unknown despite extensive search. Among the 48 (8.5%) patients in whom no medical diagnosis could be made, 30 (5.3%) received psychiatric labeling. The range of diagnoses is shown in Table 2. The remaining 18 (3.2%) patients were not diagnosed either medically or psychiatrically. Of the 100 patients who were discharged before adequate psychiatric assessment, 62 discharged themselves against medical advice (DAMA). Case notes of 47 DAMA patients were traceable for scru-
197
C.
M. Leung et al.
Table 2. Psychiatric diagnoses in the absence of
medical diagnosis
Alcohol abuse/dependence Benzodiazepine abuse/dependence Heroin abuse/dependence Dysthymialdepression Adjustment disorder Somatization disorder Scizophrenia
11 9 5 3 2 1 1
Total
32
tiny. Eight (17%) were admitted because of drugrelated problems (no statistically significant difference when compared with the assessed sample, X2 = 1.23, df = 1, p = ~0.1).
Discussion Excluding tobacco dependence, the overall psychiatric morbidity of our sample patients is 24%; substance use disorder makes up nearly half of this figure (10.7%), mainly because opiate and alcohol dependence have remained a predominantly male activity among the local lower social class [12], a fact often overlooked in a clinical setting and in most inpatient studies [13]. Drug-dependent patients are frequently hospitalized not because of their drug habits, but for associated problems, e.g., chest infections or chronic obstructive pulmonary disease. Occasionally, they malinger in order to avoid court hearings for various offenses. But though most opiate users readily admit using illicit drugs in order to obtain substitutes such as methadone, alcohol users tend to hide their drinking habits and underreport their consumption even on direct confrontation [14]. Though nonnarcotic substance use is relatively inconspicuous in the current study, the local prevalence has been rising rapidly in recent years. In 1990, cannabis, benzodiazepine, and cough mixture abuse were found in 70% of the newly reported drug cases [12]. New legislation is being prepared to deal with the problem. The low prevalence of mood disorders (dysthymia 1.2%, major depression 0.2%) reflects their uncommon occurrence among aged men in our society as compared with the West [15]. This is in agreement with the local epidemiological study by Chen et al. [16]. Studies on Taiwan Chinese showed similar findings [17]. Both biological and social factors are thought to be responsible for the
198
cross-cultural differences, which require further clarification. It is often claimed that in certain cultures, including the local Chinese, the tendency to somatize and keep feelings to oneself may make detection difficult [l&J].However, in our study, only one diagnosis of somatization disorder was made. This probably reflects the genuine rarity of somatization disorder among the hospitalized male patients, as somatization is more commonly found among females at the primary health care level. Only two cases of self-poisoning were collected in the current study. The low figure can be misleading as it refers only to male patients. However, even when this is taken into account, inpatient data for self-poisoning can still be highly deceptive as many clients discharge themselves from the A&E
Department or soon after admission. A recent local study found that poisoning made up only 0.19% of the total A&E presentations, a very low figure compared with findings in the United States [19,20]. The diluting effect due to A&E visits for minor complaints was the main explanation for the low incidence observed. The same study revealed a female predominance of 71% . Of those assessed, 3.2% were given neither a physical nor a psychiatric diagnosis. These patients commonly presented with vague symptoms such as dizzy spells or headaches. Lack of diagnosis could reflect genuine absence of pathology. On the other hand, it may represent subtle, undetected illness--physical, psychological, or both. It is evident from the above that the prevalence of psychiatric morbidity among general hospital patients depends on a large number of interrelated factors. Different physical diseases or mental illnesses affect different patient populations, depending on age, sex, smoking and drinking habits, occupation, and social class, as shown in this study. A young surgical sample is obviously different from an aged medical population. The source of referral and efficiency of the screening process at the A&E Department are other significant variables. Efficient scrutiny by competent A&E physicians and liaison psychiatrists would filter out a significant number of the psychiatric patients who would otherwise be admitted to nonpsychiatric wards. This would undoubtedly ease the burden on nonpsychiatrist physicians, though there is no evidence that they provide inferior service to psychiatric patients [21]. Thus, the importance of many factors, including geographical location of the hospital, social class of the population it serves,
Psychiatric Morbidity in a Hong Kong Hospital
admission policy, and provision of various specialty services, in determining the psychiatric morbidity among medical inpatients cannot be overemphasized. In future studies, the confounding factors listed above should be described in detail to make comparison meaningful. In Hong Kong, with a total population of 5.7 million, only one university general hospital provides a full 24-hour psychiatric liaison service at its A&E Department due to shortage of help 191. Furthermore, half of the regional hospitals lack an inpatient psychiatric service. Where there is no such support, as in our case, all patients with deliberate self-harm are admitted to general wards for observation, even when found to be physically fit. Thus, the provision of such basic “holding” facilities is the prerequisite for developing a psychiatric liaison service of any magnitude. Our study, though sex biased, suggests that organic conditions such as substance use disorder, dementia, and delirium predominate, a fact that liaison psychiatrists should be aware of in the planning of clinical service, training, and research.
Shortcoming of the Present Study Most recent studies of psychiatric morbidity in the general hospital employ a two-stage method: screening with a health questionnaire followed by a structured interview of suspected cases [22-251. This saves time and expertise but suffers from problems of sensitivity, reliability, and flexibility [26]. We attempted to overcome these difficulties by personally interviewing every patient included in the study. This was possible because one author (CML), the psychiatric assessor, was working as a registrar in medicine at the time. Our one-stage, single-rater method, however, is extremely labor intensive. Also, without a structured interview, personal biases are unchecked. Furthermore, the use of DSM-III criteria in general medical patients is limited [27,28]. Finally, as only the male ward was surveyed, further exploration of the psychiatric morbidity among female patients, likely to be different from male ones, is warranted.
References SA: Future directions in consultationliaison psychiatry. Psychother Psychosom 48168-77,
1. Cavanaugh
1988 2. Lipowski ZJ: Holistic-medical
foundations
of Amer-
ican psychiatry: a bicentennial. Am J Psychiatry 138:888-895, 1981 psychiatry: the 3. Lipowski ZJ: Consultation-liaison first half century. Gen Hosp Psychiatry 8:305-315, 1986 psychiatry: prog4. Pasnau RO: Consultation-liaison ress, problems and prospects. Psychosomatics 29:515, 1988 5. Maguire GP, Julier DL, Hawton KE, Bancroft JHJ: Psychiatric morbidity and referral on two general medical wards. BMJ 1:268-270, 1974 6. Mayou R: A British view of liaison psychiatry. Gen Hosp Psychiatry 918-24, 1987 7. Mayou R: The present state of consultation and liaison psychiatry. Psych Bull 14:321-325, 1990 8. Lai B, Tsoi TK: The psychiatrist in a general hospital: the role in consultation psychiatry. Hong Kong J Ment Health 14:9-21, 1984 psychia9. Leung CM, Lee S: The consultation-liaison try at Prince of Wales Hospital-a new look. J Hong Kong College Psychiatrists 1:57-60, 1990 10. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder, 3rd ed. Washington, DC, APA, 1980 11. Norusis MJ: SPSS/PC + V2.0 Chicago:SPSS Inc, 1988 12. Central Registry of Drug Abuse, Hong Kong Government, 1981-1990 13. Mayou R, Hawton K: Psychiatric disorder in the general hospital. Br J Psychiatry 149:172-190, 1986 14. Midanik L: The validity of self-reported alcohol consumption and alcohol problems: a literature review. Br J Addiction 77~357-382, 1982 15. Myers JK, Weissman MM, Tischler GL: Six-month prevalence of psychiatric disorders in three communities. Arch Gen Psychiatry 41:959-967, 1984 16. Chen CN, Wong-M J, Lee N, Chan-Ho MW: Mental health morbidity in a Hong Kong community. Presented at the 4th Scientific Meeting of the Pacific Rim College of Psychiatrists, Dee 1988, Hong Kong 17. Yeh EK, Hwu HG, Chang LY, Yeh YL: Lifetime prevalence of mental disorders in a Chinese metropolis and 2 townships. In Yeh EK, Rin H, Yeh CC, Hwu HG (eds), Prevalence of Mental Disorders. Proc Int Symp on Psychiatric Epidemiology, April 26-28. Taipei, Department of Health, ROC, 1985, pp 175197 18. Tseng WS: The nature of somatic complaints among psychiatric patients: the Chinese case. Compr Psychiatry 16:237-245, 1975 epidemiolog19. Yeung KC, Wong TW: Poisoning-an ical study (in press) 20. Guzzardi LJ: Role of the emergency physician in treatment of the poisoned patient. Emerg Med Clin North Am 2:3-21, 1984 21. Hendryx M, Bootzin RR: Psychiatric episodes in general hospitals without psychiatric units. Hosp Community Psychiatry 37:1025-1029, 1986 22. Goldberg DP: The detection of psychiatric illness by questionnaire. Maudsley Monograph No. 21, London, Oxford University Press, 1972 23. Harding TW, de Arango MV, Baltazar J, et al: Mental disorders in primary health care: a study of their
199
C. M. Leung et al.
frequency and diagnosis in four developing countries. Psycho1 Med 10:231-241, 1980 24. Wing JK, Cooper J, Sartorius N: The measurement and classification of psychiatric symptoms. Cambridge, Cambridge University Press, 1974 25. American Psychiatric Association: Structured clinical interview for DSM-III-R: patient edition (with psychotic screen). Washington DC, APA, 1990
200
26. Goldberg D, Huxley P: Mental Illness in the Community. London, Tavistock, 1980 27. Leigh H, Price L, Ciarcia J, Mirassou, MM: DSM-III and consultation-liaison psychiatry: toward a comprehensive medical model of the patient. Gen Hosp Psychiatry 4283-289, 1982 28. Mackenzie TB, Popkin MK, Callies AL: Clinical applications of DSM-III in consultation-liaison psychiatry. Hosp Community Psychiatry 34:628-631, 1983