The first General Hospital Psychiatry Unit (GHPU) in India was started at RG Kar Medical College and Hospital, Calcutta, India, in 1933 [1]. Over the years, the number of GHPUs have increased significantly [2], thus resulting in a greater interaction among psychiatrists, physicians and other specialists. Currently, the consultation-liaison services in India follow the consultation model, wherein a psychiatrist evaluates and manages the patient who is referred from a physician/surgeon [3].
There is a dearth of studies which have focused on consultation-liaison psychiatry in India. Data from the previous studies have suggested that the referral rates in India are very low (0.06%-3.6%), considering the higher psychiatric morbidity rates (18.42%-53.7%) which have been reported in the studies that have screened patients in other departments for psychiatric morbidity [3]. The most common psychiatric diagnosis among referred patients who were reported in the studies varied, depending on the set up. Studies on inpatient referrals have found Organic Brain Syndrome to be the most common diagnosis [4–6], while those who were referred from out-patient departments were more often diagnosed with neurotic, stress related and somatoform disorders [7, 8]. Most of the studies have included small samples and they have focused on a subset of psychiatric referrals (inpatient [4,6], outpatient [7], cardiology [8] and emergency [9,10]). With this background, a study of psychiatric referrals was conducted, with the objective of assessing the profile of referred patients, source of referral, reason for referral and the psychiatric diagnoses.
Material and Methods
The present study was a descriptive cross-sectional study which was conducted at a tertiary care teaching hospital in South India. It is a 990 bedded hospital which caters to a large population of Tumkur, India and neighbouring districts. The study population consisted of all the patients who were referred for psychiatric consultation from other departments (both in-patients and out-patients) over a period of two years, from January 2011 to December 2012. All the referred patients were evaluated by a consultant psychiatrist and diagnosis was made according to the diagnostic guidelines, as per ICD-10 (International Statistical Classification of Diseases) – Classification of Mental and Behavioural Disorders [11]. Other details like socio-demographic profile, source of referral and reason for referral were also recorded. The data which was obtained was analyzed by using descriptive statistical methods.
Results
A total of 520 patients were referred for psychiatric consultation from various departments during the study period. The referral rate was found to be 0.42%. Total number of patients who were referred from out-patient departments was 307 (59%) out of which 178 (58%) were males and 129 (42%) were females. The remaining 213 (41%) patients were in-patient referrals, among which 128 (60.1%) were males and 85 (39.9%) were females. The mean age of the study population was 38.39 years (SD-16.17), with a range of 1 to 86 years. A majority of the patients belonged to the age group of 16-45 years (n=310, 59.6%). The number of patients in the age groups of 1-15 years and above 65 years were 33 (6.3%) and 46 (8.8%) respectively.
Sources of Referral
[Table/Fig-1] shows the details of different sources (department wise) of psychiatric referrals. A majority of the referrals were made from the department of medicine (n=307, 59%). Among them, the number of in-patient referrals (n=162, 52.7%) was marginally higher than that of out-patient referrals (n=145, 47.3%). Other major sources of psychiatric referrals were departments of surgery (n=45, 8.7%), orthopaedics (n=42, 8.1%) and dermatology (n=36, 6.9%).
Sources of psychiatric referral (Department wise and In-patient vs. Out-patient)
| Department | In-patient | Out-patient | Total (%) |
|---|
| Medicine | 162 | 145 | 307 (59.0) |
| Surgery | 24 | 21 | 45 (8.7) |
| Orthopaedics | 19 | 23 | 42 (8.1) |
| Dermatology | - | 36 | 36 (6.9) |
| Pediatrics | 2 | 23 | 25 (4.8) |
| Otorhinolaryngology | 1 | 22 | 23 (4.4) |
| Obstetrics/Gynaecology | 5 | 12 | 17 (3.3) |
| Others | 19 | 23 | 42 (8.1) |
| Total | 213 | 307 | 520 (100) |
Reasons for Referral
When the reasons for psychiatric referral were analyzed, it was found that the most common reason was the presence of medically unexplained somatic complaints (n=120, 23.1%). Anxiety (n=109, 21%), abnormal behaviour (n=68, 13.1%) and substance use (n=59, 11.3%) were the other major reasons for referral. [Table/Fig-2] lists the common reasons for referral.
Reasons for psychiatric referral
| Reason for referral | In-patient | Out-patient | Total (%) |
|---|
| Medically unexplained somatic complaints | 46 | 74 | 120 (23.1) |
| Anxiety | 32 | 77 | 109 (21.0) |
| Abnormal behavior | 32 | 36 | 68 (13.1) |
| Substance abuse | 51 | 8 | 59 (11.3) |
| Depression | 29 | 27 | 56 (10.8) |
| Headache | 13 | 25 | 38 (7.3) |
| Seizures | 6 | 17 | 23 (4.4) |
| Sexual problems | 1 | 13 | 14 (2.7) |
| Others | 3 | 30 | 33 (6.3) |
Psychiatric Diagnoses
The most common psychiatric diagnosis [Table/Fig-3] made was neurotic, stress related and somatoform disorders (n=217, 41.7%), followed by mood disorders (n=67, 12.9%) and substance use disorders (n=66, 12.7%). Nil psychiatric diagnosis was made in 7.3% (n=38) of the referred patients.
Psychiatric diagnoses of referred patients
| Psychiatric diagnosis | In-patient | Out-patient | Total (%) |
|---|
| Neurotic, stress related and somatoform disorders | 72 | 145 | 217 (41.7) |
| Mood disorders | 24 | 43 | 67 (12.9) |
| Substance use disorders | 55 | 11 | 66 (12.7) |
| Psychotic disorders | 13 | 19 | 32 (6.2) |
| Organic mental disorders | 16 | 12 | 28 (5.4) |
| Behavioural syndromes associated with psychological disturbances and physical factors | 3 | 14 | 17 (3.3) |
| Others | 12 | 43 | 55 (10.6) |
| Nil psychiatric diagnosis | 18 | 20 | 38 (7.3) |
Reason for Referral vs. Psychiatric Diagnosis
The major reasons for referral and the outcomes (in terms of a psychiatric diagnosis) have been listed in [Table/Fig-4]. Neurotic, stress related and somatoform disorders were the most commonly diagnosed psychiatric disorders among the patients who were referred for the evaluation of medically unexplained somatic complaints, anxiety and headache. Psychotic disorders were diagnosed in 39.7% (n=27) of those who were referred for abnormal behaviour.
Most common psychiatric diagnosis for common reasons of referrals
| Reason for referral | Most common psychiatric diagnosis | N (%) |
|---|
| Medically unexplained somatic complaints | NSRSD* | 75 (62.5) |
| Anxiety | NSRSD* | 94 (86.2) |
| Abnormal behavior | Psychotic disorders | 27 (39.7) |
| Substance abuse | Substance use disorders | 57 (96.6) |
| Depression | Mood disorders | 34 (60.7) |
| Headache | NSRSD* | 18 (47.3) |
*NSRSD- Neurotic, stress related and somatoform disorders.
Discussion
This study was a modest attempt to recognize the pattern of psychiatric referrals in a tertiary care teaching hospital in south India. The referral rate of 0.42%, which was found in the study hospital, was comparable to the findings of most of the previous studies, which had shown a referral rate of 0.06% to 3.6% [3]. Some of the studies which had shown higher referral rates had looked into only a particular subset of patient population like in-patients [4,6], emergency patients [9,10] and cardiology outpatients [8]. There was preponderance of males in both in-patient (58% vs. 42%) and out-patient referrals (60.1% vs. 39.9%). The data from previous studies has not been conclusive in this aspect. Some studies have shown a male preponderance [7,12,13], while others have reported that female referrals were more common than male referrals [14–16].
Age distribution of the study population showed that a majority of the patients (59.6%) belonged to the age group of 16-45 years. Similar results were seen in the studies of Aghanwa et al., [14] and Bhogale et al., [7] with 61.6% and 70% of patients in this age group respectively. The proportion of the referred patients in the age group of more than 65 years was 8.8%. This was in accordance to the findings of other Indian studies. Jhingan [17] showed that 8% of study population was above 60 years and Bhogale et al., [7] found that 3.3% of the referred patients were older than 65 years. In contrast, western data suggest that the percentage of referrals in this age group is quite high [18]. This could be due to various local factors like a lesser life expectancy [19], a lack of awareness about geriatric conditions like dementia [20], preference of alternative systems of medicine like ayurveda, homeopathy and unani [21] and family neglect. Also, Indian families have a tendency by to accept geriatric problems as age related and normal.
When the sources of referrals were analyzed, it was found that a majority of the patients were referred from the department of medicine. This was in agreement with findings of previous studies which have shown that 54.3% to 64.78% of patients were referred from department of medicine [7,12,13,22]. The somatic symptoms of various psychiatric illnesses are given more importance in Indian culture. Therefore, inadvertently the patients visit general physicians for the treatment of their physical symptoms [23,24]. 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.
When the reasons for referral were analyzed, it was found that medically unexplained somatic complaints was the most common category, which accounted for 23.1% of the total referrals. This can be explained on the basis of high prevalence of functional somatic symptoms in Indian patients who have psychiatric illnesses [24]. This was lower than those in the findings in other studies, which have shown that medically unexplained somatic complaints accounted for 30% [15] and 54% [7] referrals. This could be due to growing awareness among other specialists regarding the somatic presentation of anxiety, which itself accounted for a significant 21% of the referrals. Substance use was the reason for 11.3% of the total referrals. This was similar to the findings of Singh et al., [13] which showed that 14.5% of the referrals were caused by substance use. In contrast, some studies [7,25] showed that a lower percentage (2-5%) of patients were referred for substance use, which the authors attributed to a lack of affordability. Surprisingly, the number of referrals following self harm/suicidal attempts were negligible (n=7, 1.35%) as compared to higher figures seen in other similar studies, which showed values ranging from 9.7% to 33.14% [7,12,14]. It is widely perceived by public that suicidal attempts, being medico-legal cases, are better handled by the government hospitals in terms of legal formalities [26]. This, coupled with the relatively lower treatment costs in government hospitals, may have resulted in a decreased inflow of patients following suicidal attempts, to the study hospital.
When the psychiatric diagnoses of the referred patients were analyzed, it was found that neurotic, stress related and somatoform disorders was the most common one (41.7%). This category includes some of the common psychiatric conditions like panic disorder, generalized anxiety disorder, adjustment disorders and somatoform disorders [11]. This finding was consistent with the data of a majority of the previous studies [7,8]. Interestingly, no psychiatric diagnosis was made in a significant 7.3% of the referred patients. The reasons for referral in these patients were medically unexplained somatic complaints (52.6%), headache (15.8%) and anxiety (10.5%). This group represented the ‘false-positive’ cases which were referred by doctors, possibly due to various factors like non-response to conventional treatment and abnormal illness behaviour.
It is pertinent to note that all of the above mentioned psychiatric disorders are not only common, but that they can also lead to a significant functional impairment [27]. The WHO has reported that by 2020, unipolar depression is anticipated to be the second most common cause of morbidity in the world, next only to cardiovascular disorders [28]. Also, the recent introduction of safe and effective psychotropic medication has improved the prognosis of many psychiatric conditions [29], which were once considered to be untreatable. In this context, psychiatric referrals are of utmost significance, as patients with psychiatric illnesses generally tend to consult other specialists before being referred to a psychiatrist.
Conclusion
Medically unexplained somatic complaints was the most common reasons for referral and neurotic, stress related and somatoform disorders was the most common psychiatric diagnosis. Even after decades of functioning of GHPUs, the psychiatric referral rates are abysmally low, with general physicians contributing to a majority of referred patients. A multi-disciplinary approach should be encouraged for the management of patients who attend general hospitals, in order to facilitate early recognition and management of psychiatric problems. Further studies need to focus on effects of interventions, like sensitizing other specialists, especially physicians, regarding psychiatric problems and their varied clinical presentations.