Morbidity Pattern in Psychiatric Ward in a Tertiary Care Hospital in Eastern Nepal

Introduction: Worldwide, the morbidity of psychiatric illnesses is on the rise. Quality in-patient services are a part of quality mental health services provision. Knowledge about the pattern of illness among patients admitted to the ward could help the service providers to plan better and provide better services. This study was undertaken to explore the clinico-demographic profile of patients admitted to psychiatric ward at BPKIHS.. Material And Method: This is a hospital based retrospective and cross-sectional study. After ethical approval from the Institutional Review Committee, the data of all patients admitted to Psychiatry Ward from 1st January 2007 to 31st December 2016 were collected from the data-base of Medical Records Section. The diagnoses were made according to the ICD-10 criteria. 3687 admissions were processed for the analysis. Results: Of the 3687 admissions, 2183(59.2%) were male and 1504 (40.8%) were female. The age range was 4-92 years with mean age of 32.4(±12.6)years. The majority of the admissions (62.5%) were from Sunsari (1159,31.4%) and surrounding districts (1147,31.1%). Mood disorders were the commonest diagnoses 1788(48.5%) followed by schizophrenia, schizotypal and delusional disorders 829(22.5%) and psychoactive substance use disorders 813(22.1). 92% of patients admitted were improved on discharge and three cases expired in the ward. Out of 3687 admissions, 957(26%) were readmissions. Conclusion: Mood disorders were the commonest diagnosis among the admitted patients. Outcome of hospital stay was good with 92% discharged in improved condition and only three mortalities in 10 years duration. Address seems to significantly affect the service utilization.


INTRODUCTION
Worldwide, the morbidity of psychiatric illnesses is on the rise. 1 However, the gap of the need for mental health services and the provision of available services is vast and even many of those who do get the services do not get quality services. 1Modern mental health services in Nepal started almost fifty years back but still the services are grossly inadequate.In-patient psychiatric services in Nepal are being provided mainly in the psychiatric units of medical colleges and university hospitals and some private hospitals but this is grossly inadequate.The WHO-AIMS report reported 17 community-based psychiatric inpatient units were available in the country for a total of 1.00 beds per 100,000 population and treated 3.91 patients per 100,000 population. 2 A recent study reported a total of 1.5 beds per 100,000 population and just 60 psychiatrists for a population of almost 30 milllions. 3The psychiatric department of B.P. Koirala Institute of Health Sciences(BPKIHS), Dharan(with 30 beds capacity) and Koshi Zonal Hospital, Biratnagar (with 4 beds capacity) had been the only facilities providing in-patient services to the entire population of 5.83 millions 4 in the Eastern Development Region till eight years back.Some additional beds are now available in other private medical colleges and private hospitals.Quality in-patient services are a part of quality mental health services provision.Longer inpatient stays could lead to higher direct and indirect costs and it could also isolate the patient from their social networks leading to maladaptive processes in the patients. 5oreover in context of Nepal where the health care spending is mainly based on out-of-pocket money, it could lead to catastrophic costs further compounding the situation.The average psychiatric in-patient Length of Stay(LoS) in Nepal was found to be 18.85 days. 2 In Nepal, the average cost of antipsychotic or antidepressant medicines was found to be around 8% of the daily wage of a labourer. 2][8][9][10][11] Mental disorders have been associated with longer duration of stay than physical disorders. 12imilarly, psychosis, female gender and larger hospital size were associated with longer hospital stay while discharge against medical advice, young or middle ages, being detained and being married were some of the factors associated with shorter hospital stay. 11Goldstein et al. have suggested that in addition to diagnosis, other factors such as age and treatment setting contribute to long stays and high costs. 13In another study done in South London, the mean age of the patients was 39.1 yrs (SD±12.4)with 56% of patients being male.Psychotic disorders (Schizophrenia and other psychotic disorders-42%) were the commonest diagnosis followed by mood disorders (28%), drugs and alcohol disorders (11%), neurotic and anxiety disorders (9%) and personality disorders (6%). 14Knowledge about the clinico-demographic profile of the patients admitted to psychiatric wards could help the service providers as well as the administrators to plan better and provide better services.

MATERIAL AND METHOD
This was a retrospective cross-sectional study conducted at B. P. Koirala Institute of Health Sciences(BPKIHS), Dharan with the objective of knowing the morbidity pattern of patients admitted to the psychiatric ward at BPKIHS along with sociodemographic profile.BPKIHS is the tertiary referral centre in the Eastern Development Region of Nepal.The psychiatric department of the institute provides out-patient, in-patient, 24-hour emergency services and consultation liaison services.The department has 30 bed capacity in-patient ward.The psychiatric diagnoses of all patients admitted in the ward are made according to the ICD-10 CDDG criteria by consultant psychiatrists after adequate detail work up.The medical record section of the institute keeps a well maintained electronic database with records of all inpatients according to the ICD-10 diagnostic categories.The study protocol was submitted to the Institutional Review Committee and ethical approval was taken.The data of all patients admitted to the psychiatry ward from 1st January 2007 to 31st December 2016 were extracted from the database of the medical record section using all precautions to conceal any identity of the patients.The data were entered into MS Excel, cleaned and processed for analysis using the SPSS version 11.5.There were a total of 3699 admissions during the study period out of which two were mistake admissions and ten admissions were cancelled the same day.These twelve admissions were excluded from the study and remaining 3687 admissions were analyzed.For descriptive statistics, percentage, mean, range and standard deviation were calculated and presented in tabular and graphical presentation.

RESULT
There were a total of 3687 admissions.There were 1504 (40.8%) female admissions and 2183(59.2%)male admissions of which 2730(74%) were single admission and 957(26%) readmissions.with range of 1-124 days.The bed occupancy rate was 65.2%.The overall outcome during the study period was good with 92% patients discharged in improved state and only three(0.1%)deaths in ten years period.Similarly, all patients who had expired had medical comorbidity.Those with mixed diagnosis were younger(mean age-30.29 years) as compared to those with single diagnosis and the association was significant(p=0.009).Similarly, females were younger(mean age 31.8 years) as compared to males(mean age 32.9 years) in our study sample and the association was significant(p=0.008).

DISCUSSION:
According to the Nepal Census 2011, 15 the male to female ratio in the Eastern Development Region was 92.37:100 but in our study, more males(59.2%)were admitted as compared to females.The WHO-AIMS study in Nepal had found that 54% of inpatients were male. 2 Similar findings have been noted by other studies, 7,16,17  26 Majority of patients(88.4%)were Hindu by religion followed by Kirat(5.4%).9][30][31][32] In our study, there were more admissions during month of March(10.2%)as compared to other months.The length of stay was maximum(21.8 days) in May and minimum(17.7 days) in March and there was significant association of LoS with month of admission.Our findings of maximum LoS during May is similar to the findings by G. Singh et al in India that had found that the bed occupancy rate and LoS were both high in the summer months(May-July). 30In our case, May falls in summer season in Nepal and our findings are matching with this study.
Regarding the diagnostic categories, mood disorders were the commonest (48.5%) followed by schizophrenia and substance use disorders.
Affective disorders have been reported as the commonest diagnostic category in other studies as well. 16,20,33Baeza et al reported mood disorders(60.3%)to be the commonest disorder in their study followed by schizophrenia and related disorders(28.8%)and neurotic, stressrelated and somatoform disorders(3.4%). 16imilarly, Barros et al reported in their study from Brazil that in general hospital, mood disorders were the commonest(43.5%)followed by psychotic disorders(29.3%),alcohol and other substance related disorders(10.1%)and others(7.4%). 33In our study, the mean LoS was 19.4(±13.2)dayswith majority(70.1%) of LoS of 8-28days, followed by >28days(18.2%) and 1-7days(12.7%).Our findings is similar to the findings of Barros et.al from Brazil who found that the mean LoS in general and psychiatric hospitals were 20.5±34.2daysand 20.9±68.6 days respectively. 33There was relatively less psychiatric co-morbidity(6.1%)recorded in our study though psychiatric co-morbidity have been reported as high as 45%. 34In our clinical practice also, we see co-morbid psychiatric illnesses more frequently.Similarly, medical comorbidity was reported less in our case as compared to other studies. 35The reason for this low finding could be because of lack of clear protocol to record the co-morbid illnesses in the database.In our study, 26% of admissions were readmission cases.Donisi et al 36 reported a 90days readmission rate of 32.5% in their study from Italy while Hodgson et al 37 reported 41% readmission rate at 5years.The findings of our study is much lower than both these studies.Both the studies have been done in developed country setting where health systems are stronger and loss to follow up might be less as compared to our resource poor setting.One of the major limitations of our study is being a retrospective, cross-sectional study, we could not find the causal association among various factors.Similarly, as the data was extracted from database, some of the inherent shortcomings of the database like poor recording of the co-morbidities have been reflected in this study.

CONCLUSION:
There were a total of 3877 admissions during the study period.The admissions from Sunsari district and Dharan municipality were disproportionately high indicating that proximity and access to the facility greatly determine the utilization of mental health services.The overall outcome was good with only three mortality in ten years despite regularly managing delirium tremens cases in the ward itself and 92% patients being discharged in improved state.Mood disorders were the commonest diagnosis followed by schizophrenia and related disorders.

ACKNOWLEDGEMENT
We would like to acknowledge the support provided to us by the Medical Records Section of B. P. Koirala Institute of Health Sciences, Dharan providing us with the data needed for the study and the institute authorities for giving us the permission to conduct this study.