Pattern of psychiatric referral in a tertiary care hospital

Paudel A et al.

In the modern world, mental health issues are the most important public health concerns.The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity." 1 Inclusion of mental health in the definition of health has emphasized its importance.However, in many underdeveloped countries, psychiatric disorders are not regarded as life threatening and aren't given priority.As a result, the burden of mental health issues has been increasing globally. 2,3 t is well known that psycho-social factors influence etiopathogenesis and prognosis of many chronic illnesses like diabetes, HTN, ischaemic heart disease and cancer.Life time prevalence of mental illness in these chronic conditions is estimated to be over 40%.The most common psychiatric diagnosis in physically ill patient is depression and anxiety.Early recognition and treatment of these conditions decreases cost and improves outcome of illness. 4[7] Paudel A 1 , Koirala NR 2 , Upadhyay S 3 , Mishra R 4 , Nepal P 5 , Shrestha SD 6 1. Lecturer Among 160 patients, the majority were male (55%), Hindu (90%), married (78.1%), and educated up to secondary level.Department of Medicine accounted for the highest referrals (50%) primarily for fearfulness (21.3%).Neurotic, stress-related and somatoform disorders were most common (33.1%), followed by mood disorders (28.8%).No significant association was found between psychiatric disorders and physical illnesses.

RESULT
The total of 160 referred patients (both in-patients and outpatients) participated in our study.The patients had an average age of 39.2 years, with a range of 12 to 90 years.Majority of the patients belonged to age group 30-39 years as indicated in Table 1.
The stigma associated with psychiatric disorders has been decreasing due to establishment of independent psychiatric unit in many medical colleges and general hospital.This enhances multidisciplinary approach and allows direct interaction of psychiatrists with physically ill patient.Also, increasing the number of referrals from non-psychiatry departments has led to comprehensive evaluation and management of psychiatric morbidities in physically ill patients.Inspite of its importance, there is not much focus given on this part of psychiatry.From the various published data, it is found that consultation model is followed during referral across different centres, where qualified psychiatrists evaluate the patients who are referred to them by other specialist doctors.This consultation model is followed in both inpatient and outpatient settings. 8As per studies, the referral rates for inpatient varies from 0.01 % to 3.6%, for emergency setup varies from 1.4% to 5.4% and for outpatients the referral rate varies from 0.06% to 7.17% . 9ough psychiatric services are available in almost all teaching hospitals in Nepal, very little is known about the pattern of referral from other department.Literature on the pattern of psychiatric referral is scarce in our setting.None of the available studies have focused on the association of psychiatric disorders and physical illnesses.  . Lackof awareness regarding coexistence of psychological and somatic symptoms leads to longer hospital stay, poor outcome and increase in treatment cost.Awareness and acknowledgement of psychiatric aspect of disease increases psychiatric referral, which not only recognizes the psychiatric morbidities but also improves awareness towards the discipline of psychiatry.15 Considering this background, this study aims to study the profile of patients referred to the Department of Psychiatry and Mental Health from other departments, to identify source of referral and psychiatric disorders in referred patients and to find the association between psychiatric disorders and other physical illness.Table 7 provides insight into the co-morbidities associated with different psychiatric disorders.There was no significant association between different psychiatric disorders Majorities of the referred patients were male (55%), and identified as Hindu (90%).Furthermore, the study found that 78.1% of the referred patients were married, while 46.3% had an education level up to the secondary level as indicated in Table 2.
Table 3 presents the distribution of psychiatric patients across various referring departments.The Medicine department accounted for the highest number of referrals (50%), followed by Surgery (7.5%), Orthopaedics (6.3%) and Urology (6.3%).
Table 4 highlights the reasons for referral to the Department of Psychiatry.This reflects that middle aged people tend to have lot of stress in their life and they visit non psychiatrist doctors first and get referred. 18 our study Department of Medicine contributed to maximum referrals to psychiatry (50%).This finding was similar to previous studies which have shown that 51.1% and 54.3% of cases were referred to the Department of Psychiatry from Department of Medicine. 19,20The reason could be because the patient with complain of fearfulness, multiple somatic complains and known case of mental illness, who formed a majority of referred patient sample in the present study were also managed in the Department of Medicine.The most common psychiatric diagnosis in referred patients was neurotic, stress related and somatoform disorder similar to findings in other studies. 21,22The reason could be because this category includes psychiatric conditions which are common in our settings like panic disorder, generalized anxiety disorder, adjustment disorders and somatoform disorders. 23The common reason for referral in these patients were fearfulness, known case of mental illness, disturbed sleep which is different from other studies.10,13The difference could be due to variations in the patient demographics, cultural and geographic factors that influences the symptoms in psychiatry.

CONCLUSION
This study sheds light on the critical role of liaison psychiatry within the framework of a tertiary care center.Maximum referrals from the Department of Medicine highlight the importance of a collaborative approach to healthcare that acknowledges the interconnectedness of physical and mental health.Neurotic, stress related and somatoform disorder being the most common psychiatric diagnosis of refereed patient emphasizes on the wide range of symptoms exhibited by psychiatric patients and need for comprehensive assessment and personalized treatment approach.Liaison psychiatry not only facilitates early identification and intervention for patients experiencing psychiatric symptoms but also ensures a holistic approach to healthcare that addresses both physical and mental well-being.Future studies are needed to identify barriers and guide interventions to improve psychiatric service utilization and address existing gaps in the Consultation-Liaison Psychiatry setting.
It is well known that in comparison to general population, those with chronic physical conditions tend to have high psychiatric comorbidities. 24,25 arious studies have found that 70% of psychiatric patients had co-morbid physical illness. 26,27 he most common co-morbid physical illness in patient with psychiatric disorders include cardiovascular illness, diabetes, metabolic syndrome and problems related to obesity. 28Similar finding was seen in another study where the most common co-morbid conditions were cardiovascular (40.8%), infections (30.8%) followed by neurological (13%) and endocrine (5.4%). 29In contrast to this, findings from our study revealed that 49.4% of referred patients had co-morbid physical conditions and endocrinological disorders were the most common co-morbid physical condition (16.3%).The difference could be because of less sample size in our study.This reflects the current epidemiological transition towards non-communicable disease.

CONFLICT OF INTEREST none
, Department of Psychiatry, Birat Medical College Teaching Hospital 2. Professor and Head of Department of Psychiatry, Birat Medical College Teaching Hospital 3. Lecturer, Department of Psychiatry, Birat Medical College Teaching Hospital 4. Lecturer, Department of Psychiatry, Birat Medical College Teaching Hospital 5. Lecturer, Department of Psychiatry, Manipal Colleges of Medical Sciences 6. Resident, Department of Psychiatry, Birat Medical College Teaching Hospital

Table 5
outlines the psychiatric diagnoses among the referred patients.Neurotic stress-related and somatoform disorders were the most prevalent (33.1%), followed by Mood disorders (28.8%).

Table 4 : Reason for referral of patients
were referred to the Department of Psychiatry and Mental Health during the study period.In our study maximum patients belonged to age group 30-39 years with the mean age of 39.2 years.The finding was consistent with the study done by Keertish N and Brown A.
Paudel A et al.Pattern of psychiatric referral in a tertiary care hospital DISCUSSION A total of 160 patients (both in-patients and out patients)

Table 7 : Distribution of co-morbidities among patients with different psychiatric disorders and
co morbidities of referred patients as indicated in Table8.
Paudel A et al.Pattern of psychiatric referral in a tertiary care hospital