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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 3  |  Page : 213-218

Changing pattern of clinical profile of first-contact patients attending outpatient services at a general hospital psychiatric unit in India over the last 50 years


Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Web Publication14-Sep-2017

Correspondence Address:
Mamta Sood
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.214595

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  Abstract 


Introduction: Over the last five decades, general hospital psychiatric units (GHPUs) have become important mental health service setups in India. The present study reports on the changing clinical profile of the patients attending the GHPUs over the last five decades. Methodology: A total of 500 subjects, attending a GHPU were recruited prospectively for the study. The subjects were assessed using a semistructured proforma. A comparison was made with similar studies conducted in GHPU settings over the last five decades. Results: In the present study, neurotic, stress-related and somatoform disorders formed the commonest diagnostic group (33%) followed by psychotic disorders (17%) and mood disorders (15%). The diagnostic distribution is broadly similar to the studies done at different times in the last 5 decades, though there were lesser number of patients with mental retardation and organic brain syndrome. About 15% of the subjects did not have a psychiatric diagnosis. Conclusion: GHPUs in India attend to a broad range of patients with psychiatric disorders.

Keywords: First-contact patients, general hospital psychiatric unit, GHPU


How to cite this article:
Sood M, Ranjan R, Chadda RK, Khandelwal SK. Changing pattern of clinical profile of first-contact patients attending outpatient services at a general hospital psychiatric unit in India over the last 50 years. Indian J Soc Psychiatry 2017;33:213-8

How to cite this URL:
Sood M, Ranjan R, Chadda RK, Khandelwal SK. Changing pattern of clinical profile of first-contact patients attending outpatient services at a general hospital psychiatric unit in India over the last 50 years. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Jul 18];33:213-8. Available from: http://www.indjsp.org/text.asp?2017/33/3/213/214595




  Introduction Top


Patients with psychiatric illnesses seek help from different mental health settings like general hospital psychiatric units (GHPUs), psychiatric hospitals, psychiatric nursing homes, polyclinics and office based practices in India. GHPU is the psychiatric wing in a medical school or general hospital.[1] It was earlier believed that majority of the patients visiting GHPUs suffer from psychiatric illnesses of milder severity[2] as these were located in general hospitals. Several studies over the last few decades have reported the clinical profile of the patients visiting psychiatric facility in a GHPU and these suggest that patients with all types of psychiatric disorders are seen in GHPUs.[1],[3],[4],[5],[6] Most GHPUs in India run a walk-in-clinic service that is the first contact point for the patients seeking psychiatric help. In walk-in-clinic, the psychiatrist makes brief need based assessment of the person seeking help, and provides immediate and short term advice.[8] In fact, over the last five decades, GHPUs have become the main resource for mental health care, teaching and research in India and neighboring countries surpassing the mental hospitals.[7]

Although GHPUs provide clinical care to a vast majority of patients with psychiatric disorders, the resources and funds allocated to GHPUs are woefully inadequate. Identifying characteristics of the patients who make contact with psychiatric services in GHPU settings may help in appropriate allocation and mobilization of available limited resources. Though a number of studies have looked into this matter, the last such study appeared in 1992; these studies have collected data retrospectively. In these studies, only data on psychiatric morbidity has been reported; help seeking pattern and mode of disposal of first contact patients visiting a GHPU has not been studied. In the last 3 decades, there have been voluminous expansion of mental health services in India, especially in district hospitals, private sector and in office based practice, though most such facilities are often urban centered. The period has also seen massive invasion of mass media especially a large number of radio and television channels, developments in information technology sector, internet and mobile phones. The mass media also produce a number of programs related to mental health covered by mental health professionals.

Objectives

The present study was aimed at studying the socio-demographic and clinical profile, mode of disposal, help seeking pattern of first contact patients visiting a GHPU. It reports on whether with the changing social scenario and wider availability of mental health services, there has been a change in the clinical profile of the first contact patients attending the GHPUs over the last five decades.

Methodology

The study was conducted in outpatient department of GHPU of a public funded tertiary care medical school in North India. The facility has a 32-bedded short-stay inpatient unit and an outpatient service including walk-in-clinic. The facility caters to the patients from the National Capital Region of Delhi (India), adjoining states of Uttar Pradesh, Haryana, Rajasthan as well as from distant states of Bihar, Jharkhand, Himachal Pradesh, Uttarakhand and others, where services may not be available. Due to paucity of mental health professionals and services at many places in India, persons with mental illnesses have to travel long distances to seek psychiatric help. Our setting is also approached for second or third opinion by patients who are already on treatment from different places. In India, the citizens are free to access service from any facility, depending on their convenience and resources. There are no geographically defined fixed catchment areas, and no linear pattern of referral from primary to tertiary care. Any person can access a primary, secondary or tertiary service, depending on availability in his/her geographical location and resources.

The first point of contact for persons visiting our service is the walk-in-clinic which runs on all weekdays. Walk-in-clinic is manned by three psychiatrists. They are assisted by clinical psychologists, nurses, a social worker and the support staff of the OPD on as needed basis. Every day, about 60–80 new patients are seen.

We included 500 first contact patients for our study; the study was cross sectional in design. First contact patients were defined as those subjects who had made contact with the services at our hospital for the first time. The sample consisted of every fifth new subject registering at the outpatient service during July–September 2013 seen by one of the psychiatrists posted at the walk-in-clinic. Diagnoses were made on the International Classification of Diseases –10th revision (ICD-10).[9] The purpose of the study was explained to the subjects and a written informed consent was taken from him/her or the accompanying relative, if he/she was unable to give consent. The subjects were assessed using a semistructured proforma designed for this study. The proforma included sociodemographic and basic clinical information like age, gender, education, employment status, marital status, source of referral, diagnosis, duration of illness and mode of disposal (treatment, follow up, referral or hospitalization).

A search on PubMed was made for earlier research on the similar topic from India and the findings of the present study were compared with previous studies.

The study was approved by the ethics committee of the institute.

The data was tabulated and analyzed for various demographic and clinical variables.

Results

Sociodemographic characteristics: The mean age of the sample was 31 ± 13.6 years. Most (85%) of the subjects were in the age group 16–65; 14% were less than 16 and only 1% were above 65. Fifty five percent were males and most (85%) were Hindus. More than half (57.8%) of the subjects had studied up to 10th standard, one fourth (26%) were graduates or postgraduates and 16% were illiterate. About half (50.4%) of the subjects were married, 45.4% were single and the rest were separated, divorced or widowed.

Pattern of psychiatric morbidity: About half of the subjects had been ill for more than 2 years, 30% had illness duration varying from 3 months–2 years, 8% had been symptomatic for less than 3 months and 3% had an illness of less than 2 weeks.

In most (96.2%) of the subjects, a provisional diagnosis could be made at walk-in-clinic at the first contact. Interestingly, about 14.8% of the cases had no psychiatric diagnosis. This included 48 (9.6%) subjects with headache. Other diagnoses included seizure disorder, tinnitus etc. Nearly 80% of the subjects with a psychiatric diagnosis had a single psychiatric diagnosis, and the rest had two or more psychiatric diagnoses. One third of the subjects suffered from neurotic, stress related and somatoform disorders; 7.2% had dissociative disorder, 3.4% had obsessive compulsive disorder, 4.2% had adjustment disorder, 13.6% had anxiety disorders and 4.2% had somatoform disorders. Seventeen percent of the subjects had psychotic disorders and 15% had mood disorders. Twenty (4%) subjects suffered from bipolar affective disorder and 11% had a depressive diagnosis [Table 1]. Physical comorbidity was present in 12% of the subjects.
Table 1: Clinical diagnosis (ICD 10) of first-contact subjects

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[Table 2] shows a comparison of our findings with some of the earlier studies of similar nature from India.[2],[3],[4],[5],[6],[10] The number of the patients with organic brain syndromes, mental retardation and seizure disorder is higher in the studies from 1960s.[3],[4] All these studies included addictions under personality disorders. In the initial period of GHPUs in 1960s, about half (47-53%) of the patients seen in GHPUs had neuroses[3],[4] and about one sixth to one fourth (15.1-26.4%) of the patients had psychoses. However, the number of patients with psychoses visiting GHPUs increased in “1970-80s; 29.5-69.3% of the patients had psychoses.[2],[5] On the contrary, in 1992, Chadda et al.[6] reported neurosis (54.25%) to be the commonest diagnosis and only 11.2% of the patients had psychoses. There are some minor variations between our data and the data by Mishra et al.[10] from the same center.
Table 2: Clinical diagnoses of the first-contact patients across five decades*

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Role of families: About half of the subjects (55.8%) belonged to nuclear families. Most (76.6%) of the patients were accompanied by family members. Sixty nine percent were accompanied by first degree relatives: parents (26.8%), spouse (19.6%), children (10.6%) siblings (12%) or a second and third degree relative (7.6%). Only 22% of the subjects had come alone, rest came with friends. The cost of treatment for majority was borne by either family (70.6%) or self (29%); employers bore cost of treatment in a miniscule (0.4%).

Help seeking: Sixty percent of the subjects were either self or family referred. Forty percent of the subjects were referred to our center by doctors, out of whom about 29% were referred from the other clinics of our hospital itself, mostly (86%) from medicine related specialities. Interestingly, only 12.4% of the subjects had made their first ever consultation with our center. Out of those with previous consultations elsewhere, almost all (98.2%) the subjects had consulted a doctor before making contact with our center; 19.8% had consulted a psychiatrist. Only 1.8% had last consultation with faith healers. More than half (53%) of the subjects had come to our center from outside the National Capital Region of Delhi.

Mode of disposal: All the subjects received a preliminary assessment and a management plan was made. At the walk-in-clinic, about half of the patients were assessed, given treatment and advised follow up. About one third (33.6%) were asked to come for a detailed clinical evaluation. The reasons for detailed case work up were diagnostic clarification (13%), management difficulties (15.8%) or administrative reasons (6.2%). About one fourth (24.2%) of the patients were referred to other departments of our hospital (medicine and allied departments—96.7% and surgery and allied departments—3.3%) for consultation regarding the co morbid medical problems. Maximum referrals (15.4%) were to the neurology. Only four (0.8%) patients required hospitalization for diagnostic clarification and management purposes. However, only one (0.2%) patient could be hospitalized due to nonavailability of beds and the rest were referred to other hospitals for management. Mode of disposal of the patients visiting our clinic was compared with the study by Khandelwal et al. [Table 3].[8]
Table 3: Modes of disposal at walk-in-clinic

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  Discussion Top


One of the major findings of this study is that there has not been a major change in the profile of patients presenting to the GHPUs in the Northern India in the last 5 decades, though minor variations were noticed across different centers over time.

The sociodemographic profile of the first contact subjects was in line with the earlier studies.[5],[6],[8],[10] We could only find a few such studies that included first contact subjects attending a GHPU. In 1960s, patients with epilepsy were often seen by the psychiatrists, which has changed in the recent years due to availability of neurologists and awareness amongst general public that epilepsy is a medical or neurological illness. In fact, in 1974, WHO had recognized priority mental health problems as chronic mental handicap (mental retardation, addictions and dementia), epilepsy and psychoses.[11] The earlier studies had been conducted in GHPUs with varying facilities like having only outpatient facilities,[3] both inpatient as well as outpatient facility,[2] having a mental hospital facility in nearby location,[4],[6] or the facility being the only one available in the area.[5] The lower percentage of patients with psychoses in studies by Neki and Kapoor[4] and Chadda et al.[6] was due to presence of a mental hospital in the vicinity of the GHPU facility. Another reason could be that in the 1960s, the mental health services had just started in general hospitals and any new GHPU is likely to get cross referrals from other medical disciplines, which were likely to be the patients suffering from neurotic group of disorders. As the service grew older, it started attracting patients with more severe illnesses. Across all the studies, the number of patients with neurotic illnesses is high which could be because of higher prevalence of these disorders in the general population. A gross difference in prevalence of neurotic illnesses between our study and the earlier reports could be because of the classificatory system used. In ICD-10, neurotic depression was shifted from neurotic disorders to mood disorders which might have lowered the prevalence of neurotic disorders in our study.

Interestingly, only about 12% of the subjects made their first ever consultation with our center. Our GHPU is a premier tertiary care hospital of the country. Therefore, most of the patients come here for seeking second or third opinion. Out of those with past consultations elsewhere, almost all (98.2%) the subjects had consulted a doctor before making contact with our center to. More than half of the first contact subjects seeking psychiatric help were from distant places. Unlike high income countries, in India persons with mental illnesses travel long distances to seek psychiatric help due to paucity of mental health professionals, stigma at visiting a nearby facility and nonavailability of services

In the study by Khandelwal et al.[8] all patients were given appointment for detailed evaluation whereas in our study, only one third patients were given date for detailed evaluation. This could also be because of the protocol being followed at the center. In our study, the figure for detailed evaluation appointment at the first contact itself was about 35%, though most of the subjects who continue on follow up in the walk-in-clinic are taken up for detailed evaluation at a later stage. The reason for not offering a detailed evaluation at the first contact is that almost half of the first contact patients drop out of follow up after 3–4 visits. Hence, for optimal utilization of the manpower resources, detailed evaluation at first contact is offered only in the essential cases in our service. Interestingly, about 10% of the patients in the study by Khandelwal et al.[8] were referred to other psychiatric services for various reasons like the patients were already under psychiatric care at a different place or required help from social oganizations. We had referred only 3 (0.6%) patients to outside facility for hospitalization due to no availability of bed.

This study also elucidates and confirms some of the advantages about clinical services in GHPUs like reduced stigma, interspeciality referrals, care of physical comorbidity and involvement of families. Out of the 15% of the subjects with no psychiatric diagnosis, most had a medical diagnosis like headache, seizure disorder, tinnitus etc. It was heartening to know that these patients first came to psychiatry OPD even when they had disorders related to “brain pathology” as per the commonly prevalent belief. This finding strengthens the notion that the patients visiting GHPU setups now experience less stigma compared to that in the past, and are ready to consult a psychiatrist. Also, interspeciality referrals in the hospital are common in GHPUs. About one third of the first contact patients had been referred by other specialist doctors from our hospital. Similar rates were reported by Chadda et al.[6] We referred about one fourth of the patients to other departments for care of physical morbidity. The rate is more than that (14.8%) reported by Khandelwal et al.[8] This may be because in last two decades, there has been increase in awareness among psychiatrists about adverse consequences of physical comorbidity in mentally ill.

This study also confirms that families play a significant role in help seeking in India as three fourth of the subjects were accompanied by their family members. All the subjects were paying out of pocket for the treatment and for almost all of them, cost of treatment was borne by family or self. This is true about most of the medical illnesses, as the state budget on health in India is abysmally low.

Walk-in-clinic serves the purpose of screening point, where the subjects making contact for the first time with the service were triaged on the basis of their need. The present study showed that various modes of disposal were used and were comparable to those reported by Khandelwal et al.[8] Interestingly, although a very small number of the subjects required admission, even that small number could not be accommodated in GHPU inpatient unit because number of beds has not increased in GHPUs in last many decades despite increase in population from 500 million to 125 million.

The study had a major limitation of not comparing the clinical profile of the same center over 5 decades. It would also be difficult to generalize the findings to other centers, the study being conducted in a tertiary care premier institute of the country.


  Conclusions Top


GHPUs continue to see the complete range of patients from different diagnostic categories. Over the last 5 decades, despite so many changes in the society including availability of a variety of medicines, changing lifestyle and increasing acceptability of psychiatry in general public, no major changes have been seen in the clinical profile of the patients attending the GHPUs. However, hospitalization rates have definitely decreased. The study highlights the strengths of GHPU setups like interspeciality referrals, less stigma, and involvement of family in the care of mentally ill. Walk-in-clinic in GHPUs continues to serve as an effective screening point. Multicentric and longitudinal studies of first contact subjects should be planned in future to compare profile of these patients across different sites, to elucidate profile of the first contact patients who are retained and dropout of treatment and factors responsible for the same, profile of the patients who improve with treatment and factors associated with it. These studies will also help in highlighting the lacunae in the present service delivery in these setups, which will help in improving these services.

Authors contribution

MS, SKK and RKC conceptualized the study. RR collected and analyzed the data. MS & RKC wrote the manuscript with inputs from others. The final manuscript was approved by all the authors.

Financial support and sponsorship

Nil

Conflict of interest

There are no conflicts of interest.



 
  References Top

1.
Wig NN. Psychiatric unit in general hospital: right time for evaluation. Indian J Psychiatry 1987;20:124-26.  Back to cited text no. 1
    
2.
Wig NN, Verma VK, Khanna BC. Diagnostic characteristics of general hospital psychiatric adult outpatient clinic. Indian J Psychiatry 1978;003A:262-66.  Back to cited text no. 2
    
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Dutta Ray S. Social stratification of mental patients. Indian J Psychiatry 1962;4:3-8.  Back to cited text no. 3
    
4.
Neki JS, Kapoor RK. Social stratification of psychiatric patients. Indian J Psychiatry 1963;5:76-86.  Back to cited text no. 4
    
5.
Mahendru RK, Srivastava RP, Sharma D. Mental health clinic in a teaching general hospital: some initial experiences. Indian J Psychiatry 1979;21:262-66.  Back to cited text no. 5
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6.
Chadda RK, Shome S, Thakur KN, Bhatia MS. Morbidity patterns in a general hospital psychiatric unit adjoining mental hospital. Indian J Soc Psychiatry 1992;8:52-6.  Back to cited text no. 6
    
7.
Sood M, Chadda RK. Psychosocial rehabilitation for severe mental illnesses in general hospital psychiatric settings in India. BJ Psych International 2015;12:47-8.  Back to cited text no. 7
    
8.
Khandelwal SK, Sharma PS, Das K. Role of walk-in-clinic in general hospital psychiatric units. Indian J Psychiatry 1981;23:210-12.  Back to cited text no. 8
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9.
International Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization; Geneva, 1992.  Back to cited text no. 9
    
10.
Mishra N, Nagpal SS, Chadda RK, Sood M. Help-seeking behavior of patients with mental health problems visiting a tertiary care center in North India. Indian J Psychiatry 2011;53:234-8.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
The effectiveness of mental health services in primary care: the view from developing world. World Health Organization, 2001. Available from http://whqlibdoc.who.int/hq/2001/WHO _MSD_MPS01.1.pdf. [Last accessed on 2016 Mar 2].  Back to cited text no. 11
    



 
 
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