Main findings
The current study was undertaken to evaluate the demographic and clinical variables of inpatient psychiatry referrals from other departments in a tertiary care teaching hospital. The majority of referrals were in the 20–40 years age range (66.2%), with a mean age of 33.95 (15.10) years. This observation is consistent with the findings of Tekkalaki et al,4 who reported a mean age of 35.53 years. Similarly about 63.9% of patients in the 16–45 years age range was observed by Avasthi et al,5 along with Bhogale et al,6 who reported concurring results.
Gender distribution showed male dominance (56.4%), which is similar to the results of Chaudhury et al
7 and Keertish et al,8 who reported a male distribution of 70% and 58%, respectively.
Our study displayed literacy rate of about 75%, with 25.5% of the sample uneducated and the majority with up to high school education. This corresponds to the results of Desai et al
9 and to the regional distribution of literacy and education in India.
Majority of the patients were married (68.6%). The greater number of married patients in the current study could be secondary to the majority of sample population belonging to the 21–60 years age group. A huge chunk of the patients were Hindu by religion (79.7%), which conforms with Desai et al
9 and replicates the customary religious demographics in the sampling area under consideration. Most patients belonged to nuclear family (79.1%) and had an urban background (73.3%).
Out of 18513 inpatients (18720 inpatients, 207 psychiatry inpatients excluded), a meagre 205 psychiatric referrals were received, bringing the referral rate to about 1.1%. Various other studies have shown a similar low referral rate: 0.42% in Keertish et al
8 and 1.01% in Rastogi et al
10 in India; 0.63% in Ji and Ye,11 1.32% in CY et al,
12 and 1.01% in Cui et al
13 in China; 3.78% in Risal and Sharma14 in Nepal; 1.8% in Gangat15 in South Africa; and 1.19% in Arbabi et al
16 in Iran. This implicates a very pitiful state of consultation liaison considering the alarming comorbidity rate in psychiatry (18.42%–53.7%), as determined by other researchers who have surveyed other disciplines for psychiatric disorders.17
In our assessment of referring departments, it was observed that the internal medicine department was the leading discipline when it comes to sending referrals. This was in accordance with other previous Indian studies.4 5 8 9 Comparing our results with other countries, YW et al,18 Jiang,19 Lin et al
20 and Yang21 in China, Risal and Sharma14 in Nepal, and Tema22 in South Africa also showed that most referrals were received from internal medicine. The reason for this could be that psychiatry is a medicine specialty where physicians frequently encounter illnesses with psychological component and thus they are more psychiatrically oriented. Moreover, in addition to low awareness among people, social stigma in the context of psychiatric illness and seeing a psychiatrist is very high, and thus physicians are preferred over psychiatrists.
When reasons for referrals were analysed, abnormal behaviour and agitation (26.2%) topped the list, followed by suicide/self-harm (24.2%). This finding is consistent with the study done by Rastogi et al,10 where it was ascertained that altered level of consciousness and aberrant behaviour, along with psychosis-related behaviour, were the leading reasons for referral, representing 31.9%. Tekkalaki et al
4 found self-harm to be the second leading cause, while Niranjan and Udey23 found abnormal behaviour to be the most common cause at 30.9%, similar to our study. A significant amount of psychiatric cases among admitted patients are neither recognised nor referred to psychiatrists by general physicians in general hospitals, and such cases are not evaluated for psychopathology with the same enthusiasm as for medical symptoms. Therefore usually when agitation or an abnormal behaviour of patients gets beyond the threshold of the managing staff, only then psychiatric consultation becomes prudent; however, psychological and affective disturbances which are not very troublesome do not warrant psychiatric referral.15 23 The medicolegal implications of suicidal behaviour and self-harm result in a psychiatric referral in almost all cases admitted for the same, which is clearly reflected in the hierarchical placement of suicidality and self-harm as the second leading reasons for referral.
In the present study, MDD/depression (24.4%) was found to be the most common psychiatric disorder, followed by substance use disorder and schizophrenia and psychotic disorders. Affective disorder made up 27.3% of all diagnoses, and these findings corroborate with Risal and Sharma,14 Arbabi et al,16 Tema et al,22 Shah,24 Singh et al,25 Su et al
26 and Ozkan.27 The category of substance use subsumed intoxication, withdrawal states, dependence syndromes, and mental and behavioural disorders induced by substance. Keertish et al,8 Risal and Sharma14 and Bourgeois et al
28 found results that are in concordance to our findings.
Many studies such as from India4 5 10 and a review of CLP in China by Ji and Ye11 suggest organic mental disorders to be the leading factor in psychiatric diagnosis. However, the relative lack of organic mental disorders (5.8%), similar to the findings of Keertish et al
8 and Risal and Sharma,14 could be attributed to the presence of trained neurology specialists in our tertiary centre who are comfortable in dealing with such conditions, in turn leading to fewer referrals of such cases.
About 19% of the patients we assessed did not have any psychiatric diagnoses, which is similar to Tekkalaki et al
4 and Rastogi et al
10 which showed 31% and 28.5% referrals with inconclusive or no psychiatric diagnosis, respectively. This can be attributed to patients with accidental poisoning, accidents, agitation and insomnia secondary to pain, language barrier misconstrued as irrelevant talk, and so on being considered to have no psychiatric disorder. It also implies a relative lack of understanding of psychiatric symptomatology by other disciplines and a need to sensitise medical fraternity regarding psychiatric comorbidity, as many referrals were done without proper investigations and lack of proper communication with patients, which negatively affect patient management.
On assessment of the physical axis of diagnosis, including medical and surgical conditions, it was observed that the most common condition was attributed to trauma and injury secondary to poisoning, burn and blunt trauma/fracture (30%). The findings of the current study are in accordance with the study by Niranjan and Udey23 and Christodoulou et al,29 who reported that the most common physical illness was of injuries and poisoning, with central nervous system disorders and cardiovascular system involvement the other leading physical disorders.
Implications
Consultation liaison is a developing branch in India and needs more attention. In accordance with earlier studies, it has been demonstrated that there are very few psychiatry referrals and an alarmingly low referral rate, in proportion to the psychiatric morbidities in medical setting. We suggest that psychiatry training should be given more weightage in the undergraduate medical curriculum, and that more liaison activities such as regular interdepartmental meets, case conferences and seminars should be organised between psychiatry and other disciplines, so that a better understanding of psychiatric symptomatology, early symptom recognition, swift referral and follow-up can be ensured, which would be key to improving CLP services. There is an urgent need to improve CLP services and training to provide the best and optimal care to patients and to cater the best education to the medical staff.
We found that a significant proportion of the young productive age group were referred. Patients suffering from almost all types of medical or surgical illnesses were also referred for some or other behavioural complaints. Most of the existing literature published in relation to CLP services has been inexplicit with regard to functional aspect and ways of improving services.
Further research is warranted, especially longitudinal studies on outcome variables with respect to various clinical processes, such as interviews, length of visits and follow-up activities. In addition, future studies need to assess the knowledge and attitudes of patients, families and healthcare providers regarding mental illness, C-L(Consultation- Liaison) service, barriers and so on. The findings from such assessments will help with cultural and organisational changes to better integrate C-L service into a general hospital.
