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ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 4  |  Page : 312-317  

Psychiatric emergency referrals in a tertiary care hospital


1 Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Center, Dr. D Y Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Emergency Medicine, Dr. D Y Patil Medical College, Hospital and Research Center, Dr. D Y Patil Vidyapeeth, Pune, Maharashtra, India

Date of Web Publication2-Aug-2018

Correspondence Address:
Suprakash Chaudhury
Department of Psychiatry, Dr. D Y Patil Medical College, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_180_17

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  Abstract 


Background: Acute psychiatric emergencies such as excitement, violence, stupor, and suicidal attempts, previously the domain of mental hospitals, are now handled by the general hospital psychiatric units. There is a paucity of Indian data concerning psychiatric emergency referrals. Aim: The aim is to study psychiatric emergency referrals in a teaching hospital. Materials and Methods: This hospital-based, descriptive study was undertaken in Emergency Medicine and Psychiatry Departments of a tertiary care hospital during the period of November 2016 to April 2017. All patients were first evaluated by the postgraduate resident on duty of Emergency Medicine Department and triaged using mental health triage scale (MHTS). The total sample size was 60. Sociodemographic particulars of patients and reason of referral were recorded on a special proforma, and the Brief Psychiatric Rating Scale (BPRS) was administered. Psychiatric diagnoses were made according to the International Classification of Disease, 10th Revision Diagnostic Criteria for Research. Results: Out of total 60 patients, 70% were males and 30% female. Most of the patients (41.7%) belonged to the age group of 31–40 years and 53.3% were married. Majority (61%) were referred by family members while 25% were referred by a nonpsychiatric medical professional. The most common reason for psychiatric referral was the presence of coexisting mental symptoms along with physical illness (38%) while 25% were referred as they had predominant psychiatric symptoms. The most common triage category was yellow (38%) and the least common was red category. Schizophrenia (33.3%) was the most common psychiatric diagnosis, followed by alcohol dependence (25%) and mania (16.7%). There was a significant correlation of BPRS score to severity according to triage. Conclusions: The common psychiatric disorders seen in Emergency Department (ED) are schizophrenia, substance use disorder, and mania. MHTS can be easily used by ED doctors for quick and appropriate triage of patients with psychiatric symptoms.

Keywords: Psychiatric emergency referrals, psychiatric patients, triage


How to cite this article:
Singh G, Chaudhury S, Saldanha D, Singh V, Marella S, Vhora R. Psychiatric emergency referrals in a tertiary care hospital. Med J DY Patil Vidyapeeth 2018;11:312-7

How to cite this URL:
Singh G, Chaudhury S, Saldanha D, Singh V, Marella S, Vhora R. Psychiatric emergency referrals in a tertiary care hospital. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Oct 22];11:312-7. Available from: http://www.mjdrdypv.org/text.asp?2018/11/4/312/238165




  Introduction Top


Psychiatric emergency is defined as an acute disturbance of behavior, thought, or mood of patient which if untreated may lead to harm, either to self or others. Psychiatric emergencies may include suicide, substance dependence, panic attacks, violence, delusional disorder, and victims of abuse or disaster. Acute psychiatric emergencies, which previously were the domain of mental hospitals, now present often in Emergency Departments (EDs) of general hospitals and are handled by the general hospital psychiatric units. The frequency of psychiatric emergencies in nonpsychiatric settings, such as ED of a general hospital, is poorly documented. The prevalence rate of psychiatric emergencies reported in different studies varies from 10% to 60%, indicating inadequacies in data collection.[1]

There is a paucity of reliable data concerning psychiatric emergency referrals in the emergency setting particularly from India. Most of the available recent Indian studies pertain to the routine inpatient referrals [2],[3],[4] without considering the emergency aspect of the situation.[5] The World Health Organization expert committee report on mental health recommended that as regards acute psychiatric emergencies, a service providing for their recognition followed by prompt referral to an appropriate treatment center should be available for 50% of population in a given area.[6] The wide variation in available mental health services between urban and rural areas frequently leads to the use of the emergency room as the first point of contact for a psychiatry patient. It is also noted that most MBBS graduates in India and emergency staff have less of grounding in psychiatry.

Although psychiatric services are available in most of the general hospitals in India, little is known as to why the psychiatrist is called in emergency situations and what the magnitude of the problem is. In addition, the factors such as reasons for referral, presenting complaints of the patient, and diagnoses have not been fully elaborated. Yet, research on psychiatric emergencies in India has been scarce, and there are no guidelines which help nonmental health personnel to efficiently triage psychiatric illness. For the purpose of mental health triage, a brief mental status examination is performed to quickly decide whether the participant has some psychiatric disorder, whether he is a danger to himself or others, and whether an immediate psychiatric evaluation is warranted or it can be done at a later time mental health triage services may be located within the ED of the general hospital and typically operate 24 h/day.[7] The present investigation was undertaken to study psychiatric emergency referrals and their triage in a teaching hospital.


  Materials and Methods Top


This prospective, longitudinal, hospital-based study was carried out in Dr. D Y Patil Medical College, an urban tertiary care hospital with 24 h emergency services where the patient or relative can directly walk in and request for treatment. The proposal of the project was submitted to the Institutional Ethical Committee, and the project was started after its approval. The study was conducted from November 2016 to April 2017.

Tools

  1. Sociodemographic proforma: Sociodemographic and clinical details of the patients including age, sex, marital status, occupation, source and reason of referral, presenting complaints, and mental status examination were recorded in a specially designed pro forma
  2. Mental health triage scales (MHTS):[7] MHTS are clinical tools used to guide clinical decision-making in (triage) psychiatric screening assessments. Triage scales are designed to improve the accuracy and consistency of triage clinical decision-making and facilitate timely service provision that is appropriate to the needs of the patient.


  3. The various categories in MHTS are as under:

    1. Red category indicates definite danger to life (self or others). The patient may exhibit violent or self-destructive behavior. Needs immediate psychiatric referral
    2. Orange category: The patient may be restless, extremely agitated, physically/verbally aggressive, confused/unable to co-operate, threat of harm to self/others, need to be physically restrained. Needs psychiatric referral within 4 h
    3. Yellow category: Possible danger to self or others. May be agitated/restless, show bizarre/disordered behavior, confused, withdrawn/uncommunicative, ambivalence about treatment. May exhibit symptoms of psychosis in the form of hallucinations, delusions, paranoid ideas, thought disorder, disturbance of mood in the form of elation, irritability, anxiety or severe depression and suicidal ideation. Needs psychiatric referral within 24 h
    4. Green category: The patient shows moderate distress, cooperative, gives coherent history, may be irritable without aggression, and has anxiety or depression without suicidal ideation. Needs psychiatric referral within 72 h
    5. Blue category: The patient has no acute distress or behavioral disturbance. He is co-operative, communicative and poses no danger to self or others. May be a known patient with chronic psychotic symptoms or chronic unexplained somatic symptoms. May have financial/social/accommodation/relationship problems. Requests for medication or minor adverse effect of medication. Needs psychiatric referral within 4 weeks.


  4. Brief Psychiatric Rating Scale (BPRS): It is a widely used instrument used by psychiatrists for a quick assessment of the presence and severity of various psychiatric symptoms. The original BPRS had 16 items.[8] To increase its sensitivity to psychotic and affective disorders as well as to use it with patients living in the community, the BPRS was expanded to 24 items.[9],[10] Compared to previous versions of the BPRS, the manual of administration of the 24-item BPRS offers a more detailed semi-structured interview containing more probe questions for each symptom.[11] Additional guidelines for interviews and operational definitions regarding the frequency of symptoms and social functioning alterations are available.[12] The 24-item BPRS is also a sensitive measure of symptom reduction occurring after rehabilitation intervention.[13] Moreover, less clinically experienced professionals could administer the BPRS 4.0 with high levels of inter-rater reliability.[14]


Procedure

All patients reporting to the Emergency Medicine Department of the hospital were initially evaluated by the postgraduate resident of Emergency Medicine Department on duty and was triaged (using MHTS) as per his assessment. Prompt consultation with the psychiatrist was sought whenever required. Consecutive patients from ED referred for psychiatric evaluation were included in the study after obtaining their written informed consent. Sociodemographic and clinical details of the patients including age, sex, marital status, occupation, source and reason of referral, presenting complaints, and mental status examination were recorded in a specially designed pro forma. The BPRS v4.0 was administered to all the patients. Psychiatric diagnoses were made according to the International Classification of Disease, 10th Revision Diagnostic Criteria for Research.[15] Thereafter, they were admitted to the hospital. The data were tabulated and analyzed with the help of SPSS 16 (IBM, USA).


  Results Top


The current study of 6-month duration conducted in a tertiary care teaching hospital included 60 patients who were referred from Emergency Medicine Department for psychiatric evaluation. The mean age of the patients was 32.02 (11.67) years. The range of age was 15–67 years. Out of the 60 patients, 42 (70%) were male and 18 (30%) were female. Domicile of 48 (80%) patients was urban while 12 (20%) hailed from rural areas. Demographic characteristics of the patients are given in [Table 1].
Table 1: Demographic data of 60 patients referred for psychiatric evaluation from Emergency Medicine Department (n=60)

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Out of 60 patients, 37 (61%) were brought for psychiatric evaluation by their family members while 15 (25%) were referred by a physician. The most common reason for psychiatric referral was the presence of coexisting mental symptoms along with physical illness (n = 21; 38%) while 15 (25%) were referred as they had predominant psychiatric symptoms. Most of the patients had multiple overlapping presenting complaints with maximum patients reporting disturbed sleep and appetite (n = 26; 43.4%). Five (8%) patients were brought after suicide attempt [Table 2]. Schizophrenia was the most common diagnosis (n = 20; 33.3%) followed by alcohol dependence syndrome (n = 15; 25%), mania (n = 10; 16.7%), depression (n = 6; 10%), anxiety disorder (n = 5; 8.3%), delusional disorder (n = 2; 3.3%), and conversion disorder and movement disorder (1 each; 1.7%) [Figure 1]. Ten patients had comorbid physical disorders [Table 1]. The distribution of the ten patients with medical comorbidities was as follows. Seven patients with alcohol dependence had comorbid disorders in the form of seizures (n = 3), jaundice (n = 1), diabetes with hypertension (n = 1), seizure with pancreatitis (n = 1), and upper gastrointestinal bleed (n = 1). One patient with schizophrenia had diabetes. One patient with mania had seizure disorder. The patient with movement disorder had basal ganglia infarct with diabetes and hypertension.
Table 2: Distribution of source and reason for referral, presenting complaints and findings on mental status examination of psychiatric emergency referral patients

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Figure 1: Final diagnoses of psychiatric emergency referral patients

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Most patients, 23 (38%), were triaged in yellow category [Table 3] and [Figure 2]. Comparison of BPRS score was done according to triage in psychiatric emergency referral patients and showed significant differences between the categories (P < 0.0001). Comparison of mean BPRS score showed that highest scores were obtained by patients in red followed by orange and yellow triage category [Figure 3]. The comparison of BPRS scores with addictions/habits and medical comorbidities showed that the presence or absence of either of them did not have any effect on the BPRS score [Table 4].
Table 3: Comparison of Brief Psychiatric Rating Scale score according to the different categories of triage in psychiatric emergency referral patients

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Figure 2: Triage-wise distribution of psychiatric emergency referral patients

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Figure 3: Comparison of mean brief psychiatric rating scale score according to triage of psychiatric emergency referral patients

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Table 4: Comparison of Brief Psychiatric Rating Scale score according to habits and comorbidity in psychiatric emergency referral patients

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  Discussion Top


Studies of psychiatric referrals have always been quite revealing. Such studies not only provide some idea about the prevalence of the illnesses but also focus on a number of other factors such as the attitude of the medical profession and the community at large toward the discipline of psychiatry.[16]

In the present study, most of the patients belonged to the age group of 31–50 years. The possible reasons for this may be because this is the economically productive age group; hence, the chances of being exposed to risk factors are highest in this age group. The other reason could be that this age group is more self-concerned for health-seeking behavior. A similar finding of majority of psychiatric referrals in relatively younger age group has also been reported by many earlier studies.[5],[17],[18],[19],[20],[21] The distribution of the patients is highly skewed toward males (70%), which might be attributed to the prevailing gender bias in Indian Society, where illness of male family member is taken more severely than female members. In contrast, it was reported that more females than males reported for emergency psychiatric care in few studies.[17],[18] The findings in this study support the fact that psychiatric emergency services are utilized more by male patients than female patients. Other studies also reported similar findings.[19],[22]

The majority of patients in our study were married, belonged to the urban area, either unskilled workers or unemployed with low level of literacy. Since the hospital is located in an urban area, majority of the patients were from nearby areas. In general, the patients who are literate preferred to take treatment from private practitioners or general hospital psychiatric setups. This may be the reason that most of the participants of our study belonged to lower socioeconomic status.

Majority of the patients attended ED on the advice of family members, followed by referrals by Medicine Department and private practitioners. This finding is similar to few earlier studies [17],[23] while one study reported that majority were referred from Medicine Department.[5]

The most common reason for psychiatric referral was the coexistence of mental symptoms with physical illness and for exclusion of psychiatric illness. This indicates increased awareness of other specialties about psychiatry and their desire to associate psychiatrists in general management of patients in emergency. The cases who had predominant psychiatric symptoms constituted (25%). This is in contrast to other studies which report the presence of predominant psychiatric symptoms as the most common cause of emergency psychiatric referral.[17],[22]

Most common complaints of the patients referred for psychiatric consultation were disturbed sleep and appetite. This being a vegetative symptom was present in vast majority of patients (43%). Patients had multiple overlapping complaints, the others being fearfulness, suspiciousness, and hearing of unreal voices. There were a significant proportion of patients who presented with symptoms of alcohol withdrawal (21%). This is in contrast to few Indian studies which report somatic symptoms as the most common complaints of emergency psychiatric referral patients.[5],[23] However, our findings are in agreement with many earlier studies.[17],[18],[19],[22]

In this study, the most prevalent psychiatric disorders were schizophrenia, alcohol dependence syndrome, mania, and depression whereas anxiety and other related disorders were less prominent. These findings are broadly in agreement with some earlier studies,[18],[19],[22] but contrary findings were also reported.[4],[24] The pattern of psychiatric disorders indicates that the appropriate type of psychiatric patients is reporting to ED. The lower prevalence of anxiety and neurotic disorders in the present study could be due to perceived stigma associated with mental illnesses, as such patients do not seek treatment from specialist centers, as there is common myth that psychiatrists are meant only for those having psychotic disorder, rather than all patients with mental and behavioral disorders.

Association of triage and Brief Psychiatric Rating Scale scores

A unique feature of the present study is that it involved emergency physician in the initial triage of patients with psychiatric disorders, who were subsequently assessed with the BPRS to assess the severity of the illness. Use of the triage scale was an attempt to educate and involve emergency medical staff as they are usually the ones to have the first contact with the patients. The results were gratifying results. The ED staff quickly adopted the scale. Majority of the patients were allotted the yellow triage category implying they were possibly dangerous. This finding also indicates that appropriate category of psychiatric patients was seen in the ED. Comparison of BPRS scores with triage category was done which was significant. By this study, we were able to conclude that higher the triage category more would the BPRS score and vice versa. Comparison of BPRS was done with substance use/habits, and medical comorbidity did not show any significant differences. By this, we were able to conclude that either of their presence/absence had no effect on BPRS score.

Limitations

The main limitation of the study was the small sample size due to limited time.


  Conclusions Top


The common psychiatric disorders seen in ED are schizophrenia, substance use disorder, and mania. MHTS can be easily used by ED doctors for quick and appropriate triage of patients with psychiatric symptoms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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