Medical Journal of Dr. D.Y. Patil Vidyapeeth

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 11  |  Issue : 5  |  Page : 389--394

Amalgamating psychiatric services with polyclinic in a multispecialty service hospital


Rajiv Kumar Saini1, Jyotindu Debnath2, Sunil Aggarwal3, Suprakash Chaudhury4,  
1 Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Radiodiagnosis, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
4 Department of Psychiatry, Dr. D.Y. Patil Medical College, Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India

Correspondence Address:
Suprakash Chaudhury
Department of Psychiatry, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra
India

Abstract

Background: Provision of multitude of medical services under one roof is a norm in modern hospitals. However, in many service hospitals, psychiatric services are still confined within the premises of psychiatric wards. Due to the social stigma attached to psychiatric care many psychiatric patients avoid visiting the psychiatric ward for mental health care. The main objective of this study was to improve attendance in the psychiatric outpatient department (OPD) by making it accessible and acceptable for the clientele in a busy multispecialty service hospital. Materials and Methods: This retrospective study was carried out from January 1, 2009, to December 31, 2010. During the 1st year of the study (i.e., 2009), psychiatry OPD services continued in the psychiatry ward. From January 1, 2010, psychiatric OPD was shifted to polyclinic with a new name as “Department of behavioral sciences and deaddiction.” The data for the year 2009 and 2010 were compared using the Chi-square test. Results: There was a significant rise in the total number of new OPD patients from 522 to 1779 (P < 0.05) in 2010. Among various age groups, in 41–50 years of age group (144 [27.6%] vs. 574 [32.26%], P < 0.05) and those above 70 years (12 [2.29%] vs. 96 [5.39%], P < 0.05) the rise was highly significant. There was a significant increase in the number of patients with substance abuse (38 [7.27%] vs. 188 [10.56%], P < 0.05) and childhood and adolescent psychiatric disorders (42 [8.04%] vs. 213 [11.97%], P < 0.05). Conclusion: Amalgamation of psychiatric OPD services with other specialist OPD services in service hospital resulted in better utilization of psychiatric services.



How to cite this article:
Saini RK, Debnath J, Aggarwal S, Chaudhury S. Amalgamating psychiatric services with polyclinic in a multispecialty service hospital.Med J DY Patil Vidyapeeth 2018;11:389-394


How to cite this URL:
Saini RK, Debnath J, Aggarwal S, Chaudhury S. Amalgamating psychiatric services with polyclinic in a multispecialty service hospital. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2021 Dec 6 ];11:389-394
Available from: https://www.mjdrdypv.org/text.asp?2018/11/5/389/240370


Full Text



 Introduction



High prevalence of psychiatric disorders among patients attending general hospital setting is well known, but most of them remain undiagnosed. According to rough estimates about 20%–25% patients reporting to general hospital setting suffer from identifiable psychiatric illness which contributes to significant distress, reduced ability to function efficiently, or increased cost of medical care.[1],[2] However, many such patients fail to avail psychiatric services and thus continue to suffer. Lack of awareness and social stigma are often cited as reasons for such a scenario though factors such as isolation of psychiatric facility from the main hospital as well as perceived stigma attached with the name “psychiatric” may also be equally responsible for the same.[3],[4],[5],[6] Integrating mental health services with other health services and relabeling may help to overcome these barriers and hence improve utilization of psychiatric services in service hospitals.

At present, in most service hospitals, psychiatric outpatient department (OPD) is located along with psychiatric ward and the whole complex is generally away from main hospital creating a sense of isolation and exclusion. The scenario was similar in the hospital under study. It was found that total number of patients attending psychiatric OPD was much lower than the cited prevalence of psychiatric disorders in population attending any general health-care setting. It was assumed that lack of proximity of psychiatric facility close to the main hospital and the term “psychiatric ward” may be contributing toward low attendance in psychiatric OPD. To test this assumption, psychiatric services were amalgamated with other specialist OPDs with a new name as “Department of behavioral sciences and de-addiction.” The study aimed to see the impact of such a model in terms of utilization of psychiatric services. The data were compared with pre-existing pattern wherein psychiatry OPD was located inside psychiatry ward.

 Materials and Methods



Setting

The study was conducted in a 499 bedded service hospital having all basic specialties including surgery, medicine, gynecology, anesthesia, otorhinolaryngology, ophthalmology, pediatrics, dermatology, and psychiatry. The location of psychiatric ward was about 1 km from the main OPD complex. During the first half of the study period (i.e., January 1, 2009–December 31, 2009), the location of the psychiatry OPD was within the premises of the psychiatric ward. Permission was obtained from administrative authority to start the psychiatry OPD in polyclinic complex. There was initial reluctance on the part of administration on the pretext that “psychiatric” label would be inappropriate in the corridor. A suggestion was made that a more contemporary name may be chosen. Therefore, a search was made on the internet. It was found that many setups across the globe have faced a similar situation and have been able to obviate the situation by a change in nomenclature to behavioral sciences and de-addiction. Therefore, we decided to choose a new name of the Psychiatry OPD as “Department of Behavioral Sciences and Deaddiction,” and it became functional from January 1, 2010. Workshops were conducted for medical officers and other specialists to raise awareness about the identification of common mental disorders. The presence of the psychiatrist in the same complex as other specialists facilitated cross referrals and informal clinical discussions.

Study design and period

It was a retrospective study extending from January 1, 2009, to December 31, 2010.

Sample

Data pertaining to all new patients reporting to the psychiatry OPD from January 1, 2009, to December 31, 2010, were included in the study. ICD-10 system of classification was used for making psychiatric diagnosis. Those patients who reported for follow-up and/or for re-categorization were excluded from the study group.

Treatment methods and cross-referrals

Broadly accepted psychiatric drugs and counseling methods were used for all patients. In case they suffered from other physical disorders appropriate referrals were made. The proximity of the psychiatrist in the same complex facilitated cross-referrals. In addition, the principal author conducted workshops for the medical officers and specialists of the hospital for identification of common mental health disorders.

Statistical analysis

The patient-related data from January 1 to December 31, 2009, and January 1, to December 31, 2010, was tabulated based on personal particulars, age, and diagnostic categories. The comparison was made between two halves of the study period. Statistical significance was tested using Chi-square test for different categories.

 Results



During informal interaction with patients during the first half of the study period, majority of the patients reporting to the psychiatric OPD were found to be uncomfortable with the existing setup. They expressed hesitation in entering premises of psychiatry ward though no instruments were used to measure this attitude of patients. In addition, many patients faced difficulty for laboratory investigation and opinion of other specialists for comorbid medical conditions as such facilities were located in the main hospital. The problem was overcome during the second year of the study once the psychiatry OPD was shifted to the main OPD complex of the hospital. After amalgamating psychiatric OPD with the hospital polyclinic, there was a significant rise in the total number of new patients from 522 in 2009 to 1779 in the year 2010 (P < 0.05) [Figure 1] and [Table 1]. Maximum increase in number was observed in ex-servicemen and their families (P < 0.05) [Table 1]. However, rise in cases of substance abuse (F 10–19) from 38 (7.27%) to 188 (10.56%) and childhood and adolescent psychiatric cases (F 70–98) from 42 (8.04%) to 213 (11.97%) is much higher. Similarly, cases of eating disorders (F 50), nonorganic sleep disorders (F 51), nonorganic sexual disorders (F 52), postpartum psychiatric disorders (F 53), and personality disorders (F 60–68) was much higher from nil to 38 (2.13%).{Figure 1}{Table 1}

 Discussion



The services have an effective and integrated health-care network. However, under-subscription of psychiatric referral often leads to dissatisfaction for both the clinician as well as the patient. It results in a battery of potentially avoidable investigations. Even if an incidental unrelated finding is detected, it leads to further confusion. The end result is a frustration for the clinician and continued misery for the patient followed by doctor shopping and economic loss.[7] This situation can be largely prevented by integrating psychiatric services with other specialist OPDs. The change in nomenclature to the “Department of behavioral science and de-addiction” was taken in line with current nomenclature as is practiced in modern hospitals to overcome social stigma.[8] There is nothing new in change in nomenclature once it is acknowledged that a particular name arouses negative sentiments.

Our study has been unique in that, to the best of our knowledge, this is the first time that amalgamation of psychiatric services was done in a service hospital with a new name which was contemporary. The change resulted in significantly higher number of patients with psychiatric problems reporting to the concerned specialist for treatment. There was more than four-fold rise in total number of new psychiatric cases among ex-servicemen and their families from 184 (35.2%) in 1st year to 878 (49.3%) in the 2nd year. These patients are old and commonly suffer from multiple medical problems including psychiatric disorders.[9],[10] In our study, we saw an increased number of psychiatric patients of >50 years once facility was created for their care within the main polyclinic area [Table 2], (P < 0.05).{Table 2}

[Table 2] and [Table 3] highlight that significantly higher number of child and adolescent patients have reported in the 2nd year as compared to the 1st year of the study (F 70–98) [Table 3], [Figure 2] and [Figure 3]. A recent epidemiological study conducted in this country reveal that the prevalence of child and adolescent psychiatric problems ranges anywhere from 6.46% to 24.45%.[11] Cases of dyslexia, nocturnal enuresis, borderline intelligence, tic disorders, anxiety, and depression are largely ignored, but they finally result in behavioral problems and academic decline in the children. Specialized intervention at the right time can make a significant difference in the outcome of such children.[12] With the awareness about such problems, the demand for specialized services has also increased recently. The clientele of this age group may be more likely to consult the psychiatrist in a hospital when services are available close to pediatric OPD as has been our experience. The number of children and adolescent cases with psychiatric problems (<10 and 10–20-year-old) showed a substantial increase from 42 to 213 (P < 0.05) [Table 2], highlighting the fact that parents were more forthcoming in seeking help for their children once psychiatric outpatient facility was created in the main hospital.{Table 3}{Figure 2}{Figure 3}

[Table 3] demonstrates a significant rise in the number of patients having organic psychiatric conditions [F 0–9] from 4 (1.8%) to 13 (0.73%) (P < 0.05) and substance abuse problems [F 10–19], from 38 (7.27%) to 188 (10.56%) (P < 0.05). Patients having neurological damage and substance abuse often suffer from behavioral abnormality and cognitive deficits due to which they face problems at home and as well as at workplaces. Neuropsychiatric intervention in such cases can often help in the overall improvement of such patients.[13],[14] Rise in OPD attendance of such patients proves that such patients are not averse to participate in treatment program if the services are more likely to participate in treatment program if services are made more accessible.

Psychotic conditions are often devastating for the patient and their families. There is lot of misconceptions about their etiology, and family members are hesitant to reveal the illness to other members of the society. Taking the patient to psychiatric ward is a difficult decision for fear of social stigma.[15] If an avenue is provided within the hospital setting rather than confinement in psychiatric ward, patients, and their family members are more likely to seek definitive treatment. Such conditions are fairly common, and many epidemiological studies suggest that their prevalence could be anywhere between 1% and 3%.[16] In our experience, the change in setting of the psychiatry OPD was effective in bringing more such patients into the treatment fold.

The total number of new cases of mood disorder, mixed anxiety and depression, and adjustment problems (diagnostic category F 30–39 and F 40–49) [Table 3] increased from 390 (74.7%) to 1148 (64.52%) (P < 0.05). The relative decline in percentage is artificial because of a larger number of cases of other diagnoses. These are the cases which form the backbone of psychiatric practice.[17],[18] In our experience, the total number of new cases increased about three-fold with the change in location and name of psychiatry OPD. Here, our experience matched with other similar studies wherein diversification of psychiatric services was found to be effective in early identification of such problems and the prevention of suicides.[19]

An interesting observation was that patients with eating disorders, personality disorders, nonorganic sleep disorders, and sexual disorder (F 50–69) also sought treatment from the psychiatrist without fear of social stigma when an avenue was provided for their amelioration within the main hospital polyclinic. In our experience, their number increased from 0 to 38 (2.13%). Although the actual prevalence of these disorders is much higher, the very fact that these clinical entities were identified with the new system is an encouraging sign.[20],[21],[22],[23]

Efforts aimed at improving delivery of psychiatric services have been tried in the past with success.[15],[24] These programs paved the way for the integration of psychiatric services with other hospital-related services in our country. The revolution in psychopharmacology in the past 50 years has brought in significant change in the outcome of patients with psychiatric problems. Erstwhile treatment-resistant cases are now useful members of the society, but they still require a dignified treatment setting for follow-up.

It is important to acknowledge that many major psychiatric disorders follow a long-term course and require years of follow-up. At times, the patients and their caregivers lose hope and try other methods of treatment and at times suicides do occur. However, that should not deter community outreach programs as the community gets benefited as a whole.[24],[25],[26],[27] The field of psychiatry is evolving and so should our approach. The standard interviewing methods which are elaborate and exhaustive may not be suited for every case but must be applied to the deserving few.[28] This approach helps to reduce health costs both in terms of money and man-hours.[29],[30] The role of medical officers in broadening the psychiatric services cannot be underestimated, and their training must go hand in hand. Brief educational capsules and study material should be provided to them at regular intervals to update their knowledge and to allay their apprehensions about the nature and treatment of common psychiatric problems.

Limitations

There was no control group as the existing facilities did not permit it, but the comparisons were made with the preceding years OPD attendance. It may be noted that the increase in psychiatric patients may not be solely due to change in location and name of the psychiatry OPD. The contribution of each of these factors was not studied independently. Reduction in distance may not have affected the findings since patients coming from far-flung places can easily travel for another kilometer for specific treatment, and free transport is generally provided. There may have been other confounding factors which have not been studied independently. Hospitals are visited not only by patients but also by their relatives and friends. A well laid out facility which is easily accessible sends out an important message in the community. In spite of these limitations, this study provides a window of opportunity for up-gradation of psychiatric services for our clientele.

 Conclusion



The integration of psychiatric care with other hospital-based services is need of the hour. Amalgamation of psychiatric OPD services with the mainline hospital services with contemporary nomenclature led to better utilization of psychiatric services in a multispecialty service hospital. The authors recommend further studies in this direction so that a contemporary model of psychiatric care can be created in service hospitals. In addition, there is need to augment the therapeutic armamentarium of service psychiatrists by making available services of counselors and clinical psychologists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res 2007;126:183-92.
2Ndetei DM, Khasakhala LI, Kuria MW, Mutiso VN, Ongecha-Owuor FA, Kokonya DA, et al. The prevalence of mental disorders in adults in different level general medical facilities in Kenya: A cross-sectional study. Ann Gen Psychiatry 2009;8:1.
3Kumari S, Banerjee I, Majhi G, Chaudhury S, Singh AR, Verma AN. Felt stigma and self esteem: A comparative study among hospital outdoor and community camp attending patients. Med J DY Patil Univ 2014;7:550-7.
4Kumari S, Mishra SN, Chaudhury S, Singh AR, Verma AN, Kumari S, et al. An experience of community mental health program in rural areas of Jharkhand. Ind Psychiatry J 2009;18:47-50.
5Mcdermott JA, Celice M. Community mental health: Challenges for the 21st century. Prim Care Community Psychiatry 2008;13:43-4.
6Dai YX, Chen MH, Chen TJ. Low prevalence of the use of the Chinese term for 'psychiatry' in the names of community psychiatry clinics: A nationwide study in Taiwan. Int J Soc Psychiatry 2016. pii: 0020764016660994.
7Dobmeyer J, Anne C, Milton EB, Navarrette R, Ruth A, Stephen YR. Evaluation of a collaborative mental health program in primary care: Effects on patient distress and health care utilization. Prim Care Community Psychiatry 2007;11:121-7.
8Hirosawa M, Shimada H, Fumimoto H, Eto K, Arai H. Response of Japanese patients to the change of department name for the psychiatric outpatient clinic in a university hospital. Gen Hosp Psychiatry 2002;24:269-74.
9Surtees PG, Wainwright NW, Luben RN, Wareham NJ, Bingham SA, Khaw KT, et al. Depression and ischemic heart disease mortality: Evidence from the EPIC-Norfolk United Kingdom prospective cohort study. Am J Psychiatry 2008;165:515-23.
10Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: The National Comorbidity Survey. Am J Psychiatry 1994;151:979-86.
11Malhotra S, Patra BN. Prevalence of child and adolescent psychiatric disorders in India: A systematic review and meta-analysis. Child Adolesc Psychiatry Ment Health 2014;8:22.
12Borduin CM, Mann BJ, Cone LT, Henggeler SW, Fucci BR, Blaske DM, et al. Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. J Consult Clin Psychol 1995;63:569-78.
13John EF, Levenson JL, McCance-Katz EF. Substance related disorders. In: Levenson JL, editor. Textbook of Psychosomatic Medicine. 1st ed. Washington DC: American Psychiatric Publishing; 2005. p. 387-423.
14Martin JB. The integration of neurology, psychiatry, and neurosurgery in the 21st Century. Psychiatrist 2004;28:315-6.
15Isaac MK, Kapur RL, Chandrashekar CR, Kapur M, Pathasarathy R. Mental health delivery through rural primary care-development and evaluation of a training programme. Indian J Psychiatry 1982;24:131-8.
16Yudofsky SC, Hales RE. Neuropsychiatry and the future of psychiatry and neurology. Am J Psychiatry 2002;159:1261-4.
17Avasthi A, Varma SC, Kulhara P, Nehra R, Grover S, Sharma S, et al. Diagnosis of common mental disorders by using PRIME-MD patient health questionnaire. Indian J Med Res 2008;127:159-64.
18Chaturvedi SK, Kalyanasundaram S, Jagadish A. Detection of stress, anxiety and depression in IT/ITES professionals in the Silicon Valley of India: A preliminary study. Prim Care Community Psychiatry 2007;12:75-80.
19Jacob KS. The prevention of suicide in India and the developing world: The need for population-based strategies. Crisis 2008;29:102-6.
20Hoek HW. Review of epidemiological studies of eating disorders. Int Rev Psychiatry 1993;54:61-5.
21Hossain JL, Shapiro CM. The prevalence, cost implications, and management of sleep disorders: An overview. Sleep Breath 2002;6:85-102.
22Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007;62:553-64.
23Simons JS, Carey MP. Prevalence of sexual dysfunctions: Results from a decade of research. Arch Sex Behav 2001;30:177-219.
24Wig NN, Murthy RS, Harding TW. A model for rural psychiatric services-Raipur Rani experience. Indian J Psychiatry 1981;23:275-90.
25Kates N, Craven M, Crustolo AM, Nikolaou L, Allen C. Integrating mental health services within primary care. A Canadian program. Gen Hosp Psychiatry 1997;19:324-32.
26Abel WD, Richards-Henry M, Wright EG, Eldemire-Shearer D. Integrating mental health into primary care an integrative collaborative primary care model – The Jamaican experience. West Indian Med J 2011;60:483-9.
27Bland DA, Lambert K, Raney L; APA. Resource document on risk management and liability issues in integrated care models. Am J Psychiatry 2014;171:suppl 1-7.
28Stuart MR, Lieberman JA. The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care. Philadelphia: WB Saunders; 2002. p. 129-43.
29Hall RC, Wise MG. The clinical and financial burden of mood disorders. Cost and outcome. Psychosomatics 1995;36:S11-8.
30Olsen D. Integrating Primary Care and Mental Health Key to Improving Patient Care, Lowering Costs. Primary Care Physicians Play Important Role in Detecting Mental, Behavioral Health Issues. In Medical Economics – E News. May 08, 2014. Available from: http://www.medicaleconomics.modernmedicine.com. [Last accessed on 2017 Apr 06].