Original Article Morbidity Pattern of Psychiatric Disorders in Patient Seeking Treatment in Psychiatric OPD of Private Tertiary Care Hospital Shrestha MR, * Pradhan S, ** Sharma S** *Senior consultant psychiatrist, **Psychiatrist. ABSTRACT Introduction: Mental health problem is a major public health issue in the world. However, data in most of the developing countries including Nepal are scarce. The pattern of psychiatric morbidity in private general hospital in quite different from that in mental hospital. Method: All the new patients reported to the department of psychiatry in Kathmandu hospital from 14th April 2007 to 13th April 2010 and diagnosed according to ICD=10 formed the study population for the present study. Methods: New psychiatric patients with psychiatric disorders seeking treatment in psychiatric OPD of Kathmandu hospital were included in the study. Results: A slight preponderance of males (50.3%) and residents of central region (77.8%) was observed. Patients with neurotic, stress related and somatoform disorder (38.1%) emerged as largest group followed by mood disorder (18.0%). Among all the patients, other anxiety disorders (Generalized anxiety disorder, panic disorder, etc) comprised of 26.9% and depression 15.3%. Other commonly diagnosed conditions are migraine (9.4%), schizophrenia (6.3%), alcohol dependence (4.5%) and epilepsy (3.9%). Conclusion: The onset of most mental illness occurred in adolescent and young adults. Thus, mental illness have a significant impact on person, family and nation as a whole.so, the policy makers should give high priority for mental illness for preventive, promotive and curative services in Nepal. Key words: Psychiatric morbidity, OPD, profile. INTRODUCTION The world health organization (WHO) defines mental health as a positive sense of well being encompassing the physical, mental, social, basic economic and spiritual aspects of life; not just the absence of disease. Mental and behavioral disorders are understood as clinically significant conditions categorized by alteration in thinking, mood, emotion or behaviors associated with personal distress and/ or impaired functioning. Mental and behavioral disorders are not just variation within the range of normal but are clearly abnormal or pathological phenomena. Correspondence : Dr.Mohan Raj Shrestha, Mental Hospital, Lagankhel Email: drmohanrajshrestha@hotmail.com It has been established that as many as 500 million people may be suffering from same kind of mental disorders or impairments 1. Mental and behavioral disorders are common, affecting more than 25% of all people at sometime during their lives 2. They are also universal, affecting people of all countries and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. They have an economic impact on societies and on the quality of the life of individuals and families. Around 20% of all patients seen by primary health care professionals have one or more mental disorders. 3 Mental disorders are identified and diagnosed using clinical methods that are similar to those used for physical disorders. Mental disorders are thought to impose a significant disease burden in developing as well as in developed 28 Volume 11 Number 1 Jan-June 2011
regions of the world. 4 These high prevalence relapsing and remitting conditions are well recognized as significant contributors to impaired quality of life, disablement and increased consumption of health services. 5 However in developing regions the primary public focus is upon malnutrition and infections disease. Mental disorders are not given due priority. In 1909 Adolf Meyer advocated management of mentally ill patients outside the mental hospitals and proposed a comprehensive community mental health approach. A unit of psychiatric OPD in general hospital would have an advantage over the mental hospitals because they would be easily accessible, approachable without stigma and would facilitate out patient treatment for mental health problems. Positive trends in psychiatric help seeking can be directly linked to the advantage offered by a general hospital psychiatric unit. Proximity to the medical specialties ensures prompt referral. The stigma attached to mental illness presents a serious barrier not only to diagnosis and treatment of mental disorders but also to accept them in the community.still now maximum people are out of modern treatment facilities due to poor economic Conditions prevailing superstition, stigma on mental patients and lack of education and knowledge about scientific method of treatment of mental illness.the aim of this study was documenting the pattern of psychiatric morbidity among the patients seeking treatment in psychiatric OPD of tertiary care level private hospital and Comparing the pattern of psychiatric morbidity with other published literature. METHODS This study was conducted in the out patients department of psychiatry in Kathmandu hospital, 50 bedded tertiary health care institution. All the new patients reported to the department from 14 th April 2007 to 13 th April 2010 (3 years) and diagnosed according to ICD-10 formed the study population for the present study. The study design was a retrospective detailed review of all cases records. Data were collected and analyzed using SPSS version 11.5. RESULTS Between 14 th April 2007 to 13 th April 2010, 664 new patients visited to psychiatry OPD of Kathmandu hospital. A total of 664 new cases were seen during above period of which 33 (50.3%) were male and 331 (49.7%) were female. Table 1 shows age wise distribution of cases attended in OPD. Among them majorities of patients were in age group 21-30 (N=213, 32.2%) followed by 31-40 years (N=168, 25.2%) more than 50% of cases comprised of 21-40 age group (N=381, 57.4%). Table 1: Age group distribution. Age group Male Female Total % 0-10 6 0 6 0.9 11-20 48 33 81 12.2 21-30 112 101 213 32.2 31-40 82 86 168 25.2 41-50 43 56 99 14.9 51-60 17 30 47 7.1 61-70 8 17 25 3.8 71-80 12 5 17 2.6 81-90 5 3 8 1.2 Total 353 331 664 100 Majority of the cases were from central region (N= 517, 77.8%) where the hospital is situated; followed by western region (N= 84, 12.7%). Among the cases of central region, 69.8% (N= 361) were from Kathmandu districts. Table 2: Distribution according to Residence by region. Address Male Female Total % Eastern 16 21 37 5.6 Central 259 258 517 77.8 Western 39 45 84 12.7 Mid-Western 15 3 18 2.7 Far Western 4 4 8 1.2 Total 333 331 664 100 The largest number (N= 249, 38.1%) of the new patients were suffering from neurotic stress related and somatoform disorder (F 40-48) followed by mood disorder (N= 118, 18%) Patients with migraine (G 43) constituted 9.4% (N=62). Only 3.9% (26) of patient received diagnosis of epilepsy. Patients with schizophrenia, schizotypal and delusional disorders (F 20-29) constitutes 6.3% (N=40) of the total sample. 5.8% (N= 39) of patients received the diagnosis of the mental and behavioral disorders due to psychoactive substance use which was followed by other headache syndromes (N= 28, 4.2%). Volume 11 Number 1 Jan-June 2011 29
Table 3: Diagnostic Distribution. ICD 10 Diagnostic Groups/Categories ICD -10 Code Male Female Total % of Total Organic, including symptomatic, F0-F9 0 Mental Disorder 0 0 0 0 Mental & behavioral disorders due to F10-F19 5.8 psychoactive substance use Alcohol 28 2 30 4.5 Opioids 2 0 2 0.3 Cannabinoids 1 0 1 0.2 Sedatives 0 3 3 0.5 Multiple Drug use 2 0 2 0.3 Schizophrenia, Schizotypal & Delusional F20 F29 6.3 Disorders Schizophrenia 17 8 25 4.0 Persistent delusional disorder 0 1 1 0.2 Acute transient & psychotic disorder 11 3 14 2.1 Mood Disorders F 30 F 39 18.0 Hypomania 0 2 2 0.3 Bipolar affective disorder 6 6 12 1.9 Depressive episode 33 51 84 12.7 Rec. Depressive disorder 8 9 17 2.5 Persistent Mood disorder 1 2 3 0.6 Neurotic, stress related & Somatoform disorder F 40 F 49 38.0 Phobic anxiety disorder 8 1 9 1.4 Other anxiety disorder 98 80 178 26.9 Obsessive Compulsive disorder 9 4 13 2.0 Reaction to serve stress & Adjustment disorder 2 5 7 1.2 Dissociative [conversion] disorder 2 25 27 4.2 Somatoform disorder 9 6 15 2.4 Behavioral Syndromes associated with F 50 F 59 1.9 physiological disturbances & physical factor Non-organic sleep disorder 6 3 9 1.4 Mental & Behavioral disorder associated with 0 4 4 0.5 puerperium not elsewhere classified Disorders of adult personality & behavior F 60 F 69 0.4 Specific personality disorders 1 0 1 0.2 Habit & Impulsive disorder 1 0 1 0.2 Mental Retardation F 70 F 79 0.9 Mild mental retardation 6 0 6 0.9 Disorders of physiological disturbance F 80 F 89 0 0 0 0 Behavioral & emotional disorders with onset F 90 F 99 0.5 usually occurring in childhood & adolescence Hyperkinetic disorder 2 0 2 0.3 Tic disorder 1 0 1 0.2 G 20 Parkinson s Disease 1 0 1 0.2 G 40 Epilepsy 17 9 26 3.9 G 43 Migraine 14 48 62 9.4 G 44 Other Headache Syndrome 13 15 28 4.2 Non psychiatric condition 34 44 78 11.7 30 Volume 11 Number 1 Jan-June 2011
DISCUSSION:- Psychiatric morbidity is a major public health problem in the world across developed and developing countries. Mental health is as important as physical health to daily living. Most people with mental illness are treated in the community rather than in hospitals and may do not receive treatment at all. Studies regarding psychiatric morbidity are scarce in Nepal. Present study shared that out of 664 attended in the OPD, a slight male preponderance (50.3%) was noted which is consistent with the findings of Regmi et al 6, Upadhaya 7. Psychiatric morbidity in general is reportedly higher among females. A slight male preponderance was noted in this study may reflect upon the gender bias in psychiatric help seeking being more pronounced for bread earnings male member of family. Under reporting of mental disorders among females may be linked to the inferior social position, social stigma, problems with marriage etc. Maximum patients were in the age group 21 30 years (32.3%), followed by the age group 31 40 years (25.2 %). Previous studies had also demonstrated that most of the visitors seeking psychiatric services were younger, more than half of the patients being of the age group 21 40 years (Upadhaya et al 7, Nepal e al, 1986 8, wright 1987 9, Shrestha 1987 10, Sharma 1987 11 ). Present study also showed that more than half patients (57.5%) were age group of 21 40 years. Among 304 patients 184 (60.5%) were males and 120 (36.4%) were females. More than 50% of patients were in the age group of 18 37 years 12. Majority of the patients were from the central region (77.8%) where the hospital is situated, followed by western region. Among the central region, number of cases was from Kathmandu districts (69.8%). In previous studies done by Regmi et al 6 also majority of the patients were from the central region (73.3%) which is also similar to the findings in the studies of Nepal et al (1986) 7 and Shrestha (1987), which were conducted in Kathmandu Valley. This may be due to reason that local and nearby population seemed to have benefited the most. The central region has highly populated density, easy available of services and high rate of literacy. Another reason may be due to giving the temporary address of residence. Kathmandu district is mostly populated by the people from the different district. The lower number of patients from other region does not mean the low prevalence of mental illness. Present study showed that most of the services seekers were those who were suffering from neurotic, stress related and somatoform disorder (38.1%) followed by the patients suffering from mood disorder 18.0% which is consistent with the findings of Regmi et al 6. The largest diagnostic group in the first 150 patients attending the Psychiatric OPD was neurotic and stress related disorder followed by depression and schizophrenia 8. Wright (1987) had found that 32% of the patients were suffering from epilepsy, 25% from psychosis and 13% from depression. Sharma (1987) described 42% of the patients in his study to be suffering from depression, 17% from neurosis and 16% from epilepsy In the study by shrestha (1987), 67% of the patients were suffering from psychosis, 18% from neurosis and 6% from epilepsy. In the study done by Ahmed F in 2009 majority of patients were from schizophrenia and psychiatric disorder. New psychiatric patients with psychiatric disorders seeking treatment from the psychiatric unit of district hospitals muktsar (Punjab), maximum number of patients were diagnosed to have mood disorders (57.4%) 13. The study by Dube (1970) which was conducted in the rural community of Uttar Pradesh (India) in which about 44% of the patients were suffering from neurotic and stress related disorders and 9.1% from schizophrenia 14. The reason behind the diversity of results of different studies may be many and senses of them are cultural factors, set up of study e.g. Psychiatric OPD of a general hospitals, mental hospitals, private clinic and health post. The spectrum of psychiatric cases material seen in general hospitals psychiatric unit is much wider than seen in mental hospitals. Unlike mental hospitals, where the clinical materials is predominantly psychosis, in a general hospitals psychiatric unit there is a wide range of clinical problems including psychosis, neurosis, personality disorders, drug dependence, organic brain disorders etc 15. Apart from the major groups described above, other disorders the patients were migraine (9.4%), schizophrenia, schizotypal and delusional disorders (6.4%), mental and behavioral disorders due to psychoactive substance use (6.0%) etc. Shrestha et al 10 in a prospective analysis of 300 cases attending in Volume 11 Number 1 Jan-June 2011 31
psychiatric out patients clinic in Kathmandu reported 2% of total cases having different psychiatric problems related to alcohol, all were males. In a study done by Singh, migraine comprises of 4.6% schizophrenia, schizotypal and delusion disorders 9.6%, mental and behavioral disorders due to psychoactive substance use 8.1% etc 13. Neuro patients with epilepsy constituted 3.9% of the total sample which is less than reported by Singh (9.7%). The variable attending of patients with schizophrenia is reported in different Indian studies of different setting (range 6.8 13.7%) 16. Isaac et al 16 reported that in sakalwara in a three year period 13.7% patients of schizophrenia were seen at Raipur Rani the corresponding figure was 11% 17. 6.8% were diagnosed as suffering from schizophrenia, shizotypal and delusional disorders at civil hospital Manimajra which is similar to present study (6.4%). 18 Psychotic patients represented 8.6% of the total sample. Lack of awareness, superstitions, intervention by faith healers and difficulties in bringing disruptive patients to far off treatment facilities are possible factor for lower rate of these serious disorders. Traditional healers are usually the first to be consulted in case of mental illness. As observed by sharma 19 1996 teaching faith healers to recognize psychosis and motivating them to send such patients to mental health professionals would bridge in gap between community and the psychiatrist. CONCLUSION The onset of most mental illness occurred in adolescent and young adults, commonly in the males and most are neurotic illness. Thus mental illnesses have a significant impact on the family. The costs of medication, time off work and the excess support can create a service financial burden for families. Both the care requirements and stigma attached to mental illness often lead to isolation of family member from the community and their social support network. The serious stigma and discrimination attached to mental illness are among the most tragic realities facing people with mental illness. They force people not to disclose the illness and this causing them to delay seeking health care and avoid sharing their mental health problem with friends, co-workers employers, health service providers and others in the community. Thus, there is a need to increase the awareness in the general public regarding the impact of mental illness and the need for timely treatment. REFERENCE: 1. WHO Global health situation and protection estimates Geneva, World health organization (1992a) Unpublished document WHO/HST/92.1%,available on request from division of epidemiological surveillance and health situation and trend assessment, World health Organization, 1211.Geneva 27, Switzerland. 2. WHO report (2001) Mental health: New understanding, new hope. 3. Ragier DA, Boyd JH, Burk GD, Rai DS, Mayers JK, Kramer M, Robins LN, Goeore LK, Karno M, Locke BG. One month prevalence of mental disorders in the United States. Based on five epidemiological catchments area sites. Archives of General psychiatry 1988; 45:977-86. 4. Ormel J, Non-Korff M, Ustune T. Common mental disorders and disability across cultures.jama 1994; 272:1741-48. 5. Murray CJL, Lopez AD. The global burden of diseases. A comprehensive assessment of mortality and disability from diseases injuries and risk factors in 1990 and projected to 2020. The Harvard school of public health. Harvard University Press1996. 6. Regmi SK, Khalid A, Nepal MK Pokhrel A. A study of sociodemographic characteristics and diagnostic profile in psychiatric outpatients of TUTH, Nepalese journal of psychiatry 1999; 1(1):26-33. 7. Upadhaya KD, Dutta S, Singh G. Morbidity profile of patients attending neuropsychiatry OPD at the western regional hospital,pokhara,journal of Nepal medical association 1997;38: 67-70. 8. Nepal MK, Gurung CK, Jha AK, KC G, Shah R. First 150 patients of a new psychiatric OPD: Sociodemographic profile and their diagnostic status. Journal of Nepal Medical Association 1986; 424(3): 7-19. 9. Wright C. Community mental health services in Nepal early experiences. In: proceedings of the workshop on national mental health planning 1987; 13-27. 10. Shrestha NM. A prospective analysis of 300 cases attending outpatient clinic in mental hospital. In: proceeding of the workshop on national mental health planning1987; 47-33. 11. Sharma BB. Sociodemographic analysis of 100 cases seen at Pokhara mental health 12. Ahmed F, Wahab MA, Rahaman MM. Pattern of psychiatric morbidity among the patients admitted in a private psychiatric clinic. Bangladesh journal of medical science 2009; 14(10) :38-45. 32 Volume 11 Number 1 Jan-June 2011
13. Singh GP. Pattern of psychiatric disorders in patients seeking treatment in a secondary health care instition. journal of mental health and human behavior 2009; 14(1): 38-45. 14. Dube KC. A study of prevalence and biosocial variables in mental illness in a rural and urban community in Utter Pradesh, Indian.Acta psychiatrica scandenevica1979; 46: 327-59. 15. Khanna BC, Dig NN, Verma VK. General hospital psychiatric clinic an epidemiological study. Indian journal of psychiatry 1974; 16: 211-15. 16. Isaac MK, Kapur RL, Chandrashekhran CR. Mental health delivery through rural Primary healthcare developments. Indian journal of psychiatry1982; 24:131-38. 17. Wig NN, Murthy RS, Harding TW. A model for rural psychiatric services. Raipur Rani Experinces.Indian journal psychiatry 1981; 23: 275-90. 18. Waraich BK, Lok R, Chavan BS. Decentralization of mental health services under DMHP.Indian journal of psychiatry 2003; 45: 161-65. 19. Sharma VD. Prevalent opinions of traditional healers about clients who faint or are possessed. Paper presented in epilepsy, conducted by EPICADEC, Kathmandu, 1996. Volume 11 Number 1 Jan-June 2011 33