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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 138-144

Pattern of psychiatric presentation of patients coming to the emergency unit of psychiatry department of a tertiary care teaching hospital in West Bengal


Institute of Psychiatry – A Centre of Excellence, IPGMER and SSKM Hospital, Kolkata, West Bengal, India

Date of Submission05-Nov-2021
Date of Decision26-Nov-2021
Date of Acceptance10-Dec-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Dr. Soumi Ghosh
Flat No. 202, Kalimata Abasan, 60, Ram Sita Ghat Street, Bhadrakali, Uttarpara, Hooghly - 712 232, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjp.tjp_37_21

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  Abstract 


Background: Psychiatric emergencies are characterized by acute conditions of disturbances of affect or mood, behavior, and thoughts, which, if not managed with immediate therapeutic intervention, can cause great harm to the patient and surroundings. In most of the institutions, due to lack of emergency psychiatric units, these are managed by general hospital emergency units, which is the reason for underreporting of psychiatric cases in developing countries like India.
Aim: The aim is to study the pattern of psychiatric presentation of the patients coming to the psychiatric emergency unit of a tertiary care teaching hospital in West Bengal.
Methods: This prospective, longitudinal, hospital-based study was conducted for a period of 3 months on patients attending the psychiatric emergency unit of a tertiary care teaching hospital in West Bengal. Clinical details of the patient, source and reason for referral, and presenting complaints were recorded and analyzed.
Results: Out of 200 patients attending the psychiatric emergency unit, most were female aged between 21 and 40 years. The three most prevalent presenting complaints among subjects were abnormal behavior with somatic complaints, excitement, and violent behavior followed by substance use. The foremost reason for a referral from other departments was either due to the absence of any physical illness or no abnormalities detected in the investigations conducted.
Conclusions: The results from the study could help in gaining knowledge regarding emergency psychiatric conditions, increase in preparedness for their rapid management, and improvement of emergency psychiatry services to meet the mental healthcare demands in our country.

Keywords: Consultation-liaison psychiatry, emergency psychiatry, referral reason, tertiary care teaching hospital


How to cite this article:
Dey S, Ghosh S, Mondal A, Bhattarcharya A. Pattern of psychiatric presentation of patients coming to the emergency unit of psychiatry department of a tertiary care teaching hospital in West Bengal. Telangana J Psychiatry 2021;7:138-44

How to cite this URL:
Dey S, Ghosh S, Mondal A, Bhattarcharya A. Pattern of psychiatric presentation of patients coming to the emergency unit of psychiatry department of a tertiary care teaching hospital in West Bengal. Telangana J Psychiatry [serial online] 2021 [cited 2022 Jan 17];7:138-44. Available from: http://www.:tjpipstsb.org/text.asp?2021/7/2/138/335643




  Introduction Top


Psychiatric emergencies are different from other medical emergencies and are characterized by acute conditions of disturbances of affect or mood, behavior, and thoughts which, if not managed with immediate therapeutic intervention, can cause great harm to the patient or to the surroundings.[1] As it also poses a threat to the society and family members of the patients, it needs special attention and intervention.[2] Acute psychiatric emergencies that were previously managed by mental hospitals are now treated in emergency unit of psychiatry department after being referred from various other departments of a general hospital.[3] Psychiatric emergency services are thus now an important part of mental health system globally to manage various emergency psychiatric conditions such as suicide, deliberate self-harm, acute intoxicated state, acute behavioral abnormalities, and many other conditions.[4],[5]

In our country, psychiatric services are now widely available in many of the tertiary care hospitals, the services provided in most of these institutions are that of inpatient and outpatient based services and consultation-liaison services from other non-psychiatric departments as referral basis.[6],[7],[8] Further, there is a huge gap between the demand and availability of psychiatry services in rural India, and due to the absence of proper knowledge and training regarding emergency psychiatry services and its availability, emergency psychiatry services are still very much underutilized in India.[9],[10] In majority of institutions, there is a lack of emergency psychiatric units and psychiatric emergencies are managed by general hospital emergency unit and are very much underreported for this reason in India and other developing countries; to overcome this situation, the World Health Organization recommended that centers for prompt recognition and rapid management of acute psychiatric emergencies should be made available for at least 50% of the population of a given area.[3]

There is very few literature regarding the pattern of presentation and sociodemographic profiles of patients coming with acute psychiatric emergencies in the emergency psychiatry unit of a hospital available in our county, and majority of them deal with the psychiatric emergencies on consultation-liaison basis.[3],[7],[10],[11],[12] The place of our study is a tertiary care teaching hospital in West Bengal that runs a 24-h basis emergency psychiatry unit, which provides ample opportunity to assess the variety of presentation of patients with acute emergency situation and their sociocultural background as well as allows their further follow-up in our inpatient department as needed.

The aim of our present study is the assessment of pattern, presenting symptoms at psychiatric emergency, and their final psychiatric diagnosis according to the International Classification of Diseases-10 (ICD-10). The results from the study could help the clinicians and psychiatrist in future to gain knowledge regarding emergency psychiatric conditions, to increase preparedness for their rapid management and also to improve the condition of emergency psychiatry services to meet the mental healthcare demands in our country.


  Materials and Methods Top


This prospective, longitudinal, hospital-based study conducted on patients attending the psychiatric emergency unit of an urban tertiary care teaching hospital in West Bengal with 24-h emergency services where patients are referred from the emergency unit from other departments for psychiatric evaluation, as well as where patients can also directly walk in and request for treatment. The study was conducted from May 2021 to July 2021, over a period of 3 months. The data was collected from the patients came in emergency psychiatry unit over this 3 months after taking proper informed consent from them and their guardians if special situations where the patients may not be in a state to give proper consent. The data include age and sex distribution, source of referral, presenting complaints, final psychiatric diagnosis, and intervention provided. All diagnoses we made according to the ICD-10 criteria. Ethical approval from the institutional ethics committee was taken, and analyses were done using descriptive statistics.


  Results Top


Age and sex distribution

After assessing 200 patients coming to our emergency unit of the psychiatry department in 3 months period, we had found that the mean age of the patients was 34.6 years. Among them, 130 (65%) patients, i.e., majority were female and the rest 70 (35%) patients were male. Majority of them, 80 of the 200 patients (40%), belong to the age group of 21–40 years, 40 of them (20%) were below the age group of 21 years, 54 of them (27%) belonged to the age group of 41–60 years, and 26 of them (13%) were above 60 years of age [Table 1].
Table 1: Age and sex distribution among the patients

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Sources of referral

As shown in [Table 2], among 200 cases, majority of cases were referred to the psychiatric emergency unit from general emergency department, i.e., 52 (26%). A significant number of patients directly coming to the department of psychiatric emergency which accounts for 34 (17%). Rest of the patients were referred from emergency units of following departments such as general medicine emergency - 24 (12%), neuromedicine - 22 (11%), neurosurgery - 15 (7.5%), general surgery - 12 (6%), gynecology and obstetrics - 11 (5.5%), physical medicine - 6 (3%), rheumatology - 6 (3%), orthopedics - 5 (2.5%), pediatric - 4 (2%), gastroenterology - 3 (1.5%), ENT - 3 (1.5%), dermatology - 2 (1%), and ophthalmology - 1 (0.5%) [Table 2] and [Figure 1].
Table 2: Sources of referral of the patients attending psychiatric emergency ward

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Figure 1: Distribution according to source of referral

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Presenting complaint

[Table 3] shows that the most common complaint due to which an emergency psychiatric consultation was done was episode of unresponsiveness, shortness of breath, and hysteria-like symptoms (n = 52, 26%) followed by excitement and agitation (n = 33, 16.5%) and substance abuse (n = 23, 11.5%). Other presenting complaints were nonspecific physical symptoms (n = 18, 9%), features of anxiety symptoms such as anxiety and palpitations (n = 12, 6%), sleep disturbances (n = 12, 6%), altered sensorium (n = 15, 7.5%), headache (n = 9, 4.5%), suicidal attempt by different means (n = 8, 4%), complications due to psychotropic medications (n = 6, 3%), and hyperactivity and inattention (n = 6, 3%) [Figure 2].
Table 3: Presenting complaints of the patients

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Figure 2: Presenting complaint of the patients

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Mental status examination

[Table 4] shows the mental status examination among the study subjects attending the psychiatric emergency unit. The most common finding is psychomotor agitation (36.5%) followed by anxious affect (34.5%) and worrying thoughts and hypervigilance (28.5%). Delusions (21.5%), abnormal movement (19.5%), and perceptual abnormalities (16.5%) are some of the findings.
Table 4: Mental status examination of the patients

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Final diagnosis

Wide varieties in diagnosis were found among the patients attending the psychiatric emergency unit of our hospital. Out of 200 cases, a provisional diagnosis of psychiatric illness could be made in 181 cases. Most common among them were dissociative conversion disorder (n = 32, 16%) with female predominant. Followed by substance use disorder (n = 27, 13.5%), the most common was alcohol, i.e., 15 cases, and all of them were found to be male (38.5%). Among 16 (8%) patients of bipolar affective disorder, 11 were female and 5 were male. Patients of Acute and transient Psychiatric disorder were 15 (7.5%) in number and most cases among them were female i.e. 12. Total Schizophrenia cases were 14 (7%) in number and there was 3 cases of mania (1.5%).Both schizophrenia and mania cases were found to be equal in both gender. Organicity due to any cause were 13 (6.5%) with male cases were more than female was noted. Other cases like severe depressive episode(5.5%), Mental and behavioural disorder associated with the puerperium not elsewhere classified (5%) , somatoform disorder (4.5%), emotionally unstable personality disorder (2%), panic disorder (2%), migraine (2%), generalized anxiety disorder (1.5%),acute stress reaction (1.5%), vomiting associated with other psychological disturbances (1%) and tic disorder (0.5%) were found to be more among female. While cases of obsessive compulsive disorder (1.5%), Habit and impulse disorder (1.5%) and conduct disorder (0.5%) showed male cases more than female as shown in [Table 5] and [Figure 3].
Table 5: Distribution of final diagnosis according to gender of the patients

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Figure 3: Diagnosis (International Classification of Diseases-10 CDDG diagnostic codes) according to sex

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Diagnosis (International Classification of Diseases-10 CDDG diagnostic codes) according to gender

The provisional diagnosis according to the ICD-10 categories across both genders which were made by the psychiatrist/psychiatric residents attending the patients in the psychiatric emergency unit is tabulated in [Table 6] [Figure 4]. It shows that, out of 200 cases, in 191 cases , any psychiatric diagnosis could be made. Among them 54 (27%) belongs to neurotic, stress related and somatoform disorders(F40-F48) and 47(87.03%) were female. 33 (16.5%) cases were male. Patients of Mood [affective] disorders (F30-F39), among them 22 (66.66%) were female and 11(33.33%) were male. Others cases of schizophrenia, schizotypal and delusional disorder (F20-F29), behavioural syndrome associated with physiological disturbances and physical factor (F50-F59), Disorders of adult personality and behaviour (F60-F69) were more common in female whereas cases of Organic, including symptomatic, mental disorders(F00-F09) and mental and behavioural disorders due to psychoactive substance use(F10-F19) more common in male. Behavioral and emotional disorders with onset usually occurring in children and adolescence (F90–F98) were found in the same proportion in both genders. Many cases belonging to other conditions from ICD-10 often associated with mental and behavioral disorders such as disorders of nervous system, i.e., 2 (1%) cases of epilepsy (G40), 4 (2%) cases of migraine (G43), and 1 (0.5%) case of other headache syndromes (G44), were also noted.
Table 6: Distribution of diagnosis (international classification of diseases-10 CDDG diagnostic codes) according to gender of the patients

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Figure 4: Final diagnosis according to the International Classification of Diseases-10 codes

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Complications due to psychotropic medication

We have noted few patients who were known case of psychiatric illness and under psychotropic medications attended our psychiatric emergency unit with some complications they developed after taking psychotropic medication. Out of 200 cases, six were suffering from complications, among them 4 patients were having Extrapyramidal symptoms like acute dystonia, akathisia . One case of Schizophrenia was reported to suffer from post injection syndrome after receiving injection Olanzapine LA 300 mg by intramuscular route around buttock and 1 case of neuroleptic Malignant syndrome was also noted during the study period.

Interventions provided to the patients attending the psychiatric emergency ward

In most of the cases (n = 128, 64%), initial treatment with medications, and in some cases, brief psychoeducation were provided and send back to home. While 37 cases (18.5%) were admitted in the psychiatric emergency observation ward, 35 cases (17.5%) were referred to other departments to rule out any organicity.


  Discussion Top


Emergency psychiatry is a branch of psychiatry to provide treatment and relief in acute cases of mental illness, which can be an imminent factor to the patient and his/her life. Emergency psychiatric service is a relatively new subspecialty in India that has been introduced since last few decades.[13] In the early 1960s and 1970s, the psychiatric services in India were mostly asylum based until the Government of India launched National Mental Health Program on 1982 to meet the mental healthcare need of the general people, which, after a series of conference to assess the functioning of mental health services in India, recommended that emergency psychiatry services for 24 h should be provided along with the daily inpatient and outpatient services to meet the acute psychiatric emergencies.[14],[15] According to the National Mental Health Survey conducted all over India on 2016 by the National Institute Of Mental Health and NeuroSciences, there is still a huge treatment gap in mental healthcare system in India ranging approximately 28%–83% for all mental disorders, despite all the efforts to increase mental healthcare delivery across the country.[16]

In West Bengal, our institute is the only institute that provides a 24-h emergency psychiatry service to the patients in association with psychiatry indoor and outdoor facility. Patients come either after being referred from other nonpsychiatric departments or come directly with acute psychiatric emergency to our psychiatric unit. We have conducted this study over a period of 3 months and encountered with 200 patients who had come to the emergency psychiatric unit. The sample size is quite less not only according to the time duration than the previous studies in the literature but also according to the recording of previous year of our emergency psychiatric unit.[12],[17] The reason may be due to restriction on transportation and effect of lockdown in India due to COVID-19 pandemic.[18],[19]

According to the distribution of sociodemographic profiles, the mean age of the patients coming to emergency psychiatry unit was 34.6 years and majority belonged to the age group of 21–40 (40%) years and were female (35%). This result is consistent with the studies previously conducted in India which also shows a female preponderance with an age group of 19–49 years.[12],[17] In contrary to this finding, a study conducted by Chisty et al. over 134 patients showed a male predominance.[20] Most of the patients were married (48.5%). The reason may be because majority of the patients were female who comes from the surrounding area which is a major urban town, Kolkata. This result is consistent in other studies on psychiatric referral conducted in metro cities of India.[21]

According to source of referral, majority of the patients were referred from the department of general emergency (26%) followed by department of general medicine (12%). This is similar to some previous studies where majority of the referrals were from emergency.[12],[22] There was also some studies conducted in India that showed majority of referrals in emergency psychiatry of general psychiatry unit from department of general medicine.[21],[23] The difference may be due to the fact that patients referred from general medicine and other departments are mostly patients who are treated in outdoor and not on acute emergency state while acute patients are mostly dealt in the emergency department. A significant number of patients (17%) also came to the psychiatry emergency unit directly, which is a finding not seen in previous studies. The reason for this is probably the awareness and knowledge among the local people regarding the availability of a 24-h emergency psychiatric unit in our hospital.

Most of the patients presented with the complaints of episode of unresponsiveness, shortness of breath, and hysteria-like symptoms, which is different from other studies conducted by Bhogale et al. and Kelkar et al. in India.[22],[24] Deliberate self-harm was found to be the most common presenting symptom in the study conducted by Kumar et al.[17] Another study conducted by Singh et al. showed disturbed sleep and appetite to be the most common presenting symptom.[3] The reason for acute emergencies such as suicide is less referral to the psychiatric emergency unit in our hospital because these cases are mainly treated in the emergency department on observation basis and psychiatric treatment is provided to these patients on consultation-liaison basis.

On mental status examination, psychomotor agitation is found in majority of the patients (36.5%), which is similar to the findings of previous studies.[3],[17]

According to diagnostic point of view based on the ICD-10 diagnostic criteria, dissociative conversion disorder was the most common psychiatric diagnosis (16%), with a female predominance (24.6%). This is contrary to the study by Naskar et al. where delirium was the most common diagnosis and Kumar et al. that showed schizophrenia to be the most common.[12],[17] Another study by Chisty et al. showed bipolar disorder to be the most common psychiatric diagnosis.[20] The difference in our study may be attributed to the fact that the young married female predominance where dissociative disorder is quite common psychiatric condition to be found.

After initial assessment the patient were majority of the patients were given pharmacotherapy (64%) and sent back home after initial management and brief psychoeducation to the family member and to the patient, depending on the diagnosis and as per routine emergency protocol. This is a result seen similarly in other studies as well.[12],[20] A number of patients (17.5%) were who were primarily diagnosed with organicity or no psychiatric diagnosis was found in them were referred to other departments according to symptomology for further managements.

With the increasing mental healthcare burden in our society, the unmet need of mental healthcare services in becoming more evident day by day. Emergency psychiatry, though a relatively new subspecialty in psychiatry services, plays a very important role to manage acute psychiatric emergency situation which can be life-threatening. Although there is an increase in awareness regarding emergency psychiatric conditions among healthcare providers, the availability of emergency psychiatric services is very less in our country. To improve the services of mental healthcare, increasing awareness for emergency psychiatric situations and facilities in government hospitals to treat acute psychiatric condition in emergency basis for 24 h should be made available to people to reduce mortality and morbidity associated with various mental illnesses.

Limitations

The major limitation of our study was the small sample size. The reason may be due to restriction on transportation and effect of lockdown in India due to COVID-19 pandemic. Moreover, one of the other important limitations lies with the fact that this study being tertiary care hospital-based study, the findings may not reflect the current pattern of psychiatric emergency care on a large community basis.


  Conclusions Top


The common psychiatric disorders attending the psychiatric emergency unit in our tertiary care teaching hospital are dissociative conversion disorder, substance use disorder, and bipolar affective disorder. The data that we have obtained here will be helpful in understanding the presenting complaints of the patients attending the psychiatric emergency unit as well as the pattern of patients who are referred from various departments to our psychiatric emergency unit. Thus, the results from the study could help in gaining knowledge regarding emergency psychiatric conditions and would increase preparedness for their rapid management, as well as it would lead to improvement of emergency psychiatry services to meet the mental healthcare demands in our state.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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