Download 8. John S. A Clinical Study of Prevalence and Pattern of

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
Name of the candidate and address
2.
Name of the institution
3.
Course of study and subject
4.
Date of admission of the course
5.
Title of the topic:
Dr. SMITHA L. RASQUINHA
POST GRADUATE STUDENT
DEPARTMENT OF PSYCHIATRY
ST. JOHN'S MEDICAL COLLEGE
BANGALORE- 560 034
ST. JOHN`S NATIONAL ACADEMY OF
HEALTH SCIENCES
MD PSYCHIATRY
01.06.2013
DEPRESSION, ANXIETY, SOMATOFORM SYMPTOMS AND DISORDERS AMONG
REFERRED IN-PATIENTS IN A TERTIARY HOSPITAL:A CROSS-SECTIONAL STUDY
6. Brief resume of the intended work
6.1 Need for the study:
Consultation-Liaison Psychiatric (CLP) services in Indian general hospitals
commonly follow a Consultation Model, where a referral is made by a physician to
psychiatrist or clinical psychologist, who proceeds to evaluate and suggest appropriate
intervention.[1,2]
Over the past several decades, physicians across specialties and countries are realising the
increasing need to recognise, diagnose and treat psychiatric symptoms and disorders which
affect treatment outcome of physical illnesses. This is reflected in the large number of studies
in Consultation-Liaison Psychiatry in the recent past. However, there is a clear need for
Indian studies relating to Consultation-Liaison Psychiatry.
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Current literature also indicates that, in spite of high rates of psychiatric morbidity in Indian
patients attending various non-psychiatric departments of a general hospital, psychiatric
referral rates remain low.
The pattern of ICD-9 diagnosis by clinical interview among the inpatient referrals to general
hospital psychiatry department of St. John’s Medical College Hospital showed Neurotic
depression and alcohol dependence as the most frequent diagnoses. A diagnosis of
schizophrenia was relatively infrequent. In about 20% of the cases, no physical illness was
detected and their somatic complaints were considered to be psychologically determined.[3]
There is a need to study those with unexplained somatic complaints and the neurotic
depression group (Dysthymia F34.1). In ICD-10, the group F40-F48 includes anxiety
disorders along with adjustment disorders and somatoform disorders.
Among the referrals of survivors of attempted suicide, a study done at St. John’s Medical
College Hospital showed the most frequent ICD-10 psychiatric diagnosis (by unstructured
interviews), of adjustment disorders.[4]
A clinical audit of CLP referrals was done and was presented in St. John’s Medical College
Hospital, Department of Psychiatry in 2007. This showed referrals were more common from
medicine department and its allied disciplines. The most common identified symptoms and
disorders were related to depression and alcohol use.
The following are the results of some unpublished studies done in the field of CLP at St.
John’s Medical College Hospital. These studies were done in selected population sub-groups
in superspeciality departments (2002-2011). A study on 75 End Stage Renal Disease patients
on hemodialysis (using HADS, BHS, SSI, CCI and SCID) showed symptoms of major
depression (14.7%), dysthymia (8%) and adjustment disorder (20%).[5]
In a study of psychiatric morbidity among SLE patients (using GHQ-28, MMSE, HADS,
WHO-QOL and SCID) 46% of the patients qualified for a depressive disorder. [6] Another
study (using MMSE, HADS, and SCID) 55.72% showed depressive symptoms and disorder
in hypothyroid and sub-clinical hypothyroid patients.[7] One study (using HADS and
M.I.N.I.plus) observed that 91.7% of 150 patients studied in pain and palliative care had
anxiety and depressive symptoms.[8] The variance observed in all these studies can be
explained due to the difference in assessment methods and sampling related differences.
Thus there is a need to continue to study the common psychiatric co-morbidity particularly
anxiety, depression and somatoform symptoms among all the departments in the general
hospital as opposed to earlier studies done in selected population sub groups in
superspeciality departments. Commonly, unexplainable somatic symptoms, anxiety and
depressive symptoms are picked up by physicians and surgeons in a general hospital.
Nevertheless, there is a need to systematically evaluate these symptoms to prevent over or
under-diagnosis of psychiatric disorders. This study will target patients across a variety of
departments in a teaching general hospital attached to a medical college.
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6.2 Review of Literature
A review by Nabarro showed a substantial proportion of psychiatric morbidity in
medical and surgical patients remaining unrecognized, leading to low psychiatric referral
rates.[9]
Wise and colleagues noted that referral rate to consultation-liaison psychiatry services in
most general hospitals is around 1%, even though prevalence of psychiatric disorders range
from 30% to 60% in such services.[10]
Diefenbacher & Strain observed 4429 psychiatric referrals over a 10 year period, to find a
consultation rate to psychiatry in the region of 0.9–1.7%.[11]
A review of Indian literature by Grover et al. showed psychiatric referral rates in India to be
anywhere between 0.06% to 3.6%.[1] Studies that showed higher referral rates had looked into
only a particular subset of patient population like emergency patients, or superspecialty
outpatient referrals.[12,13] In contrast to the West, Indian research in Consultation-Liaison
Psychiatry has been meagre, with only 117 studies on psychiatric aspects of various physical
illnesses in Indian Journal of Psychiatry from 1950-2010.[1,14]
Singh et al. in one descriptive study reviewed the all referral cases from different inpatient
and outpatient department, in Nepal Medical College and Teaching Hospital. There were 484
referred cases during the study period and around half the referral were from department of
medicine (49.8%), surgery (11.2%), Eye/ENT (10.3%). Among the referral cases depression
was diagnosed in 26.9%, anxiety in 15.5% and substance related problem in 14.5%.[15]
A retrospective study was done by Bhogale et al. in which 338 psychiatric referrals over a
period of about a year were studied. Socio-demographic data, source and reason for referral,
diagnosis and treatment advised were noted. More than two-third of the referrals were male
patients and belonged to the productive age group of 16 years to 45 years. 83.17% of the
patients were referred from general medicine, medicine allied and medical superspecialty
departments. Unexplained physical symptoms was the commonest reason for referral
(64.44%). The commonest psychiatric diagnosis was neurotic, stress related, somatoform
disorders (45.54%).[16]
Studies observing referral patterns show 55% to 65% of patients are referred from department
of medicine.[15,16,17]
In a study of 520 patients referred for psychiatric consultation in a tertiary care teaching
hospital in South India, Keertish et al. found neurotic, stress related & somatoform disorders
most common.[2] This category includes some common psychiatric conditions like panic
disorder, generalized anxiety disorder, adjustment disorders and somatoform disorders.
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Aim:
To study anxiety, depression and somatoform symptoms and disorders among inpatients referred for non-acute psychiatric intervention in a tertiary care setting.
Objectives:
1. To study the relationship between psychiatric morbidity, socio-demographic and
clinical variables.
2. To compare PHQ-SADS and HADS screening instruments for anxiety and
depression.
3. To compare psychiatric morbidity among medical and surgical referrals.
7. MATERIALS AND METHODS:
7.1 Study design:
This is a cross sectional descriptive study.
Study population:
Inpatients from clinical wards referred to Consultation-Liaison Psychiatric services at
St. John’s Hospital, requiring non-acute psychiatric intervention will be the study population.
The Hospital is a 1200 bedded tertiary hospital with well equipped medical, surgical and
superspeciality wards. On an average 8 to 10 references are received per day of which 3 to 4
cases need acute psychiatric intervention. The remaining 5 to 6 cases form the study
population who will be screened using the following criteria.
Inclusion criteria:
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Age group between 18- 65 years of either gender.
Patients who know Kannada, Konkani, Hindi or English.
Those who consent.
Exclusion criteria:
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Patients with dementia, delirium or mental subnormality.
Patients referred from Intensive Care Unit.
Severe sensorimotor difficulty that may impair interviewing and screening
assessments.
Patients who get discharged within 72 hours of reference.
Primary Axis 1 psychiatric disorders (Schizophrenia/ Schizoaffective disorder and
Bipolar Affective Disorder) on treatment.
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Period of study:
Study period is from December 2013 to June 2015.
Sample size:
A total of 150 In-patient referrals from all the clinical departments for CLP at St. John’s
Medical College.
Sampling method:
Simple random sampling will be adopted among eligible cases for the study.
Method of data collection:
Data collection will be started after obtaining clearance from the ethical committee. All
inpatients referred to the department on a Tuesday and Friday will be screened for suitability
according to the inclusion and exclusion criteria. These two days are chosen so that cases
from one particular unit of psychiatry are selected. The dissertation guides belong to the unit
and it helps for supervision and co-ordination. Informed consent shall be obtained from the
participants.
The ‘Data Collection Sheet’ will include the following sections:
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Socio-Demographic Data
Source of and reasons for referral
Current Psychiatric and Medical diagnoses and treatment.
Past psychiatric diagnoses and treatment.
All patients included in the study, after obtaining valid consent, will be administered the
PHQ-SADS and HADS scales.
The Patient Health Questionnaire (PHQ-SADS), developed by Spitzer and colleagues,
consists of PHQ-9, GAD-7, and PHQ-15 measures, plus panic measure from original PHQ.
Cutpoints of 5, 10, and 15 represent mild, moderate, and severe levels of depressive, anxiety,
and somatic symptoms, on the PHQ-9, GAD-7, and PHQ-15 respectively. Also, a cutpoint of
10 or greater is considered a yellow flag on all 3 measures (i.e., drawing attention to a
possible clinically significant condition), while a cutpoint of 15 is a red flag on all 3 measures
(i.e., targeting individuals in whom active treatment is probably warranted).[18]
The Hospital Anxiety and Depression Scale (HADS) was originally developed by Zigmond
and Snaith in 1983, and is commonly used to determine the levels of anxiety and depression
that a patient is experiencing.
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The HADS is a fourteen item scale; seven of the items relate to anxiety and seven relate to
depression. Each item on the questionnaire is scored from 0-3 and this means that a person
can score between 0 and 21 for either anxiety or depression. Scores range from 0-21 and are
graded as 0-7: normal, 8-10: mild, 11-14: moderate, 15-21: severe. It has been shown that the
HADS gives clinically meaningful results as a psychological screening tool, in clinical group
comparisons and in studies with several aspects of disease and quality of life.[19]
The Mini-International Neuropsychiatric Interview (M.I.N.I. Plus) is a short structured
diagnostic interview, developed jointly by psychiatrists and clinicians in the United States
and Europe, for DSM-IV and ICD-10 psychiatric disorders. It consists of questions with ‘yes’
or ‘no’ answers to detect present and past DSM-IV-TR and ICD 10 Axis I disorders. With an
administration time of approximately 15 minutes, it was designed to meet the need for a short
but accurate structured psychiatric interview for multicenter clinical trials and epidemiology
studies, and to be used as a first step in outcome tracking in non-research clinical settings. It
explores 26 disorders and is a more detailed version of the MINI, which details 17 psychiatric
disorders.[20]
Hence, patients that score significantly on the PHQ-SADS and HADS scales will be
administered the structured clinical, psychiatric interview using the M.I.N.I. plus which will
take about 20 minutes. Thus the subjective data will be obtained by subjective report. The
objective data will be obtained from a significant family member or care taker living with the
patient for at least a year.
Methodology for data analysis:
Data distribution will be examined for normality and analyzed using descriptive
statisctics. Continuous variables will be presented as ‘mean +/- SD’ or median and
interquartile range. Between group comparison will be done using the Student t-test for
normal distribution, and the Mann-Whitney U test for skewed distribution. Categorical
variables will be expressed as percentages, between group comparison done using the
Pearson’s chi-square test and Fisher’s exact test, when indicated, assuming statistical
significance for p<0.05.
7.2 Does the study require any investigation or intervention to be conducted on
patients or other humans or animals? If so please describe briefly.
No laboratory investigations or interventions will be carried out.
7.3 Has ethical clearance has been obtained from your institution in case of 7.2?
Yes
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8. List of References:
1. Grover S. State of consultation-liaison psychiatry in India: Current status and vision
for future. Indian J Psychiatry. 2011; 53:202-13.
2. Keertish N, Sathyanarayana MT, Kumar BGH, Singh N, Udagave K. Pattern of
Psychiatric Referrals in a Tertiary Care Teaching Hospital in Southern India. J Clin
Res. 2013,7:1689-1691.
3. Srinivasan, K., Babu RK, Appaya P, Subrahmanyam HS. "A study of inpatient
referral patterns to a general hospital psychiatry unit in India." General hospital
psychiatry 9.5 (1987): 372-375.
4. R.B. Galgali, Sanjeev Rao, M.V. Ashok, P. Appaya, and K. Srinivasan. Psychiatric
diagnosis of
self poisoning cases : A general hospital study. Indian J
Psychiatry. 1998 Jul-Sep; 40(3): 254–259.
5. Dinesh AA. Study of Depression and Anxiety of Patients with End-Stage Renal
Disease on Dialysis. (M.D. Disseratation, RGUHS, 1999).
6. Tom V. A Comparative Study of Depression in Clinical and Sub-clinical Depression.
(M.D. Disseratation, RGUHS, 2002).
7. Rajiv R. Prevalence of Psychiatric Morbidity among Patients with SLE- A Hospital
based Prevalence Study. (M.D. Disseratation, RGUHS, 2004).
8. John S. A Clinical Study of Prevalence and Pattern of Anxiety and Depression in Pain
and Palliative Care Patients. (M.D. Disseratation, RGUHS, 2008).
9. Nabarro J. Unrecognized psychiatric illness in medical patients. Brit Med J 1984;289:
635-6.
10. Wise M, Rundell JR. Concise guide to consultation psychiatry. 2nd edition.
Washington: American Psychiatric Press; 1994.
11. Diefenbacher A, Strain JJ. Consultation-liaison psychiatry: stability and change over a
10-year-period. Gen Hosp Psychiatry. 2002 Jul-Aug;24(4):249-56.
12. Goyal A, Bhojak MM, Verma KK, Singhal A, Jhirwal OP. Psychiatric morbidity
among patients attending cardiac OPD. Indian J Psychiatry. 2001; 43:335-39.
13. Kelkar DK, Chaturvedi SK, Malhotra S. A study of emergency psychiatric referrals in
a teaching general hospital. Indian J Psychiatry. 1982; 24:366-69.
14. Parkar SR, Sawant NS. Liaison Psychiatry and Indian research. Indian J Psychiatry
2010;52:S386-8.
15. Singh PM, Vaidya L, Shrestha DM, Tajhya R, Shakya S. Consultation liaison
psychiatry at Nepal Medical College and Teaching Hospital. Nepal Med Coll J. 2009;
11(4):272-4.
16. Bhogale GS, Katte RM, Heble SP, Sinha UK, Patil PA. Psychiatric referrals in multispeciality hospital. Indian J Psychiatry. 2000; 42: 188-94.
17. Michalon M. Consultation-liaison psychiatry: a prospective study in a general hospital
milieu. Canadian Journal of Psychiatry. 1993; 38(3):168-74.
18. Spitzer RL, Kroenke K. Validation and utility of a self-report version of PRIME-MD:
the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient
Health Questionnaire. JAMA. 1999 Nov 10;282:1737-44.
19. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr
Scand. 1983 Jun;67(6):361-70.
20. Sheehan DV, Lecrubier Y. The Mini-International Neuropsychiatric Interview: the
development and validation of a structured diagnostic psychiatric interview for DSMIV and ICD-10. J Clin Psychiatry. 1998;59 Suppl 20:22-33.
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9.
SIGNATURE OF CANDIDATE
10.
REMARKS FROM GUIDE
11.
11.1 NAME & DESIGNATION OF
GUIDE
Dr. R.B. Galgali
Professor
Department of Psychiatry
St. John's Medical College
Bangalore - 560 034
11.2 SIGNATURE OF GUIDE
11.3 NAME AND DESIGNATION
OF CO-GUIDE
Dr. Nutan Ranjan
Sr. Resident
Department of Psychiatry
St. John's Medical College
Bangalore - 560 034
11.4 SIGNATURE OF CO-GUIDE
11.5 HEAD OF DEPARTMENT
Dr. Sunita Simon
Professor & HOD
Department of Psychiatry
St. John’s Medical College
Bangalore – 560 034
11.6 SIGNATURE OF HOD
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12.1 REMARKS OF THE
CHAIRMAN AND DEAN
12.2 SIGNATURE OF DEAN
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