|Year : 2021 | Volume
| Issue : 1 | Page : 40-48
Profile of patients seen in the emergency setting: A retrospective study involving data of 5563 patients
Sandeep Grover, Devakshi Dua, Swapnajeet Sahoo, Subho Chakrabarti
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||30-Jan-2021|
|Date of Decision||25-Feb-2021|
|Date of Acceptance||01-Mar-2021|
|Date of Web Publication||30-Jul-2021|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: There are limited numbers of studies from India, which have evaluated the demographic and clinical profile of patients seen in the emergency setting. Aim: This retrospective study aimed to evaluate the profile of the patients, seen in the emergency setting by a psychiatry team. Methodology: The psychiatry emergency register was reviewed for the data for 6 calendar years (2014–2019), for the demographic and clinical profile. Results: 5563 patients were evaluated by the emergency psychiatry team during the period of 6 years, with the number of patients seen in each calendar year varying from 693 to 1057. The mean age of the patients availing psychiatry emergency services was 38.35 years (standard deviation: 16.65), with a significant proportion (13.1%–16.7%) of them in the elderly age group. Majority of the patients were male (64.6%) and were seen initially by the medicine and allied branches (87.8%). The most common diagnosis was delirium, and this was followed by affective disorders. Substantial proportions of the patients had substance use disorders (18.5%) and self-harm (9.8%). Nearly four-fifths of the patients were managed with psychotropic medications, and nearly one-fifth were treated with psychotherapeutic interventions, while more than half underwent investigations. Conclusion: The present study suggests that delirium, followed by affective disorders, substance use disorders, and intentional self-harm are the most common psychiatric diagnoses, among patients seen in the emergency setting. These findings can have important implications for organizing the psychiatric services in the emergency setting and for training.
Keywords: Delirium, emergency psychiatry, self-harm, substance use disorders
|How to cite this article:|
Grover S, Dua D, Sahoo S, Chakrabarti S. Profile of patients seen in the emergency setting: A retrospective study involving data of 5563 patients. J Mental Health Hum Behav 2021;26:40-8
|How to cite this URL:|
Grover S, Dua D, Sahoo S, Chakrabarti S. Profile of patients seen in the emergency setting: A retrospective study involving data of 5563 patients. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Dec 7];26:40-8. Available from: https://www.jmhhb.org/text.asp?2021/26/1/40/322819
| Introduction|| |
The emergency rooms across the world, including India, see a large influx of patients. Most of these patients present with medical and surgical problems. A substantial proportion of these patients also have comorbid psychiatric problems, while some of the patients present primarily due to psychiatric emergencies. Data from the developed countries suggest that the majority of the patients presenting to the accident and emergency room with psychiatric ailments usually present with agitation (due to primary psychiatric disorders, such as psychosis, bipolar disorder, and dementia), self-harm, substance withdrawal, or intoxication, dissociative symptoms, catatonia, and delirium.,,,, Considering the high prevalence of psychiatric morbidity in the accident and emergency room, in some of the developed countries, psychiatric services are well organized and mental health professionals are available in person or through tele-services to cater to the needs of the patients with psychiatric emergencies., Further, the services are organized in such a way that the patients requiring inpatient care are later shifted from the emergency to the inpatient unit.,
In contrast to the developed countries, psychiatric emergency services are poorly organized in most of the centers in developing countries like India. Patients presenting with psychiatric emergencies in the background of physical illnesses are either managed by the medical–surgical colleagues, who attempt to medically stabilize the patient and ask the patient to consult the outpatient psychiatric services. Patients presenting primarily with psychiatric ailments are either not attended to or are provided some first aid and asked to attend the psychiatry outpatient services. Patients presenting with self-harm are also discharged after medical stabilization, without proper psychiatric evaluation. In occasional cases, psychiatric consultations are sought from the consultation–liaison psychiatry teams, who are available on call.,,,,, Some of these calls are not attended by mental health professionals. This demotivates the physicians to make a psychiatry call and resultant poor consultation rates. Given this, the majority of the patients presenting to the emergency services are not attended by mental health professionals.
The lack of mental health services in the emergency setting in India is reflected by limited research in this area, which is limited to a few centers., Most of these studies have been conducted over a short duration of time with small sample size. Some of these studies have reported the profile of the patients presenting to the emergency setting, for whom psychiatric consultations are sought from the on-call teams. These studies suggest that only 1.42%–5.4% of all the patients presenting to the emergency are referred to the psychiatry on-call teams.,,,,,,, The most commonly reported diagnoses in these patients include delirium, depression, anxiety disorders, substance withdrawal, dissociative disorder, and self-harm. The occasional study has screened all the patients presenting to the emergency for psychiatric morbidity. One of the studies screened all the elderly patients (i.e., those aged ≥60 years) presenting to the medical emergency and reported that the prevalence of psychiatric morbidity in these patients was 47.4%, with delirium being the most common psychiatric disorder, followed by dementia and depression. When substance dependence was also considered, the total prevalence of psychiatric morbidity was 62%. If one compares these findings with those for patients referred to the psychiatry on-call team, it is evident that there is a wide gap in the actual prevalence and those who are referred to the psychiatry on-call teams. However, it is important to note that it is impossible to assess all the patients for psychiatric ailments in the emergency setting, as this will require large workforce.
At our center, about a decade back, we reorganized our services to the emergency setting, by having a mental health professional (a junior resident, i.e., a postgraduate trainee) in the emergency setting from 8.00 am to 8.00 pm and then having a resident on call for the time frame of 8.00 pm to the next day 8.00 am. The trainee resident initially evaluates the patient, and then, the patient is reviewed by a senior resident (a qualified psychiatrist) and then finally by the consultant in-charge of the patient. Compared to the on-call model, this model (known as the hybrid model) led to an increase in the psychiatry referral rates to about double from emergency and also led to subtle changes in the diagnostic profile of the patients seen by the psychiatry team in the emergency setting. This model also helped enhance psychiatry care by an increase in the referral of patients to the medical emergency from the psychiatric outpatient setting for acute management and medical stabilization. We had earlier presented the data of about 1 year, after the re-organization of the services. However, there is a need to understand how this service has grown over the years, and what is the profile of patients is seen in the emergency setting. Looking at the larger dataset can help in improving the psychiatric emergency services and can also help in providing a model, which can help other centers to organize the psychiatric services in the emergency setting. Accordingly, this study aimed to evaluate the profile of the patients, seen in the emergency setting by the psychiatry team.
| Methodology|| |
This study was conducted at the Emergency Services Department of the Postgraduate Institute of Medical Education and Research, Chandigarh, which is a tertiary care hospital in North India. The psychiatry emergency services cater to patients attending medical, surgical (including trauma), as well as pediatric services. Usually, patients who attend emergency services are referred from other hospitals. However, a significant proportion of the patients attend emergency services by self-referrals. Some of the patients are also referred from the outpatient services of the hospital to the emergency for the management of acute conditions.
Before 2012, psychiatry services were provided round the clock, in the form of on-call services, in which medical–surgical teams consult the psychiatry team, after initial evaluation. The psychiatry referrals in this model were close to about 1.74%. From 2012, the services were reorganized, and a psychiatry trainee resident was stationed in the emergency complex. This led to an increase in the number of psychiatric referrals to about 2.4%.
In the hyrbid model, the patients are initially evaluated by the medical–surgical teams and depending on the need are referred to the psychiatry emergency team. The initial assessment is done by the trainee psychiatrist (junior resident) under the direct supervision of a senior resident. Every patient thus evaluated is discussed with a consultant and a plan of management formulated. All psychiatric diagnoses are made based on the International Classification of Diseases-10 (ICD-10) criteria. The patients are managed by the psychiatry emergency services independently or jointly with the medical/surgical teams till they are stabilized, transferred to the ward, or discharged. The record of all the patients thus evaluated by the psychiatry team are maintained in a register. This includes basic information in the form of age, gender, clinical details, diagnosis, and management carried out in the form of psychiatry emergency register. This register is reviewed on weekly basis to check the completeness of the data. The data are also electronically stored in the form of Statistical Package for the Social Sciences (SPSS (IBM Corp., Armonk, NY)) SpreadSheet.
For this study, the data from the psychiatry emergency register were extracted for the period of January 1, 2014, to December 31, 2019. The data were analyzed using the SPSS, the twentieth version (SPSS-20). Frequency and percentages were computed for the categorical variables. Continuous variables are evaluated in the form of mean and standard deviation (SD).
| Results|| |
During the period of 6 years (January 1, 2014–December 31, 2019), a total of 5563 patients were evaluated by the emergency psychiatry team with the number of patients seen in each calendar year varying from 693 to 1057. The mean age of the patients availing psychiatry emergency services was 38.35 years (SD: 16.65), with a significant proportion (13.1%–16.7%) of them in the elderly age group. The majority of the patients were male (64.6%) and were seen initially by the medicine and allied branches (87.8%). There was a stable pattern in terms of mean age, the proportion of the elderly, and the primary source of referral over the years. There was a gradual increase in the number of patients seen per year from 2016 onward [Table 1].
The most common diagnosis was from the F0 category of ICD-10 followed by the F3 (19.5%) and F1 (18.5%) categories. Other common presentations were from the F2 (9.3%) and F4 (9.1%) categories. The diagnosis was deferred in 5% of the patients. A substantial proportion of the patients (9.8%) presented with self-harm, while 1.8% were considered to not be suffering from any mental disorder at the time of assessment.
Among the organic mental disorders, delirium was the most common diagnosis (92.1%) followed by dementia (3.9%) and organic psychosis (3.7%). Among patients suffering from substance use disorders, the most common substance was alcohol (55.0%) followed by opioids (31.1%). In the patients suffering from psychotic disorders, half of the patients were diagnosed with schizophrenia (57.7%), and this was followed by the diagnosis of acute and transient psychosis (24.75%). Other diagnoses were psychosis not otherwise specified (14.5%) and schizoaffective disorder (9.7%). Affective disorders formed the second-largest diagnostic category, with a nearly equal distribution of patients suffering from depressive disorders and bipolar disorder. Dissociative disorder was the most common diagnosis in the anxiety disorder group (53.9%), and this was followed by adjustment disorder (17.3%).
A small proportion of the patients presented due to the adverse effects of medications, of which lithium toxicity (20.4%) was the most common, and this was followed by neuroleptic malignant syndrome (18.3%), extrapyramidal side effects (61.3%), and drug-induced psychosis (4.3%).
Nearly four-fifths of the patients were treated with psychotropic medications, and nearly one-fifth were treated with psychotherapeutic interventions, while more than half underwent investigations [Table 2]. About 25% of the patients were referred to the psychiatry or de-addiction outpatient services at the times of discharge.
When the diagnosis was considered based on age, a significantly higher proportion of the elderly patients suffered from delirium, dementia, and affective disorders, while a higher proportion of the adult patients presented with substance use, psychotic, and anxiety disorders [Table 3]. Among children and adolescents, anxiety disorders, including dissociation, were the most common diagnoses, which was significantly higher than adults and the elderly.
When the diagnosis was compared for both the genders, it was seen that a higher proportion of males presented with delirium and substance-related disorders. However, a higher proportion of females contacted the emergency services for psychotic, affective, and anxiety disorders [Table 4].
When the referrals from different specialties were compared, higher proportions of the patients admitted with surgical specialties were diagnosed with delirium and substance use disorders. However, more referrals came from medicine and allied sciences for anxiety disorders [Table 5].
When the trends were evaluated over the years, it was seen that compared to 2014, there was an increase in the number of patients with a diagnosis of F0 category in 2015; after this, there was a decrease in the number of patients with F0 category in 2016, which again increased in 2017, and after which the numbers were relatively stable. There was a steady increase in the number of patients with affective disorders (from 2016 to 2019) and those with psychotic disorders (from 2015 to 2019). There was a gradual decline in the number of cases with substance use disorders from 2014 to 2018, which showed a slight upward trend in 2019 [Figure 1].
In terms of the proportion of patients with each diagnostic category, there were a steady decline in the percentage of patients with F0 category from 2015 to 2019, a steady increase in the proportion of cases with affective disorders from 2015 to 2019, an increase in the proportion of cases with psychotic disorders from 2015 to 2018, followed by a slight decline in 2019, and an increase in the proportion of patients with catatonia from 2015 to 2019. There was a wide fluctuation in the number of patients with substance use disorders [Figure 2].
In terms of a specific diagnosis, there was a steady increase in the number of patients with unipolar depression from 2015 to 2019. The number of patients with delirium per year showed wide fluctuations over the years, without any secular trend. The number of patients with alcohol use disorders remained almost stable from 2015 to 2019 [Figure 3].
When the proportions were evaluated, there was a steady increase in the proportion of patients with depression from 2015 to 2019. For other diagnoses, there were fluctuations, with no specific trend [Figure 4].
| Discussion|| |
This study aimed to evaluate the profile of patients seen by the psychiatry emergency team over 6 years. The study included the data of 5563 patients seen by the psychiatry emergency team by following a hybrid model, in which a psychiatry trainee resident is stationed in the emergency setting. In the previous study, the hybrid model for the emergency psychiatric services was shown to be associated with an increase in the referral rates for many diagnoses, with an increase in the proportion of patients with intentional self-harm (ISH) being evaluated by the psychiatry emergency team.
The present study suggests that the elderly (≥60 years) form 14% of the patients seen in the emergency setting. The most common diagnostic categories of patients evaluated in the emergency setting include delirium, followed by those with affective disorders, substance use disorders, and psychotic disorders and those presenting with ISH. There are three studies from India, which have reported the diagnostic profile of patients with psychiatric disorders evaluated in the emergency setting.,, These studies have either followed the referral pattern,,, or have screened a particular age group.,, The studies that have included participants of all age groups have included 100–1153 patients and evaluated the referrals for duration of 6–18 months.,,, In one of the earliest studies, in which authors included 100 patients, the authors reported that half of the patients presented with somatic symptoms and one-third of the patients presented with altered sensorium, suicide attempt, and excitement. A recent study, which included 1153 patients also, reported that about half (47.7%) presented with medically unexplained somatic complaints, and in terms of diagnosis, 43.45% of the patients evaluated were diagnosed with stress-related and somatoform disorders. Another study, which included data of 268 patients, reported substance use disorder (15.67%) to be the most common reason for referral, and this was followed by dissociative (conversion) disorder (14.55%), other anxiety disorder (12.31%), somatoform disorder (10.82%), depressive disorder (10.07%), and suicidal attempt (5.97%). The previous study, which compared the on-call and the hybrid model, suggested that delirium (23%) was the most common diagnosis during the phase when on-call referrals were followed, and this was followed by substance use disorders (21.1%), psychotic disorders (13.6%), self-harm (13.1%), and dissociative disorder (12.8%). However, when the hybrid model was followed, substance use disorders (18.9%) were the most common diagnoses and this was followed by delirium (17.8%), self-harm (17%), and dissociative disorder (13%). When the profile of the present study is compared with the existing literature, certain similarities and differences are evident. The similarities are in the form of delirium, substance use disorders, and affective disorders being among the most common diagnoses, as reported in some of the previous studies. However, when one compares the profile reported with some of the other studies, which have reported somatic symptoms or medically unexplained symptoms to be the most common diagnosis or symptom, for which psychiatric consultation is sought, it can be said that the profile of patients in the present study is different from these studies. However, if these findings of previous studies are interpreted as manifestation of depression- and stress-related and somatoform disorders, then it can be said that the present study also support the findings of these studies too.
A significant proportion of the patients evaluated by the psychiatry emergency team belonged to the elderly age group. A previous study, in the emergency setting, showed that psychiatry morbidity is quite high among the elderly. This may explain the high proportion of the elderly among those referred to the psychiatry emergency team. Two studies have evaluated the profile of elderly patients attending the emergency setting. One study from NIMHANS, which involved 230 elderly, reported that mood disorders (30.87%), followed by dementia (16.52%), and delirium formed the most common diagnostic categories. Another study, which screened all the elderly patients attending the medical outpatient services and included the data of 232 patients reported delirium (34.1%) to be most common diagnosis, followed by dementia (9.5%) and depressive disorders (8.2%). Findings of the present study support these studies in terms of the delirium and depressive disorders being the two most common psychiatric diagnoses among the elderly attending the emergency services. In the present study, compared to nonelderly patients, elderly subjects more frequently had a diagnosis of delirium, dementia, and depressive disorders. However, compared to elderly patients, adult patients more frequently had diagnoses of substance dependence, psychotic disorders, and anxiety disorders. As previous studies from India have not compared these two groups, it is not possible to compare the findings of the present study with the existing literature. However, these differences suggest that there are different needs of patients of different groups, presenting to the emergency setting.
In the present study, when the diagnoses were compared for both the genders, it was seen that a higher proportion of males presented with delirium and substance-related disorders. However, a higher proportion of females contacted the emergency services for psychotic, affective, and anxiety disorders. These findings are supported by the previous studies from India which suggest higher prevalence of affective and anxiety disorders among the females. Studies from India in different settings (community and clinic) too suggest higher prevalence of substance use disorders in males compared to females., Occasional studies from India have compared the gender differences of diagnostic profile of patients presenting to emergency and referred to psychiatric services. Findings of differences seen in the present study are in general consistent with these studies.
The higher prevalence of delirium in the patients consulted from the surgical setting is in the expected line, considering the higher prevalence of delirium in postoperative patients.
In terms of trends of the diagnostic profile, the present study suggests that over the years, there is a consistent trend for an increase in the number of patients with affective disorders. For other diagnostic categories, there were fluctuations in terms of the ranking of various diagnostic categories. These findings can have important implications for organizing psychiatry services in the emergency setting and training of psychiatry trainees. Although there was a fluctuation in the number of patients diagnosed with delirium, seen in the emergency setting over the years, it formed the largest diagnostic category. Delirium forming the largest diagnostic category is in the expected lines, as a majority of the patients seeking help in the emergency setting for medico–surgical illnesses often have severe illnesses and a host of risk factors for delirium. The high referral rates for delirium also possibly reflect that the availability of the psychiatry team in the emergency setting possibly increases the referral rates to improve the outcome of patients with various medico–surgical illnesses. Because of this, it can be said that an emergency setting can be considered as an appropriate setting for providing training to both psychiatry and medical trainee residents for delirium. Providing adequate care to patients with delirium in an emergency setting by the psychiatry team, and seeing their patients improve with intervention by the psychiatry team can also help in changing the attitude of the medical and surgical trainees toward psychiatric illnesses. Affective disorders formed the second-largest diagnostic category and showed a steady increase in the proportions of patients seen over the years. There could be many reasons for the increase in the prevalence of affective disorders. First, depressive disorders form one of the largest psychiatric morbidities in patients with various physical illnesses. Second, high rates of depressive disorders could be related to an increase in the number of cases with ISH referred to the psychiatry emergency teams. Third, an increase in the sensitivity of the medical and surgical colleagues toward the diagnosis of depression, due to constant interaction with the psychiatry emergency team, could have contributed to higher referrals for those with depression. From the point of psychiatry training and providing services to the patients attending the emergency services, there is a need to make the psychiatry trainees aware of how to diagnose depressive disorders in the presence of medical illnesses. Another important finding of the present study is that patients with substance use disorders form about one-sixth of the patients seen by the psychiatry emergency team. This finding suggests that many patients with substance-related complications present to the emergency setting. This finding suggests that training of psychiatry residents for substance use disorders should focus on the management of emergencies related to substance use disorders.
Patients with ISH formed about 10% of the patients evaluated by the psychiatry team. This could be because a significant proportion of the patients with ISH present in the emergency. Usually, these patients who receive emergency medical and surgical care are requested to attend the psychiatry outpatient services, and few patients are referred to the psychiatry team. However, possibly, due to the availability of the psychiatry team in the emergency premises, a large proportion of the patients with ISH are referred for psychiatric evaluation. Accordingly, it can be said that following the hybrid model of providing psychiatry services in the emergency setting not only improves the psychiatry care for patients with ISH but also provides an opportunity for training the psychiatry residents.
Considering the largest diagnostic categories, it can be said that the psychiatry services in the emergency setting should be organized in such a way that the medical and surgical trainees are sensitized to the common psychiatric diagnosis and they need to be equipped to screen their patients for these common morbidities. This can be done by training them to use the currently available instruments, such as confusion assessment method (for delirium), different versions of patient health questionnaire (i.e., PHQ-2, PHQ-4, PHQ-9), CAGE for substance use disorders, and use “is path warm” for suicidal behavior before discharging the patients with self-harm presenting to the emergency setting. This can help in improving referrals to the psychiatry team.
This study has certain limitations, which must be kept in mind while interpreting the results. These include retrospective study design and analysis limited to a certain number of variables, which are part of the emergency register. This study did not evaluate the prevalence of psychiatric morbidity in all patients seen in the emergency setting. Future prospective studies, with more details of demographic and clinical variables, can provide more insights into the profile of patients with psychiatric ailments, seeking help in the emergency setting.
| Conclusion|| |
To conclude, this study suggests that delirium, followed by affective disorders, substance use disorders, psychotic disorders, and ISH are the most common psychiatric diagnoses among patients seen in the emergency setting.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]