Retrospective Analysis of Cases Consulted at the Department of Psychiatry in a General Hospital in Guangzhou, China

  

    
Diagnosis
    
2016
    
2017
    
Χ2-statistic
    
P
  
  

    
Disregard of mental and behavioral disorders
    
65 (7.0%)
    
60 (7.8%)
    
0.332
    
0.564
  
  

    
Dementia
    
45 (4.9%)
    
37 (4.8%)
    
0.006
    
0.939
  
  

    
Delirium
    
9 (1.0%)
    
6 (0.8%)
    
0.187
    
0.666
  
  

    
Mental disorders due to brain damage and    dysfunction and to physical disease
    
159 (17.2%)
    
99 (12.8%)
    
6.283
    
0.012
  
  

    
Schizophrenia, schizotypal, and delusional    disorders
    
20 (2.2%)
    
19 (2.5%)
    
0.164
    
0.686
  
  

    
Mood disorders
    
207 (22.4%)
    
172 (22.2%)
    
0.004
    
0.948
  
  

    
Neurotic, stress-related and somatoform disorders
    
373 (40.3%)
    
269 (34.8%)
    
5.478
    
0.019
  
  

    
Behavioral syndromes associated with    physiological disturbances and physical factors
    
23 (2.5%)
    
25 (3.2%)
    
0.856
    
0.355
  
  

    
Disorders of adult personality and behavior
    
2 (0.2%)
    
0 (0%)
    
1.674
    
0.196
  
  

    
Behavioral and emotional disorders with onset    usually occurring in childhood and adolescence
    
1 (0.1%)
    
0 (0%)
    
0.836
    
0.360
  
  

    
Acatalepsia
    
11 (1.2%)
    
84 (10.9%)
    
74.643
    
0.000
  
  

    
Mental/behavioral disorders due to the use of    psychoactive substances
    
11 (1.2%)
    
2 (0.3%)
    
4.800
    
0.028
  
  

    
Mental retardation
    
0 (0%)
    
1 (0.1%)
    
1.197
    
0.274
  

Table 4: Laboratory values at hospital admission.

Discussion

Substantial developments in the biopsychosocial-medical model have enabled improvements in the identification of mental diseases by non-psychiatrists. In addition, due to recent developments, particularly the increased use of new medical technology and psychiatric medications over the past decade, CLP has become an important part of psychiatry [12].

More than a third of medical and surgical inpatients have psychiatric comorbidities, and up to half of the inpatients have mental health issues [1,13,14]. However, more than half of the cases of psychiatric comorbidities in patients are not recognized by the primary medical teams [15]. Ji et al. analyzed domestic studies conducted in China and found that the rate of psychiatric consultations was between 0.02% and 3.60% [16]. Although the psychiatric consultation rate observed in our study was 1.4-1.7%, it does not reflect the actual prevalence of mental disorders in the general population. He et al. reported that the rate of incidence of depression or anxiety disorders recorded in fifteen tertiary care hospitals from five cities in China was 16.5% [10]. Li et al. found a rate of incidence of 14.27% for depression or anxiety disorders in cardiovascular outpatients from fourteen tertiary care hospitals in China [17]. In terms of the distribution of cases among “principal departments,” non-surgical departments had the highest frequency, which was in line with previous reports from China [18,19]. The department of neurology made the highest number of consultations, accounting for close to one third of the cases in the two year-period of our study. This result was consistent with findings of other studies, suggesting that neurological diseases are strongly associated with mental disorders [20-22].

The most common reason for consultation was unexplained somatic symptoms, which accounted for 52.05% of the cases over the two-year period of this study. The second and third most common reasons are a history of mental disorders in patients admitted for physical disorders, and mental/behavioral disorders due to organic diseases, respectively. It was easier for non-psychiatrists to identify mental disorders when the patient met the abovementioned conditions. Furthermore, there was a significant increase in reasons for consultation like psychological evaluation, and mental/behavioral disorders due either to organic diseases or perioperative stress in 2017, compared to those in 2016. In contrast, there was a significant decrease in reasons for consultation like unexplained somatic symptoms, history of mental disorders in patients admitted due to physical disorders, and mental/behavioral disorders due to overuse of psychotropic drugs in 2017 compared with those in 2016. These changes may be due to greater attention being paid to mental health by both non-psychiatrists and patients. There was an increased need for psychological assessment in non-psychiatry departments, while the consultation of cases with a history of mental disorders had decreased significantly. Due to the improved ability of non-psychiatrists to accurately assess depression and anxiety in patients, and the use of psychotropic drugs by non-psychiatrists to treat them, the number of patients requiring psychiatric consultation had decreased. It is also noteworthy that acceptance of mental disorders by patients had improved. An increasing number of patients with unexplained somatic symptoms, or mental or behavioral disorders were willing to take the initiative to visit the outpatient department of psychiatry in the general hospital. The total number of outpatients visiting the psychiatry department in our hospital was 21850 in 2017, an increase of 20.63% over the previous year.

If we consider the diagnosis, there were 585 and 374 cases diagnosed as generalized anxiety disorder or depression in 2016 and 2017, respectively. Together, they accounted for 56.41% of the total number of consultations. These results were consistent with those reported previously, both in China and worldwide, which indicates that somatic symptoms were the primary reason for a hospital visit among most of the patients with depressive disorder or anxiety disorder [10,23,24]. Recently, it has been observed that mild, rather than severe, mental disorder has become the most common type of psychiatric disease diagnosed upon consultation in general hospitals. In addition to the high rate of incidence of depressive or anxiety disorders, and the probability of those being comorbidities with physical disorders, our study also demonstrated that greater attention is being paid to psychological factors. This was not limited only to severe mental disorders, but was also observed for mild mental disorders [10,19,23,25,26].

A previous study reported that although 20-40 % patients had mental disorders, most of them were underdiagnosed [12]. This means that without systematic screening by psychiatrists, the mental healthcare needs of many patients could go unmet, or scarce resources could be misallocated. Along with developments in CLP in the past decade, psychiatric consultations in general hospitals have also increased. Possible reasons for this could be: 1) Increased knowledge and awareness regarding mental illness among non-psychiatrists, which has increased the rate of identification of mental illness; 2) The stressful nature of the job and patient-physician relationship, which encourages physicians practicing strictly within the scope allowed under law to seek professional help for looking after their own mental health; 3) Intense social competition resulting in increased stress that has led to a rise in the rate of incidence of mental disorders. Moreover, due to an aging population, there is an increase in cases of neurological and mental disorders due to cardiovascular and cerebrovascular diseases, senile dementia, and metabolic disorders; 4) Due to the stigma associated with mental disorders, patients often refuse to visit a psychiatrist, but prefer to visit a general physician instead for somatic symptoms or follow-up of previously treated physical disorders. Thus, in order to decrease the rate of underdiagnoses or misdiagnoses of mental disorders, it is important to train clinicians in non-psychiatry departments to identify and treat mental disorders, especially by recognizing the somatic manifestations of mental disorders. Moreover, Multidisciplinary Teams (MDTs) are effective in strengthening cooperation between psychiatric and nonpsychiatric departments [27,28]. Hong et al. compared the effects of different modes of liaison psychiatric service and found that a combination of comprehensive assessment, psychiatric consultation and interdisciplinary teamwork was very efficient in reducing the duration of hospital stay and medical expenses [29]. This proactive and comprehensive consultation model is worthy of being promoted in general hospitals in order to improve the diagnostic accuracy of non-psychiatric doctors and encourage patient compliance with recommendations of psychiatric consultation [30,31].

Our study was subject to a few limitations. First, consultation diagnosis was based on a clinical interview by psychiatrists without using a structured clinical interview questionnaire. Second, consultation data retrieved from one of the hospitals had certain geographical limitations. Third, our study did not account for followups and recovery rates, and did not evaluate the risk of patient suicide. Continuation of CLP services will benefit the overall wellbeing of patients [32]. Although a preliminary analysis of all consultations was conducted in the study, we did not focus on a particular disorder. Future studies that focus on the progression of a specific physical disease with depressive or anxiety comorbidities and explore the impact of mental illness on the outcome of the physical disease are required.

Conclusion

We found that there was a considerable need for consultations with the psychiatry department in the general hospital. The primary reason for psychiatric consultations was unexplained somatic symptoms that are clinical manifestations of depressive or anxiety disorders. It is important to encourage psychiatric consultation, and train clinicians from non-psychiatry departments to identify somatic manifestations of mental disorders with greater efficiency, as well as to extend psychiatric services to tertiary healthcare centers and other healthcare services.

Funding

This study was supported by grants from the Science and Technology Program of Guangzhou (Grant No. 202002030262) and the Key Projects Foundation of South China University of Technology (Grant No.2018ZD11).

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