Inpatients Psychiatric Morbidity at Pakistan Institute of Medical Sciences (PIMS)
Design: Descriptive study.
Place and Duration of Study: Psychiatry Department, Pakistan Institute of Medical Sciences, Islamabad. Data collection was done for six months (July 2000 to January 2001).
Subjects and Methods: 113 consecutively randomized patients were admitted in the psychiatry department at Pakistan Institute of Medical Sciences. Patients were admitted to psychiatry Department Pakistan Institute of Medical Sciences, Islamabad, between (July 2000 to January 2001). Three cases were excluded because of age group under 10, restricting the analysis to 113 cases. Data was collected for the following variables age, sex, duration of admission reason for admission diagnosis and the treatment given during their stay.
Result: Of 113 patients, 64 were males and 48 were females between the age group of 11 and 80 years. Data was established with reference to the patients admitted with different psychiatric illnesses, their ages and gender.
Conclusion: Our study found a trend toward a higher risk of admission in different psychiatric disease with reference to different age groups and genders.
KEY WORDS: Diagnosis, Psychiatric services
Psychiatric illnesses are very common and affect major strata of the society all over the world. Prevalence of psychiatrist illness in different population is estimated to be 15 to 20% in community and 30% among general practice patients1,2. Prevalence among general hospitals out patients and inpatients is estimated to be 20 to 30% and 25 to 40% respectively3,4. In Pakistan their have been few studies examining the prevalence and patterns psychiatric morbidity in the community and at the level of psychiatric outpatients and inpatients5,6. We still need studies to estimate the prevalence and pattern of psychiatric disorders in the community. The epidemiological studies however, are very difficult and expensive to conduct in a county with limited resources. The studies conducted at tertiary care level can give a broad overview of pattern and symptomatology of psychiatric disorders, especially for the severe mental disorder. The present study aims to describe the socio-demographic variables and the frequency of different diagnostic categories of the patients admitted at Pakistan Institute of Medical Sciences.
SUBJECTS AND METHODS
Between 6th July 2000 to 5th January 2001, 116 patients were admitted in the Department of Psychiatry at Pakistan Institute of Medical Sciences, Islamabad. This hospital provides services to a large geographical region of Islamabad and Rawalpindi territories. The population served by this hospital is both urban and rural in nature. Before admission, all patients were examined with specific attention to the neurological system. Appropriate laboratory investigations were requested to exclude possible physical illnesses. After admission all the cases were discussed in the ward rounds. During this academic ward all the patients, their histories, diagnosis and treatment are review. The diagnosis was based on ICD-10 system of classification7 .All the patients presenting during six months period were included in the study except for three patients who were excluded because they were under 10 years of age thus restricting the analysis to 113 cases. All the records of patients admitted during this period were retrieved and the information was collected for the following variables: age, sex, diagnosis, duration of admission and treatment.
Out of the 113 patients, 64 (57%) were males and 49 (43%) were females. Frequency of various psychiatric diagnosis, gender and relationship of illness with age, are shown in table-I and table-II respectively. Depression was the most common ailment affecting the patients as 18.7% patients were found to be admitted with this disorder. Amongst the patients with anxiety disorders, 16.7% of the patients were admitted because they were suffering from Dissociative (Conversion) disorder out of which 3.6% were males and 12% were females. 4% of the total neurotic patients admitted or 0.9% of the total admissions were suffering from post traumatic stress disorder. The other diagnostic categories of patients suffering from anxiety disorder are shown in table-1.
Thirteen patients (11.6%) were admitted with Manic Depressive Psychosis, out of which 11 were males hence (9.8%)and 2 were females (1.8%). Total number of patients admitted in schizophrenia was 8.04%, 4% males and 4.5% werefemales. Other diagnosis categories in psychotic disorders are shown in table-1.Four patients were admitted with organic psychiatric disorders out of which one male and one female was sufferingform Alzheimer’s disease, one male was suffering from Huntington’s chorea and one female was suffering fromepilepsy with behavioral disturbance. Drug dependence led to 8% of the total admissions. Admissions due to druginduced extra pyramidal syndrome were 4.46%.
The total admitted patients suffering from mental retardation with Behaviour disturbances were 3.6%.
In our study the 18.7% of the patients admitted were suffering from depression. Depression is one of the most common mental illness. Most of the patients suffering from depressive illness are treated as out patients but some of the patients may need hospitalization. 21 patients were admitted with depressive illness 12 were males and 9 were female patients. Most of the patients were in the age range of 21 and 40.
Approximately 18.8 million American adults-or 9.5 percent ages 18 and over, suffer from a depressive illness (major depression, bipolar disorder, or dysthymia) each year women are nearly twice more likely to suffer from major depression than men. While major depression can develop at nay age, the average age at onset is the mid-20s8. Breuer and Freud viewed hysterical symptoms as arising from repressed sexuality9, but this psychoanalytic view is less generally accepted nowadays. An alternative behavioral model has been suggested in which conversion symptoms are considered as a form of nonverbal communication10-12.
Although this study was limited to a small number of patients and conducted only on inpatients, it shows many similarities, with most of the previous studies conducted on conversion disorders. It tends to affect the younger, less mature and less sophisticated person, a finding common to most previous studies13. The predominance of females was compatible with most of he previous studies conducted. Conversion disorders represent consistent findings through out these years (4.8%). This is similar to the patterns seen in the inpatient settings of Pakistan3. The prevalence in out patient setting in India14 was between 6-11% of all psychiatric out-patients. On the contrary, in the outpatients department of Bethlem and Maudsley Hospitals, London, 3.5% were diagnosed as “hysteria” in 1955 to 1957. In 1967 to 1969, only 0.5% were so diagnosed15. These findings support the notion that the incidence and prevalence of conversion disorders although has declined in the west but is still quite high in developing countries. In this sample dissociative disorder was twice more common in females compared to males (4.20% vs 60%). The predominance of females in dissociative disorder is a well known finding in finding in psychiatric epidemiology for which several explanations have been offered. A plausible explanation might be that depressive disorders in females are expressed in the form of dissociative disorders due to restrictions on the females in our society to express the psychological distress openly. This can also explain the much less prevalence of depression found in this study. This hypothesis, however, needs to be tested in further studies.
A very interesting finding is that neurotic disorders like generalized anxiety disorder, phobic disorder, personality disorders and obsessive compulsive disorders were much less common compared to say, for example bipolar disorder (35% vs 11.5%). This is in no way an indication of low prevalence of these disorders. This appears to be due to the fact that these disorders are treated mostly in outpatient settings. As most of our training takes place in the inpatient setting, the trainees are less likely to see these conditions and develop the suitable skills in diagnoses and management of these disorders which hitherto form a significant proportion of psychiatric morbidity. Patel16 echoed similar concerns while commenting on psychiatric services in Africa as trainees rarely encountered any case of anxiety and depression, rendering training in these subjects merely a theoretical exercise.
With bipolar disorder, which affects approximately 2.3million American adults or about 1.2 percent of Americans age 18 and older in a given year-the average age at onset for a fist manic episode is during the early 20s8. The total number of admissions of patients suffering from Manic Depressive Psychoses was 11.6%. Most of the admitted cases fell in the range of 21-40 years of age.
In the study of schizophrenia, the population at risk is often considered to be those in the age range of 15-54 17. The 6-month period prevalence rate was 13/1, 000 and averaged 8.8/1,00018. Out of the total of 9 patients admitted with schizophrenia 4 of them were males and 5 were females, all of them were in the range 20-50 years of age. Total admitted patients suffering from acute psychotic illness were 5.35%. Hence 6 admissions were done out of which 3 were males and 3 were females. Patients who were admitted were very aggressive, acute psychosis is not a common diagnostic entity encountered in Western studies. Postpartum psychoses represented 1.8% of total admissions during this period. With an incidence of 1-2 per 100 live births this is not a common disorder in western countries. However with high fertility rate in Pakistan, this is relatively common disorder and the number of admissions during this period represents this fact19. All the patients admitted during this period with drug addiction (18% of all admissions) were male using either one or combination of drugs and alcohol. The patients were between 20 to 40 years of age. Drug use, particularly alcohol and marijuana, which is common among young men and infrequent among women, may contribute to the high rate of mental disorders in this population. A relationship between drugs and psychosis has been suggested before, as when Hammond and colleagues hypothesized that substance abuse results “ in increased morbidity and contributes to the observed male-predominance among Palauan schizophrenics”20.
Five cases admitted were suffering from extra pyramidal syndrome out of which 3 (2.7%) were male and 2(1.8% were female). Three patients were suffering from Neuroleptic syndrome out of which 2 were male and 1 was female. This is considerable physical morbidity resulting from use of anti-psychotics3. This appears to be due to fact that antipsychotic use by inadequately trained healers is quite common. We have observed that even the spiritual healers are using depot medication for psychosis inappropriately.
Our study found a trend toward a higher risk of admission in different psychiatric disease with reference to different age groups and genders.
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