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Assessment of psychiatric comorbidities and sociodemographic profiles of the patients referred to the general hospital psychiatric unit of a tertiary care hospital in Kolkata, West Bengal

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INTRODUCTION
assesses the referred patient and provides management either inpatient or on an outpatient basis. 5 The majority of the referred patient's falls into the categories mentioned as: (a) Primary medical illness with comorbid psychopathology; (b) psychiatric illness directly resulting from a primary organic condition, ex. delirium; (c) medically unexplained physical symptoms, such as somatoform and functional disorders; and (d) psychiatric emergencies such as suicidal attempt by different means, admitted to medical/surgical units. 2 In spite of comorbid psychopathology among patients from non-psychiatric departments being quite high in India (31-34% among inpatients and 18.32-53.7% among outpatients), the referral rates in India (0.15-1.54%) are much lower in comparison to the developed countries (2.2-1.2%) in the world. 3,6 The reasons can be of many such as, social stigma regarding psychiatric illness, giving primary importance to physical illness neglecting the psychiatric symptoms, poor psychiatric awareness among patients, family members, as well as the health-care providers. 7 By the implementation of C-L psychiatry services on a wider basis, this discrepancy can be overcome to a large extent.
The co-occurence of general medical disorder and psychiatric illness is one of the most common and disabling combinations, with approximately 30% of individuals with comorbidities are having both of physical and psychiatric disorders. 8 According to Levenson et al., patients with associated psychopathology had longer duration of hospital stay, more chance to undergo interventional procedures, overburdening the health-care resources, and poorer prognosis. 9 A timely psychiatric intervention in these cases can improve the outcome including mortality and morbidity.
Keeping in mind the above-mentioned facts and the prerequisite for "a superior and more appropriate management," C-L psychiatry has emerged as the need of the hour for a wholesome therapeutic approach. The data available show the underutilized status of C-L services in health-care sectors of India and also the need for the improvement in future. 10 The study conducted here aims to assess sociodemographic profile and psychiatric comorbidities of patients referred for consultation services from non-psychiatric departments of a tertiary care hospital.

MATERIALS AND METHODS
The study includes all the indoor and outdoor patients referred to the department of psychiatry during or after OPD hours for C-L psychiatry from other departments of the hospital. The study period was from June 12, 2020, to September 12, 2020, that is, over a period of 4 months. The diagnosis was made according to the International Classification of Diseases, Tenth Edition (ICD-10). The details recorded include sociodemographic profiles, department and mode of referral (inpatient or outpatient), reason of referral, presenting complaint, and final psychiatric diagnosis (according to ICD-10). The data collected on selected days of the week (Wednesday and Friday) with the help of a self-designed semistructured pro forma after taking proper consent from the patients or legally appropriate caretaker. Eligibility criteria include all the inpatient or outpatient referral from departments other than psychiatry of either sex and no age limit was set. Exclusion criteria -convicted patient, patient without any attendant, under trial patient, and patients admitted by court of law due to lack of reliable informant. The study was approved by ethical committee of the institute. Analysis was done using descriptive statistics.
All the demographic variables are shown in Table 1.

Final psychiatric diagnosis
There are wide varieties in psychiatric diagnosis of the patients referred from other departments ( Figure 2).   Table 4.

Psychiatric diagnosis versus gender
Psychiatric diagnosis according to ICD-10 was analyzed on the basis of total patients referred ( Figure 3) and gender (Figure 4), it was found that organic disorders (F00-F09) and mental and behavioral disorder due to psychoactive substance use were more common in men (n~34, 72.34%), whereas, schizophrenia, schizotypal, and delusional disorder (F20-F29), mood disorders (F30-F39), neurotic, stress-related and somatoform disorders (F40-F48), behavioral syndrome associated with physiological disturbances and physical factors (F50-F59), and disorders of adult personality and behavior (F60-F69) all were more common in female, as shown in Table 5.    Figure 2: Final psychiatric diagnosis of the study subjects DISCUSSION C-L psychiatry is a relatively newer branch of psychiatry that often used synonymously with the term "psychosomatic medicine," a concept gave by Felix Deutsch on the year 1922. The basic aim is to bring psychiatrists in close proximity to other health-care specialist to assess psychiatric comorbidities and to provide optimal health care as well as indulging in research activities. 11 The very beginning of C-L psychiatry concept in India started on 1933 with the establishment of first General Hospital Psychiatry Unit by Dr. Girindra Sekhar Bose at the premise of R.G. Kar Medical College in Kolkata which is the center of our current study as well. 11 However, till now, the branch is not been utilized of its full potential. According to the previous study in India, majority of C-L psychiatry services are provided as an on call basis, where after receiving an referral patient file, the on-duty psychiatrist of the day attends the patient of the respective department or the patient is sent to the psychiatric outdoor along with the attendant regarding evaluation and opinion. In majority of the institutes, it's the junior resident (60%) who attends the referral followed by senior residents (21.1%) and faculty members (18.9%). The departments of clinical psychology, psychiatric social workers, and psychiatric nursing are also a part of C-L psychiatry team in a very few premiere institutes in India. 12 In the current study, there are total 203 referrals in the 4-month duration. Among them, 144 were inpatient-and 59 were outpatient-based referral. The mean age group of referral is 36.33 years, with 22 (10.83%) of patients has age ranging from 60 years and above which is bit on higher side than a previous study conducted in India and rest 181 (89.1%) of them has age below 60 years, similar results found in other studies as well. 2,8 Majority of them were female (53.2%), while some other studies conducted before, shows a male predominance. 8,13 Most of the patients were from urban (38%), joint family (85%), married (67%), homemaker (33.99%), and studied till high school (36.4%).
The most common source of referral being department of general medicine (21.1%) followed by department of neuromedicine (9.8%),which is also a common finding in earlier studies done in India and other countries as well. 10,14,15 The reason for this is poor knowledge regarding psychiatric signs and symptoms and the social stigma, majority of the patients prefers to approach to the general medicine department and the general physicians rather than psychiatrists. 8,10 The reason for high referral to neuromedicine department attributes to similar clinical presentation of psychiatric disorders such as pseudo-seizures, dissociative disorders to that of various neurological diseases. 16,17 There were significant less number of referral from general surgery (n~10, 4.9%), than what found in other previous studies. 8,10 Most common reason of referral was suicidal attempts by different means (n~34, 16.7%), it also includes deliberate self-harms and parasuicidal attempts, which reflects the implementation of Mental Healthcare Act that mandates psychiatric consultation in suicidal attempts. 18   dependence (18.47%), past history of psychiatric illness (28.6%). 3 Another study in India by Bhogale et al., shows unexplained somatic symptoms for the most common reason for referral (64.44%). 14 Being a super speciality tertiary care teaching hospital, there are also some referral for psychiatric clearance before renal transplantation surgery (n~7,3.4%), and gender reconstruction surgery (n~4, 1.97%) which is much lower than a previous study conducted at tertiary care hospital of India. 2 It somewhere reflects the underutilization of the facilities.
According to psychiatric diagnostic point of view (ICD-10 criteria), major depressive disorder (13.3%) and delirium (9.3%) were the most common to be found, in contrary to some other studies conducted in India that shows somatoform disorders and neurotic disorders to be the most common diagnosis. 13 When diagnosis was assessed according to ICD-10 categories, it is found that organic disorders are to be the most common diagnosis (n~47, 23.15%) followed by mood (affective) disorders (n~46, 22.66%).
A number of patients (n~11, 5.4%) received nil psychiatric diagnosis and most of them were person who required psychiatric clearance for either renal transplant surgery or gender reconstruction surgery. This finding is much lower that found in the previous studies in India. 2,3 With the increasing concern regarding mental health in association with physical health, C-L psychiatry plays an important role to bridge the gap between the two sectors. It can also play a major role to extend mental health services on primary care level and provide a great help to the primary health care workers by increasing the awareness regarding recognizing early signs and symptoms and management of psychiatric illnesses. 5 They can also be considered the most potential persons to provide telepsychiatry services at remote areas over the phone where there is a scarcity of psychiatric services.

Limitations of the study
The study has all the limitations of being a cross-sectional study, also as it is been conducted over a period of 4 months which is a short duration and also on specific days of the week. Hence, the results cannot be generalized to other hospitals and on general community.

CONCLUSION
Consultation-liaison psychiatry is a new emerging branch of psychiatry in India to bridge the gap between mental and physical healthcare thus providing optimal care to the patients. There is still lack of knowledge and awareness among healthcare worker regarding this sub speciality and the purpose of our study is to increase awareness regarding the demand and the necessity of the consultation-liaison psychiatry services in our country for better integrated management of the patients in future.