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Indian J. Psychxat. (1982), 24(4), 366—369

A STUDY OF EMERGENCY PSYCHIATRIC REFERRALS IN A TEACHING

GENERAL HOSPITAL*

D. K. KELKAR', D.P.M., M.N.A.M.S.

S. K. CHATURVEDI", M.D.
S. MALHOTRA4, M.D.

SUMMARY
The socio-demographic and clinical characteristics of one hundred consecutive referrals from
emergency O.P.D. of a teaching general hospital were studied. The referral rate was 5.4%. The source,
reason and purpose of the referrals were studied. Half of the patients had presented with somatic symptoms.
Altered sensorium, suicidal attempt and excitements together constituted one third of all emergency referrals.
The diagnosis of neurosis was given in half of the patients and one third of all patients were labelled as suffer-
ign from hysterical neurosis. The nature of the presenting complaints and psychiatric diagnoses were com-
parable to that of the other studies.

General hospital psychiatric units are Studies of psychiatric referrals h a v e

h a n d l i n g most of the a c u t e psychiatric always been q u i t e revealing. Such studies
emergencies like excitement a n d violence n o t only provide some idea a b o u t the
suicidal a t t e m p t s , stupor etc. which p r e - prevalence of the illnesses b u t also focus
viously were the domain of m e n t a l hospitals. on a n u m b e r of other factors like the a t t i -
Often operating as the "Semipermeable t u d e of the medical profession a n d the
m e m b r a n e of the m e n t a l health system" c o m m u n i t y a t large towards the discipline
the psychiatric emergency services a r e called of psychiatry (Ghatterjee, 1977).
upon to m a n a g e the emotional turmoil of T h e r e is a paucity of d a t a concerning
the p a t i e n t a n d then direct the p a t i e n t to psychiatric emergency referral^ in the I n d i a n
long t e r m sources of t r e a t m e n t (Schwartz, setting. M o s t of the available studies
1972). If communities are to be per- p e r t a i n to the routine inpatient referrals
suaded to accept even aggressive a n d u n - (Wig, 1973; J i n d a l a n d Hemrajani, 1980 ',
manageable patients, t h e n it is m a n d a t o r y Ghatterjee, 1977) without considering the
t h a t emergency services must exist where emergency aspect of the situation. Studies
these p a t i e n t s are a t t e n d e d to a t once in h a v e been r e p o r t e d of emergency psychiatric
crisis. T h e expert committee r e p o r t on consultations in W e s t m countries (Anstee,
m e n t a l h e a l t h recommended t h a t as regards 1972 ; Ungerleider, 1960 ; Whitley &
a c u t e psychiatric emergencies a service pro- Deniston, 1963 ; Eastwood et al., 1970).
viding for their recognition followed by T h o u g h psychiatric services are a v a i l a b l e
p r o m p t referral to a n a p p r o p r i a t e treat-
in almost all teaching general hospitals
m e n t centre should b e available for 5 0 %
in I n d i a little is known as to why the psy-
of population in a given area within a
chiatrist is called in emergency situations
period of 5 years ( W . H . O . , 1975).,
a n d what the m a g n i t u d e of the p r o b l e m

1. Paper presented at 34th annual conference of Indian Psychiatric Society, Madras, January 7-9, 1982.
2. Junior Resident ^
3. Senior Resident I Department of Psychiatry, P.G.I. M.E. R., Chandigarh-160012
4. Lecturer (at present Asstt. Prof.) '
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EMERGENCY PSYCHIATRIC REFERRALS 3fc7~

is. T h e p r e s e n t study is carried o u t with gency O . P . D . d u r i n g the study
the aim of throwing some light on these period.
matters. (2) Socio-demographic p a r t i c u l a r s such
as a g e , sex, marital status, income
MATERIAL & METHOD a n d occupation.
T h e study was c a r r i e d o u t in the (3) Source, rezson (why) a n d purpose
emergency o u t p a t i e n t d e p a r t m e n t ( O . P . D . ) (for w h a t ) of referral.
of the N e h r u Hospital, a teaching general (4; Presenting complaints.
hospital, a t t a c h e d to the Postgraduate Insti- (5) Psychiatric diagnosis according to
t u t e of M e d i c a l E d u c a t i o n & R e s e a r c h , L C D . 9.
C h a n d i g a r h , during the period J u l y 26 to
OBSERVATIONS
August 31st, 1981.
T A B L E 1. Referral Rate
DESCRIPTION OF THE SERVICE
Sample :
I t is a 24 h o u r general emergency 100 consecutive psychiatric emergency referrals from
service w h e r e the p a t i e n t s or relatives can emergency referrals from emergency O.P.D.
directly walk-in a n d request for t r e a t m e n t . during 26-7-81 to 31-8-81 (35 days)
T h e p a t i e n t is first briefly e v a l u a t e d by
Total number of emergencies during the
a Resident doctor (a p o s t g r a d u a t e student
in General Medicine) o n d u t y a n d if in study period 1847
his assessment it is a n emergency, the Psychiatric referral rate 5.4%
patient is registered a n d given a registra- Number of total emergencies per day 52.8
tion n u m b e r . Consultation with a specialist
is sought if the resident doctor feels t h a t Number of psychiatric referrals per day 2.8
the services of the specialist a r e needed T A B L E 2. Socio demographic characteristics
in the evaluation a n d m a n a g e m e n t of the
patient. T h e u l t i m a t e decision as to which
Age (inyrs.)
patient requires p r o m p t consultation with Below 24 —45
the specialist rests w i t h the Resident doctor. (4 cases less than 15 yra.)
D u r i n g the study period the m a i n 25-44 —43
45 + —12
investigator ( D . K . K . ) was o n call d u t y
round t h e clock. H e a n d the second a u d r o r Sex
Male —51
attended to all emergency psychiatric re-
Female —49
ferrals a n d provided the necessary consult-
Marital status
ation a n d m a n a g e m e n t . M o s t patients
Married —65'
were asked to a t t e n d regular psychiatric Single —35
O.P.D. after the a c u t e emergency problems
Income (Rs. per month)
were t a k e n care of.
Below 399 —50
O n e hundred consecutive emergency 400-799 —29
referrals were taken for the study which 800+ —21
weie seen from 26th J u l y to 31st August, Occupation
1981 (35 days). T h e following particulars Housewives —46
of all the cases were noted on a special Clerical & skilled —23
proforma a n d the d a t a was analysed. worker
Unskilled workers —14
(1) T o t a l n u m b e r of psychiatric referrals Students —14
from emergency O . P . D . compared Others —3
w i d i total a t t e n d a n c e a t the emer-
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S6d b. K. KELKAR el at

TABLE 3. Source of referral (N=100) TABLE 7. Psychiatric diagnosis.

PSYCHIATRIC DIAGNOSIS (I.C.D.9)

SI. No. Source
S NO. DIAGNOSIS NO OF CASES
1 Family friends or patient's attended on 73 (N=100)
their own
1. NEUROSIS 51
2 Private practitioners (General physi- 25 (HYSTERIA. 3 4 )
cians) & other hospital 2. FUNCTIONAL PSYCHOSIS 13

3 Law enforcement 2 3 ACUTE SITUATIONAL DISTURBANCE 8

4 ORGANIC PSYCHOSIS 7
5. ALCOHOLIC INTOXICATION 2
TABLE 4. Reasons of referral {why the patients
6. OTHERS J
were referred by the Resident doctor) 7 NO PSYCHIATRIC DISORDER 13
8- DIAGNOSIS DEFERRED 3
1—IRE
S.NO REASONS FOR REFERRAL NOOF
PATIENTS
N.-100 DISCUSSION
1 PREDOMINANT PSYCHIATRIC SYMPTOMS 43
2. NO PHYSICAL ILLNESS DETECTED 18 REFERRAL RATE
3 OLD CASE OF PSYCHIATRIC SERVICE 1 5
1 3
The emergency psychiatry referral rate
4. MENTAL SYMPTOMS COEXISTINS WITH
PHYSICAL ILLNESS of 5.4% of this study was comparable to
ORGANIC ILLNESS INSUFFICIENT TO 6
5. Western studies in which it ranges from
EXPLAIN SYMPTOMS
6. ANY OTHER 5 2.2 to 5.6% (Anstee, 1972 ; Watson, 1969 ;
Whitley and Deniston, 1963). This referral
rate was higher than the inpatient referral
TABLE 5. Purpose of referral {for what the rates reported in various studies which rang-
patients were referred) es from 1.17 to 2.49% (Shukla et al.} 1980 ;
PURP0SE 0 F
Wig and Shah, 1973). This shows that
I—J REFERRAL Y
the psychiatrist's opinion is more often
SNO PURPOSE C - REFERRAL NO.OF PATIENTS sought in emergency outpatient department
(N.100)
than during ordinary inpatient care. The
PURELY FOR PSYCHIATRIC 55
MANAGEMENT
number of patients requiring psychiatric
FOR DIFFERENTIAL DIAGNOSIS 24
consultation everyday (two to three) was
AND MANAGEMENT quite high.
ASSOCIATED PSYCHIATRIC 21
MANAGEMENT SOCIO-DEMOGRAPHIC CHARACTERISTICS
Patients below 24 years of age consti-
TABLE 6. Presenting complaints tuted 4 5 % out of which 4 patients were
under 15 and hence were child psychiatric
emergencies. There were equal number of
H PRESENTING COMPLAINTS
males and females (51 and 49 respectively.)
S.NO COMPLAINTS NO, OP CASES
Majority of patients were married. Poor
(N = 100) (income below Rs. 399 per month) formed
1 SOMATIC SYMPTOMS 51
a significant number (50% of patients).
2. SUICIDAL ATTEMPT t3
PURPOSE OF REFERRAL
3. HYSTERICAL FITS 1 1

*. EXCITEMENT I VIOLENCE 10 The problem of diagnosis arose in 24

5. ALTERED SEN50RIUM 9 patients out of which 18, were referred
6 ACUTE ANXIETY SYMPTOMS 6 because no physical illness was detected.
However in 9 patients of this group there
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EMERGENCY PSYCHIATRIC REFERRALS 369

was no psychiatric illness as well. These becomes impossible. The authors recom-
cases were "medically clear" and hence mend that at least a separate cubicle should
the psychiatrist was called for consultation. be available for the psychiatrist in the
In 21 patients the psychiatrist was called emergency room. It was observed that
for associated psychiatric management, relatives were highly disturbed as well.
which is an indication of increased awaer- It is suggested that psychiatrist must spend
ness of the physicians about psychiatry some time with the relatives to answer
and their desire to associate psychiatrists their queries and explain adequately the
in "the general management of patients in plan of management. We advised all the
an emergency. psychiatric patients to attend the psychiatric
Suicidal attempt (13%), excitement O.P.D. the next day. Both the patient and
and violence (10%) and altered sensorium the relatives found it reassuring to be
(9%) constituted 32% of the total referrals invited for a second visit.
which indeed are emergencies. Other situa-
tions that can also be considered emergencies REFERENCES
were the dramatic presentations of hysteria ANSTEE, B. H . (1972). Psychiatry in the casuality
and acute anxiety attacks. These figures Department Brit. J . Psychiat., 120, 625.
are comparable to Ungerleider's (1960) COLEMAN, J . V., ERRERA, P. (1963). The General
Hospital Emergency Room and its psychiatric
and Snaith and Jacobsen's study (1965). Problems. Am. J. Public Health, 53, 1294,1301.
Fifty one patients presented with somatic CHATTERJEE, S. B., RUTTY, P. R . (1977). A study
of psychiatric referrals in military practice in
symptoms and this figure is very high as India. Ind. J . Psychiat., 19 (3), 32.
compared to Anstee's study (1972), where EASTWOOD, M . R . , MINDHAM, R. H . S.; TENNET,
it was 24%. In the study of Gautam T . G. (1970). The physical status of psychiatric
emergencies. Brit. J r . Psychiat., 116, 545.
(1978) the vast majority (88%) of the sample GAUTAM, S. K. S, (1978). A comprehensive study of
of patients presenting with somatic symp- patients presenting with somatic symptoms.
toms were neurotics. Coleman and Errera Dissertation submitted to Bangalore University,
Bangalore, India.
(1963) points out that physical complaints International classification of diseases. (1979). 9th
may be the individual's last way open to revision, W.H.O., Geneva.
help before this adjustment fails entirely JINDAL, R. C , HEMRAJA.NI, D . K . (1980). A study
of Psychiatric referrals in a General Hospital.
but they nonetheless represent a determined Ind. J . Psychiat., 22, 108.
orderly pattern of behaviour. SHUKLA, G. D., MISHRA, D . N . , NIGAM, P. (1980).
Utility of psychiatric unit in teaching general
In half of the patients a diagnosis of hospital : A study of in-patient psychiatric
neurosis was given (Hysteria 34, Anxiety referrals. J r . Assoc. Phys. Ind., Vol. 28.
9, Depression 8). In 13% of cases no SNAITH, R. P., JACOBSEN, S. (1965). Emergency
ward. Brit. J r . Psychiat., I l l , 18.
psychiatric disorder was discernible. This SCHWARTZ, D . A., WEISS, A. T . , MINER, J . M.
is a higher figure than the Western studies (1972). Community Psychiatry and Emer-
gency. Am. J . Psychiat., 129, 710.
(Ungerleider, 1960, Eastwood et al., 1970),
UNGERLEIDER, J . T . (1960). T h e psychiatric emer-
but is comparable to inpatient referrals in gency analysis of six months, experience of a
our country where it ranges from 6 to university hospital's consultation service. Arch.
Gen. Psychiat., 3, 593.
15% (Shukla et al., 1980 ; Wig and Shah, WATSON, J . P. (1969). Psychiatric problems in acci-
1973). dent departments, Lancet, i, 877.
W. H . O . (1975). Organization of mental health
COMMENTS services in developing countries. sixteenth
report of the W. H . O . Expert Committee on
The emergency outpatient department? mental health, W. H . O . , Geneva.
WHITLEY, J . S.; DENISTON, D. M. (1963). The
are always overcrowded. It becomes very psychiatric casuality. Brit. J . Psychiat., 109,488.
difficult to maintain confidentiality. Be- W I G , N . N., SHAH, D. K. (1973). Psychiatric unit
cause of lack of space and noisy surrcund- in a general hospital in India : Patterns of
inpatient referrals. Journal of the Indian
ngs a proper interview with the patient Medical Association, 6 0 (3), 83.