psychiatric profile of pediatric population presenting to a psychiatry clinic in a tertiary care...
TRANSCRIPT
PSYCHIATRIC PROFILE OF PEDIATRIC POPULATION PRESENTING TO A
PSYCHIATRY CLINIC IN A TERTIARY CARE CENTRE
Ajay Risal, Pushpa Prasad SharmaDepartment of Psychiatry, KUSMS
Dhulikhel, Kavre, NepalSAR- WONCA & GPAN Conference 2010
BACKGROUNDWHO statistics shows the prevalence of
disabling mental illnesses among children and adolescence attending health care centers ranging between 20-30% in urban and 13-18% in rural areas
Hassan Z.K., 1991
2
Various studies from developing countries including Nepal and India show that a significant percentage (7-35%) of pediatric population suffers from mental illness
Verghese et al, 1974; Shrestha DM, 1986; Chadda RK et al, 1994; Regmi SK et al, 2000; Pokharel A. et al, 2001; Malhotra S. et al, 2002; Srinath S et al, 2005; Mahat P et al, 2006;
Shakya DR, 20103
PSYCHIATRIC DISORDERS IN PEDIATRIC POPULATION
Disorders usually affecting adult, but also distressing in pediatric group like mood and anxiety disorders
Disorders commonly diagnosed among child and adolescents like MR, SLD, ASD
Other Disorders like Seizures and migraine 4
A great majority of children and adolescents visit other sources of help-seeking before coming to a psychiatric service for different psychological problems
Regmi SK et al, 2000; Shakya DR, 2010
5
Mental and psychiatric services for children lag behind those for adults in developing countries Murray and Lopez, 1996
There is lack of specialized in-patient child psychiatry units
Awareness regarding mental illnesses at community as well as at the level of health care providers is limited
Sarwat A. et al, 2009 6
There are very few centers in Nepal which provide mental health services to children and adolescents
We have extreme scarcity of child mental health resources and paucity of data related to child psychiatric illnesses
Keeping this in mind, this study was carried out in our university hospital setting 7
AIMS & OBJECTIVESTo study psychiatric manifestations in
pediatric patients (below 18 years) presenting to a psychiatry clinic in a tertiary care hospital
8
MATERIALS AND METHODSI. Study Population: All the patients of pediatric age group
(18 years and below) who were brought by their relatives to Psychiatry OPD of Dhulikhel Hospital directly or referred by pediatrician or other specialists from October 2008 to October 2010 (a period of 2 years duration)
9
II. Methodology: A retrospective file review was done
from October 2008 to Mid-April 2010 (18 months) to get demographic details of such patients
A prospective study was done from Mid-April 2010 to October 2010 (6 months)to analyze the psychiatric manifestations
10
III. Sample sizeTotal (Oct’08-Oct’10)= 1686 months prospective study (April’10-
Oct’10)=80
11
IV. Procedure:Among the total patients studied for two years
(N=168), demographic variables like age, sex and cast were analyzed
Among the patients prospectively studied for six months(n=80), ICD-10 psychiatric diagnosis was analyzed in relation to the demographics, referral patterns and treatment related factors
12
V. Statistical Analysis:SPSS software package (Version 16, SPSS
Inc., Chicago , USA) was used to analyze the data
Descriptive statistics and Chi-square test was used to obtain the desired results
13
RESULTSTABLE 1. DEMOGRAPHIC FINDINGS
S.N.
VARIABLESNUMBER (%)N=168 (100%)
1. AGE(YEARS)* 0 to 4years 2 (1.2)
5 to 9 years 9 (5.4)
10 to 14 years 45 (26.8)
15 to 18 years 112 (66.7)
*Mean (S.D.)= 14.77 (2.99)
14
S.N. VARIABLES NUMBER (%) N=168 (100%)
2. SEX Male 48 (28.6)
Female 120 (71.4)
3. CAST/RACE Brahmin 71 (42.3)
Chhetri 32 (19.0)
Newar 28 (16.7)
Mangolian 23 (13.7)
Terai / Madhesi sub castes 1 (0.6)
Dalit / Disadvantaged 13 (7.7)
15
FIG. 1. PEDIATRIC PATIENTS IN PSYCHIATRY CLINIC FROM OCT’08-OCT’10
16
TABLE 2. PSYCHIATRIC DIAGNOSIS (APRIL’10- OCT’10)
S.N. PSYCHIATRIC DIAGNOSIS NUMBER (%)N=80 (100%)
1. ISH 11 (13.8)2. Depression, Dysthymia and
Adjustment Disorders
11 (13.8)
3. Dissociative/Conversion Disorder 12 (15.0)4. Anxiety Disorder 5 (6.2)5. Evolving Personality Disorder 2 (2.5)6. Seizure Disorder 12 (15.0)7. Headache Syndromes 7 (8.8)8. Others 9 (11.2)9. Not Recorded/ Undiagnosed 11 (13.8)
17
TABLE 3. PSYCHIATRIC DIAGNOSIS AMONG DIFFERENT AGE GROUPS
S.N. PSYCHIATRIC DIAGNOSIS
AGE GROUP (YEARS) STATISTICS
0 -4 N1=1
(1.25%)
5-9 N2=3
(3.75%)
10-14 N3=22
(27.5%)
15 –18 N4=54(67.5%)
2
dfp-value
1. ISH 0(0.0%) 0(0.0%) 4(36.4%) 7(63.6%)
17.389240.832
2. Depression, Dysthymia and Adjustment Disorder
0(0.0%) 0(0.0%) 2(18.2%) 9(81.8%)
3. Dissociative/Conversion Disorder 0(0.0%) 0(0.0%) 4(33.3%) 8(66.7%)
4. Anxiety Disorder 0(0.0%) 0(0.0%) 1(20.0%) 4(80.0%)
5. Evolving Personality Disorder 0(0.0%) 0(0.0%) 1(50.0%) 1(50.0%)
6. Seizure Disorder 0(0.0%) 0(0.0%) 3(25.0%) 9(75.0%)
7. Headache Syndromes 0(0.0%) 1(14.3%) 1(14.3%) 5(71.4%)
8. Others 1(11.1%) 1(11.1%) 2(22.2%) 5(55.6%)
9. Not Recorded/ Undiagnosed 0(0.0%) 1 (9.1%) 4(36.4%) 6(54.5%)
18
TABLE 4. PSYCHIATRIC DIAGNOSIS AMONG THE SEX GROUPS
S.N. PSYCHIATRIC DIAGNOSIS SEX STATISTICSMALEN1=23
(28.75%)
FEMALEN2=57
(71.25%)
2
dfp-value
1. ISH 1(4.3%) 10(17.5%)
15.63880.048*
*p-value <0.05
2. Depression, Dysthymia and Adjustment Disorder
7(30.4%) 4(7.0%)
3. Dissociative/Conversion Disorder 1(4.3%) 11(19.3%)
4. Anxiety Disorder 2(8.7%) 3(5.3%)
5. Evolving Personality Disorder 1(4.3%) 1(1.8%)
6. Seizure Disorder 1(4.3%) 11(19.3%)
7. Headache Syndromes 2(8.7%) 5(8.8%)
8. Others 4(17.4%) 5(8.8%)
9. Not Recorded/ Undiagnosed 4(17.4%) 7(12.3%)
19
TABLE 5.PSYCHIATRIC DIAGNOSIS AMONG DIFFERENT CAST GROUPS
S.N. PSYCHIATRIC DIAGNOSIS CAST/RACE STATISTICS
BrahminN1=34
(42.5%)
ChhetriN2=11
(13.75%)
NewarN3=13
(16.25%)
MangolianN4=13
(16.25%)
Dalit / Disadvantaged
N5=9(11.25%)
2
dfp-value
1 ISH
3(8.8%) 1(9.1%) 3(23.1%) 3(23.1%) 1 (11.1%)
26.74632
0.730
2. Depression, Dysthymia and Adjustment Disorder 4(11.8%) 2(18.2%) 2(15.4%) 2(15.4%) 1 (11.1%)
3. Dissociative/ Conversion Disorder 6(17.6%) 2(18.2%) 0 (0.0%) 2(15.4%) 2(22.2%)
4. Anxiety Disorder 2(5.9%) 2(18.2%) 1 (7.7%) 0 (0.0%) 0 (0.0%)
5. Evolving Personality Disorder 1(2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (11.1%)
6. Seizure Disorder 7(20.6%) 1 (9.1%) 2(15.4%) 2(15.4%) 0 (0.0%)
7. Headache Syndromes 6(17.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (11.1%)
8. Others 2 (5.9%) 2(18.2%) 3(23.1%) 1 (7.7%) 1 (11.1%)
9. Not Recorded/ Undiagnosed 3(8.8%) 1(9.1%) 2(15.4%) 3(23.1%) 2(22.2%)
20
TABLE 6. PSYCHIATRIC DIAGNOSIS & REFERRAL CENTRES
S.N. PSYCHIATRIC DIAGNOSIS
REFERAL CENTERS STATISTICS
PediatricsN1=35
(43.75%)
MedicineN2=21
(26.25%) EmergencyN3=6 (7.5%)
Other Hospitals
N4=4 (5%)
Direct N5=14
(17.5%)
2
dfp-value
1. ISH 4(11.4%) 5(23.8%) 2 (33.3%) 0 (0.0%) 0(0.0%)
99.294320.000***
p <0.001
2. Depression, Dysthymia and Adjustment Disorder
0 (0.0%) 3(14.3%) 0 (0.0%) 0 (0.0%) 8 (57.1%)
3. Dissociative/ Conversion Disorder 8(22.9%) 0 (0.0%) 4 (66.7%) 0 (0.0%) 0 (0.0%)
4. Anxiety Disorder 0 (0.0%) 3(14.3%) 0 (0.0%) 1 (25%) 1 (7.1%)
5. Evolving Personality Disorder 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (14.3%)
6. Seizure Disorder 9 (25.7%) 3(14.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
7. Headache Syndromes
5 (14.3%) 2 (9.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
8.Others 1 (2.9%) 2 (9.5%) 0 (0.0%) 3 (75%) 3 (21.4%)
9. Not Recorded/ Undiagnosed 8(22.9%) 3(14.3%) 0 (0.0%) 0 (0.0%) 0(0.0%)
21
TABLE 7.PSYCHIATRIC DIAGNOSIS & OTHER PHYSICAL ILLNESSES
S.N. PSYCHIATRIC DIAGNOSIS PRESENCE OF PHYSICAL ILLNESS STATISTICS
YESN1=40 (50%)
NON2=40 (50%)
2
dfp-value
1 ISH 3 (7.5%) 8 (20%)52.63880.000***
***p< 0.001
2. Depression, Dysthymia and Adjustment Disorder 2 (5.0%) 9 (22.5%)
3. Dissociative/Conversion Disorder 0 (0.0%) 12 (30%)
4. Anxiety Disorder 1 (2.5%) 4 (10%)
5. Evolving Personality Disorder 0 (0.0%) 2 (5.0%)
6. Seizure Disorder 12 (30%) 0 (0.0%)
7. Headache Syndromes 7 (7.5%) 0 (0.0%)
8. Others4 (10%) 5 (12.5%)
9. Not Recorded/ Undiagnosed 11(27.5%) 0 (0.0%)
22
TABLE 8. PSYCHIATRIC DIAGNOSIS & MAGICORELIGIOUS TREATMENT
S.N. PSYCHIATRIC DIAGNOSIS TREATMENT BY MAGICORELIGIOUS MEANS
STATISTICS
YESN1=12 (15%)
NON2=68 (85%)
2
dfp-value
1 ISH
0 (0.0%) 11 (16.2%)
32.55680.000***
***p< 0.001
2. Depression, Dysthymia and Adjustment Disorder
0 (0.0%) 11 (16.2%)
3. Dissociative/Conversion Disorder 8 (66.7%) 4 (5.9%)
4. Anxiety Disorder 0 (0.0%) 5 (7.4%)
5. Evolving Personality Disorder 0 (0.0%) 2 (2.9%)
6. Seizure Disorder 0 (0.0%) 12 (17.6%)
7. Headache Syndromes 1 (8.3%) 6 (8.8%)
8. Others1 (8.3%) 8 (11.8%)
9. Not Recorded/ Undiagnosed 2(16.7%) 9 (13.2%)
23
DISCUSSIONMaximum patients (66.7%) were seen
among the age group 15-18 yrs 71.4% of the pediatric population were
female Similar findings were seen in a study
among 100 pediatric patients in Dharan with predominance of age group 13-18 years (79%) and females ( 53%)
Shakya DR, 2010 24
Female predominance was also seen in an Indian study by Prabhuswamy M. et al, 2006 while similar study by Chaudhury S et al, 2007
and Sarwat A. et al, 2009 showed male majority
25
Only 1.2% cases were found below four years of age in our study
Similar findings were seen in the Chaudhury S
et al, 2007 study ↕
Psychiatric structure before 4-5 years is usually not sufficiently developed to permit internal conflicts of pathological significance 26
The most common diagnosis (15%) was dissociative disorder equalizing to seizure
It was followed by depression spectrum disorder and ISH (13.8% each)
This was in accordance with the findings by Shakya DR, 2010
27
Diagnosis of Depression (30.4%) was maximum among males while dissociation (19.3%) was commonest among females which was statistically significant (p<0.05)
28
Clinic-based studies from different countries have reported high rates of dissociative disorders in the south Asian population* when compared to the studies done among western population**
*Srinath S et al, 1993; Chandrasekaran R et al, 1994; Chaudhury S et al, 2007
** Lehmkuhl GB et al, 1989; Tomasson K et al, 199129
Indian culture discourages direct expression of emotional distress
Physical symptoms are a common way of expressing psychological distress
↕Cross-cultural variation in rates of
dissociative disorder
Bhalla and Bhalla, 1986; Perera H. et al, 2004 30
We did not find specific child psychiatric illnesses like SLD, ADHD, ASD, MR as noted in other In-patient and Child Guidance Clinic Based studies by Perera H. et al, 2004; Sarwat A. et al, 2007; Chaudhury S. et al, 2007
↕Our sample pool was from a recently
developing psychiatric unit dealing mainly with general psychiatric out-patients
31
Maximum (43.75%) referral was from pediatrics department, mainly for dissociative disorder (22.9%) which attained statistical significance (p<0.001)
Similar findings were seen in various other studies
(Perera H. et al, 2004; Chaudhury S et al, 2007)
32
This can be explained by the fact that most of the pediatric population visit other specialists, mainly pediatricians rather than directly coming to the psychiatric care as reported in the Shakya
DR, 2010 study in BPKIHS
33
On evaluating the presence of other physical illnesses, maximum was seen in seizure disorder, while least physical findings were seen in patients with dissociative disorder attaining statistical significance (p<0.001)
34
15% of the pediatric population were found to be treated by magico-religious means before coming to the hospital, most of them were having dissociative disorder (66.7%), which also showed statistical significance (p<0.001)
35
LIMITATIONS It is a hospital based study carried out on a
sample size of <200 hence the results cannot be generalized
Stigma, which may have a negative influence to psychiatric referral, was not studied
Retrospective analysis of clinical records may have led inefficient data gathering
Structured format to obtain parent feedback was not used 36
FUTURE DIRECTIONSCommunity based surveys should be carried
out on larger scale to find out the depth of the psychiatric problems in children
Appropriate sample size should be usedProspective analysis need to be encouragedEffect of stigma on psychiatric referral need to
be studiedFeedbacks from parents has to be studied
using a structured format 37
ACKNOWLEDGEMENT:Mr. Seshananda Sanjel, MPH, Lecturer,
KUSMS, Dhulikhel, Kavre, NepalPatients of Dhulikhel Hospital
THANK YOU!!!!!! 38