PSYCHIATRIC PROFILE OF PEDIATRIC POPULATION PRESENTING TO A PSYCHIATRY CLINIC IN A TERTIARY CARE CENTRE Ajay Risal, Pushpa Prasad Sharma Department of.

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)

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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

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III. Sample sizeTotal (Oct’08-Oct’10)= 1686 months prospective study (April’10-

Oct’10)=80

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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

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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

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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)

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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)

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FIG. 1. PEDIATRIC PATIENTS IN PSYCHIATRY CLINIC FROM OCT’08-OCT’10

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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)

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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%)

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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%)

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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%)

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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%)

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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%)

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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%)

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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

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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

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Diagnosis of Depression (30.4%) was maximum among males while dissociation (19.3%) was commonest among females which was statistically significant (p<0.05)

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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

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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)

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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

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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)

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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)

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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