The
Incidence of Outpatients In A Private Psychiatric
Setting
.........................................................................................................................
Chiam KH MBBS (IMU)1,
Chandrasekaran PK MBBS (M'pal),
M.Psych.Med (Malaya), AM (M'sia), F.Neuropsych
(Melb)2
1 House Officer, Alor Star Hospital, Malaysia
2 Consultant Neuropsychiatrist, NeuroBehavioural
Medicine, Penang Adventist
Hospital, Malaysia
Correspondence to:
Dr. Prem Kumar Chandrasekaran
465 Burmah Road, Georgetown,
10350 Penang, West Malaysia.
Tel: +604-2227772
Fax: +604-2263366
E-mail: premkumar@pah.com.my
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ABSTRACT
Objective
The authors wanted to roughly determine
the incidences of the various psychiatric
disorders presenting to a private psychiatric
outpatient clinic at any given time.
Method
This is a simple, cross-sectional, descriptive
study involving 165 patients attending
the NeuroBehavioural Medicine Clinic in
the Penang Adventist Hospital, Malaysia.
The patients were studied during a three-week
period and the incidence of the various
mental conditions was determined.
Results
The most common illnesses were anxiety
disorders (32.1 percent) and mood disorders
(27.2 percent). Schizophrenic disorders
(21.2 percent) were also common in private
practice.
Conclusions
Anxiety and depression were the most common
diagnoses presenting to psychiatrists
in private practice. Our observations
point to the need for awareness of these
incidences as effective treatment depends
on early detection of these disorders.
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The types of psychiatric
conditions seen in private practice in Malaysia
can vary from that seen in a government setting.
Issues pertaining to accessibility and cost
determine this variability. The aim of this
study is to roughly determine the incidence
and pattern of the various psychiatric illnesses
that present to a private psychiatric setting
and to highlight the need for awareness of those
incidences for earlier detection of the said
disorders, in the hope of being of particular
benefit to the primary care-giver and the practicing
family physician.
The study design is one of
a cross-sectional, descriptive type. The period
of study was over a three-week period in September,
2005 and included all new and follow-up patients
seen at the NeuroBehavioral Medicine clinic
at the Penang Adventist Hospital, Malaysia,
during the principal investigator's fourth year
medical school elective posting. The number
of cases amounted to 165 (n=165) and consisted
of those with prior appointments, as well as
walk-in patients. Axis I psychiatric diagnoses
were recorded and then accorded into six main
categories of common mental disorders. The data
was then inserted into a graph to determine
the types and incidences of the various psychiatric
conditions.
Patients of all ages had
conditions that included disorders such as schizophrenia,
mood disorders, anxiety disorders, organic brain
syndromes, substance-related disorders and other
psychiatric illnesses (consisting of somatoform
and personality disorders). The total number
of cases was 165. The highest incidence of conditions
presenting to this private clinic appeared to
be anxiety disorders and mood disorders, having
53 patients (32.1 percent) and 45 patients (27.2
percent) respectively. This was followed by
schizophrenia with 35 patients (21.2 percent),
and the rest being of smaller denominations.
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Figure 1 Incidence of Psychiatric Diagnoses |
As can be seen from the figures, anxiety and
depression constitute the major portion of psychiatric
disorders in the private outpatient clinic.
Most of the cases presented with symptoms of
anxiety or depression and there were others
that presented with a combination of both, usually
with one symptom standing out more prominently
than the other. However, mixed anxiety-depression
cannot be seen as a stable diagnosis as many
people diagnosed with it eventually shift to
other diagnoses(1).
Anxiety is as common as depression for several
reasons, one being that they can occur together
due to similarities in their psychopathology.
The other reason is the competitive nature of
our living standards nowadays, both in the workplace
and academic institutions. The final reason
focuses on a population that is prone to develop
anxiety and these are people who have the Cluster
C or the anxious or fearful personalities. The
dependent and obsessive-compulsive personalities,
when partnered and present together in an individual,
pose a significant and drastic component towards
the tendency of developing a generalized anxiety
disorder(2).
Depression has been the commonest psychiatric
diagnosis and constitutes 5.3 percent of the
Malaysian population. Putting this into a rough
figure, the estimate would breech almost 1.2
million individuals suffering from depression
in Malaysia alone. In comparison to a prevalence
of about 2-3.5 percent in 1984, such a tremendous
climb in the numbers of those suffering from
the disorder would put depression as the primary
cause of morbidity in years to come. Despite
the differences of incidences seen across the
globe, the variations are minor. Studies of
psychiatric patients reveal that when structured
diagnostic instruments are used and strict diagnostic
criteria applied, there are fewer differences
in the rates of psychotic and mood disorders
between ethnic groups(3). The common
attributes of depression include stresses in
the workplace, financial difficulties, health
complications, family problems, arguments and
marital discord. A local study that determined
core symptoms of depression and dysthymia in
patients undergoing dialysis found that amongst
all stressors in life, depression took the highest
toll on various morbidities, including renal
failure(4). However, only a fraction
would seek professional help probably due to
poor understanding, self-medication, high ego
in the male population and the stigma of seeing
a psychiatrist, the latter being the commonest
reason(5).
Schizophrenia and related psychoses were also
commonly encountered, charting a 21.2 percent
incidence. A Spanish experience in Barcelona
had recorded an incidence of 3.47 per 10,000
population from 1982-2000 involving 21,236 subjects
with schizophrenia and other psychosis-related
diagnosis(6). McGrath et al (2004)
found the distribution of rates was significantly
higher in males compared to females(7).
Ethnic differences however, may play a part
in the skewing of other figures. DelBello (2002)
noted that African Americans receive fewer mood
disorder diagnoses and Lewis et al (1980) observed
that violent, mentally-ill African American
adolescents were more likely than similarly
violent and ill white adolescents to be incarcerated
rather than hospitalized. Whaley (1998) reported
that mild forms of suspiciousness are more prominent
in African Americans than in whites and are
associated with depression, suggesting that
African American culturally-based suspiciousness
of a white-dominated mental health care system
may be misinterpreted as a psychotic symptom(3).
Substance-related disorders were also prevalent,
with an incidence of 9.7 percent followed by
organic brain disorders (7.3 percent) and finally
the other psychiatric disorders (2.4 percent).
The substance abuse group mainly comprised those
with heroin dependence syndrome, in sustained
remission with substitution therapy. Most were
young males and some had polydrug abuse. Martin
(2003) stated that while girls were more likely
to be diagnosed with abuse or dependence on
only one drug, boys were more likely to be diagnosed
with simultaneous abuse or dependence on more
than one drug. More male teenage substance abusers
also had disruptive disorders, whereas females
had higher rates of depression. Studies have
consistently documented high rates of psychotic
disorders among adolescent substance abusers.
They also found that certain co-occurring disorders
are associated with certain treatment outcomes,
especially depression or attention-deficit hyperactivity
disorder that may contribute to early drop-outs
and poor treatment outcomes(8).
Making a correct diagnosis is therefore crucial
in the early stages of dealing with a psychiatric
disorder. For this, awareness of the incidences
of the common psychiatric conditions is necessary.
On a lighter note, it has been suggested that
a 'parking diagnostician' could improve the
accuracy of diagnosis(9).
Limitations
Firstly, the setting being only outpatients
may not reflect the actual incidence of psychiatric
conditions nationally as the government hospitals
here in Malaysia have large psychiatric in-patient
facilities. Secondly, the diagnoses were not
further divided into specific sub-diagnoses
as in the Diagnostic and Statistical Manual
of Mental Disorders - Fourth Edition (DSM-4)
that may have provided a better breakdown of
the depressive and anxiety variants. Thirdly,
descriptive demographic data were not included,
thus disabling the use of statistical tests
for further analysis. Lastly, as the symptomatology
of the patients was not recorded, actual pattern
studies could not be conducted.
Although the findings of this study do not
lead to a newer conceptual understanding of
the incidence of psychiatric disorders than
what is widely known, and that the project was
undertaken merely to promote interest in research
to budding medical professionals, the simplicity
of this observational study design serves its
purpose in creating awareness that any kind
of information can be turned into useful data
when the correct framework is incorporated.
Anxiety and depression appear to be the main
diagnoses presenting to psychiatrists in private
practice. This is an important observation as
anxiety and mood disorders can be effectively
treated if detected early.
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- DelBello MP. Effects of ethnicity on psychiatric
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- Farahidah MD, Hatta SM. Depression among
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- Gray AJ. Stigma in psychiatry. J R Soc
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- Tizon JL, Ferrando J, Pares A, Artigue
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- McGrath J, Saha S, Welham J, Saadi OE,
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- Martin K. Substance-abusing adolescents
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- McDonald F. A brief report of a psychodiagnostic
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