| Abstract|| |
Background: Private psychiatric clinics provide help for the bulk of our population, but they have not been evaluated systematically. It is time that we analyze the functioning of these set-ups to improve functioning. This paper is a modest attempt to analyze one such clinic.
Aims: To analyze the diagnostic distribution of the clients attending the clinic and to study the pattern of follow-up.
Materials and Methods: All records from April 1 st 1997 to 31 st March 1999 were analyzed. This is a descriptive study.
Results and Conclusions: A total of 3077 new patients visited the clinic in this period. The male:female ratio was 54:46. Diagnostic distribution revealed the following: schizophrenia 20%, affective disorders 40%, OCD 8%, dissociative disorders 5.5% and anxiety disorders around 4.5%. The pattern of visits revealed that 50% of the patients dropped out after the first visit. Another 25% did so in next the two visits.
Keywords: Diagnostic distribution, drop out, India, private psychiatric clinic anaylisis of a psychiatric clinic
|How to cite this article:|
Agarwal AK. Analysis of patients attending a private psychiatric clinic. Indian J Psychiatry 2012;54:356-8
| Introduction|| |
Mental health facilities in the government set-up are very limited, and a vast population of this country's mental health care is provided by private practioners and hospitals. There is a strong need for analyzing the functioning of these clinics so that one can improve them. A literature search regarding Indian studies revealed only one study in a private practice set-up in 1972. 
| Aims and Objectives|| |
To analyze the diagnostic distribution of the clients attending the clinic and to study the pattern of follow-up.
| Materials and Methods|| |
The author is running a private psychiatric clinic, and the records of the patients coming to the clinic were maintained. This is a retrospective record analysis. A description of the private practice set-up of the author can be provided on request.
Analysis of the data
This data pertains to the period from 1 st April 1977 to March 31 st 1999. These years have been chosen because these were the first 2 years when full records were maintained. The record keeping was started in mid-1996. As these records were maintained for clinical purposes, the information available in each case record was not uniform. All records were analyzed by a research assistant. Diagnosis was reassessed after perusing the record again and many diagnoses were changed. The ICD-10 diagnostic system was used. But, sometimes, symptomatic diagnosis like headache has also been used. Improvement has been recorded as mentioned in the case record on last entry. The record may have indicated improved, unchanged, worse or no information. No scales were used, and these could be taken as subjective assessment of the patients, their caretakers and the clinician.
| Results|| |
The total number of patients seen during the study period was 3077, but 29 records was missing and hence 3048 patients were analyzed.
Males were 58%. Level of education revealed that 4% were illiterate, 31% had 1-10 years of education, 44% had 11-14 years of schooling and 21% were post-graduates. Diagnostic distribution is provided in the accompanying table. This data very clearly reveals that the major load of clinical work in a private psychiatric set-up constitutes of affective disorders and other minor psychiatric disorders while schizophrenia with acute psychosis constitutes 20% of the work load only.
Nearly 50% of the patients dropped out after one visit while another 16% did so after the second visit, 7% after the third visit and 27% attended more than three visits.
- All anxiety disorders were 4.5%
- Percentages were not calculated for other categories as the numbers were small
These figures are quite alarming because more than 75% of the patients stopped coming after the third visit.
Differential pattern of drop out for different disorders has also been provided in [Table 1]. To understand this differential pattern, one will have to take into account the improvement rate for different disorders within the first three visits. Sixty-eight percent patients of schizophrenia, 71% of affective disorders and 76% of dissociative disorder patients reported subjective improvement.
| Discussion|| |
The findings of one private practice set-up may not be generalizable to others as this was more of a tertiary-level private clinic where people came from long distances for an opinion.
Schizophrenia and acute psychosis together constituted only 20% of the case material. Affective disorders were the largest group, constituting nearly 40%. Other psychiatric disorders whose numbers were higher were obsessive compulsive disorders and dissociative disorders. These disorders are very disabling and are usually accepted as psychological by medical professionals and hence reach a psychiatric clinic easily. On the other hand, anxiety disorders, panic disorders, phobia and other minor psychiatric problems that are much more common in the community do not reach a psychiatric clinic as most of these are managed by non-psychiatric physicians and the public avoids consulting a psychiatrist for these disorders. The pattern of patients in the clinic should also decide the pattern of education in psychiatric post-graduation.
A study  performed in 1972 from Lucknow reported that schizophrenia constituted 27.2% in private clinics and 31.3% in hospitals, and depression was 34.3% in private clinics and18.2% in hospitals, respectively. Current figures for schizophrenia are much less. This is largely due to the fact that minor mental health problems also reach the clinic in current times. The time is not far when minor psychiatric illnesses will form the bulk of psychiatric practice, and it may be happening even now in large metros.
One of the most worrying aspects of this study is the high drop out rate after one visit. Nearly 30% continued treatment beyond three visits. Devenathan  reported a drop out rate of 53% after the first visit from a private clinic in Bangalore. The figure is strikingly similar. The set-ups are entirely different. The Bangalore clinic has much a smaller total attendance and the psychiatrist spends much more time per patient. Could the drop out rate be a reflection of cultural acceptance of mental disorders in this country? Most people reach a mental health facility after traveling long distances and they have to pay for travel, doctor's fee and the drugs. The middle and poor class find that treatment expenses can be met only after curtailing other essential expanses. Under such circumstances, people go to a doctor only when the disease produces palpable discomfort and the treatment is given up as soon as there is relief from the discomfort. Shamsunder  commented that while medicines are given free in his hospital for 1-2 months, yet the patients come only when they can spare time from other pressing chores or when the illness is too disturbing. Economic factors, distance from clinic etc. have often been considered as key factors responsible for treatment discontinuation. They may play a role but there appear to be other factors that are responsible for treatment stoppage.
The non-adherence rates in schizophrenia  in published works vary from 10% to 76%, with a mean of 41%. However, the non-adherence rates in these studies are not comparable as they were mainly concerned with prescription compliance. What is more interesting is that most of these studies were carried out in the west, where treatment is usually free, yet the non-compliance rates were so high. Indian patients are taking treatment on their own, and yet a large number were compliant.
The patients suffering from diseases like schizophrenia, where symptoms are more severe and disturbing, tend to persist with treatment longer than illnesses where symptoms are more understandable and tend to be relieved more easily.
Some measures need to be taken to improve the drop out rates. It could be worthwhile to employ one or two local people who could be asked to visit people who have dropped out and try to understand their problems. The first visit fee may include the fee for two visits.
Lastly, it is recommended that analysis of case records in different types of set-ups should be carried out so that one could understand the nuances of psychiatric practice.
| Conclusions|| |
The case records of one private clinic have been analyzed for the period from 1 st April 1997 to 31 st March 1999.
A total of 3077 new patients visited in the clinic in the 2-year period.
The male:female ratio was 54:46.
Diagnostic distribution revealed the following: schizophrenia 20%, affective disorders 40%, OCD 8%, dissociative disorders 6% and anxiety and related disorders of around 4%. The rest of the conditions were much less frequent.
The pattern of visits revealed that 50% of the patients dropped out after the first visit. Another 25% did so in the next two visits.
Considering the drop out rates according to the diagnosis, one observes that there was a 35% drop out after the first visit in schizophrenia, 45% in affective disorders, 44% in OCD and 63.5% in dissociative disorders. This differential drop out rate is related to the quality of illness.
| Acknowledgment|| |
The author would like to thank Ms. Hem lata who collected this data as a research assistant.
| References|| |
|1.||Sethi BB, Gupta SC. An analysis of 2000 private and hospital psychiatric patients. Indian J Psychiatry 1972;14:197-205 |
|2.||Devanathan S. Personal communication. 2010. |
|3.||Shamsunder C. Letter to the editor. Noncompliance of prescriptions by the patients. Indian J Psychiatry 2008;50:73-4 |
|4.||Byerly MJ, Nakonezny PA, Lescouflair E. Antipsychotic Medication Adherence in Schizophrenia. Psychiatric Clin North Am 2007;30:437-52. |
Anil Kumar Agarwal
B104/2, Niralanagar, Lucknow 226 020, Uttar Pradesh
Source of Support: None, Conflict of Interest: None