RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

KARNATAKA, BANGALORE

PROTOCOL FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE AND ADDRESS

DR. LAKSHMI NIRISHA P

Postgraduate

Department Of Psychiatry,

St. John’s Medical College Hospital

Sarjapur road, Bangalore -560034

2 NAME OF THE INSTITUTION

ST.JOHN’S MEDICAL COLLEGE

3 COURSE OF STUDY AND SUBJECT

M.D. Psychiatry

4 DATE OF ADMISSION

16st April 2012

5 TITLE OF THE TOPIC

“Trends in in-patient care in department of psychiatry before and after

implementation of ICD 10 in a tertiary care centre.”

6. Brief resume of the Intended work:

6.1 Need for the study 

There has been a significant change in the assessment and management of psychiatric

disorders in the past two decades. There has been introduction of psychiatric

classification system, newer psychiatric medications and newer treatment guidelines.

All these changes can be expected to have an impact on the duration of stay in hospital,

quality of life, rehabilitation, mortality and morbidity. Western literature has

contributed significantly in this regard. This study is an attempt to understand the

impact of the above changes on in-patient care, using patient case files in a general

hospital psychiatry unit. Such information can help understand the role of classificatory

systems in general and provide valuable insights to prepare for ICD11 which is

expected in a few years time.

6.2 Review of literature

Mental disorders often result in profound disability. The World Health

Organization has determined that mental illness is one of the largest contributors to

disability worldwide1. Studies have shown that mental health arena underwent major

changes in the treatment during 1990s 2 along with changes in the Classificatory system.

Comprehension of illnesses is a key purpose of a classificatory system. The changing

comprehension of disorders with changes in classification could be expected to impact

practice. Becoming aware of changing trends in practice following implementation of

ICD10 will help plan for changes following the upcoming ICD11.

One of the hallmarks of epidemiologic analysis is the understanding that health

outcomes in a population can only be fully understood if their frequency and

distribution is examined in terms of person, place, and time. Trend analysis is used for

public health surveillance and monitoring, for forecasting, for program evaluation, for

policy analysis, and for etiologic analysis (investigation of potentially causal

relationships between risk factors and outcomes). Some of the aspects that one can

focus on study of time trends include:

1 Comparing one time period to another time period: This form of trend

analysis is carried out in order to assess the level of an indicator before and after

an event. Evaluating the impact of programs, policy shifts, or medical and other

technical advances are carried out using interrupted time series analysis. This is

described later.

2 Making future projections: Projecting rates into the future is a means of

monitoring progress toward a national or local objective or simply providing an

estimate of the rate of future occurrence. Projecting the potential number of

future cases can aid in the planning of needed health and other related services

and in defining corresponding resource requirements.

Interrupted time series analysis (ITS)

Interrupted time-series analysis is a statistical method for analyzing temporally

ordered scores to determine if an experimental manipulation, a clinical intervention, or

even a serendipitous intrusion, has produced a reliable change in the scores. It is a

research design that collects observations at multiple time points before and after an

intervention (interruption). It detects whether an intervention has had an effect

significantly than the underlying trend. Policy makers may find ITS designs a useful

way to assess the impact of specific policies that could remain un-assessable otherwise3.

Global literature on trend analysis in Psychiatry

Trend analysis has been used in numerous prospective and retrospective studies

globally. Country specific data registers either electronic or manual have been

extensively used for research purposes in psychiatry in many countries4.

In a study by Arndt S et al (2011), who studied the trends of substance abuse

using substance abuse database (1998-2008) whether the percentage of older adults

entering substance abuse treatment for their first time was increasing and whether there

were changes in the use patterns leading to the treatment episode, particularly an

increase in illicit drugs. They concluded that only little is known about the long-time

users, their current medical state, cognitive abilities, and psychiatric symptoms after

such a long exposure time. Previous studies on heroin and cocaine exposure focused on

individuals identified much earlier in life, and that aging long-term users might

represent a relatively large but unknown population 5.

A retrospective analysis of hospital statistics done by Patrick Keown et al

concluded Psychiatric inpatient care changed considerably from 1996 to 2006, with

more involuntary patients admitted to fewer NHS beds and increasing proportions of

involuntary patients admitted to private facilities6.

A retrospective study done by Jan Vevera et al (2005) to study the violent

behaviour in schizophrenia; they studied four independent samples from Prague in time

period of 1949-2000.They used data from the years 1949, 1969, 1989 and 2000.They

studied various aspects of in-patient care in schizophrenia. They found there was no

significant linear trend in violence between 1949 and 2000 cohort. They found that 83

patients from the 1949 cohort never received antipsychotics. These had markedly longer

total duration of hospitalisation (9.23 years; s.d=11.54) than patients who received

antipsychotics (1.74years; s.d=4.04).The limitation of the study was that it included

only hospital admissions, therefore violence when the patient is in community is left

out, as the data were taken from urban psychiatric settings, rural populations might be

different 7.

A time trend study was done by Colleshaw et al in 1999, in adolescent mental

health for 25 year period. This study set out to assess whether adolescent emotional and

behavioural problems have become more common in the UK, by comparing parent

ratings collected from general population samples in 1974, 1986 and 1999. Conduct

scores increased markedly for both genders, for all family types, and across all social

class categories over this 25-year period. Overall, each successive cohort had increased

odds of high conduct problems of around 1.5. Time trends appeared more marked for

non-aggressive conduct problems than for aggressive problems. They found rates of

emotional problems remained stable between 1974 and 1986, and then increased

between 1986 and 1999, both for males and females. Analyses that accounted for the

overlap between conduct problems, emotional difficulties, and hyperactive behaviour

confirmed a strong independent effect of cohort on the rate of conduct problems. They

concluded evidence on secular change in the prevalence of psychosocial disorders

provides strong support for the role of environmental influences on psychosocial

development. An examination of broader societal trends affecting the lives of children

and adolescents seems likely to provide important clues as to possible reasons for trends

in mental health8 .

A study done by Centorrini F et al, to test the hypothesis that combinations and

total daily doses of psychotropics are rising (2009 versus 2004). In 2009, Clinical

Global Impression (CGI)-severity scores were 6% lower at intake and improved 1.7

times more than in 2004, as hospitalization-length decreased by 12%. Polytherapy (> or

= 2 psychotropics) increased in 2009. Total psychotropics per patient (3.1-3.2)

remained stable but mood-stabilizers/patient increased markedly and

antipsychotics/patient decreased somewhat in 2009. In 2009, final total antipsychotic

doses (mg/day) increased by 97%, and mood-stabilizers by 75%.They concluded

combinations and doses of antipsychotic and mood-stabilizing drugs

for inpatients increased markedly (2004 vs. 2009) without consistent correspondence of

agents/person and doses, without apparent increase in major adverse effects, and with

possibly superior clinical improvement 9.

Indian literature

A review study was done by Suresh Bada Math et al with respect to the psychiatric

epidemiological studies done in India.. They found the prevalence of mental illness

ranged from 9.5 to 370/1000 population. They found most of the studies were done in

small population around 6000. It is seen that Psychiatric epidemiology lags behind

other branches of epidemiology due to difficulties encountered in conceptualizing,

diagnosing, defining a case, sampling, selecting an instrument, lack of resources and

stigma. They found that descriptive epidemiological studies had undergone

unprecedented growth in India, but at the same time advances with respect to cost

effective, analytical and prospective experimental epidemiological studies have been

minimal10.

Mental health problems constitute a wide spectrum ranging from sub-clinical states to

very severe forms of disorders. Majority of the epidemiological studies focused on

visible mental health problems. Invisible mental health problems continue to remain

unexplored and unaddressed. Mental healthcare priorities need to be shifted from

psychotic disorders to common mental disorders and from mental hospitals to primary

health centres11.

In India not many studies have been done with respect to time trends in

psychiatry patient care, although changes across time with specific cohorts have been

attempted in few studies such as the Madras Longitudinal study12.

A retrospective study done by Dr Savita Malhotra et al to study the

sociodemographic and clinical profile of patients, who presented to the child and

adolescent psychiatric services of a tertiary care centre over a 26-year period (1980-

2005) in three time periods using case records of patients. There was a trend towards

decrease in number of cases in younger age group (0-5 years) and those with diagnosis

of mental retardation, epilepsy and organic brain disorder. There was a trend towards

increase in number of cases in the older age group (10-15 years) and those with

diagnosis of psychotic disorders, affective disorders, disorders of psychological

development, and hyperkinetic and conduct disorders. They concluded that time trends

revealed a significant shifts in demographic and diagnostic profile of a CAP clinic. The

study suggested that there is a need to strengthen services for disorders like depression,

specific learning disorders and hyperkinetic disorders13.

Hospital based epidemiological studies using time trends can reflect changes in

help-seeking, clinical practice and priority areas. Therefore our study aims to utilise the

data available over the past three decades and study various trends in inpatient care in a

general hospital psychiatry department.

6.3 OBJECTIVES

Primary Objective

To study the diagnostic trends in in-patient care in the department of psychiatry in three

time points (years) each before and after the implementation of ICD 10.

Secondary objectives

● To study admission trends- emergency/elective

● To study the use of ECT and various other interventions.

● To assess duration of hospital stay.

7.MATERIALS AND METHODS

STUDY DESIGN

Retrospective study

STUDY SITE

Department Of Psychiatry In St John’s Medical College Hospital, Bangalore

DURATION OF STUDY

Two Years

7.1 SOURCE OF DATA

Case files of psychiatry department at the St John’s Medical College Hospital over 25

years period.

Records of Out-patient cards and In-patient charts are maintained by the Medical

records department of the hospital. OP and IP charts are maintained for a stipulated

period as recommended by Medical Council of India. However, Psychiatry case files

have been separately stored since 1982.From the year 1985 a semi-structured Proforma

has been used to record the case details. Each psychiatry case file is allotted a specific

number and arranged according to the number, month and year of admission in a safe

and secure room in our hospital. It can be accessed only by mental health professionals

with prior permission from the HOD due to confidentiality purpose. The data for the

proposed study is being obtained from these files.

SAMPLE SIZE

It was found that 6 years of psychiatry case files constitute approximately 4500 files, a

minimum of 2000 in the three sampled years each before and after implementation of

ICD10.

7.2 METHOD OF COLLECTION OF DATA

Three time points, (which will be the minimum needed to show a trend) will be selected

before ICD 10 (1986, 1989, 1992) and after introduction of ICD 10 (2005, 2008, 2011).

The time periods chosen are based on two aspects: 1) A time-lag after the ICD9 and

ICD 10 implementation respectively, so that the classificatory system is influencing the

practice and 2) Availability of adequate records since 1985. Case records of in-patients

admitted during that time period will be studied and data of interest would be collected.

DATA COLLECTED FROM THE CASE FILE

1 Age

2 Gender

3 Type of admission: emergency/elective / readmission

4 Duration of stay

5 Diagnosis : ICD Code / Category

6 Documented Medical co-morbidities

7 Treatment given: Nature of medications and dosages across major psychiatric

categories

8 Use of ECT

9 Other documented interventions like Psychotherapy, Psychiatric Social Work

intervention.

In order to plan for this study, 30 Case files from the time periods of interest were

randomly picked and studied for availability of data of interest. Almost all the data were

available in all the files selected. A sample of the proforma for the data collection from

the case file is enclosed.

QUALITY OF DATA

A quality of data measure will be created that documents the completion of data and

reliability of different types of data of interest. This will be applied for every record.

The time trends will be constrained through this quality measure, before drawing

conclusions.

CONFIDENTIALITY

Case records will be kept in locked store room in the department and will be studied by

the student and guides only.

STATISTICAL ANALYSIS

Data would be analyzed for normality. Descriptive statistics would be used. Mean and

proportions will be obtained and changes in time trends will be evaluated using chi-

squares statistics. Also segmented (or piece wise regression) as described by Gillings et

al14 (or its non - parametric equivalent) will be carried out for each variable of interest.

7.3 Does the study require any investigations or interventions to b e conducted on

humans or animals? No

7.4 Has ethical clearance been obtained from your institution in case of 7.3 . Yes

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9. Signature of the candidate :

10. Remarks of the guide :

11. Name and designation of

11.1 Guide : DR. ASHOK. M.V

PROFESSOR

DEPARTMENT OF PSYCHIATRY

11.2 Signature :

11.3 Co-Guide : DR. JOHNSON PRADEEP

ASSISTANT PROFESSOR

DEPARTMENT OF PSYCHIATRY

11.4 Signature :

11.5 Head of the department: DR SUNITA SIMON KURPAD

PROFESSOR AND HOD

DEPARTMENT OF PSYCHIATRY

11.6 Signature :

12.1 Remarks of the chairman and principal:

12.2 Signature :

PROFORMA FOR DATA COLLECTION

YEAR : SL.no :

1 PSYCHIATRY FILE NO. :

2 NAME OF THE PATIENT :

3 AGE (in years) :

4 GENDER : MALE( ) FEMALE( )

5 TYPE OF ADMISSION :(EMERGENCY/ELECTIVE/READMISSION)

6 DIAGNOSIS ICD CODE/CATEGORY) :

7 DURATION OF STAY(No. of days) :

8 MEDICAL COMORBIDITY :

9 TREATMENT GIVEN

a. NATURE OF MEDICATION :

b. DOSAGE :

10 ECT :

11 OTHER INTERVENTIONS :