|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
PSYCHIATRIC EMERGENCIES IN GENERAL PRACTICE difficulties of diagnosis and treatment LACHTAR Chokri , BELLAAJ LACHTAR Faouzia, AMAMI Othman, JARRAYA Anouar Sept.2003 - SFAX UNIVERSITY - TUNISIA |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
q ABSTRACT |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
The mental disorders with predominant somatic expression constitute a frequent reason of consulting in general practice. The aim of our study was to appreciate the frequency and the nature of mental troubles as observed, in urgency, by generalist practitioner. Methods : Our study was a retrospective one. It deals with patient’s examination data, in a cabinet of a general practitioner, during six months. Results: 21.6% of our patients had presented mental troubles. 27.3% among these mental troubles were psychiatric urgencies. These urgencies were dominated by the psychiatric manifestations, with prevalent somatic expression (86.6%). Taking charge of these cases was started, in the square and permitted, on one hand the exclusion of a medico-chirurgical urgency, on the other hand the resolution of crisis in most of the cases. The acute psychosis cases, diagnosed in 6% were urgently sent for hospitalisation in psychiatric service. Conclusion: Generalist physician has a primordial role in diagnosing and, possibly, taking charge of the urgency psychiatric situations.
Key Word : general practice, Psychiatric emergencies
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
q FULL TEXT |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Neglected for a long-time, the emergencies are actually considered as an important degree of system care. Moreover, the activity of emergencies services is growing gradually .In France, for example, general hospitals collected over 9 millions of persons in 1998. This number is increasing nearly 4% each year. Among these urgencies, 10 % to 30% need a psychiatric approach {1} The majority of studies in UK and in USA showed that the frequency of mental disorders in the general practitioner’s activity is high (from 30 % to 40 %) {2}. The general practitioner is frequently confronting cases of psychiatric disorders, in particular, those where somatic expression is prevalent. Psychiatric emergencies have a diversity of clinical states expressed in mode of “crisis”. The mental disorders, particularly those observed in an emergency context, often raise difficulties for the general practitioner, both in terms of diagnosis, and for the therapeutic conduct. These difficulties are really seen, not only in diagnosis step, but also in the therapeutic conducts; and they are, essentially, due to the lack of training and information about mental health.
Appreciate mental disorders frequency, viewed in the emergency context, in a general practitioner cabinet. Underline the difficulties to make differential diagnosis between a medico-chirurgical emergency and a psychiatric emergency, with prevalent somatic manifestations. Analyze the attitude and the therapeutic possibilities of the general practitioners, when facing up to these mental disorders.
Our study was retrospective. It includes the case of psychiatric emergency, taken from the files of patients who were consulting their general practitioner, during six months. We were interested in: Socio-demographic data, consultation motives, diagnosis of mental disorder (reported to DSM IV), therapeutic conducts, evolution of the patient’s situation and hospital’s psychiatric department response or the private psychiatrist’s response, after referring the patient. The data treatments were done by Epi Info Version N° 6.
1- Frequency 1133 patients, all pathology confounded, had consulted at the period of study. A psychiatrics trouble diagnosis has been retained in 21.6 % of cases (then 245 cases). Among those 245 cases, we have regrouped 67 psychiatric urgency cases (27.3% of cases of psychiatrics trouble and 5.9 % of the whole of our consultants). Those psychiatric urgencies cases had different psychopathological registers. 2 - Socio-demographic data a - age and sex (Table ) Table : Age and sex of our patients
The sex frequency was approximately the same for both sexes (sex- ratio =1.08). The average age of our patients was 33.5 years. Men had a less average age than women (31.5 years against 35 years). b – Marital status We have, also, noted almost as many singles (51%) as married (49%). For the married patients the average number of infants was 3.7. c – Profession - 64% of our patients were unemployed persons, or daily workers. - Students represented nearly 20% of our consultants. d - habits - 25% of our patients have addictive behavior. 3 - antecedents a - Psychiatric family’s antecedents -12% (8 cases) of our patients have psychiatric family antecedents. -Anxious troubles were the dominant (5 cases)
b - Medical and psychiatric personal antecedents (Chart n°1)
-The 3/4 of our patients didn’t have any personal medical antecedent - 51 % of our patients have mental troubles in their personal antecedent. It was dominated by the somatoform troubles (27%) and the anxious troubles (15%). We have fined only one case of schizophrenic antecedent, one case of bipolar trouble, and one only case of suicide attempt. 4 – Motives of consulting (Chart n°2
Psychiatric manifestations were consultation’s motive only in 11 % of the cases. Whereas 58% have consulted for urgent somatic manifestations. These manifestations were centred, firstly, on the cardiovascular sphere, and secondly on the digestive and locomotors areas.
5 - diagnosis Axe i of dsm iv (Chart N° 3 and Chart N° 4)
a - Somatoform troubles (43%) Somatoform troubles have been seen in 43% of the cases. It was dominated by the conversion troubles (26 cases among 29: i.e.89.7%). The painful troubles were diagnosed only in 4.5% of the cases. b - Anxious troubles (42%) Anxious troubles were interested 29 cases. These troubles have been most frequent with female patients. Panic troubles and panic attack troubles were the most frequent troubles
The post- traumatic stress state was retained in three cases, and was usually following death of one of the parents. The other anxious troubles were seen only in 5 cases among the 26 cases of anxious trouble. c - Schizophrenia and other psychotic troubles (6%) - Schizophrenia and other psychotic troubles were found only in 4 cases (two cases of schizophreniform trouble and two other psychotic troubles). d – Humour troubles (3%) - We have seen humour troubles only in two cases. One of them has consulted for maniac episode, dealing with a bipolar trouble. e - Other mental disorders: *Troubles of movements induced by medicines - Two patients have consulted, in urgency, for troubles of movements induced by medicines: - One of them, treated for a chronic psychosis, suffers from acute dyskinesia induced by neuroleptics. And one case of acute dystonia, induced by neuroleptics. It was a young student, suffering of non-specified anxious troubles, but he had used the haloperidol, prescribed for a near parent who had a maniac episode. *Delirium: - The diagnosis of delirium, has been retained in one case, of an old man (80 years old) presenting a senile dementia. 6 - Somatic states - The somatic state was normal in 83.6% of the cases.
7 - Urgency’s therapeutic conduct: (Chart N° 5)
Treatment was based on anxiolytics only in 70% of the cases, on associating anxiolytics and antidepressant in 10.5% of the cases, and anxiolytics associated with neuroleptics in 1.5% of the cases. We have used parenteral way in urgency with 34% of cases. Our purpose wasn’t the superior efficacy of this route comparatively to oral route, but the need on the placebo effect, for some cases. The short-term evolution was favourable in 80% of the cases.
General practitioners see an important proportion of patients suffering from mental health problems. In our study, we find that psychiatric trouble diagnosis was retained in 21.6% of cases (245 cases in our sample). Within those 245 cases, we have regrouped 67 psychiatric urgency cases, thus 27.3%. A recent multicentric study showed that one consultant of 5, consulting the general practitioner; suffer from a mental health problem. These mental health problems can or not, be expressed and admitted, as they should be. {3} Most of the studies done in the United Kingdom, and in the USA, where the generalist is an obligatory intermediate, reported that 10% to 30% of the whole of patients consulting the general practitioner suffer from psychiatric problems. A third of this category of patients may be considered as new episodes of psychiatric sickness. In almost half of the cases, this psychiatric pathology can’t be diagnosed by the physician {2} The anxious and depressant states are largely dominant with a proportion of 79% of the whole of observed psychiatric troubles. {4} In our series, the anxious and somatoform troubles are the mostly observed, with cumulative frequency of 85%. Whereas, the current urgencies in the psychiatric services are, decreasingly: suicideconducts (36%), anguish (14%), depression (11%), agitation (10%), delirious ideas (10%), somatic complaints (8%), alcoholism (6%), authorities demands (3%). {5} the results of our study are different. furthermore, our study, concerning general practitioner, showed the supremacy of somatoform troubles (43%), and anxious troubles (42%). somatic complaints were the consulting main in 58% of cases. thus, in his daily practice, the generalist physician must take care about some pitfalls {6}: neither seeing the psychiatric disease, nor the degree of its gravity. badly evaluate, psychiatric urgency’s degree, and/or, the role of psyche ignoring the psychological origin, of functional or hypochondriac troubles, retained and treated as somatic troubles. physician should remember that some spectacular psychiatric diseases can be hidden by some other serious somatic ones {7}.
The term of “the hidden psychiatric morbidity” was first introduced, in 1970, by Goldberg and Blackwell {8}. This term refers to psychiatric disorders, which are recognized by the psychiatrist, and not by the general practitioner. Similarly, Goldberg (9} showed that, whenever the patient showed to his physician, some psychological plaints, he had 95% of chance to receive a psychiatric diagnosis. On the contrary, the patient who showed the somatic nature of his troubles has only 47% of chance to see the real psychiatric origin of his troubles. This emphasizes the difficulties of identifying psychiatric troubles, when the somatic manifestations are prevalent. In our series, the major part of diagnosis was for the somatoform troubles (43%) and anxious troubles (42%). Indeed, a statement was made in previous studies {10}, and affirmed that: For general practitioner, public psychiatry corresponds, to the heavy pathology. As for the light pathology, it stayed managed by the practitioner, who accepts cooperating, only with some selected psychiatrists. Moreover an international recent study, done in fourteen countries by the Healh World Organisation, about mental illness in general health care, showed that being the habitual practitioner of patient permits to double the scores of mental disorders diagnosing.{11} In our series, the short-term evolution was favourable in 80% of the cases. The treatment was based on anxiolytics in most of the cases. The psychotherapy’s help (reassurance, listen, and dedramatization) was very beneficial for the patient. About this subject Balint said: “the frequent used medicament by the generalist physicians is the physician himself”. {12} In his thesis presented in 1998 and entitled: “the generalist physicians of private practice in the governorate of Tunis (Tunisia) facing psychiatric troubles” Dr Choubani {4} noted that: 88.4% of the physicians, questioned in the inquiry, esteemed that they were insufficiently formed, for treating patients suffering from psychiatric troubles. 70% feel therapeutic difficulties, when they have patients with psychiatric troubles. For half of the physicians, the principal difficulty was how to choose the type of treatment, in such situations. Nearly, the totality of physicians agrees that taking charge of psychiatric troubles wasn’t especially depending on the psychiatrists. Those physicians refer their patients to psychiatrists, of private sector, in reason of personalisation of relations, and of a greater receptiveness. But, the letters of responding, emanating from psychiatrists, don’t satisfy their needs neither of diagnosis, nor of directives of treatment, and of prognosis.
In another study, in Denmark, two-third of the general practitioners thought they needed further training. The need was independent of the general practitioner’s evaluation of his/her own psychiatric education. {13} The fundamental role of the general practitioner, and his intervention in relation to the specialist, has been underlined since 1850 by Falret, in his treatment of mental diseases, and lunatic asylums: “the generalists need to recognize mental illness well, because they are alone confronted to the first symptoms. These symptoms change easily because they belong to sentiment and character domain. They should also treat the disease since its invasion. But, they must inform the specialists, about all etiologic circumstances, and proper symptoms of the patient. “However, the physician does, not only, treat the confirmed diseases, but he should especially search to prevent them.” {in 4} CONCLUSION Psychiatric emergency is difficult for the general practitioner, as much because of his lack of training, as the difficulties of distinguishing psychic from somatic features. As from our study, we underline these statements: The frequency of psychiatric troubles, at the general practitioner activity. The important impact of these troubles, in the socio-familial and professional life, of the patient, out of an earlier diagnosis and an adequate taking charge. We recommend the application of the National Mental Health Program instructions {14, 15}, and particularly: Reinforce the theorist formation (post- university teaching) and the practical formation (training in psychiatric services) of firstline physicians. Favourite pertinent communication between specialized services and the firstline physicians in the public or the private sector. Think to widen the future mental health interests, not only in the treatment and prevention of recidivism, but and above all, in the prevention of mental disorders.
BIBLIOGRAPHY
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
AUTHORS 1- Dr Lachtar Chokri: general practitioner - Competence of psychiatry – 10 street 18th January - 3080 Jebeniana – Tunisia 2- Dr Bellaaj Lachtar Faouzia: Assistant lecturer of psychiatry, Psychiatry « B » Department; Hedi Chaker University Center hospital; Sfax; Tunisia. e-mail : faouzia.lachtar@gnet.tn - Tel ( 00216 74 242 438), Fax (00 216 74 241 384) - Adress : Psychiatry « B » Department; Hedi Chaker University Center hospital; 3029 Sfax; Tunisia 3- Dr. Amami Othman: Lecturer of psychiatry, Psychiatry « B » Department; Hedi Chaker University Center hospital; Sfax; Tunisia 4- Pr Jarraya Anouar: Professor of psychiatry Head of psychiatry « B » Departmen, Psychiatry « B » Department; Hedi Chaker University Center hospital; Sfax; Tunisia. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
ÓÚíÇ æÑÇÁ ÊÑÌãÉ ÌãíÚ ÕÝÍÇÊ ÇáÔÈßÉ Åáì ÇáÅäÌáíÒíÉ æ ÇáÝÑäÓíÉ äÃãá ãä
ÇáÒãáÇÁ ÇáäÇØÞíä ÈÇáÅäÌáíÒíÉ æ ÇáÝÑäÓíÉ ÇáãÓÇåãÉ Ýí ÊÑÌãÉ åÐÇ ÇáÈÍË æ ÅÑÓÇáå
Åáì ÃÍÏ ÅÕÏÇÑÇÊ ÇáãæÞÜÜÚ : ÇáÅÕÜÜÏÇÑ
ÇáÅäÌáíÜÜÒí – ÇáÅÕÜÜÏÇÑ ÇáÝÑäÓÜÜí |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Document Code OP.0034 |
ÊÑãíÒ ÇáãÓÊäÏ
OP.0034 |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Copyright ©2003 WebPsySoft ArabCompany, www.arabpsynet.com (All Rights
Reserved) |