Pattern of practice on mental health issues and attitude towards referral among general medical practitioners of North India

Background: Still, in a larger part of the world, people with mental illnesses rst consult general practitioners (non-psychiatrist practitioners) to treat their mental illness. Many such patients seek psychiatric consultation with reluctance after being referred by general practitioners due to stigma. The study aimed to assess the attitude of general medical practitioners towards consultation-liaison psychiatric services. Methods: In this cross-sectional survey, a total of 61 general medical practitioners, specialists, and subspecialist physicians, surgeons from a city of North India were evaluated in a questionnaire which was designed based on previous studies and observations to assess their attitudes towards liaison psychiatric services. Findings: Nearly 98% of the general practitioners deal with the patient of psychiatric illness, out of which nearly 30% treat the patient of their own. Nearly 88% of practitioners referring a patient to psychiatrists. More than 90% of general practitioners reported psychiatric problems are associated with medical illness. More than 40%prescribe psychotropic medication, out of which benzodiazepine is the most commonly prescribed one. Depression is commonly encountered in general medical practice. More than 70% of practitioners are not comfortable prescribing psychotropic medications. About 16.39% of general practitioners faced diculty in referring patients to a psychiatrist for various reasons. Conclusion: General practitioners treat many patients with psychiatric illness though they are not comfortable prescribing psychotropic medications.


Introduction
Since time immemorial, stigma is closely associated with mental illnesses. Due to stigma, misconceptions about mental illnesses as well as lack of awareness, a large proportion of patients with mental illnesses remain untreated or consult traditional healers, which attribute to a large treatment gap as found in the recent National Mental Health Survey 2015-16, sponsored by Government of India (Gururaj et al., 2016). These above factors also direct the patients with mental illnesses to consult general physicians and non-psychiatrist practitioners as people perceive consulting a psychiatrist will also increase stigma. Hence, in a larger part of the world, non-psychiatrist practitioners treat patients with mental illness, and antidepressants are the commonly over-prescribed medications (Kar, 2016).
Over the past few decades, a new sub-specialty has emerged, which works in the interface of psychiatry and other medical disciplines. It is known as consultation-liaison psychiatry, and it intends to deliver collaborative care for patients having medical illnesses with psychiatric co-morbidities (Chen et al., 2016).
Consultation-liaison service improves mental health care for up to three months; also improves client satisfaction and medication adherence (Gillies et al., 2015). However, the existing evidence regarding the effectiveness of consultation-liaison services seems inadequate as found in a Cochrane database systematic review, indicating the need for more extensive research in this area (Gillies et al., 2015).
A systematic review found that patients who are young, from an urban background, history of past psychiatric illness, and having psychosis are commonly referred for psychiatric consultation (Chen et al., 2016). There is a need for educating general care physicians about early recognition of mental illnesses so that timely referral can be achieved.
Delay in referral to consultation-liaison psychiatric services occurs in medical conditions like delirium, as reported in an Indian study (Grover et al., 2014). Several factors like -old age, severe motor retardation, visuospatial disturbances, and signi cant disturbance of sleep attribute to delay in referral (Grover et al., 2014).

Method
This was a cross-sectional study conducted at various hospitals and clinics in a city of North India. Study participants were general medical practitioners (non-psychiatric medical practitioners). To be included in a study, the participant must be a medical practitioner (clinician) with a minimum MBBS degree. Written informed consent was taken from the participants. Study participants were evaluated on a semistructured questionnaire that intends to assess attitudes and practices about mental illnesses. The questionnaire included socio-demographic data and questions to assess the practice of psychiatry and the attitude of medical practitioners regarding referring the patient to a psychiatrist. Questionnaires in an envelope were personally given to all the general medical practitioners, approachable. A purposive sampling technique was adopted for this study. Data were collected from January 2018 to March 2018..

Result
During the survey, approximately 200 medical practitioners approached, but only 61(30% )were consented and completed in all respects. Most of the participants,44(72.14%), were male, and 17(27.86%) were female. The speci c di culty reported for not giving consent by the practitioners is lack of time.
Nearly 98%dealing patients with psychiatric illness out of which nearly 30% treating the patient.
More than half (63.93% )of practitioners refer the patient to the psychiatric department, whereas 36.07% of practitioners had treated the patient with psychiatric problems by themselves.
88.52%practictioners referring the patient to psychiatrists, more than 91.8%reported psychiatric problems are associated with medical illness. More than 42.62%prescribe psychotropic medication, out of which benzodiazepine is prescribed more. 40.90%Depression is commonly encountered in general medical practice.
More than ½ (54.1%) of the practitioner offer psychological intervention in the form of counseling. More than 70% of practitioners are not comfortable prescribing psychotropic medications.
16.39% of general practitioners faced di culty in referring patients to psychiatrists. A common problem for referring the patient's family members is unwilling to consult a psychiatrist, and sometimes the patient is not agreed because of stigma. [ Table 1]

Discussion
The collaborative care model in mental health care is an essential pillar of mental health care. In the United States, many primary care physicians and psychiatrists refer patients with mental illnesses to religious mental health providers (Lawrence et al., 2014) as a part of integrated care of mental illness.
Primary care physicians and practitioners of various medical disciplines are the rst contact points for a signi cant portion of patients with psychiatric illnesses.
In this study, Nearly 98%general medical practitioners dealing patients with psychiatric illness deal with psychiatric illness, out of which nearly 30% treat the patient for psychiatric problems. Chatterjee et al. Psychological factors had an aetiological role to play in less than 20% of the physical illness.
Psychological factors play an essential role in the genesis and treatment of many physical illnesses, especially psychosomatic disorders (Kalplan & Sadock 1991). A study done by, Chadda et al. found most of the clinicians did not think psychological factors to be of much importance in physical illness genesis. (12)in contrast to our study, we found more than 90%practitioner believe that psychological factors can affect the course and outcome of medical disorders. Almost all doctors agreed that psychological factors are important in physical illness (K. Nauta 2019). similarly, in our study, more than 90% of practitioners believe that psychological factors can affect the course and outcome of medical disorder similar nding of Morgan et al.'s study, most physicians and surgeons of a hospital in London believed that psychological factors could affect the prognosis of medical diseases and these factors must be assessed routinely. Most of the physicians recognized social and psychological aspects as essential factors of the diseases. The majority of physicians believed that the presence of CL psychiatrists in ward rounds and morning reports is also necessary, and psychiatric consultation is bene cial for the management of surgical patients and dealing with substance-dependent patients. The role of psychiatric disorders is, for example, well-known as comorbid conditions able to affect the course of CPD with many sequelae (Daré et al., 2019).
A majority -of G.P.s found it easier to start prescribing psychotropic drugs than to stop (Svensson etal2019). Similarly, 48% of all participants agree that they should be able to prescribe psychotropic drugs (Nauta 2019) in our study, more than 42.62%prescribe psychotropic medication out of which benzodiazepine prescribing more.
In the present study, depression, anxiety and sleep were the common problems found in patients who were attending their clinic for their medical problems, similar nding was noted in a survey by Mathur (1977) of 638 soldiers hospitalized for physical illnesses and trauma in a military hospital has revealed psychiatric morbidity in 34.5% of them, manifesting mainly in states of depression (47.9%) and anxiety (40.9%). In contrast, a study by Grover and Avasthi (2018) reported that among the three most common psychiatric syndromes seen in CLP setting, delirium gured as one of the three most common diagnoses 79 (87.8%) followed by substance use disorders (70%), self-harm (60%), and depression (38.9%).
The G.P.s were overwhelmingly in favor of using psychotherapy for the treatment of mild mental illness. (16) similarly, more than ½ (54.1%) of the practitioner offer psychological intervention inform of counseling. More than 70% of practitioners are not comfortable prescribing psychotropic medications.
About more than 16% of practitioners were facing di culty in referring the patient to the psychiatry department. A common problem for referring the patient is stigma patient family members are unwilling to consult a psychiatrist, and sometimes the patient does not agree. The same result was found in a study done by Singh et al 2017 most of the patient was of those who refused to consider the possibility that their presenting symptoms had anything to do with psychiatric illness. About 63.8% refused to consider the possibility that they may have a mental illness. Almost all patients asserted that their symptoms had a "physical" basis. (11) Conclusion General practitioners treat many patients with psychiatric illness though they are not comfortable prescribing psychotropic medications. Physicians indicate less attention to psychosocial aspects of diseases, possibly due to lack of training during their educational courses and stigma related to the psychiatric problem . The establishment of CL psychiatry ward provides this opportunity for medical students to become more familiar with the bio-psycho-socio-spiritual nature of diseases, and consequently to have better skills for the screening of psychiatric problems in medical diseases for the treatment and better outcome. CL psychiatrists provide information to their non-psychiatrist colleagues via meetings and workshops other than consultations. This information signi cantly helps provide better services by physicians and causes more familiarity with psychiatric aspects of diseases, and increases the number of requested consultations.
The present work raises the question of underestimation of psychiatric morbidity by a substantial number of non-psychiatric clinicians in their day-to-day clinical practice and lack of awareness on their part to recognize the role of psychological factors in the pathogenesis and management of various illnesses. This necessitates the need to improve upon undergraduate medical education in psychiatry in India and develop liaison psychiatric services in India. There is also a need to increase public awareness about psychiatric disorders and correct misconceptions related to psychiatry. Referral services should be better by 1. training the general medical Practitioners to treat the psychiatric co-morbidity with physical illness 2. and motivate them for referral services. Hence, patients get better treatment on time.