Profile of Psychiatric Patients Visiting Outdoor of Psychiatric Department at Aziz Bhatt Shamed Teaching Hospital, Gujarat

1. Assistant Professor, Department of Psychology, Hafiz Hayat Campus, University of Gujarat, Punjab, Pakistan 2. Assistant Professor, Department of Sociology, Govt. College University, Lahore, Pakistan 3. BS Student, Department of Psychology, Hafiz Hayat Campus, University of Gujarat, Punjab, Pakistan PAPER INFO ABSTRACT Received: June 27, 2020 Accepted: August 25, 2020 Online: September 15, 2020 The objective of the study was to explore the profile of psychiatric patients visiting outdoor of psychiatric department at Aziz Bhatt Shamed Teaching Hospital Gujarat, Pakistan. It was conducted from January, 2020 to March, 2020. Through census sampling, 300 psychiatric patients were approached in outdoor setting visiting to Aziz Bhatt Shamed Teaching Hospital, Gujarat. Data were collected through a Performa consisting of two parts; Socio-demographic information and Clinical profile of patients. In order to diagnose the patients, different diagnostic criterions based on DSM-V were used. The study consisted of 53.7% females and 46.3% males. Findings of the study indicated that patients were suffering from Depressive Disorder 26.3%, Substance Abuse Disorder (11.3%), Generalized Anxiety Disorder (10.7%) and Schizophrenia (10.3%). Further, it concluded that females have higher proportions of psychiatric disorders as compared to males. Major Depressive Disorder was most prevailing psychiatric disorder in clinical population


Introduction
Profile of psychiatric patients play major role in assessment and treatment procedures of clinical population (APA, 2006).The information related to sociodemographic variables of clinical population, different assessment and treatment approaches practiced in clinical settings help the consultants in order to formulate new trends in clinical practices. Psychiatric profile obtained from one setting gives more accurate picture of casual factors, the rate or frequency of different prevailing disorders in that community, true picture of prognosis. It may be used as guidelines for practicing and introducing different assessment and treatment approaches for psychiatric patients based on their personal characteristics. Current study was conducted in a public sector teaching hospital of Gujarat city, so personal characteristics of patients e.g. age, gender, education and clinical picture of symptoms were determined. Biswas, Uddin and Mostafa (2017) reported the clinical profile of psychiatric patients along with their disorders for one-year data in Bangladesh. They reported the schizophrenia, depression and bipolar as the highest prevalent disorders. Pedneault (2020) described the depression, OCD (obsessive compulsive disorder), anxiety, PTSD (post traumatic stress disorder) and substance abuse disorder as the main psychiatric disorders.
In the current study, different psychiatric disorders were explored in outdoor patients of Aziz Bhatt Shamed Hospital, Gujarat on the bases of diagnostic criterions given in DSM-V (2013). Following disorders were explored:

Depression
According to DSM-V (2013) depression, also called a clinical depression, person who suffers from this experience may report constant hopelessness, sadness, and loss/lack of happiness in daily activities. Physical symptoms may involve chronic pain and stomach problems. Further, sad mood, fatigue, weight loss, problems with sleep, appetite, disturbed thinking, guilt feelings and suicidal thoughts or attempts may be experienced by the individuals suffering from depression. In order to diagnose the disorder, individual report these symptoms for at least in last two weeks of duration and these symptoms have an adverse effect on quality life of individuals.
As Lyer and Khan (2012) reported that all these symptoms disturb person life to an extent that may lead to suicide attempts.

Generalized Anxiety Disorder
Generalized anxiety disorder is a condition in which the individual feel persistent anxiety and worry about some events and feelings that involve threaten and inappropriate reactions (Gale & Davidson, 2007). The symptoms are extreme anxiety and worry occurring for more days than six months, person finds it hard to control the anxiety, restlessness is associated with anxiety and worry, feeling on edge, problem in concentration, muscle tension and problem in sleep, anxiety and worry cause clinically substantial distress and damage in social, occupational, and personal life.

Obsessive Compulsive Disorder (OCD)
OCD is categorized by disturbing, worrying thoughts (obsessions), and recurrent, formalized behaviors (compulsions) which are long lasting, considerably disturb functioning which may cause distress. When obsession arises, it always links with an enormous increase in anxiety and distress. Afterward compulsions perform to remove this related anxiety/distress. Common compulsion involves washing, checking, counting, praying, touching, tapping and avoidance (Lack, 2012).

Panic Disorder
According to DSM-V (2013), it is an anxiety disorder that involves experience of panic attacks which are repeated and often unpredicted. The panic attacks are followed by one month or more. Individual alter their behavior to avoid situations that might invoke an attack, the symptoms for panic attack is accelerated heart rate, shaking of hands and legs, chest pain, difficulty in breathing, feeling of dizziness, tingling sensations, sweating and nausea or abdominal problem.

Post-traumatic Stress Disorder
PTSD evolves after when individual face a traumatic event, it may be a single event or more long-lasting traumatic experiences. Emotional disturbances and some other symptoms are linked with PTSD that cause distress and damage person's social interactions, their work ability, or other important areas of functioning (Tull&Gans, 2020). The stress that is due to the traumatic events causes psychoemotional and physio-pathological problems (Iribarren, Prolo, Neagos, Chiappeli, 2005).

Schizophrenia
Symptoms may include delusions (fake ideas that remain consistent even when presented with evidences opposing of that idea), hallucinations (involve hearing voices, seeing things, etc), confused speech, disorganized movement, negative symptoms, inability to follow activities and lack of motivation. According to DSM-V (2013), these symptoms must be present for at least one-month or longer period for the diagnosis of schizophrenia.

Substance Abuse Disorder
Substance abuse disorder include taking the substance in large amount, has a desire to stop using the substance but not able to do it, spending most of the time in receiving, drinking, or getting the drugs.

Specific Learning Disability
It is a neurological disorder that originates in school-age but may not be predictable till adulthood. It involves the enduring problems that child may experience in any of the three areas, reading, writing and math, which are important for learning. Penesetti (2018) depicted that the problems start during school-age even some children do not experience it until adulthood.

Intellectual Disability
Problem in intellectual functioning includes "problems in reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience". Further, problems in adaptive functioning in different areas e.g. social relation, motor ability, and self-help skills are the significant areas that disturb in individuals' experience intellectual disability.

Epilepsy
Epilepsy is a neurological disorder in which brain is not working properly that causes seizures which are uncontrolled movement of body, uncommon behaviors and impaired sensation. Individual may loss his awareness for some time and after seizures may forget about what happened. In seizures too much electrical discharge occurs in brain that disturb functioning of person Epileptic symptoms may differ from individual to individual. Some may gaze blankly for a few seconds and other involves muscles contraction and spasm (Mayo Clinic, 2019).

Somatic Symptoms Disorder
According to DSM-V (2013) the somatic symptoms is a disorder that involve one or more somatic complains and that are accompany with excessive feelings, thoughts and behavior related to somatic complains. These thoughts and behaviors are associated with health concern for more than six months.

Bipolar Disorder
According to DSM-V the bipolar disorder is defined as group of disorder that causes fluctuation in individual mood, energy, or ability to work. The individual may experience at least one episode of mania or hypomania. In mania, the elevated, talkative, or irritable mood that must remain for at least one week and present for all the day. In hypomania, the mood must remain same for at least four consecutive days and present for all day.

Dissociative Identity Disorder (DID)
According to DSM-V (2013) the criteria for DID is to disturbance in identity described by two or more different personality conditions, which may be define as an experience of possession in some culture. The disturbance involve loss in sense of self and sense of agency, related to change in behavior, awareness, affect, memory, reasoning, and sensory-motor functioning.
Keeping in view the above mentioned psychiatric disorders, profile of patients e.g. age, occupational history, family history, marital history, availability of mental health service, reason of referral, source of referral, and presenting complaints not only have great influence on development of psychiatric disorder but it also interferes in the course of treatment. Shahid. et al. (2015) studied the psychiatry profile of patients of tertiary care emergency department of Karachi. They concluded that 331 of the patients had psychiatric disorders including depressive disorder, bipolar disorder, schizophrenia, dementia, conversion disorder, panic attacks, mood disorders and stress disorder. Further, most of the psychiatric patients had presenting complaints of sleep problems, aggressive behavior and somatic complains. Rehman, Khan and Shahbaz (2016) conducted research from 1995 to 2004 in psychiatric department of Jinnah Postgraduate Medical Center, Karachi that involve data of 10 years and continued to review until 2016. The pattern of diagnoses showed mood disorders (42.42%) schizophrenia, delusional disorders (26.50%) and individual with mental and behavioral problem due to substance use (9.6%).
The findings of current study will help to understand the profile of psychiatric patients particularly in the surrounding of Gujarat city as it is the first study in district Gujarat. Besides, there is no research conducted on the profile of psychiatric patients attending outdoor department of ABSTH (Aziz Bhatt Shamed Hospital) which is a public sector hospital, so findings of the current study established the knowledge about mental health problems in government level hospital of Gujarat. Another important significance of the study is that it will help to introduce the new mental health services or modify the existing services according to the need of psychiatric patients.

Material and Methods
After taking permission from research committee of Department of Psychology, University of Gujarat and medical superintendent of ABSTH, patients were approached in outdoor setting from January, 2020 to March, 2020. Total 300 patients who visited psychiatric unit of ABSTH Gujarat were contacted using census sampling technique. The inclusion criteria of the study were that the patients with both gender (male and female) visited psychiatric unit of hospital were included in the sample. Having any physical illness or patients who were not diagnosed as having psychiatric problem by the psychiatrist or clinical psychologist was excluded from the sample. The data were collected by the use of self-tailored instrument which developed keeping in view the literature and cultural perspective of Pakistan. It consists of three parts. First part of the instrument was related to the consent of participant. It contains information about purpose and topic of the research. Further, it also elaborated the volunteer participation and client's right to withdraw from the research at any point. The informed consent ensured that provided information remains confidential and will only be used for research purpose. Second part of the instrument contains demographic information of participants included age, gender, education, occupation, marital status, residential area, family system, family income, no of siblings and birth order, etc. While the third part of the instrument consist of information related to the source of referral, reason of referral, clinical symptoms/ presenting complaints of psychiatric problems, diagnostic categories, treatment related information, severity of symptoms and duration of problem etc. The participants were diagnosed by the psychiatrist and clinical psychologist according to the diagnostic criterions of DSM-V (2013).Descriptive (frequencies &percentages) statistics was used to analyze the data.

Results and Discussion
The data were analyzed using statistical package for social sciences (SPSS, 21.0 version). There were total 300 psychiatric patients; table 1 described participants' characteristics (age, gender, education, occupation, marital status, residential area, family system and home) using frequencies and percentages. Sample of the study comprised of 139 males and 161 females. The majority of the patients was 25-39 years old, graduated unemployed, unmarried, belonged to urban areas, lived in joint family system and had their own houses. Findings further indicated that most of the patients (31.3%) were referred by the parents due to their psychological symptoms (32.0 %). Depressive symptoms were common among psychiatric patients (24.7%), which were categorized from 1 year to 6 years based on symptoms duration (37.7%). Findings revealed different psychiatric disorders in different frequencies such as major depressive disorder (79, 26.3 %), substance abuse (34, 11.3%), generalized anxiety disorder (32, 10.7%) and schizophrenia (31, 10.3%) were found in most of the patients. On the other hand, some of the psychiatric disorders rarely reported such as eating disorder, dissociative identity disorder and gender identity disorder had ratio of 1 (0.3%). Furthermore, OCD was found in 22 (7.3%) psychiatric patients as compared to PTSD which was reported in 20 (6.7%) patients. Panic attack was found in patients with the percentage of 3.3%, epilepsy with 5.7%, specific phobia with 3.7%, bipolar with 2.7% while separation anxiety disorder, ADHD and adjustment disorder were reported by 4 patients with the percentage of 1.3% in each category. Other reported disorders were learning disability and somatic symptoms disorder had 2.3% ratio, autism spectrum was found with1% ratio, while intellectual disability and sex avoidance disorder had only 0.7% ratio. The detailed descriptions of the diagnoses of the patients were given in graph 1. Findings also revealed that patients experienced symptoms at severe level with the ratio of 46% following the moderate and mild level of symptoms with41.7% and 12.3% respectively indicated by graph 2.

Discussion
The first objective of the study was to explore the demographic profile and clinical symptoms of the psychiatric patients visiting outdoor of psychiatric unit of Aziz Bhatt Shamed Hospital, Gujarat. The results revealed that psychiatric illnesses were more common in females, between 25 to 39 years old age group and educated up to graduated level. Further, psychiatric illnesses were more prevalent among unmarried as compared to married people, in urban areas as compared to rural areas, in joint family system and among those who were living in their own house. The results are supported by the Abumadini (2003) who depicted some variations that highest proportions of psychiatric disorders were more prevalent between 20 to 49 years' old with the 72% and among those patients who were unemployed (70%).In current study, male and female ratio was 1:2, which means psychiatric illnesses had more prevalence rate in females as compared to males. Mirza and Jenkins (2004)studied risk factor, prevalence and treatment of anxiety and depressive disorder in Pakistan supported the similar results that psychiatric disorders were found in females with 25-57% as compared to males with 10-15%.
Most of the psychiatric patients lived in urban areas (35.0%), whereas 73.3% had personal homes. Majority of the psychiatric patients were living in joint family system (40.0%). The study conducted by Mirza and Jenkins in 2004 provided similar results that living in joint family system were positively related with depression and anxiety disorder.
Further, the present study demonstrated that parents were the source of referral for majority of patients (31.3%), self-referred were (17.3%), 32% were referred because of psychological symptoms and 37.7% had duration of symptoms between 1 to 6 years. The results are similar with Sarwat, Nawab and Nisar (2015) who studied profile of psychiatric patients attending outdoor clinic of a tertiary care hospital, Karachi represented that most of the psychiatric patients were not referred by doctors and come with their own help. Lyne, et al., (2010) explored the reasons of referral of diagnosed psychiatric patients. They reported that most of the patients came for depressive symptoms which are similar with current findings. Moreover, Sood, Ranjan, Chadda and Khandelwal(2017) provided similar results that 30% patients had the duration of 3 months to 2 years and 8% from less than 3 months.
The present study described that patients suffering from psychiatric illnesses had depressive symptoms (24.7%).Other symptoms of "agitation", behavioral changes, problem of alcohol or other drugs, aggressive behavior and idea of persecution and suicidal behavior rate were low in present study. A study by Padilha, Schettini, Junior, Azevedo (2013) showed similar results that most of the psychiatric patients having depressive symptoms like depressed mood, loss of pleasure, and sleep problem (28.1%) and also showed less symptoms of suicidal behavior.
The second objective of current study was to explore the frequencies of different psychiatric disorders among psychiatric patients visiting outdoor of ABSTH. Majority of patients visited ABSTH were suffering from depressive disorder (26.3%), whereas 10.7% had anxiety, 11.3% fulfilled diagnostic criteria of substance abuse and 10.3% were diagnosed as Schizophrenics. Sarwat et.al (2015) reported in profile of psychiatric patients attending outdoor clinic of a tertiary care hospital, Karachi similar results that most of the patients presenting to psychiatric clinic were suffering from depression disorder (51.6%) following the anxiety disorder (30.9%). Findings of Shahid et al., (2015) are also consistent with the current findings as it reported that most of the patients (331 out of 1127) were suffering from depressive disorder (29.3%).Findings of having the symptoms of psychiatric disorders at severe level were confirmed by Padilha et.al (2013) which showed that majority of the patients admitted in emergency department were at severe level of psychiatric disorder.

Conclusion
The study concluded that the percentage of psychiatric disorders is increasing day by day. Another alarming indication of the findings is that women are more suffering from psychiatric illnesses as compared to men which need to be seriously dealt as in Pakistani culture women are playing the major role in child rearing. So, if we want to save our future nation, we need to curtail the percentage of psychiatric illness among female population.
One of the most important strength of the current study is that it is the first study conducted in a public sector hospital of Gujarat which not only serves the biggest portion of populations of Gujarat city but also provides health related services to the surroundings villages and small urban areas.
However, findings cannot be generalized because it is based on one psychiatric setting.

Recommendations and Implications
In future research, sample size should be increased with an additional objective of a comparative profile picture of patients visiting private and public sector hospitals.
Finding of the current study indicates the increasing trend of psychiatric disorders among general public. Hence, highlights the need of treatment and rehabilitation services in hospitals and health centers. On the basis of current findings, suggestions can be given to Govt. Health department to increase the budget in the sector of mental health services. Further, NGOs can also be involved in arranging the mental health services for general public at low cost.