Referrals to a Consultation-Liaison Psychiatry Service in a Tertiary Care COVID-19 Hospital in Northern India: A Comparison With Global Trends

COVID-19 has posed an unprecedented challenge to mental health professionals in terms of addressing mental health care needs of the general population as well as management of acute neuropsychiatric manifestations among hospitalized COVID-19 patients.¹ The role of consultation-liaison (C-L) psychiatry services are crucial, and there is a need to strengthen and adapt according to the emerging challenges posed by the ongoing pandemic. We assessed clinical profiles and psychiatry referral patterns at a 265-bed COVID-19 unit attached to a multidisciplinary tertiary care teaching hospital in Northern India. During the early stages of COVID-19 pandemic, a COVID-19 C-L psychiatry service was developed consisting of a consultant psychiatrist, consultant addiction psychiatrist, resident doctors, and clinical psychologists. This team received psychiatry referrals electronically and coordinated via smart phones with the psychiatry residents posted on shift duty as part of the COVID-19 management team at the facility. Diagnoses was made based on clinical evaluation and mental status examination as per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. The study was approved by the institute's ethics committee.

A retrospective chart review of the consultations was conducted for all inpatients assessed by the COVID-19 C-L psychiatry team over a 7-month period (June 2020 to December 2020). Out of the total 3914 patients admitted during our study period, 272 (6.9%) patients were referred for psychiatric consultation. Of these, 205 (75.4%) patients were seen as first consult while the rest were follow-up consultations. Nearly half of the patients (94, 45.8%) were evaluated in wards, 63 (30.7%) in intensive care units, and 48 (23.4%) in high-dependency units. The median age of those referred for first consultation was 48 years (interquartile range, 32–62 years). About 30% of the patients were older than 60 years. There were more male (131, 63.9%) than female patients. Pre-existing substance use disorder and psychiatric disorder was detected in 29 (14.1%) and 25 (12.2%) patients, respectively. Seventy-three percent of the referrals had at least one comorbid medical or surgical condition. Common reasons for psychiatric consultation included altered sensorium (43.4%), irritability/agitation (36.1%), altered sleep-wake cycle (35.1%), anxiety/restlessness (28.3%), disturbed sleep (27.3%), and impaired communication (26.3%). A recent history of self-harm was found in about 7% of the patients, with about 4% of the subjects reporting active suicidal ideations. Common psychiatric diagnoses included delirium (39%), anxiety and stress-related disorders (17.5%), and substance use disorders (15.6%). Most patients (72, 90%) who developed delirium had one or more medical/surgical comorbidities. About 15% of the referrals did not have a psychiatric diagnosis (Table 1 ).

Table 1.

Clinical Characteristics and Frequency of Various Clinical Diagnoses of Patients Referred to the COVID-19 Consultation-Liaison Psychiatry Service

Clinical characteristic	% (frequency) N = 205
Pre-existing psychiatric disorder (other than SUDs)	12.2 (25)
Major depressive disorder	3.9 (08)
Bipolar disorder	2.9 (06)
Anxiety disorder	2.9 (06)
Schizophrenia	1.0 (02)
Obsessive compulsive disorder	1.0 (02)
Dissociative disorder	0.5 (01)
Pre-existing SUDs	14.1 (29)
Alcohol use disorder	11.7 (24)
Cannabis dependence syndrome	1.0 (02)
Opioid dependence syndrome	1.5 (03)
Clinical diagnosis
Delirium	39.0 (80)
Hyperactive delirium	22.9 (47)
Mixed delirium	9.2 (19)
Hypoactive delirium	6.8 (14)
Anxiety and stress-related disorders	17.5 (36)
Major depressive disorder	5.4 (11)
Bipolar disorder	2.9 (06)
Schizophrenia and other psychotic disorders	2.5 (05)
Organic brain disorder	2.0 (04)
Obsessive compulsive disorder	1.5 (03)
SUDs/Intoxication	15.6 (32)
Alcohol-related disorders	12.7 (26)
Cannabis dependence syndrome	1.0 (02)
Opioid dependence syndrome with withdrawal	1.0 (02)
Opioid/benzodiazepine intoxication	1.0 (02)
Deliberate self-harm	4.4 (09)
Primary insomnia	0.5 (01)
No psychiatric diagnosis	15.1 (31)

SUD = substance use disorder.

Our study had a fairly large sample size, as compared to some similar studies reported from different parts of the world.2, 3, 4 The median age of our sample was relatively lower than the median ages of 55, 64, and 71 years, reported in similar studies from Turkey, Spain, and United Kingdom, respectively.^{2 , 4 , 5} The differences might be due to differences in the age of general population structure, with India having a younger population.

The common reasons for psychiatric consultation in our patients were confusion/altered sensorium, agitation or irritability, disturbed sleep pattern, and impaired communication, which are similar to those reported in earlier studies among hospitalized COVID-19 patients.^{1 , 3 , 4} Our finding of delirium being the most commonly diagnosed condition is also consistent with that reported in other similar works.2, 3, 4

Prevalence of anxiety and stress-related disorders, depression, and deliberate self-harm was found to be lower in our study than in other studies. This could be because this specific COVID-19 facility had more severely ill COVID-19 patients, where a high prevalence of delirium was expected due to greater illness burden. In addition, as detailed psychiatric assessments were sometimes not possible due to patients being too severely physically ill, some such cases might have been missed.

In conclusion, referral pattern to our C-L psychiatry service in a COVID-19 facility at a tertiary care teaching hospital in India was comparable to that of global trends. Delirium was the most commonly diagnosed condition, followed by anxiety disorders, substance use disorders, depression, and deliberate self-harm. Longitudinal studies are needed to understand the natural history and long-term psychiatric outcomes among hospitalized COVID-19 patients after recovery.