European Journal of Cardiovascular Medicine

Mental health disorders constitute a significant proportion of the global disease burden, with an estimated 970 million people worldwide living with a mental disorder [1]. In India, the National Mental Health Survey (2015-2016) reported a lifetime prevalence of mental disorders at 13.7%, with substantial treatment gaps exceeding 80% for most psychiatric conditions [2]. The integration of mental health services within general hospital settings through consultation-liaison psychiatry has emerged as a crucial strategy to address this treatment gap, particularly in resource-constrained environments.

Consultation-liaison psychiatry serves as an interface between psychiatry and other medical specialties, facilitating the identification and management of psychiatric morbidity among physically ill patients [3]. Studies have demonstrated that psychiatric comorbidity is present in 20-40% of hospitalized patients, significantly impacting treatment outcomes, length of hospital stay, and healthcare costs [4]. Despite this high prevalence, referral rates to psychiatric services remain disproportionately low, particularly in developing countries where awareness regarding the psychological aspects of physical illness may be limited [5].

In rural India, the challenges are particularly pronounced. The shortage of trained mental health professionals, limited psychiatric infrastructure, geographical barriers, and deep-rooted social stigma associated with mental illness contribute to underdiagnosis and delayed treatment [6]. According to recent estimates, India has approximately 0.3 psychiatrists per 100,000 population, with the majority concentrated in urban areas, leaving rural populations severely underserved [7]. General hospital psychiatric units play a pivotal role in bridging this gap by enabling collaborative care models.

The pattern of psychiatric referrals in Indian hospitals is influenced by multiple factors, including the awareness of treating physicians regarding psychological components of illness, the perceived severity of symptoms, and the comfort level of both healthcare providers and patients in seeking psychiatric consultation [8]. Previous studies have reported that most referrals originate from medicine departments, with common reasons including deliberate self-harm, substance use disorders, and behavioral disturbances [9]. However, there remains a paucity of data from rural settings, where the epidemiological profile and healthcare-seeking behaviors may differ significantly from urban populations.

Recent investigations by Bhardwaj et al. (2024) in North India reported that substance use disorders and mood disorders constituted the majority of psychiatric referrals [10]. Similarly, Pingali et al. (2020) highlighted the predominance of male patients and referrals from medical departments in their tertiary care study [11]. Studies examining rural-urban disparities have documented significant differences in the quality and accessibility of inpatient psychiatric care, emphasizing the need for context-specific research [12].

Given the scarcity of literature on consultation-liaison psychiatry in rural Indian settings, this retrospective study was undertaken to assess the sociodemographic and diagnostic profiles, reasons, and referral patterns for psychiatric consultations in a rural tertiary care hospital in Central India. The findings are expected to provide valuable insights into hospital-based mental health service utilization and inform strategies for improving the integration of psychiatric care within general hospital settings.

Study Design and Setting This retrospective observational study was conducted at a rural medical college hospital in Maharashtra, India. The hospital serves as a tertiary care referral center catering to a predominantly rural population from surrounding districts. Study Period and Sample The study reviewed medical records of all inpatients referred to the Department of Psychiatry from various hospital departments between January 1, 2024, and June 30, 2024. The sample size included all eligible referrals during the study period matching the inclusion criteria.As this was a retrospective record based study including all eligible cases, no formal sample size calculation was performed. Inclusion and Exclusion Criteria Inclusion criteria comprised all inpatients who received formal psychiatric consultation during the study period and had complete referral and evaluation documentation. Exclusion criteria included outpatient referrals, incomplete medical records, patients who were discharged before psychiatric evaluation, and referrals where consent for evaluation was refused. Data Collection Data were collected using a semi-structured proforma designed for this study. The proforma captured the following information: (1) Sociodemographic variables including age, gender, marital status, education, occupation, and socioeconomic status (classified using Modified BG Prasad Scale for 2024); (2) Clinical details including past psychiatric history and family history of psychiatric illness; (3) Referral information including referring department, reason for referral, and time of referral; and (4) Diagnostic assessment based on clinical evaluation by consultant psychiatrists. Diagnostic Classification All psychiatric diagnoses were classified according to the International Classification of Diseases, 10th Revision (ICD-10) criteria. The diagnostic categories included: Mental and Behavioral Disorders due to Psychoactive Substance Use (F10-F19), Schizophrenia and related disorders (F20-F29), Mood disorders (F30-F39), Neurotic, stress-related and somatoform disorders (F40-F48), Behavioral syndromes associated with physiological disturbances (F50-F59), Organic mental disorders (F00-F09), and Intentional self-harm cases (X60-X84). Ethical Considerations The study was approved by the Institutional Research and Ethics Committee prior to commencement. Patient confidentiality was maintained throughout the study, and data were anonymized for analysis. Statistical Analysis Data were entered into Microsoft Excel and analyzed using SPSS version 26.0. Descriptive statistics were presented as mean ± standard deviation for continuous variables and frequencies with percentages for categorical variables. Chi-square tests were used to assess associations between categorical variables, and independent t-tests were employed where applicable for comparing continuous variables between groups. A p-value of less than 0.05 was considered statistically significant.

Sociodemographic Characteristics

A total of 543 patients referred for psychiatric consultation were included in the study. The age of participants ranged from 12 to 85 years, with a mean age of 40.34 ± 18.86 years, indicating a wide age distribution. The majority of referrals were concentrated in young and middle adulthood, with 66.3% of patients below 45 years of age, while only 6.1% were aged 76 years or above. There was a clear male predominance, with 365 males (67.2%) and 178 females (32.8%), resulting in a male-to-female ratio of approximately 2.05:1. With respect to marital status, 461 patients (84.9%) were married, while 82 (15.1%) were unmarried. Regarding educational status, the majority of patients had education up to the secondary level (47.3%), followed by higher secondary education (21.0%). Illiterate individuals constituted 12.0% of the sample, whereas only 1.1% were postgraduates, indicating that most referrals belonged to low-to-moderate educational backgrounds. In terms of occupation, 373 patients (68.7%) were employed, while 170 (31.3%) were homemakers. Assessment of socioeconomic status revealed that most patients belonged to the lower (28.5%) and lower-middle (26.9%) classes, together accounting for over half of the study population. Only 8.1% belonged to the upper socioeconomic class.

Table 1: Sociodemographic Characteristics of Study Population (n=543)

Past psychiatric illness was reported in 31.3% (n=170) of patients, while 9.4% (n=51) had a positive family history of psychiatric disorders. The association between past psychiatric history and current diagnosis was statistically significant (χ² = 28.45, p < 0.001).

Analysis of referring departments revealed the most common reason was Excessive Alcohol and Tobacco consumption (30.4%), followed by Suicide attempt & counselling (21.2%), and Psychiatric evaluation (12.5%). Panic attacks accounted for 7.0%, and abnormal/uncooperative behaviour formed 6.3%. Least referral causes included Impaired attention & hyperactivity (0.4%) and ICU psychosis (0.4%), showing substance-related and self-harm related cases dominated the referrals.(Table 2)

The most common diagnosis was Mental & Behavioural disorder due to psychoactive substance use (30.4%), followed by Intentional self-harm (20.8%). Mood disorders contributed 13.6%, neurotic/stress-related disorders were 12.7%, and psychiatric evaluation cases were 12.5%. Organic mental disorders were 7.4%, while schizophrenia-related disorders were relatively less (1.8%). Overall, substance use and self-harm formed the major psychiatric burden in this population.(Table 2)

Table 2: Distribution of Referrals as per Reason for Referral and Psychiatric Diagnosis (n=543)

Distribution of Referrals as per Reason for Referral

Distribution of Referrals as per psychiatric diagnosis

Graph 1 indicates the association between the clinical reason for referral and the final ICD-10 diagnosis and the distribution differed significantly across diagnostic groups (p<0.001), indicating a statistically significant association between presenting complaint and diagnosis. Overall, the most frequent ICD-10 category was mental and behavioural disorders due to psychoactive substance use (165 cases), largely contributed by referrals for excessive alcohol and tobacco use (169 cases; 78.6% substance use diagnosis) and tobacco consumption (26 cases; 92.3% substance use diagnosis). Referrals for suicide attempt/counselling (115 cases) predominantly resulted in intentional self-harm diagnosis (90.4%). (Two patients referred for suicide attempt did not receive a final diagnosis of intentional self harm due to incomplete clinical information.)Anxiety-related complaints were mainly diagnosed as neurotic/stress-related disorders, especially panic attacks (38 cases; 97.4% neurotic/stress disorder) and anxiety with crying spells (78.9% neurotic/stress disorder). Symptoms such as low mood, lack of interest, irritability, aggression and disturbed sleep were chiefly classified under mood (affective) disorders (e.g., 100% of low-mood referrals and 84.6% of irritability/aggression referrals). Abnormal behaviour and irrelevant talk were strongly linked to organic mental disorders (94.1%), while muttering to self/disorganized behaviour was mainly associated with schizophrenia spectrum disorders (60%). Overall, the findings suggest that referral complaints closely aligned with corresponding ICD-10 diagnoses in this population.

Graph 1: Association between Reasons for Referral and ICD-10 diagnostic categories

Graph 2 shows the association between ICD-10 diagnostic categories and the department from which the patient was referred. Most referrals came from the Medicine department (N=201) followed by Orthopaedics (N=137) and Casualty (N=80).Across ICD-10 categories, Mental & Behavioural Disorder due to psychoactive substance use was predominantly referred from Orthopedics (67.3%), showing that substance-use related cases were more common from Orthopedics. Intentional self-harm cases (N=113) were majorly from Medicine (72.6%), reflecting high referral load of self-harm patients through Medicine. Neurotic, stress-related and somatoform disorders (N=69) were mainly referred from Casualty (68.1%), suggesting acute psychological stress/anxiety-related cases were frequently routed through emergency services. Psychiatric evaluation represents referrals requiring assessment where no ICD 10 diagnosis was assigned at the time of evaluation. And the difference was statistically significant(p<0.001)

Graph 2: Association between ICD-10 diagnostic categories and Referring Departments

This retrospective study provides comprehensive insights into the patterns of psychiatric referrals in a rural tertiary care setting in Maharashtra. The findings highlight significant trends in consultation-liaison psychiatry that have important implications for mental health service planning and delivery in resource-limited environments.

The mean age of patients in our study (40.34 ± 18.86 years) is consistent with previous Indian studies reporting that the economically productive age group is most commonly referred for psychiatric consultation [13]. The male predominance (67.2%) observed in our study aligns with findings from multiple Indian studies, including those by Keertish et al. (2013) and Suresh et al. (2015), who reported male preponderance ranging from 60-70% [14]. This gender disparity can be attributed to the higher prevalence of substance use disorders among males and potentially lower healthcare-seeking behavior among rural women due to sociocultural barriers [15].

A notable finding of our study was the predominance of patients from lower and lower middle socioeconomic strata (55.4%), which is consistent with the rural catchment area of our hospital and reflects the socioeconomic realities of rural Maharashtra. This finding aligns with extensive literature demonstrating the strong association between lower socioeconomic status and increased psychiatric morbidity [23]. Economic stressors, limited access to mental health resources, occupational hazards, and reduced social support networks among lower socioeconomic groups contribute to increased vulnerability to mental health disorders. The high proportion of patients from economically disadvantaged backgrounds underscores the need for affordable and accessible mental health services in rural healthcare settings.

The predominance of referrals from the Medicine department (37%) is a consistent finding across consultation-liaison psychiatry studies globally. Oriji et al. (2020) similarly reported medicine as the primary referring department in their Nigerian study, attributing this to the high prevalence of psychiatric comorbidity in patients with chronic medical conditions [16]. The substantial contribution from Orthopedics (25.2%) and Casualty(14.7%) reflects the high burden of trauma and emergency related psychiatric presentations in rural hospital; setting.

Substance use disorders emerged as the most prevalent diagnostic category (30.4%), a finding that corroborates the increasing concern regarding alcohol and substance abuse in rural India [17]. National Surveys indicate rising alcohol consumption patterns in rural areas, which is reflected in our hospital-based findings. The overwhelming male predominance among substance use disorder cases aligns with national epidemiological data and sociocultural norms regarding substance use [18]. The association between lower socioeconomic status and substance use disorders observed in our study population is well-documented in literature, with economic stress, limited recreational opportunities, and occupational factors contributing to increased substance use in economically disadvantaged communities.

The high proportion of intentional self-harm cases (20.8%) is particularly concerning and highlights the significant burden of suicidal behavior in rural populations. Studies have consistently demonstrated higher suicide rates in rural India compared to urban areas, attributed to factors including agrarian distress, easy access to pesticides, and limited mental health resources [19]. The relatively equal gender distribution in self-harm cases in our study differs from some urban studies and may reflect region-specific stressors affecting both genders. The predominance of lower socioeconomic status among our study population may partially explain the high self-harm rates, as economic hardship and financial stress are well-established risk factors for suicidal behavior.

Mood disorders and neurotic disorders, which showed female preponderance in our study, are consistent with global epidemiological data demonstrating higher prevalence of depression and anxiety among women [20]. However, the overall lower representation of these conditions compared to substance use disorders may indicate underrecognition by referring physicians or internalization of symptoms by female patients.

The substantial proportion of cases referred for "psychiatric evaluation" without confirmed diagnosis (12.5%) reflects the complexity of consultation-liaison work and the need for comprehensive assessment before reaching diagnostic conclusions. This finding also underscores the importance of psychiatric training for non-psychiatric physicians to improve the quality of referrals [21].

The presence of past psychiatric history in 31.3% of patients emphasizes the chronic and recurring nature of mental disorders and the need for continued follow-up and community-based mental health services. Gramaglia et al. (2025) highlighted similar patterns among frequent users of psychiatric consultations in emergency settings, emphasizing the need for integrated care models [22].

LIMITATIONS

The study has certain limitations, including its retrospective design, single-center setting, and potential selection bias due to exclusion of incomplete records. The referral-based model may underestimate the true psychiatric morbidity, as many patients with mental health needs may not receive referrals due to physician awareness gaps or time constraints.Inter rater reliability of psychiatric diagnosis could not be assessed due to retrospective nature of the study.

This retrospective study from a rural teaching hospital in Central India demonstrates that substance use disorders and intentional self-harm constitute the major burden of psychiatric referrals, with the Medicine and Orthopedics departments being the primary referring sources. The significant male predominance, particularly in substance use disorders, and the substantial proportion of patients from lower socioeconomic backgrounds and with past psychiatric history highlight the need for targeted interventions and strengthened mental health services in rural areas. Enhanced interdisciplinary training programs for non-psychiatric physicians, integration of mental health screening protocols in general hospital settings, development of community-based follow-up systems, and provision of affordable mental health services for economically disadvantaged populations are essential for improving psychiatric care delivery. These findings provide valuable baseline data for planning consultation-liaison psychiatry services in similar rural healthcare settings across developing countries.

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