Unrecognized psychiatric disorders among adult patients admitted into a general hospital in Maiduguri, Northeastern Nigeria

Introduction Patients with unrecognized psychiatric disorders in general hospitals, suffer economic and psycho-social difficulties. This study aimed to determine (i) prevalence and pattern of psychiatric disorders, and (ii) prevalence of unrecognized psychiatric disorders among adult in-patients of a general hospital. Methods In this two-stage, cross-sectional study, we used (i) General Health Questionnaire (GHQ) and Composite International Diagnostic Interview (CIDI) to assess the prevalence of psychiatric disorders, and (ii) Patient Encounter Form to determine unrecognized psychiatric disorders, among patients admitted into a general hospital. Results Of the 283 respondents, 174 (61.5%) had GHQ scores of ≤ 4. Eighty seven respondents (31%) had psychiatric disorders of which 85 (98%) were not recognized. The frequency of Depression and Anxiety disorders were 61.5% and 26.2% respectively. Unmarried (2.3, 1.2-4.3; p < 0.00), females (2.1, 1.1-4.05; p = 0.01) and patients with “unexplained symptoms” (≤ = 8.4, p< 0.00, df = 1) were more likely to have diagnosis of depression and anxiety disorder. Conclusion We conclude that one-third of the patients in the general hospital, had co-morbid psychiatric diagnoses, mostly unrecognized by their physicians. Unmarried, females and respondents with unexplained symptoms were associated with depression and anxiety disorders. We recommend the posting of psychiatric trainees to general hospitals, and training of general practitioners on the use of simple depression and anxiety screening instruments.


Introduction
The prevalence of psychiatric disorders among patients admitted into general hospitals compared to that of community [1], is higher, it ranges between 16 to 61 percent [2][3][4]. Depression and anxiety disorders were the most common psychiatric disorders reported in general hospitals [5]. Patients with unrecognized or misdiagnosed psychiatric disorders in general hospitals, fail to receive appropriate treatment [6,7], and this has economic and psychosocial implications (increased cost of health care, increased length of hospital stay, increased rates of readmissions, decreased quality of life), and increase mortality [8]. Non-recognition of psychiatric disorders by general practitioners in many developing countries may lead to poor referral of patients to psychiatric hospitals, and patients' poor access to mental health care services, especially in places where there is shortage of mental health specialists. The present study aimed to determine (i) prevalence and pattern of psychiatric disorders, and (ii) prevalence of unrecognized psychiatric disorders among adult in-patients of a general hospital.

Study setting
We conducted this study at the General Hospital, Maiduguri, in North-eastern Nigeria. The hospital receives referral from all the Primary Health Care (PHC) Centers and cottage hospitals in the state.

Study design
This is a cross-sectional hospital-based study of male and female patients aged ≥ 18 years, admitted into the medical, surgical and gynaecological wards of the State General Hospital from 14th to 28th April, 2008. We excluded unconscious patients and those who refused consent.
Substituting in the above formula, n= (1.96² x 0.30 x 0.70) / 0.05² = 323 Since, the total in-patients population of the hospital is <10,000, the sample size was corrected using the formula: nf= n/(1+(n)/N) Where: nf = the desired sample size for a population < 10,000; n = the desired sample size for a population >10,000; N = the estimate of the total in-patients at the medical, surgical and gynaecological wards of the hospital = 165.
Thus, ns = 109/0.8 = 136 To allow for test of associations, we increased the sample size to 300. Therefore a sample size of 300 was used for the study.

Sampling Technique
We used systematic sampling technique to select samples for the study and divided the sample size of 300 between the wards (using proportional allocation method based on the ratio of their bed spaces). Thus, the medical and surgical wards with a bed space of 60 each were allocated 110 participants each, while the gynecological ward with a bed space of 45 was allocated 80 participants. In each ward, we selected every third patient admitted until the required sample size was achieved.

Study Instruments
We used a pre-designed Socio-Demographic Questionnaire, the (GHQ-28) to screen the respondents for psychiatric disorders. It is a self-administered screening instrument that detects psychiatric symptoms in patients regardless of their diagnosis [11]. The Likert method for scoring GHQ was used, and set the cut off score at ≥ 4.
GHQ-28 has been validated for use in Nigeria [12]. Staff of the  [13]. For this study, the modules of CIDI for the diagnoses of depressive disorders, anxiety disorders (Phobias, panic anxiety disorders, and generalized anxiety disorder), somatoform disorders and substance use disorders were used. The aim is to identify conditions that are known to be common in this setting [14]. A Hausa version of the CIDI developed by back translation method for a previous survey, [14] was used for participants who speak only Hausa. We adapted the patient encounter form (from the World Health Organisation collaborative study of psychological problems in general health care) to measure the level of psychological illness recognised by the general practitioner [15]. The form has sections for classification of presenting symptoms, overall rating of the patient's health, diagnosis and severity of the physical and psychological disorder and treatment offered for the psychological symptoms. The attending medical doctor was requested to fill the form.

Data collection and procedure
We recruited two resident doctors with experience on data collection, and who speak both English and Hausa language fluently.
They were trained on the use of the study questionnaires and interview techniques for this study. The duration for data collection was five weeks and each interview lasted 30 minutes.

Ethical consideration
Research and Ethics Committee of Federal Neuro-psychiatric hospital, Maiduguri approved the study protocol, and we obtained permission for the study from General Hospital, Maiduguri. Patients gave their written informed consent and confidentiality of the patients was ensured. We gave medical advice to participants with psychiatric distress and referred those with serious distress to a psychiatric hospital for expert care.

Data Entry and Analysis
We used SPSS version 13 to analyze the data and descriptive statistics to report frequencies, proportions and tables. Categorical variables were analyzed using Chi square (χ 2 ) test, level of statistical significant set at p < 0.05, at 95% confidence interval.

Discussion
In this study, we found that a third of in-patients with physical illnesses at the State General Hospital Maiduguri also had a co-

Conclusion
We conclude that a third of patients presenting to general hospital

Competing interests
The authors declare competing interest.

Acknowledgments
We acknowledge the following: Prof Olusegun Baiyewu; Management and staff of the state general hospital Maiduguri; Management and staff of the Federal Neuro-psychiatric hospital Maiduguri.