AUDIT OF OUTPATIENT PSYCHOTROPIC PRESCRIBING HABITS IN PATAN HOSPITAL

A Study of the rate of prescribing of psychotropic drugs in the outpatient clinics of Patan hospital which reveals surprisingly low rates of prescription (1.3%). The author goes on to compare this with a proposed gold standard and to suggest reasons why the rate is so low. diagnoses of 322 outpatient consultations in the Primary Care Department of the hospital revealed only one patient in whom the main diagnosis was psychiatric. During primary care consultations in the US the number of visits during which a psychotropic medication was prescribed was 6.5%.4 Although this contained a large number of prescriptions for benzodiazepines and therefore probably does not serve as an adequate "Gold Standard".


BACKGROUND:
Psychiatric disease is a life threatening and a potentially treatable condition which should generally be within the realm of a General Practitioner to treat effectively.The recognition and treatment of it is commonly thought to be a core skill of generalist medical personnel. 1A large cross sectional study of a Nepal village population revealed there to be a case rate of about 12% for formal psychiatric disorders. 2Attempts to find the proportion of the population suffering from psychiatric disease in Lalitpur, the hospital catchment area have found similar figures. 3Most of these disorders are reactive, but substance abuse and somatisation are also common.Watson notes that in a series of psychiatric patients in Tansen, Nepal, over 50% presented with somatic symptoms.It is therefore easy for doctors to mistakenly treat the patient's complaints as organic.He also notes that of the 59% of patients who attended follow up, 57% were improved.This indicates that significant success is achievable with predominantly outpatient treatment by a General Practitioner.

PROBLEM STATEMENT:
Anecdotal evidence suggested that the outpatient diagnosis of psychiatric disease was made very infrequently in Patan Hospital.Analysis of the final

AUDIT OF OUTPATIENT PSYCHOTROPIC PRESCRIBING HABITS IN PATAN HOSPITAL ABSTRACT:
A Study of the rate of prescribing of psychotropic drugs in the outpatient clinics of Patan hospital which reveals surprisingly low rates of prescription (1.3%).The author goes on to compare this with a proposed gold standard and to suggest reasons why the rate is so low.
diagnoses of 322 outpatient consultations in the Primary Care Department of the hospital revealed only one patient in whom the main diagnosis was psychiatric.During primary care consultations in the US the number of visits during which a psychotropic medication was prescribed was 6.5%. 4 Although this contained a large number of prescriptions for benzodiazepines and therefore probably does not serve as an adequate "Gold Standard".

STUDY AIM:
To find out the percentage of outpatient consultations that result in the prescription of a psychotropic drug on a single day.To compare this with a gold standard figure.

THE GOLD STANDARD:
Was set at 7%, ie seven percent of all outpatient prescriptions were expected to contain a psychotropic drug.This was set with several criteria in mind: a.The prevalence of psychiatric disorder in the community is known to be about 12% (see above) b.The prescription rate for psychotropic drugs seems to vary between about 5% and 15% in primary care consultations from other centres.
e-mail: <appleby@umn.mos.com.np>c.Experienced general practitioner at Patan Hospital pick up one to three cases in a day (about 35 patients), about 3-8%.d.An Audit of outpatient prescriptions in a semirural hospital in Nepal where the recognition of psychiatric disease has been made a priority showed that 14% of prescriptions contained a psychotropic drug. 5eatment of psychiatric disorder by modalities other than medication is very rare in Nepal, unless we consider the role of traditional healer.Patan hospital staff work on a Western medical model of treatment and therefore are highly unlikely to be referring patients to traditional healers for treatment of psychiatric disease.It was therefore considered that the prescription rate for psychotropic drugs parallels the diagnosis rate.

METHOD:
On a predetermined day, not known to prescribing doctors and health assistants, all prescriptions were collected from the hospital pharmacy at the end of the day and analysed to see which contained a psychotropic medication.
The following drugs were considered to be "psychotropic", all antidepressants, all benzodiazepines, all antipsychotics, major tranquillisers and lithium.Medications excluded were: Antiepileptics including phenobarbitone, vitamin preparations including all B vitamins and propranolol.The prescription of tricyclics for other purposes (eg nerve pain) was considered too small to significantly affect the result.The study was performed on a day when no psychiatric clinic was run in the hospital so as to chiefly reflect the performance of the outpatient (Primary Care) department where about 75% of prescriptions originate.

RESULTS:
On the given day 378 adult patients and 164 children were seen in the Primary Care department.The Medical, Paediatric, Gynaecological and Surgical outpatient Departments also saw patients that day (number about 150 total) and wrote outpatient prescriptions which were indistinguishable from Comparing this with gold standard of 7%, and using the Z test and standard error of proportion we find that for a sample size of 649 should yield 45 psychotropic prescriptions (+/-14 for 2SD).Thus the result lies far outside the 99% confidence limit (P>0.01) and is therefore very highly significant.This would still be true even if the gold standard had been set much lower.

DISCUSSION:
Patan hospital's psychotropic prescribing habits lie far outside the expected values.There are several reasons why Patan hospitals Primary Care department may see a smaller proportion of psychiatric patients than might be expected.A large Government Mental Hospital is situated about three hundred yards from Patan Hospital.Patients may go there in preference.However, mental disease is heavily stigmatised and most patients with psychiatric disorder in Nepal initially understand their illness to be physical so this seems a weak confounding factor.
It could be argued that because the study took place on a day when the psychiatric clinic was not running that all patients needing psychotropics were being adequately prescribed for by that clinic.This was taken into account however when chosing the gold standard.Also the low numbers being treated in the psychiatric clinic do not bear this out (about 30 per week).
It seems certain that appropriate prescription of psychotropics is often missed for reasons which may include the following: Some authors have noted that treatment of depression in Asian patients may be unsatisfying because of patients' unwillingness to accept the diagnosis and reluctance to take treatments that have little immediate effect. 6This is backed up by the author's personal experience that patients in Nepal find psychiatric diagnoses unsatisfactory explanation for their symptoms.Watson has described success with a way of communicating psychiatric diagnoses to Nepali patients which avoids terms equivalent to "mental" and uses the Napali word for "nerve disease". 7dicine is taught with emphasis on organic disease in Asian Medical Schools, training institutes and teaching hospital.Medical specialists hold a greater respect than generalist or psychiatrists and social/psychological models of disease are poorly understood in this environment.

CONCLUSION:
Patan Hospital as a whole prescribes psychotropic drugs to outpatients at a rate per patient far lower than expected.This almost certainly reflects a failure to diagnose and treat patients with remediable and life threatening disorders.
To meet the gold standard will require significant reorientation of staff and this will involve new models of illness for both the patient and the prescribers.