What are the most commonly diagnosed psychological disorder?

Introduction

Mental disorders are among the top causes of morbidity and account for approximately 14% of all deaths globally [45] and approximately 11% of the world’s population currently lives with a mental disorder [29]. Alarmingly, this estimate is higher in Puerto Rico, as revealed by findings from a recent behavioral health needs assessment conducted on the island. This assessment reported 12-month prevalence rates for any mental disorder to be approximately 24% among adults ages 18 to 64 [9]. Moreover, Puerto Ricans with a serious mental illness make up 7.3% of the adult population. It is estimated that nearly half [43.1%] of Puerto Rican adults with some type of mental disorder are in need of mental healthcare services [9]. These findings elucidate the magnitude of the mental health disparity crisis on the island, with inaccessible quality mental healthcare being a leading driver of such disparity [21, 43]. Since 2008, there has been a consistent migratory stream from the island to the United States. Included in this efflux of people are specialty mental healthcare providers such as clinical psychologists and psychiatrists, which further worsens the conundrum of lack of access to quality mental healthcare services [41, 42]. Thus, there is an urgent need to address this. Considering many patients receive medical and surgical care from general hospitals, these institutions are uniquely situated to facilitate access to mental healthcare services through rapid identification of mental disorders and initiation of appropriate interventions. In fact, a recent meta-analysis revealed that between 4 and 32% of inpatients receiving care in a non-psychiatric general hospital setting evidenced clinically significant levels of depression [46]. An earlier review of epidemiological studies revealed the prevalence of mental disorders in general hospital inpatients ranged from 41 to 46%, with organic brain syndrome, adjustment disorders with depressed mood and alcohol abuse being the three most commonly diagnosed [30]. Such a characterization has yet to be accomplished in Puerto Rico. Thus, the current study’s research team implemented a retrospective observational study of cross-sectional data to assess the most frequently diagnosed mental disorders in medical and surgical inpatients of a general hospital system in southern Puerto Rico between 2015 and 2019.

In order to achieve such a characterization, the systems that facilitate rapid identification of mental disorders and the provision of mental health services for medical and surgical inpatients of a general hospital are of critical value and worth briefly mentioning. Two widely used systems to integrate mental and physical health care of medical patients are the collaborative care [40] and consultation-liaison models [39]. The collaborative care model is mostly used in outpatient, primary-care settings and have limited implications for use in general hospital settings. The consultation-liaison [C-L] model, however, is more relevant for this present study’s aim and in fact, is the model which was used by our clinical team as detailed in the methods section below. Briefly, the C-L model entails two distinct yet overleaping components as the name implies: consultation and liaison. The consultation component is a process whereby attending physicians, surgeons, patients themselves or family members may request mental health services, and a clinical team member responds to this request by conducting an initial assessment, arriving at a clinical diagnostic impression, facilitating interventions as needed and making appropriate referrals if warranted. Liaison services are an especially crucial aspect in the provision of mental health care services to medical inpatients as this component requires a certain degree of integration at not only the service level [i.e., multidisciplinary teams] but at the organizational level as well [37]. Most attention in the literature, however, is given to the consultation aspect of the C-L model [14]. This selective attention is rather unfortunate as the liaison component, as overviewed in the discussion section below, is an aspect that warrants urgent attention and widespread implementation to achieve integrated care models in general hospital settings in an effort to curtail the mental health disparities that exist among medical populations such as in Puerto Rico. The success of detecting current mental disorders and facilitating interventions among the sample of medical and surgical inpatients of this present study is owed, in part, to the clinical health psychology C-L integration model implemented.

Methods

The research team conducted a retrospective study examining cross-sectional biopsychosocial variables obtained from a sample of 5494 inpatients that received medical or surgical care from a general hospital in Ponce, Puerto Rico between January 2015 and December 2019.

Participants

Participants were inpatients age 21 years and older, admitted to cardiovascular surgery, coronary care, intensive care and skilled nursing units of Damas Hospital, a general hospital in Ponce, Puerto Rico. These patients received a standardized clinical evaluation at bedside during their hospital stay and gave informed consent for data collection. Patients diagnosed with a current depressive, neurocognitive, anxiety, substance-related, and addictive and schizophrenia spectrum disorders according to DSM-5 criteria during their bedside standardized clinical evaluation were included in the study as these diagnostic categories were the most commonly diagnosed during this four-year period. Additionally, those who did not meet DSM-5 criteria for a current diagnosis during hospitalization were included as a comparison group. The Institutional Review Board of the Ponce Research Institute approved this study. Every author certifies that the study was performed in accordance with the ethical standards, as set by the 1964 Declaration of Helsinki and its later amendments.

Procedures

Clinical team

The Clinical Psychology Services Program [CPSP] of Ponce Health Sciences University provides clinical health psychology services that include screenings, standardized clinical evaluations, brief psychotherapy, psychophysiological interventions, neuropsychological rehabilitation, and consultation-liaison [C-L] services in general hospital settings across the southern region of Puerto Rico. The provision of C-L health psychology services at Damas Hospital is the product of an academic agreement between Ponce Health Sciences University and Damas Hospital, an agreement that has been ongoing since 2002. The clinical team is coordinated by a psychiatrist and is made up of three licensed clinical psychologists, two of which are health psychologists, and one is a certified neuropsychologist. Additionally, 12 advanced practicum students of the PhD and PsyD clinical psychology programs of Ponce Health Sciences University are part of the clinical team and receive on-site, same day supervision for each patient seen and standardized clinical interview performed. The CPSP have established agreements with affiliate hospitals where standing orders are in place for select hospital units. Standing orders are the backbone of the clinical team’s liaison services and entail the administration of routine standardized clinical evaluations for all patients admitted to the following units: [a] cardiovascular surgery, [b] coronary care, [c] intensive care, and [d] skilled nursing units. Additionally, the clinical team provided clinical health psychology consults as requested by attending physicians, regardless of the inpatient unit to which the patient was admitted. For this present study, the research team analyzed sociodemographic and psychosocial data, current ICD-10 medical diagnoses, and current DSM-5 mental disorder diagnoses the CPSP clinical team made at patients’ bedside during the standardized clinical evaluation.

Standardized clinical evaluation

The standardized clinical evaluation entailed a mental status examination, exploration of psychological and emotional symptoms, a review of past physical and mental illness history, and a review of social functioning. Clinical inventories such as the Mini Mental Status Exam [15], Beck Depression Inventroy-II [6], and Beck Anxiety Inventory [7] were used to aid in the exploration of mental status and psychological-emotional symptomology. Additionally, a review of laboratory results, medications, and physician and nurse progress notes was conducted to aid in ruling out organic causes of possible mental aberrations. The CPSP clinical team performed the standardized clinical evaluation at the patient’s bedside. If warranted, the clinical team made a current DSM-5 diagnosis and a corresponding brief treatment plan was implemented for the duration of the patient’s hospital stay. For patients that did not evidence clinically significant symptoms as determined by the DSM-5 during evaluation, no diagnosis was made, and these patients’ data was used as a comparison group. The clinical inventories mentioned above were not included in the data analysis process as these measures were not available in the digital database alongside the current DSM-5 diagnoses and sociodemographic variables.

Measures

Sociodemographic, medical diagnosis, and past mental health history

Questionnaires generated by the clinical team were used to collect the following biopsychosocial variables: age, biological sex, civil status, level of education, employment status, and monthly household income. Past history of mental disorder and history of substance use/abuse variables were also included in the study. ICD-10 medical diagnoses were obtained from chart reviews performed by the CPSP clinical team.

Data analysis

SPSS 27 [IBM Corp] was used to perform data analysis. Data preparation and exploration procedures were conducted, and data was examined for errors and quality. Missing data analysis was conducted, and missing variables were replaced with multiple imputation linear regression method, with 10 imputations utilized. [31]. All missing data [12—monthly household income variables and 23—civil status variables] in this dataset were less than 5%. Descriptive statistics were performed to assess measures of central tendencies, standard deviation, and confidence intervals. Chi-squared tests of independence were conducted to assess associations between the top five diagnosed mental disorders and select sociodemographic indicators. Multinomial logistic regressions were conducted to evaluate the odds of being diagnosed with a DSM-5 depressive, neurocognitive, anxiety, substance-related, or schizophrenia spectrum disorder compared to no disorder among inpatients. The Benjamini-Hockberg procedure [8] was applied to control for false discovery rates due to multiple comparisons in the adjusted multinomial logistic regression model.

Results

Data from a total of 5494 inpatients was analyzed. The mean age of this patient sample was 62.2 years, 95% CI [61.75, 62.65]. There were more females [57.8%] than males and the majority of patients were unmarried [53.2%]. Additionally, 83.6% were unemployed or retired and 26% reported having obtained less than a high school education. Overall, more than half [53%] of the entire sample was diagnosed with a current DSM-5 mental disorder during hospitalization. Major depressive disorders accounted for 42%, neurocognitive [33%], anxiety [11%], substance-related [8%], and schizophrenia spectrum [6%] of the five most frequently diagnoses made by the CPSP clinical team. Further, 97% of all patients evidenced a chronic physical condition. Ninety-nine per cent [99.4%] of male patients had a chronic physical condition compared to 95% of female patients. Fifty-nine percent [59%] of male patients had comorbid mental and physical conditions compared to 48% of females.

Specific DSM-5 diagnoses

Among major depressive disorders diagnoses [MDD], recurrent episodes [70%] were most frequently diagnosed and recurrent episodes with psychotic characteristics [6.9%], the least frequent. Within neurocognitive disorders [NCD], delirium due to another medical condition [24.8%] was most commonly diagnosed and unspecified delirium [6.8%] the least common. Generalized anxiety disorder [72.5%] was the most frequently diagnosed anxiety disorder and alcohol use disorder [48%] the most frequently diagnosed substance-related disorder. Schizophrenia and brief psychotic disorder were the most and least common diagnosed within the schizophrenia spectrum disorders, 34.6% and 6.7%, respectively.

Comorbid chronic physical conditions and diagnosed mental disorders

Overall, cardiovascular disease, orthopedic conditions, chronic respiratory, gastrointestinal and cancer diagnoses were the most prevalent comorbid medical conditions in this sample. Thirty-five percent [35%] of this sample were evaluated in the skilled nursing unit, 24% coronary care, 22% intensive care and 19% cardiovascular surgery unit. Among patients diagnosed with major depressive disorders, slightly more than one in five patients [24%] also lived with a co-occurring cardiovascular disease. The least frequent co-occurring chronic physical disease among patients with depressive disorders was immunologic disease, accounting for 0.2% of all ICD-10 diagnoses among this patient group. Chronic neurological diseases were the most common co-occurring physical conditions among patients diagnosed with a DSM-5 neurocognitive condition [22%], and chronic endocrine disorders [1%] were the least common. Slightly more than one out of every four patients [27%] diagnosed with an anxiety disorder also had a co-occurring cardiovascular disease. Chronic immunologic disorders were least common among this group of patients, accounting for 0.3% of ICD-10 diagnoses. Similarly, patients diagnosed with a substance-related disorder had higher cardiovascular disease comorbidity [18%] than any other chronic physical condition. Lastly, among patients diagnosed with a schizophrenia spectrum disorder, 5.8% also lived with a co-occurring cardiovascular disease.

Routine standardized clinical evaluations as part of the administrative standing orders accounted for 84% of all DSM-5 diagnoses made and the remaining 16% were made from physician or patient requested consults. The two most common diagnoses resulting from the administrative standing orders [routine standardized clinical interviews—the liaison component] were neurocognitive and major depressive disorders, accounting for 20% and 19%, respectively. Diagnoses made from all consults, however, consisted primarily of major depressive disorders [37%], followed by substance use disorders [9%].

Association of biological sex and mental disorder diagnoses in a general hospital setting

An unadjusted multinomial logistic regression model revealed that biological sex is differentially associated with being diagnosed with a current mental disorder during hospitalization. The overall model was significant χ2 [5] = 215.659, p