Differences in diagnostic distributions of mental disorders between a general hospital and a specialized center: a cross-sectional studyABSTRACT
Introduction: The distribution of mental disorders is expected to differ between patients treated in general hospitals and those receiving care in specialized psychiatric centers, but evidence remains limited. We aimed to describe and compare the observed frequencies of mental disorders in two psychiatric services, each corresponding to one of these settings.
Methods: We conducted a cross-sectional study through medical record review in both hospitals. Eligible records had at least one diagnosis documented by a psychiatrist or psychiatry resident. For comparability, the first ICD-10 diagnosis assigned to each patient was considered the reference. Diagnoses were grouped into seven classes: neurodevelopmental disorders (F70–F99), organic (F00–F09), drug-related (F10–F19), schizophrenia spectrum (F20–F29), bipolar (F30, F31, F34.0, F38, F39), depressive (F32, F33, F34.1), and anxiety-related/personality disorders (F40–F59, F60–F69). Diagnostic distributions were compared using Pearson's χ2 test (p < 0.05).
Results: A total of 327 records were analyzed. Pearson's χ2 test indicated significant differences between samples (χ2 = 34.12, df = 6, p < 0.001). Schizophrenia spectrum and bipolar disorders were more frequent in the specialized center, whereas depressive and organic disorders predominated in the general hospital.
Conclusion: In this study, psychiatric populations of the general and specialized hospital presented distinct diagnostic distributions. These findings, though limited by sample size, sampling procedures, absence of sociodemographic data, and the focus on primary diagnoses, contribute descriptively to the scarce Brazilian literature on psychiatric diagnostic profiles and suggest that clinical practice, together with diagnostic biases inherent to unstructured assessments, may influence recorded frequencies.
KEYWORDS
Mental Disorders; Cross-Sectional Studies; General, Hospitals
RESUMO
A distribuição dos transtornos mentais tende a variar entre pacientes atendidos em hospitais gerais e aqueles acompanhados em serviços psiquiátricos especializados, embora as evidências sobre essas diferenças ainda sejam limitadas. Este estudo teve como objetivo descrever e comparar as frequências observadas de diagnósticos psiquiátricos em dois serviços hospitalares, representando esses diferentes contextos assistenciais.
Métodos: Trata-se de um estudo transversal baseado na revisão de prontuários médicos. Foram incluídos prontuários com ao menos um diagnóstico registrado por psiquiatra ou residente de psiquiatria. Para fins de comparabilidade, considerou-se o primeiro diagnóstico classificado conforme a CID-10 atribuído a cada paciente. Os diagnósticos foram agrupados em sete classes: transtornos do neurodesenvolvimento (F70–F99), orgânicos (F00–F09), relacionados ao uso de substâncias (F10–F19), do espectro da esquizofrenia (F20–F29), bipolares (F30, F31, F34.0, F38, F39), depressivos (F32, F33, F34.1) e ansiosos/de personalidade (F40–F59, F60–F69). As distribuições diagnósticas foram comparadas por meio do teste qui-quadrado de Pearson (p < 0,05).
Resultados: Foram analisados 327 prontuários. Observou-se diferença significativa entre as amostras (χ2 = 34,12; gl = 6; p < 0,001). Transtornos do espectro da esquizofrenia e bipolares foram mais frequentes no centro especializado, enquanto transtornos depressivos e orgânicos predominaram no hospital geral.
Conclusão: As populações psiquiátricas dos dois serviços apresentaram perfis diagnósticos distintos. Apesar das limitações relacionadas ao tamanho e à composição amostral, à ausência de dados sociodemográficos e ao foco nos diagnósticos principais, os resultados contribuem de forma descritiva para a literatura nacional sobre perfis diagnósticos em psiquiatria e sugerem que fatores clínicos e vieses diagnósticos inerentes a avaliações não estruturadas podem influenciar as frequências observadas.
PALAVRAS-CHAVE
Transtornos Mentais; Estudos Transversais; Hospitais Gerais
INTRODUCTION
The study of the distribution of diseases is essential for clinical practice and public health planning. For clinicians, such data affect the predictive value of any diagnostic investigation1. In public health, epidemiological studies measure the burden of health-related conditions and provide information for health authorities to evaluate population needs2,3. Therefore, studies on the frequency and distribution of diseases support informed decisions in both clinical and public health contexts.
Epidemiological studies on mental disorders in Brazil remain limited despite their importance4. To date, only two large-scale studies have investigated the rates of psychiatric disorders among adults in the community4-7. However, no comprehensive, nationally representative study has yet assessed the occurrence of mental disorders in the Brazilian population with a robust methodology and minimal limitations8. Nevertheless, research in Brazil has examined the distribution of mental disorders in specific settings or populations. Many of these studies have focused on common mental disorders among primary care patients or working populations, often identifying socioeconomic and environmental factors associated with psychological distress4,8,9. These findings highlight the need for more extensive and systematic research to address the shortcomings in national mental health data.
In this regard, studies describing the diagnostic distribution of patients treated in psychiatric services, whether in general hospitals or specialized centers, are also scarce in the Brazilian literature. Patients treated in general hospitals typically represent a broader sample of the general population, whereas those treated in specialized psychiatric centers are, in theory, a subpopulation with more complex or severe conditions. Consequently, these populations are expected to differ in their nosological profiles10. However, there is insufficient data to substantiate this hypothesis.
With this in mind, we conducted a cross-sectional study to describe and compare the observed frequencies of mental disorders among patients receiving care at two psychiatric services: one located within a general hospital and the other part of a center exclusively dedicated to psychiatry and mental health. Data were collected through a review of medical records, focusing on the first diagnosis assigned to each patient. Both study settings are affiliated with the Federal University of Rio de Janeiro (UFRJ).
METHODS
Study Setting
This study was conducted at the Institute of Psychiatry of the Federal University of Rio de Janeiro (IPUB) and the Clementino Fraga Filho University Hospital (HUCFF). Both institutions are affiliated with the Federal University of Rio de Janeiro and are part of the Brazilian public health system. They provide higher education and tertiary healthcare services, delivering high-complexity care for patients who require specialized interventions.
IPUB is an institution dedicated exclusively to psychiatry and mental health. Its general outpatient clinic offers free treatment and follow-up to adult individuals from the city and state of Rio de Janeiro, most of whom are referred from primary care.
Patients arriving for their first appointment at the general outpatient clinic are interviewed by a multidisciplinary team composed of a nurse, a social worker, and a third-year resident physician. The team jointly evaluates whether the patient should be treated at the service and formulates a diagnostic hypothesis, which is documented in their medical record as the admission diagnosis, using a code from the International Classification of Diseases (ICD). Once admitted to the general outpatient clinic, the patient is referred to the care of one of the resident physicians in their first year of training. The resident physician will then continue to assist the patient for two years on. The residents’ training is supervised by senior psychiatrists.
Unlike IPUB, HUCFF is a general hospital that offers, in addition to nearly all medical specialties, a service in psychiatry and medical psychology. Patients at HUCFF are primarily treated at this hospital due to the presence of complex organic diseases rather than mental disorders. Consequently, the psychiatry service at HUCFF plays a crucial role as a consultation-liaison psychiatry service11. This means that its outpatient clinic accepts new patients based on consultation requests from other medical specialties within the hospital, as well as referrals from colleagues in other health units. Patients who were previously admitted to the service's inpatient unit may also continue to receive follow-up care at the outpatient clinic. So far, the service has not received patients referred directly by the primary care of the public health system. Additionally, the psychiatry residency program at HUCFF was established only in 2013, making it relatively recent compared to the psychiatry specialization program at IPUB, which was founded in 1969. Prior to the establishment of the psychiatry residency at HUCFF, patients in the psychiatry and medical psychology service were treated by physicians and professors hired by the institution.
At both IPUB and HUCFF, unstructured psychiatric interviews are the standard practice for physicians in the clinic and should be conducted with a view to formulating – or maintaining – a diagnostic hypothesis after each consultation. Medical records should include this information, as well as data on the course and outcomes of treatment. As of the time of writing this paper, diagnoses are recorded using ICD-10 disease codes.
Study Design
In this cross-sectional study, the medical records of patients attended at the general outpatient clinic of IPUB were analyzed, as well as those of patients followed by the psychiatry and medical psychology service at HUCFF. The method of selecting medical records differed between the two institutions. At IPUB, the records were selected randomly, while at HUCFF, they were selected based on convenience. Random selection was feasible at IPUB because it is a specialized psychiatric institution, ensuring that all records pertained to patients with psychiatric disorders. In contrast, at HUCFF, a large general hospital, convenience sampling was necessary. Random selection there might have yielded records of patients with no history of psychiatric care, and we lacked the resources and time to screen for such cases systematically. Thus, at HUCFF, the records were obtained from outpatient clinic lists and inpatient ward registers.
We acknowledge that the distinct sampling strategies (random at IPUB and convenience at HUCFF) may have introduced selection bias, and this difference is discussed in the Limitations section. No formal sample size calculation was performed, as the study aimed to describe diagnostic distributions in available records rather than to test predefined hypotheses. We recognize that the final number of records (n=327) is modest and limits the power of statistical comparisons.
The inclusion criterion applied was: (1) having at least one diagnosis recorded by a psychiatrist or psychiatry resident during the patient's follow-up period in the unit. The exclusion criterion was: (1) not having been assessed, hospitalized, or followed by the psychiatry service. Of the initially selected 603 medical records, a total of 327 met the inclusion and exclusion criteria. The process of reviewing medical records spanned from February to September 2024.
For analytic purposes, we explicitly defined the cutoff point as the first psychiatric diagnosis recorded by a psychiatrist or psychiatry resident, used as the reference diagnosis. This choice aimed to ensure comparability across records and avoid confounding by later changes during follow-up. However, we recognize that not distinguishing between initial, crisis-related, or later diagnoses may limit interpretive precision.
Sociodemographic data were not systematically collected from medical records and therefore were not included in the analysis.
Procedure
The 327 medical records were reviewed to identify the first psychiatric diagnosis assigned to the patient by a psychiatrist or psychiatry resident at the institution. Next, the identified diagnoses were organized in a table using ICD-10 codes. The older diagnoses based on ICD-9 codes were translated into ICD-10 codes12.
For statistical analysis, a single diagnosis was considered per evaluation, even when there was more than one diagnostic hypothesis or comorbid diagnoses. Although comorbidities are common in psychiatric populations, we analyzed only the primary diagnosis, following ICD-10 hierarchy13, to ensure comparability and avoid double-counting. In this framework, the ICD prioritizes organic diagnoses over non-organic ones. Consequently, F0 and F1 codes take precedence over F2, F3, F4, F5, and F6. Moreover, neurodevelopmental disorders (a group in which our study included F7, F8, and F9 codes) are considered organic in nature and typically develop earlier than dementias or substance use disorders. Therefore, we chose to grant them precedence over the other categories.
Having made this initial analysis, the ICD-10 codes were grouped under the major diagnostic groups shown in Table 1. The statistical analysis was based on the data extracted from the final table containing the diagnoses classified into the major diagnostic classifications. All data that would identify the records and the patients were removed to ensure anonymity.
Statistical analysis
A descriptive analysis was performed based on the number of diagnoses categorized by major diagnostic groups at each institution. This approach allowed for the determination of the relative frequency of each diagnostic group within the sample at each institution, serving as a descriptive measure of the diagnostic distribution in each setting. Results were rounded to two decimal digits.
Diagnostic distribution between both hospital samples were compared using Pearson's X2 assuming a critical p value of < 0.05 for statistical significance. Diagnostic tabulation, descriptive analysis, and Pearson's test were calculated with R-commander package for R statistic software for windows, version 4.4.114.
The data for this study were collected as part of the research project "Diagnostic Validity in Psychiatry: an analysis of longitudinal diagnostic stability in clinical practice", which was approved by the research ethics committee of IPUB/UFRJ and HUCFF/UFRJ (approval no. 75470823.5.0000.5263 and no. 75470823.5.3004.5257).
RESULTS
Pearson's X2 test revealed significant differences in the observed frequencies of diagnoses across the samples (X2 = 34.12, df = 6, p < 0.001), indicating that the diagnostic distributions between the hospitals are not identical. This finding supports the hypothesis that general and specialized hospitals exhibit distinct diagnostic profiles. Nevertheless, these results warrant further exploration through a descriptive analysis.
We found similar observed frequencies between the two hospitals for anxiety-related disorders, drug-related disorders, and neurodevelopmental disorders. However, the observed frequencies of bipolar disorders and schizophrenia spectrum disorders - often classified as "severe mental illnesses" - were higher at IPUB. In contrast, depressive disorders and organic mental disorders were more frequent at HUCFF (see Table 2 for absolute counts and relative frequencies). The observed frequencies of anxiety-related disorders and depressive disorders were high in both hospitals, ranking as the second and third most common diagnoses at IPUB, and as the first and second most common at HUCFF.
In both samples, we observed an apparent scarcity of certain diagnoses, such as post-traumatic stress disorder (only two cases at IPUB and one at HUCFF), obsessive-compulsive disorder (only one case at IPUB), pervasive developmental disorders (F84 in ICD-10, with only one case at IPUB), and eating disorders (only one case of binge eating disorder at HUCFF, and one of bulimia at IPUB). At HUCFF, some diagnoses within the anxiety-related disorders group stood out: one case of fibromyalgia, one of factitious disorder, one of skin-picking disorder, and one psychogenic non-epileptic seizure. No cases of ADHD were identified in either sample.
Although Pearson's X2 tests were performed to compare the diagnostic distributions between the two hospitals, these analyses have an exploratory and descriptive character and should be interpreted only as observations of the frequencies in the medical records evaluated, without pretense of population inference. Considering that no formal calculation of the sample size was performed and that the two groups were obtained by different strategies (random sampling in the IPUB and convenience sampling in the HUCFF), statistical comparisons are subject to selection bias and have limited inferential validity. Therefore, the results should be understood as a description of the diagnostic distributions in the specific samples studied.
DISCUSSION
Our study revealed distinct nosological profiles of psychiatric patients treated in a general hospital compared to those treated in a specialized center. In both hospitals, anxiety-related and depressive disorders collectively accounted for a substantial proportion of the total diagnoses (64% at HUCFF and 41% at IPUB). In contrast, a key difference between the two hospitals was the higher frequency of severe mental disorders observed at IPUB compared to HUCFF. Furthermore, organic mental disorders and depressive disorders were more frequent at HUCFF than at IPUB.
Other epidemiological studies conducted with the Brazilian population have also reported high frequencies of anxiety and depression, reflecting a global trend5,6,8. Still, notably, at IPUB, the combined observed frequencies of schizophrenia spectrum disorders and bipolar disorder accounts for 41% of all diagnoses, the same proportion as the combined observed frequencies of anxiety and depressive disorders at the same institution.
As far as we know, this is the first study aiming to compare the nosological profiles of mental disorders among patients receiving care from psychiatry services at a general hospital (HUCFF) and a specialized psychiatry center (IPUB) in Rio de Janeiro. An extensive literature review revealed few studies addressing the epidemiological profile of patients treated in psychiatry teaching clinics15-17. We identified only one previous study examining the frequency of mental disorders at IPUB, conducted in 201818. In this study, Oliveira et al. reported a high frequency of severe and persistent mental disorders, including schizophrenia spectrum disorders and bipolar disorders, findings that align closely with those of our study. They attributed this high frequency of severe and persistent mental disorders to the institution's high level of complexity. Additionally, we found only one earlier study, conducted in 1997, that analyzed the nosological profile of patients treated by the Psychiatry and Medical Psychology Service at HUCFF19. This study, conducted by Fortes and Campos (1997), analyzed diagnoses made during initial consultations based on the ICD-9 classification. The authors reported a predominance of neuroses (hysterical, anxious, and depressive) and a minority of psychotic patients, findings consistent with those observed in the HUCFF patient sample in our study.
The disparity regarding the higher frequency of schizophrenia spectrum disorders and bipolar disorders at IPUB compared to HUCFF may be explained by the pathways through which patients access these services. At IPUB, it is assumed that patients are referred following evaluations in their local territories, in primary care, which act as filters for severity and complexity. Consequently, cases arriving at IPUB for screening are more likely to represent severe disorders. In contrast, the psychiatry service at HUCFF historically absorbed patients differently, primarily through internal consultations within the general hospital19. These patients were often already under the care of other specialties within the hospital and subsequently began psychiatric follow-up without considering the availability of mental health services in their local areas that handle less complex cases. As a result, patients were frequently integrated into the psychiatry service without assessing whether tertiary care was necessary. For cases deemed less severe or complex, referrals to primary or secondary care within the patient's residential territory were not consistently made. This lack of filtering may explain why the observed frequency rates of diagnoses at HUCFF more closely resemble those observed in primary care settings or the general population5,8,20,21.
The institutional context is also relevant when interpreting our findings, as HUCFF is not a typical general hospital but rather a university-affiliated one. This context shapes its patient population and may explain some of the diagnostic patterns observed in our study. As a tertiary university hospital, HUCFF primarily admits patients due to complex, severe, or rare organic diseases, and the psychiatry service often provides support to other specialties within the hospital. Consequently, the psychiatric caseload at HUCFF may be enriched with secondary psychiatric conditions and cases linked to severe clinical disorders, which could contribute to the higher frequency of organic and depressive disorders observed in this setting.
In the study by Fortes and Campos (1997), the authors also sought to explain the observation of a minority of psychotic patients treated in the general hospital. They hypothesized that individuals with severe mental illness have their own distinct and specialized spaces for treatment. Additionally, they observed that, as the Psychiatry and Medical Psychology Service at HUCFF functions as a support unit for other departments within the hospital, the patient population it serves tends to reflect cases of hidden mental health issues among individuals seeking clinical care19.
Interestingly, Fortes and Campos (1997) reported a low rate of diagnoses of Organic Mental Syndromes in his work and hypothesized that this proportion would increase in the future with training provided to professionals and residents in the psychiatry service at HUCFF19. In this context, our study found a higher frequency of organic mental disorders at HUCFF compared to IPUB. In our view, this is reasonable, particularly when considering that some of the diagnoses identified in the medical records revealed mental disorders secondary to clinical diseases typically treated in tertiary university hospitals, such as lupus and Wilson's disease. Furthermore, the presence of certain specific diagnoses at HUCFF - such as fibromyalgia, factitious disorder, skin-picking disorder, and psychogenic non-epileptic seizures - leads us to assume that somatizing patients seek clinical hospitals, believing their issues to be of organic origin. In fact, some previous studies on the Brazilian population have highlighted high rates of somatoform disorders4,5,21.
In our study, drug-related disorders showed frequency rates similar to those reported in previous community studies conducted in Brazil20. However, most of these studies analyzed alcohol use separately, treating it as an independent group4,5. In this context, some studies have identified alcoholism as one of the most frequent disorders, particularly among men, alongside anxiety and depression. In contrast, our study encompassed substance use as a whole under drug-related disorders. In the reviewed medical records, we identified the diagnostic descriptors F10, F12, F14, and F19, corresponding to mental and behavioral disorders associated with the use of alcohol, cannabinoids, cocaine, and multiple substances, respectively. Consequently, our study may have underestimated the frequency of alcohol use disorders. This underestimation could be attributed to diagnostic bias among physicians, as will be discussed later. Another possibility, specifically in the case of IPUB, is that patients whose primary health issue is substance dependence are redirected to a specialized research outpatient clinic for substance use and addiction rather than being followed up in the general outpatient clinic. The same limitation applies to disorders related to tobacco use, as their diagnostic descriptor was not identified in the medical records reviewed in our study. In contrast, in the study conducted by Andrade et. al (2002), tobacco use significantly inflated the prevalence of substance use disorders because it was specifically assessed using a structured diagnostic instrument4.
We were struck by the scarcity of certain diagnoses in the sample, such as ADHD, PTSD, OCD, and eating disorders, despite their reported high prevalence rates in other studies21-23. At IPUB, this finding may be explained by the presence of specialized research outpatient clinics for specific conditions, including panic disorder and OCD, eating disorders, PTSD, and dementia. Patients diagnosed with these disorders during the general clinic screening are likely referred directly to these specialized clinics, with their medical records filed within the respective clinic archives. Additionally, these specialized clinics have open access, meaning patients can seek care directly without first going through the general outpatient triage. However, at HUCFF, there are no such specialized clinics, which suggests the need for a different explanation for the underrepresentation of certain diagnoses. One hypothesis is the presence of diagnostic biases among clinicians, such as premature closure (early stop) and recall bias (memory bias). In this context, the development of structured interviews in psychiatry aimed to reduce biases such as these24. However, a distinguishing feature of our study is that it relies on diagnoses reflecting how clinicians make diagnostic decisions in real-world practice, at least within academic settings. In clinical practice, clinicians typically formulate diagnostic hypotheses based on unstructured interviews and likely employ a prototypical approach25-27. In contrast, most of the studies reviewed in the literature analyzed diagnoses made using structured diagnostic instruments, which are not commonly used in routine clinical practice24,28.
Both IPUB and HUCFF are university hospitals where undergraduate and postgraduate students, including residents, engage in hands-on clinical training. This raises the question of whether the differences in the diagnostic profiles between the two hospitals might influence the learning experience of these students. This is particularly relevant for students at IPUB, which, as our study revealed, has a higher observed frequency of severe mental disorders, resulting in a nosological profile distinct from that of the general population.
Our study has several important limitations. First, we did not collect sociodemographic variables from the medical records included in the sample. As a result, it was not possible to analyze correlations between diagnostic distributions and demographic characteristics such as age, sex, or socioeconomic status, which profoundly restricts interpretation.
Second, the sample size was modest (n=327), and the criteria for selecting records differed between institutions—random sampling at IPUB and convenience sampling at HUCFF. These methodological differences may have introduced selection bias, further compounded by the absence of integrated electronic medical record systems in both hospitals. Data collection was also conducted by a single researcher, which may have increased the risk of extraction errors. No formal sample size calculation was performed, since the study aimed to provide descriptive information rather than to test predefined hypotheses; nonetheless, the limited sample reduces statistical power.
Third, we considered only the first diagnosis recorded in each patient's medical record as our reference point. This strategy enhanced comparability and minimized confounding by later diagnostic changes, but it also precluded distinguishing between initial, crisis-related, or late diagnoses, thereby reducing interpretive precision.
Fourth, we analyzed only the primary diagnosis according to ICD-10 hierarchy. Although this ensured consistency and avoided double-counting, it excluded comorbidities, which are highly prevalent and clinically relevant in psychiatric populations. This limitation should be considered when interpreting our findings.
Finally, our findings are descriptive of the diagnostic distributions in these two academic hospital settings and cannot be extrapolated to the general population.
Despite these limitations, our study fulfilled its descriptive aim of comparing diagnostic distributions in two academic hospital settings in Rio de Janeiro. These findings provide insight into the clinical profiles of patients seen at a specialized psychiatric hospital and a general hospital, without implying generalization to the wider population. They may nonetheless serve as a reference for clinicians working in similar contexts and as a basis for future, more rigorous studies.
CONCLUSIONS
Our study demonstrated that psychiatric populations in a specialized center (IPUB) and in a general hospital (HUCFF) exhibit distinct diagnostic distributions, with severe mental disorders predominating at the specialized center and depressive and organic disorders more frequent at the general hospital. While the findings are limited by sample size, selection procedures, absence of sociodemographic data, and the focus on primary diagnoses only, they provide a descriptive contribution to the scarce Brazilian literature on psychiatric diagnostic profiles. Moreover, by reflecting unstructured clinical practice in academic settings, the study also highlights the role of potential diagnostic biases in shaping recorded distributions.
DATA AVAILABILITY STATEMENT
The data that support this study are available from the authors upon request.
ACKNOWLEDGMENTS
We extend our sincere gratitude to Antonio Leandro Nascimento for his valuable contributions regarding the psychiatry service at HUCFF and for facilitating the principal researcher's access to the institution.
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