|Year : 2015 | Volume
| Issue : 2 | Page : 104-108
Pattern of mental distress among chronic disease subjects in urban Puducherry, India
Kalaiselvi Selvaraj, S Ganesh Kumar, Akkilagunta Sujiv
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||16-Mar-2015|
S Ganesh Kumar
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Aim: Limited information is available on the status of mental distress among chronic disease subjects attending primary care settings in India. This study aimed to assess the pattern of mental distress among chronic disease subjects. Materials and Methods: This facility based cross-sectional study was carried out among chronic disease subjects attending urban health center attached to a Medical Institution in Puducherry, India. Mental distress was assessed by general health questionnaire-12. Data on associated factors were collected by structured questionnaire. Results: Mean age of the subjects was 58.2 12.8 years. Around 80% of the subjects found to have mental distress. Mental distress was comparatively more among females, educated more than middle school, person living in the nuclear family and suffering from joint pain (P < 0.05). Subjects who had both diabetes and hypertension reported more mental distress. Females had comparatively more mental distress after adjusting for potential confounders. Conclusion: Mental distress among chronic disease subjects in this setting is high especially among females screening of this high-risk group may help in taking appropriate interventional measures.
Keywords: General health questionnaire-12, India, mental distress, primary care setting, screening
|How to cite this article:|
Selvaraj K, Kumar S G, Sujiv A. Pattern of mental distress among chronic disease subjects in urban Puducherry, India. CHRISMED J Health Res 2015;2:104-8
|How to cite this URL:|
Selvaraj K, Kumar S G, Sujiv A. Pattern of mental distress among chronic disease subjects in urban Puducherry, India. CHRISMED J Health Res [serial online] 2015 [cited 2020 Dec 4];2:104-8. Available from: https://www.cjhr.org/text.asp?2015/2/2/104/153252
| Introduction|| |
Mental health is an important issue especially among subjects with chronic diseases in developing countries like India. Mental health abnormalities can have a broader spectrum from mental distress to full blown psychiatric disorders. Identification of mentally distressed person at earlier stage in chronic diseases will help the person to come back to their normal life soon. In case of chronic diseases, the impact of mental health problems was more than double compared to those without any disease. ,, In case of diabetes, at least 10-35% of the diabetics were found to have mental health problems most commonly this disease is associated with depression and anxiety disorders. ,,,, Co-existence of diabetes with mental health problems leads to several consequences such as poor blood glucose control, increased incidence of macrovascular complications, increased health care cost and poor quality of life. ,, Existence of mental disorders also increases the likelihood of coronary heart disease among diabetics.  Mental distress also found to be more among subjects with hypertension. ,, Some studies had been conducted in India to assess mental disorders among subjects with chronic diseases. , In this regard, screening for mental distress is an important parameter to be considered among chronic disease subjects.
At primary health care level, it is essential to identify mental disorders through screening. Guidelines by American Diabetes Association as well as International Diabetes Federation insist on mental health screening among diabetic subjects. , For screening in primary care settings, general health questionnaire-12 (GHQ-12) is most commonly used because of a simple question items and easy administration to the subjects.  Within this context, this study was aimed to estimate the prevalence and factors associated with mental distress among chronic disease subjects in urban Puducherry, India.
| Materials and methods|| |
Study design and setting
This is a facility based cross sectional study carried out among chronic disease subjects attending the noncommunicable disease clinic in Urban Health Centre attached to a Medical Institution in Puducherry, India.
Minimum sample size was found to be 247 based on expected prevalence of 10% as mental distress,  4% absolute precision, 5% alpha error with nonresponse rate of 10%.
This urban health center caters to the population of around 9600 from nearby four urban areas. Noncommunicable disease clinic is being conducted in this health center regularly on every Wednesday. In total, there were around 400 patients registered in this chronic disease clinic who belong to service areas of urban health center. Patients were reviewed every fortnightly and given medications free of cost. Hence, it is expected that all chronic disease patients registered in this center will visit this center at least once during this study period. All patients who had hypertension, diabetes, osteo-arthritis and other chronic morbidities attending the chronic disease clinic in urban health center during the month of March 2014 were included in the study. If the patient were not able to comprehend the questions and if they did not make any visit during the study period they were excluded from the study.
The validated GHQ-12 questionnaire had 12 items with coded responses in Likert scale. , Out of these 12 items, six items were directly related to positive mental health and six items were asked in a negative way. Each item was scored from 0 to 3. Hence, the total GHQ-12 can vary from 0 to 36. Patients who had GHQ score more than 12 were classified as having mental distress. 
Method of data collection
After getting informed consent, patients were interviewed regarding sociodemographic characteristics, comorbidities, their present mental health well-being using structured questionnaire. Trained medical interns who were proficient in Tamil interviewed the subjects by face-to-face interview method, and they were supervised by investigators. To assess mental health well-being, validated GHQ-12 was used in Tamil language. Data on alcohol and tobacco use, conflicts in the family, family history of mental disorders were collected. If the subject has taken minimum of 30 ml of 40-50% alcohol or any form of tobacco in the preceding 30 days of the interview, then the subject was considered as current alcohol user or tobacco user respectively.
Sociodemographic characteristics were described in percentages and mean ± standard deviations. Association of mental distress with other personal characteristics was analyzed using Chi-square test and multi-variate analysis. P < 0.05 was considered as significant. Adjusted odds ratio (AOR) obtained from the most parsimonious model is reported in the results section.
| Results|| |
A total of 230 subjects had attended the chronic disease clinic during the study period. Mean age of subjects was 58.2 years ± 12.8 years. Around three-fourth (77.8%) of the participants were females. Half of them were belong to elderly age group, and 67% of them had completed less than primary school education. Majority of the participants (68.7%) had lower or upper lower socio-economic status background. Hypertension was the most common chronic disease (68%) present among the study participants [Table 1].
Overall, 80% of the subjects were identified as mentally distressed. In bi-variate analysis, mental distress was most commonly observed among females, educated more than middle school, person living in nuclear family, having joint pain and reported multiple morbidities at the time of the study compared to males, illiterate, person living in joint or extended families, does not have any joint pain and experiencing no or one morbidity respectively. Factors like substance abuse and history of any family conflict did not have any statistically significant association with mental distress [Table 2]. Though the presence of either hypertension or diabetes did not have any association with mental distress, patients who had both diabetes and hypertension reported comparatively more mental distress. On multivariate logistic regression analysis, when all the factors significant at 0.1% level of bivariate analysis were entered as explanatory variables, only gender and experiencing multiple morbidities were found to be significant factors. Females had significantly more likely to experience mental distress compared to males even after adjusting for other potential confounders (AOR = 3.44 [95% confidence interval (CI) - 1.55-7.64]). Similarly, participants who experienced multiple morbidities had tendency to report more mental distress compared to those who does not have any morbidity or single morbidity alone (AOR = 2.03 [95% CI - 0.97-4.24]) [Table 3].
|Table 3: Multi-variate analysis on mental distress and associated factors|
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| Discussion|| |
This study had shown a high prevalence of mental distress among chronic disease patients. This prevalence of 80% is higher compare to the prevalence of mental distress reported in general population of primary care settings (3-7%)  and among chronic disease patients from other studies (10-40%). ,,, This major difference could be due to the presence of multi morbidities among the subjects in the study. A study done among elderly in the community settings from selected states of India had shown the prevalence of mental distress as 46-55%. This study among elderly had also used same GHQ-12 scale with score 12 as cut-off to determine to mental distress level.  A study from Chandigarh in India also reported the prevalence of mental distress as 51-82% among elderly using a different scale. 
Similar to other studies observation, this study also had shown a high level of mental distress among females, who were suffering from joint pain and those who affected by both hypertension, as well as diabetes. ,,,, The higher prevalence of mental distress among females could be due to lack of coping skills, social support mechanisms, higher prevalence of osteo-artritis among females and availability of time to think over their disease status. In this study, being a diabetic alone did not increase the risk of mental distress, but co-existence of hypertension and other co-morbidities had increased the risk. The similar findings were demonstrated from other studies also. ,, These studies showed occurrence of co-morbidities along with diabetes, macro and Micro vascular complications of diabetes and insulin administration had increased the risk of mental distress not per se by diabetes itself. Age has shown mixed results from various studies. Studies done among the diabetic populations had reported increasing mental distress among younger individuals. In contrast to this, United Nations Population Fund report on status of elderly among selected states of India had shown increasing mental distress as age advances. 
The results of this study should be interpreted carefully. The study tool used in this study was entirely used for screening purpose. Unlike other studies, we did not make any effort to classify the type of psychiatric illness among distressed individuals by primary care physician. Those subjects with total GHQ score more than 12 were referred to a psychiatrist for further evaluation. We could not cover all the subjects registered in the clinic which may affect the outcome. Majority of the subjects were females because many males having chronic diseases receive their medication from private providers.
| Conclusion|| |
Mental distress among chronic disease subjects in this setting is high especially among females. Identification and mental health screening of this high-risk group may help in taking appropriate interventional measures.
| Acknowledgment|| |
We thank the interns, staff of urban health center, and the subjects participated in the study.
| References|| |
Sulaiman N, Hamdan A, Tamim H, Mahmood DA, Young D. The prevalence and correlates of depression and anxiety in a sample of diabetic patients in Sharjah, United Arab Emirates. BMC Fam Pract 2010;11:80.
Fortin M, Bravo G, Hudon C, Lapointe L, Dubois MF, Almirall J. Psychological distress and multimorbidity in primary care. Ann Fam Med 2006;4:417-22.
Joshi K, Kumar R, Avasthi A. Morbidity profile and its relationship with disability and psychological distress among elderly people in Northern India. Int J Epidemiol 2003;32:978-87.
Fisher L, Skaff MM, Mullan JT, Arean P, Glasgow R, Masharani U. A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with Type 2 diabetes. Diabet Med 2008;25:1096-101.
Maharaj RG, Reid SD, Misir A, Simeon DT. Depression and its associated factors among patients attending chronic disease clinics in southwest Trinidad. West Indian Med J 2005;54:369-74.
Pouwer F, Tack CJ, Geelhoed-Duijvestijn PH, Bazelmans E, Beekman AT, Heine RJ, et al.
Limited effect of screening for depression with written feedback in outpatients with diabetes mellitus: A randomised controlled trial. Diabetologia 2011;54:741-8.
Frederick FT, Maharajh HD. Prevalence of depression in type 2 diabetic patients in Trinidad and Tobago. West Indian Med J 2013;62:628-31.
Jimenez-Garcia R, Martinez Huedo MA, Hernandez-Barrera V, Lopez de Andres A, Martinez D, Jimenez-Trujillo I, et al.
Psychological distress and mental disorders among Spanish diabetic adults: A case-control study. Prim Care Diabetes 2012;6:149-56.
Li C, Ford ES, Zhao G, Strine TW, Dhingra S, Barker L, et al.
Association between diagnosed diabetes and serious psychological distress among U.S. adults: The Behavioral Risk Factor Surveillance System, 2007. Int J Public Health 2009;54 Suppl 1:43-51.
Footman K, Roberts B, Tumanov S, McKee M. The comorbidity of hypertension and psychological distress: A study of nine countries in the former Soviet Union. J Public Health (Oxf) 2013;35:548-57.
Oshodi YO, Adeyemi JD, Oke DA, Seedat S. Psychiatric morbidity in hypertensives attending a cardiology outpatient clinic in West Africa. Niger J Clin Pract 2012;15:84-8.
Fan AZ, Strine TW, Muppidi SR, Greenlund KJ, Croft JB, Berry JT, et al.
Psychological distress associated with self-reported high blood pressure and high blood cholesterol in U.S. adults, 2007. Int J Public Health 2009;54 Suppl 1:94-9.
Ramachandran V, Parikh GJ, Srinivasan V. Depression in hypertensive subjects. Indian J Psychiatry 1983;25:260-3.
Prakash O, Gupta LN, Singh VB, Singhal AK, Verma KK. Profile of psychiatric disorders and life events in medically ill elderly: Experiences from geriatric clinic in Northern India. Int J Geriatr Psychiatry 2007;22:1101-5.
American Diabetes Association. Standards of medical care in diabetes-2009. Diabetes Care 2009;32 Suppl 1:S13-61.
Patel V, Araya R, Chowdhary N, King M, Kirkwood B, Nayak S, et al.
Detecting common mental disorders in primary care in India: A comparison of five screening questionnaires. Psychol Med 2008;38:221-8.
Wiltink J, Beutel ME, Till Y, Ojeda FM, Wild PS, Münzel T, et al.
Prevalence of distress, comorbid conditions and well being in the general population. J Affect Disord 2011;130:429-37.
Baradaran HR, Mirghorbani SM, Javanbakht A, Yadollahi Z, Khamseh ME. Diabetes distress and its association with depression in patients with type 2 diabetes in Iran. Int J Prev Med 2013;4:580-4.
[Table 1], [Table 2], [Table 3]