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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Screening for mental health disorders among adults using the primary care evaluation of mental disorders patient health questionnaire: A community-based study
Deepak Sharma1, Naveen Krishan Goel1, Ajeet Kumar Sidana2
1 Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
2 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
| Date of Submission | 21-Aug-2022 |
| Date of Acceptance | 09-Sep-2022 |
| Date of Web Publication | 09-Mar-2023 |
Correspondence Address:
Deepak Sharma,
Department of Community Medicine, Government Medical College and Hospital, Chandigarh
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/aip.aip_139_22
Background: Screening the adult population for mental disorders is essential for early diagnosis and prompt treatment. The current study aimed to assess adults' prevalence and predictors of mental health disorders. Methodology: This community-based, cross-sectional study was conducted among 1056 adults. After obtaining their written informed consent, trained workers administered the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire. Data were analyzed using Epi Info software for Windows. Results: Out of 1056 study participants, 121 (11.5%) suffered from any mental health disorder. The most common mental health disorder was depression (5.1%), followed by anxiety (4.6%), somatoform disorder (2.8%), probable alcohol abuse (1.8%), and panic disorder (1.5%). In the logistic regression model, the odds of suffering from any mental health disorder were significantly higher among those having a chronic disease (odds ratio [OR] =1.8 [1.1–2.9]) and currently consuming tobacco (OR = 2.0 [1.2–3.3]), as compared to their counterparts. Conclusion: Around one-tenth of the study population suffered from any mental health disorder, the most common being depression. It is imperative that the general population be made aware of the signs and symptoms of mental health problems. Patients should be encouraged to seek early treatment for their mental health problems.
Keywords: Chronic disease, mental health, tobacco
How to cite this URL:
Sharma D, Goel NK, Sidana AK. Screening for mental health disorders among adults using the primary care evaluation of mental disorders patient health questionnaire: A community-based study. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Apr 1]. Available from: https://www.anip.co.in/preprintarticle.asp?id=371427 |
| Introduction | |  |
Mental health disorders are common in developed and developing countries worldwide. The global prevalence of mental disorders is 17.6%.[1] In India, an estimated 6%–7% of the population suffer from mental disorders.[2] The disability-adjusted life year due to psychiatric disorders is 4.7%.[3] The Mental Health Survey of India reported that 10.6% of the population suffer from any mental disorder. The prevalence of depressive disorder, phobic anxiety disorder, other anxiety disorders, and alcohol use disorder is 2.7%, 1.9%, 1.2%, and 4.6%, respectively.[4] Mental disorders have a significant impact on the quality of life of an individual. The work performance and output are decreased. The individual finds it challenging to engage with society. There is a stigma attached to psychiatric morbidities due to which patients do not seek timely help from a qualified health-care provider. This leads to an escalation in disease severity and eventually increases the burden of mental health problems in society.[5]
A review of existing literature shows that mental disorders are more common among the elderly, the most common being depression.[6] There are some gender differences in the patterns of mental morbidities. Studies have found a higher prevalence of depression and anxiety among women than men.[7],[8],[9] Tobacco use harms one's mental health. Tobacco users are trapped in a vicious cycle; tobacco consumption makes a person vulnerable to developing a mental illness, which eventually makes people more likely to use tobacco.[10] Links have been established between chronic diseases and psychiatric morbidity. Depression is reported to be higher in patients with cardiovascular cases, diabetes patients, and cancer patients.[11]
The importance of mental health promotion is now being globally recognized. The World Health Organization launched the Special Initiative for Mental Health (2019–2023) to achieve equity in mental health services through universal health coverage.[12] India implemented a health policy launched in 2014 to reduce mental health problems, promote prevention activities, and enhance mental health among its residents.[13] With this background, the present study assessed the prevalence and predictors of mental health disorders among adults. The results of this study are expected to help policymakers design suitable strategies for improving people's mental health.
| Methodology | | |
This community-based, cross-sectional study was done in the rural field practice area, sector 56, Department of Community Medicine, Government Medical College and Hospital (GMCH), Chandigarh. The inclusion criteria were age 18 years and above and resident of sector 56 for at least 6 months before this study. A sample size of 1109 was calculated based on the following presumption: expected prevalence of depression = 2.7%[4] (National Mental Health Survey [NMHS], India), absolute precision = 1%, confidence level = 95%, and nonresponse rate of 10%. A simple random sampling methodology was used to select the households. One individual was selected randomly and interviewed in each of these selected households. Trained medical social workers administered the questionnaire to the selected study participants.
In the current study, the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) was used for screening for mental health problems (depressive disorder, somatoform, panic disorders, other anxiety disorders, probable alcohol abuse, bulimia nervosa, and binge eating disorders). This was the first instrument designed for primary care settings, using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-MD). It is a valid measure for assessing mental disorders.[14],[15] The cutoffs for diagnosing a particular mental health disorder are mentioned in the instruction manual.[16] The independent variables included in this study were age, gender, education (literate/illiterate), marital status (married, unmarried, divorcees, and widows), type of family (nuclear/joint), tobacco use, and suffering from a chronic disease (hypertension, diabetes, and coronary heart disease). A study participant was considered suffering from chronic disease based on the available medical records with him/her. For the current study, a "current tobacco smoker" was defined as an adult who reportedly smoked tobacco at least once in the past month preceding the survey. Similarly, a current smokeless tobacco user was one who reportedly consumed smokeless tobacco at least once in the past month preceding the survey.
The data were analyzed using Epi Info software for Windows. The proportion of people suffering from individual mental health disorders is reported. For the current study, participants who suffered from at least one of these eight mental health conditions were classified as suffering from any mental health disorder. The Chi-square significance test was used to determine the relationship between the sociodemographic variables and suffering from any mental disorder. In addition, binary logistic regression was utilized to determine the predictors of study participants suffering from at least one mental health disorder. Statistical significance was defined as P < 0.05. The Ethics Committee of GMCH, Chandigarh, granted the ethical approval for this study.
| Results | | |
A total of 1056 study participants participated in the study (response rate of 95.2%). The mean age of the study participants was 39.6 years (standard deviation = 14.4). The age group distribution shows that 53.5% (565/1065) were aged 18–39 years, followed by 33.8% (357/1056) aged 40–59 years and 12.9% (134/1056) aged 60 years and above. There were 57.5% (607/1056) of males, 15.6% (165/1056) of illiterates, and 66.1% (698/1056) living in a nuclear family. Around three-fourth of the study participants were married (70.8%, 748/1056), 23.4% (247/1056) were unmarried, 5.4% (57/1056) were widows, and 0.4% (4/1056) were divorcees. A total of 140 (13.3%, 140/1056) participants suffered from chronic diseases, which comprised hypertension (8.0%, 85/1056), diabetes (7.1%, 75/1056), and coronary heart disease (1.4%, 15/1056). There were 15.8% (167/1056) of current tobacco users (13% of smokers and 14.8% of smokeless tobacco users).
Out of 1056 study participants, 121 (11.5%) suffered from any mental health disorder. The proportion of study participants suffering from depression was 5.1% (major depression syndrome: 2.0% and other depression syndromes: 3.1%). The somatoform disorder was present in 2.8%, while panic disorder, other anxiety disorders, and probable alcohol abuse were found in 1.5%, 4.6%, and 1.8% of the study participants, respectively. There was no case of bulimia nervosa and binge eating disorder.
The bivariate analysis showed that elderly study participants (17.2%) and illiterate individuals (18.8%) were more likely to suffer from any mental disorder than their counterparts (adults: 10.6% and literates: 10.1%). Similarly, widowed individuals (22.8%), those suffering from at least one chronic disease (20.0%), and those consuming tobacco (16.2%) had significantly [Table 1] higher mental morbidity, as compared to their counterparts. In the logistic regression model, it was revealed that the odds of suffering from any mental health disorder were higher among those suffering from at least one chronic disease (OR = 1.8 [1.1–2.9]) and currently consuming tobacco (2.0 [1.2–3.3]), as compared to their counterparts [Table 2]. | Table 1: Factors associated with any mental disorder among study participants
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 | Table 2: Logistic regression model of the predictors of any mental disorder among the study participants
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| Discussion | | |
Using a community-based study design, the current findings have revealed the prevalence rates of mental health disorders among the adult population. In our study, the prevalence of any mental health disorder was 11.5%. The NMHS reported the prevalence of any mental morbidity as 13.42% (Punjab) and 10.56% (India).[4] It is pertinent to mention here that our study used the PRIME-MD PHQ, while NMHS has used the Mini-International Neuropsychiatric Interview (MINI). Our study findings revealed depression among 5.1% of study participants. Similar to our finding, a study conducted in Uttarakhand, India, reported that 6% of the study participants suffered from depression.[17] The NMHS, India, reported depression disorder in 2.7% (India) and 1.83% (Punjab).[4] A study from North-West India reported the prevalence of depression to be 8.94%.[18] Another study from Delhi reported the prevalence of depression to be 22.1%. Studies around the world have documented a high prevalence of depression.[19] A community-based study in Ghana reported that 25.8% of the study participants were depressed.[20] Another community-based study from China reported the prevalence of depression to be 26%.[21] The varied prevalence of depression across studies is attributed to the different study populations and areas. Furthermore, there is a difference in the questionnaire/tool used for assessing depression, which includes MINI, Beck's Depression Inventory, Depression Anxiety Stress Scale (DASS) Scale. In our study, we used the PRIME-MD PHQ. This valid measure used in primary care settings is based on the DSM of diagnostic criteria.
Patients of somatoform disorder experience various physical symptoms. Since no associated medical ailment can explain these physical symptoms, the patient repeatedly visits a physician and undergoes numerous medical tests. There is a need to screen these patients and offer them psychiatric health services. The prevalence of the somatoform disorder in our study was 2.8%. A higher prevalence of somatoform disorder has been reported in a study by Chander et al. from India (5%).[22] Another study from Palestine reported that the prevalence of Somatic Symptom Disorder (SSD) was 32.5%.[23] A possible explanation for this competitive higher prevalence is that the abovementioned studies are hospital based, while ours is community based. The other reason is the different tools used to assess somatoform disorder.
Further, in our study, we found that 4.6% of participants had an anxiety disorder. NMHS report shows that in the Punjab state of North India, 0.29% suffer from a generalized anxiety disorder.[4] A study from Saudi Arabia reported that the prevalence of anxiety is 62.1%.[24] In our study, the prevalence of panic disorder was 1.5%. A nearly similar finding has been reported in a study conducted in Maharashtra, wherein 0.9% of the participants had panic disorder.[25] Alcohol abuse can lead to neglecting essential duties, thus affecting work productivity. Besides this, it contributes to conflict, stress, and financial instability. In our study, the prevalence of probable alcohol abuse was 1.8%. The NMHS shows that the prevalence of alcohol use disorder in India is 4.6%, while in Punjab, it is 7.9%.[4] A population-based study in Hong Kong reported that the prevalence of alcohol abuse was 6.7%.[26] Again, the contrasting findings of the prevalence of anxiety, panic, and alcohol use across studies might be attributed to the distinct study populations, areas, and varied instruments/scales used to record them.
In our study, those suffering from a chronic disease had higher odds of suffering from at least one mental disorder. The possible explanation is that suffering from chronic illnesses might make a person stressed regarding their treatment outcome. Further, patients might find it tough to adapt to the ongoing treatment, thus affecting their mental health. Studies have documented the positive association between chronic diseases and mental disorders.[27],[28],[29] Another study in China reported that comorbid physical diseases are risk factors for somatic symptom disorder.[30] In our study, we found that current tobacco use was positively associated with suffering from any mental disorder. Similar findings have been reported in studies done in Brazil and another study conducted in our country.[31],[32]
Smoking tobacco has been linked to mental health disorders. A cohort study linked the association of tobacco use during adolescence to influence the onset of depressive symptoms.[33] Furthermore, tobacco smoke is linked to the development of anxiety disorders.[34] Then, there are factors that link concurrent tobacco consumption and alcohol use and cigarette consumption.[35] In our study, we found no association of mental disorders with gender and marital status. Contrary findings have been reported in studies conducted by Abate and Srivastava et al.[7],[36]
The strength of this study is the community-based approach, a large sample size, and a validated tool to assess mental morbidity. A limitation of the study is its cross-sectional study design, due to which we cannot attribute causality to risk factors. Another limitation is that the study tool used in our study (PRIME-MD PHQ) does not give a clinical but only a presumptive diagnosis. Nevertheless, the study tool is a valid measure for screening mental health illnesses, and thus, the results of this study are valuable for policymakers.
| Conclusion | | |
The present study found that around one-tenth of participants suffered from any mental health disorder. It was higher among those suffering from a chronic disease and those currently consuming tobacco. It is, therefore, recommended that adults should be regularly screened for any mental health disorder, and those found suffering from them should be referred to the nearest health-care facility, where mental health services are available. People should be made aware of the ill effects of consuming tobacco in any form. Those currently using tobacco users should be encouraged to quit. Since coexisting chronic diseases can worsen mental disorders, it is imperative to manage them effectively by promoting a good lifestyle and ensuring medication compliance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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