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 Table of Contents  
Year : 2017  |  Volume : 33  |  Issue : 2  |  Page : 177-180

Comparison of psychological distress and its associated factors among chronic disease and healthy subjects in rural Puducherry, India

Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication30-Jun-2017

Correspondence Address:
Karthik Laksham Balajee
S/o K. Laksham, 33, 6th Cross Street, Jawahar Nagar, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9962.209190

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Context: There is paucity of data on the comparison of psychological distress among chronic noncommunicable disease (NCD) and healthy subjects in developing countries such as India. Objective: To assess and compare psychological distress and its associated factors among chronic disease and healthy subjects. Materials and Methods: A cross-sectional study was conducted in a rural field practice area attached to a tertiary care medical institution in Puducherry, India. Data were collected from the chronic disease subjects which included those with diabetes and or hypertension registered in the rural health center. Healthy subjects residing nearest to the corresponding case from the respective village were taken as controls. Psychological distress was assessed by General Health Questionnaire 12 (GHQ 12). Results: There were 260 subjects with 130 in each group. Subjects with chronic disease had significantly higher proportion of psychological distress (50.8%) compared to healthy subjects (35.4%). The mean ± standard deviation GHQ 12 score of those with chronic disease is also significantly higher than that of healthy subjects (13.35 ± 4.89 vs. 11.15 ± 4.43, P< 0.001). Binary logistic regression analysis showed that subjects with diabetes and/or hypertension had higher psychological distress (adjusted odds ratio = 1.9, 95% confidence interval: 1.1–3.5) compared to healthy subjects. Conclusion: Subjects with diabetes and/or hypertension have higher proportion of psychological distress compared to healthy subjects. Screening subjects with chronic NCD for psychological distress may help to take appropriate measures.

Keywords: Chronic disease, diabetes, General Health Questionnaire 12, hypertension, mental health

How to cite this article:
Balajee KL, Kumar GS, Shidam UG. Comparison of psychological distress and its associated factors among chronic disease and healthy subjects in rural Puducherry, India. Indian J Soc Psychiatry 2017;33:177-80

How to cite this URL:
Balajee KL, Kumar GS, Shidam UG. Comparison of psychological distress and its associated factors among chronic disease and healthy subjects in rural Puducherry, India. Indian J Soc Psychiatry [serial online] 2017 [cited 2020 Jan 19];33:177-80. Available from: http://www.indjsp.org/text.asp?2017/33/2/177/209190

  Introduction Top

Many chronic medical conditions are complicated by emotional and psychological disorders. However, the emotional dimensions of such chronic medical conditions are often overlooked when medical care is considered. Chronic medical conditions such as diabetes mellitus and hypertension are associated with mental health problems such as depressive syndromes. About one-third of people with diabetes suffer from clinically relevant depressive disorders.[1] People with diabetes with somatic symptoms, sleep disturbances, or anxiety have poor glycemic control.[2] Psychological distress is an independent risk factor for death in patients with diabetes.[3] In patients with hypertension, 10–20% have some form of psychological distress,[4],[5] and it acts as a barrier against adequate medication adherence.[6] The risk of cardiovascular death is also higher in patients with both hypertension and common mental disorders.[7] Thus, chronic physical diseases occurring along with mental disorders are associated with increased morbidity and mortality.

Recent data showed an increase in the trend of noncommunicable diseases (NCDs) such as diabetes and hypertension, especially in developing countries including India.[8],[9] Studies from India have shown that the prevalence of psychological morbidity is higher among patients with chronic diseases compared to normal subjects. The mean stress score of hypertensive patients is higher than that of normotensives in a study from rural Maharashtra,[10] and the prevalence of depression among patients with diabetes is higher than that of normal subjects in a study from Chennai.[11] A hospital-based study in Mangalore in patients with chronic diseases such as diabetes, heart disease, and hypertension has shown that 19% of them had anxiety and 29% had depression,[12] whereas the prevalence of mental distress among patients with diabetes or hypertension is 80% in urban Puducherry,[13] and the prevalence of depression among patients with diabetes is as high as 84% in Ludhiana.[14] The present study aimed to assess the psychological distress and its associated factors among the subjects with chronic disease and to compare their mental status with that of healthy subjects in rural Puducherry.

  Materials and Methods Top

Setting and study design

This was a cross-sectional study done from May to June 2014 in the rural field practice area of a tertiary care center in Puducherry, which consists of four villages. Family folders of all residents in the field practice area are maintained in rural health center. All adult residents in four villages will be screened regularly for diabetes and hypertension. Those subjects having diabetes and or hypertension were followed up in our rural health center every month, and follow-up investigations will be done and drugs will be provided free of cost. In addition to this, whenever any adult patient arrives at our out-patient department for any general complaint, they will also be screened for diabetes and hypertension. This will ensure that normal subjects in our study are not suffering from diabetes or hypertension.

Sample size estimation and sampling technique

Based on the expected prevalence of 50% mental distress among chronic disease patients,[15] 20% relative precision, and 5% alpha error, the minimum sample size required was found to be 100. However, all the 130 patients registered in NCD clinic of the rural health center with diabetes and or hypertension and attended the clinic during the study period were included as cases, and age-matched (±5) healthy subjects residing nearest to the corresponding case from the respective village were taken as normal. Subjects with gestational diabetes were excluded from the study.

Method of data collection

The questionnaire contained sociodemographic details such as age, gender, occupation, educational status, and income along with the General Health Questionnaire (GHQ 12). The GHQ was initially devised by Goldberg (1987) to screen for psychiatric illnesses in the primary care setting.[16] The GHQ 12 version having 12 items was later validated by the World Health Organization.[17] The GHQ 12 was used to assess the current mental health of the participants and it focuses on two major areas – the inability to carry out normal activities and the appearance of new and distressing incidents. The GHQ 12 questionnaire was translated in Tamil and pretested. The principal investigator trained the interns posted at the rural health center in administering the questionnaire. After getting informed verbal consent, each participant was interviewed. Each item in the GHQ 12 was rated on a four-point scale (less than usual, no more than usual, rather more than usual, or much more than usual). We have used the Likert method of scoring (0, 1, 2, and 3) with score range at 0–36. Scores up to 12 were considered normal and a score more than 12 was considered as an evidence of psychological distress. The WHO validation study of GHQ for screening mental illness in general health care has shown that a threshold of 12 using the Likert scoring (0, 1, 2, and 3) had a sensitivity of 79% and specificity of 77%.[17] With the help of the “guidelines for management and follow-up of Type 2 diabetes mellitus and hypertension,” case sheets of the participants were reviewed and adequacy of follow-up investigations was checked. The total time required for each participant was 8–10 min. At the end of the interview, health education on importance of compliance to treatment and the need for periodic blood testing was given. All subjects who were found to have psychological distress (GHQ score >12) were explained about their psychological status and were referred to the psychiatry clinic of the rural health center for further management.

  Results Top

The total number of subjects interviewed was 260 with 130 in each group. Most of the subjects (92.3%) in study were above 40 years. There was no significant difference in the age, gender composition, and family type between the two groups [Table 1]. Most of the subjects belong to socioeconomic Class 3 and 4 (Modified Prasad's Classification).
Table 1: Baseline characteristics of study participants

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Among the 130 patients with NCDs, 62 (48%) had hypertension, 22 (17%) had diabetes, and the rest 46 patients (35%) had both hypertension and diabetes. The mean duration of illness was 4.4 years. Seventy-six out of 130 patients (58.5%) with NCDs were diagnosed <5 years, 32% (42 out of 130) were diagnosed within 5–9 years, and 12 patients (9%) were diagnosed more than 10 years. More than half of the patients (58.5%) have their disease diagnosed in the last 5 years. The mean GHQ 12 score of the subjects having chronic disease is higher than that of the normal subjects (13.35 ± 4.89 vs. 11.15 ± 4.43), and this difference is statistically significant (t-score: 3.810, P < 0.001). Fifty percent of NCD patients had some form of psychological distress (using GHQ 12 questionnaire) and among the normal subjects, it is 35%. Chi-square value = 6.274, P = 0.01, indicated that the prevalence of psychological distress was more among NCD patients compared to normal subjects. Higher age group is associated with higher prevalence of psychological distress, but the association is statistically insignificant. Binary logistic regression was used to adjust the independent variables such as age, gender, education, occupation, socioeconomic status, family type, smoking and alcohol status. Subjects with chronic NCDs such as diabetes and/or hypertension were found to have higher risk of developing psychological distress (adjusted odds ratio 1.9, 95% confidence interval: 1.1–3.5) compared to normal subjects [Table 2].
Table 2: Psychological distress among study participants based on the General Health Questionnaire 12

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  Discussion Top

Our study highlighted the fact that the prevalence of psychological distress is higher in patients with NCDs such as diabetes and/or hypertension compared to general population. Half of the patients with common NCDs had psychological distress, which is similar to the results obtained from Nepal [15] and Madrid.[18] However, this is less compared to the study in urban Puducherry where 80% of subjects with NCD had psychological distress.[13] This varied difference in these studies may be due to influence of other factors such as geographical difference and work pressure along with change in lifestyle due to urbanization.

In the Ludhiana study,[14] higher proportion of female patients with diabetes had depression compared to men; but our study did not find any such gender differences in psychological distress. Similar to the study done from urban Puducherry,[13] our study too did not show any association between substance abuse and distress among subjects having chronic diseases such as diabetes or hypertension. There is a significant difference in the education and occupation status of subjects with chronic diseases and that of the normal subjects. This difference in educational status between the two groups might have led to the difference in occupation, as those with higher education tend to get government job in comparison to less educated. Moreover, people with diabetes and/or hypertension may remain unemployed due to their illness. However, the reasons for these differences in education and occupation between two groups were not brought out in this study. However, all sociodemographic factors were adjusted while doing regression analysis and none of these were found to be significantly influencing the psychological status of the subjects. This is similar to a Mangalore study where age, marital status, or education had no influence.[12] Further studies may elucidate the effect of these factors in psychological distress among chronic disease subjects.

The study has got its own limitations. We have studied only the subjects with diabetes and/or hypertension registered in our clinic. The psychological status of patients with other chronic diseases such as asthma and osteoarthritis was not measured. The cause and effect between the chronic diseases studied and psychological distress could not be assessed as this is a cross-sectional study. The study did not assess the clinical status of those taking treatment for diabetes and/or hypertension. This limits us from assessing whether the psychological distress is more in those with adequately controlled disease or otherwise. The questionnaire used to identify subjects with psychological distress is a screening tool and not a diagnostic tool. The psychological morbidity is assessed at the level of symptoms using GHQ and not at the level of disorders. Studying the psychological morbidity at the level of disorders requires more comprehensive psychiatric assessment and it was not done in this study. Certain factors such as family conflicts and multiple morbidities were also not assessed in this study. Despite these limitations, this study gives valuable information on comparison of psychological distress among patients with chronic NCDs with healthy subjects, which can help the concerned authorities to strengthen counseling measures for this vulnerable group.

  Conclusion Top

Subjects with diabetes and/or hypertension have higher proportion of psychological distress compared to normal subjects in the study setting. Patients with NCDs should be routinely screened for psychological distress and should be appropriately managed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2]

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