|AWARD PAPER: DR BB SETHI AWARD PAPER
|Year : 2018 | Volume
| Issue : 1 | Page : 37-47
Profiling the initial 1st Year cohort of patients utilizing a tertiary hospital-based geriatric mental health-care service using the “Service Evaluation Framework”
Subhash Das, Nitin Gupta, Anadrika Debbarma, Manoj Kumar Bajaj
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Web Publication||29-Mar-2018|
Dr. Nitin Gupta
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
Source of Support: None, Conflict of Interest: None
Background: Increase in life expectancy of Indians will require revamping the health-care infrastructure for the elderly. In India, either there are not too many specialized geriatric mental health services available across the country or those that are available have problems of resources and quality. With this perspective, the Department of Psychiatry, Government Medical College and Hospital, Chandigarh, developed the Geriatric Mental Health Clinic (GMHC) for the elderly residing in and around Chandigarh. The aim of the study was to study the initial 1-year cohort and assess their satisfaction levels as well as to see whether their functioning improves with the intervention so provided. Materials and Methods: Using the “service evaluation framework,” the patients and caregivers who attended the GMHC over a period of 1 year were evaluated using tools such as Hindi Mental State Examination (HMSE), Everyday Abilities Scale for India (EASI), Global Assessment of Function (GAF) scale, World Health Organization quality of life-BREF (WHO-QoL-BREF)-Hindi version, and Patient Satisfaction Scale (PAT-SAT). In addition, sociodemographic and clinical profile data of the service users were compiled. Results: A total of 105 cases formed the cohort under study, wherein 70% had functional psychiatric illness and almost more than half of the cases had comorbid physical illness, hypertension being the most common. GAF score of 45.42 and WHO-QoL-BREF score of 78.7 at the time of follow-up suggested that there was “slight impairment in socio-occupational functioning” and “poor QoL,” respectively. However, GAF and HMSE scores were significantly decreased in those with organicity. Overall service users reported good service-cum-clinician satisfaction scores on PAT-SAT; there was also significant reduction of EASI score from that of baseline, suggesting improvement in functioning. Conclusions: Findings show that the newly started GMHC, even though in its incipient stage, is attracting patients of all diagnostic categories, from expected catchment areas, is being able to deliver interventions which are bringing about clinical and functional improvement, and service users are not reporting dissatisfaction.
Keywords: Geriatric, quality of life, satisfaction
|How to cite this article:|
Das S, Gupta N, Debbarma A, Bajaj MK. Profiling the initial 1st Year cohort of patients utilizing a tertiary hospital-based geriatric mental health-care service using the “Service Evaluation Framework”. Indian J Soc Psychiatry 2018;34:37-47
|How to cite this URL:|
Das S, Gupta N, Debbarma A, Bajaj MK. Profiling the initial 1st Year cohort of patients utilizing a tertiary hospital-based geriatric mental health-care service using the “Service Evaluation Framework”. Indian J Soc Psychiatry [serial online] 2018 [cited 2019 Aug 24];34:37-47. Available from: http://www.indjsp.org/text.asp?2018/34/1/37/228784
| Introduction|| |
Life expectancy has increased in India and by 2050 the elderly population is projected to be about 19% of the total population. This brings a new challenge to the health-care system as the elderly have their own myriad of health issues ranging from physical illnesses such as diabetes mellitus, hypertension, and cardiovascular problems to mental illnesses such as depression and dementia. The recently concluded National Mental Health Survey of 2017 has also pointed out that the lifetime and current prevalences of mental morbidity were 15.11% and 10.90%, respectively, in those who were aged 60 years or more; the highest prevalence being in the age group of 50–59 years. This number is only set to increase in future as the proportion of elderly gradually rises.
In addition, the presence of mental morbidity and cognitive dysfunction in the elderly limits the functional capacity of those afflicted to such an extent that even the activities of daily living become challenging for them; neuropsychiatric disorders among the older adults comprise 6.6% of the total disability. The overall quality of life (QoL) in the elderly is generally poor due to the presence of mental illness, and very few Indian studies exist in this regard.
Keeping the above scenario in perspective, the World Health Organization has emphasized on the importance and relevance of imparting training to mental health professionals, development of policies, and most importantly “developing age-friendly services and settings.”
Need for the study
In India, no specialized geriatric services could be initially developed due to lack of a governmental policy on older adults till 1998. Thereafter too, there are not too many specialized geriatric (“age friendly”) mental health services available across the country; those available have problems of resources and quality. With this background and perspective, this study was planned using a “service evaluation framework” in order to develop an insight whether patient-friendly, adequately resourced geriatric services were being run from a tertiary care hospital setting in a satisfactory manner or not.
In order to develop a better understanding of the methodology adopted, the results presented, and discussion thereafter, it will be pertinent to provide a detailed description of the service first itself, i.e., the Geriatric Mental Health Clinic (GMHC).
Need for the service
The Department of Psychiatry, Government Medical College and Hospital, Chandigarh, has been providing tertiary mental health-care services since February 1994 to the union territory of Chandigarh. However, its catchment area also includes the neighboring states of Punjab, Haryana, Himachal Pradesh, extending up to New Delhi and parts of Rajasthan, Uttar Pradesh, and Uttarakhand.
Apart from the regular outpatient clinics for adults, the department has developed and been running specialty outpatient clinics such as Child Guidance Clinic (for children with mental health needs), De-addiction Clinics (for substance abuse-related problems), and Marital and Psychosexual Clinic (for sexual and marital issues).
In addition, though the institute had been providing generic services for the elderly in the form of a geriatric outpatient department (OPD) being run by the Department of Community Medicine since February 2012 (www.gmch.gov.in), yet these were geared toward addressing their physical health needs and not their psychological, social, and mental health needs.
Keeping in view the World Health Organization (WHO) projection of increasing burden of the elderly in the future, the increased prevalence of morbidity (especially dementia and related disorders), and the need to provide integrated care for older populations in less resourced settings, this unmet service need was addressed by the department by initiation of a separate clinic for the elderly in January 2015.
Objectives of the service
The service was set up keeping in perspective the following objectives for the service users (i.e., patients and their caregivers) as follows:
- There should be easy access for the service users
- The service should be able to deliver exclusive and specialized care in the way it has been envisaged
- Psychosocial support and holistic care to patients attending the clinic
- Appropriate guidance to caregivers of the patients
- Consultation–liaison services with other specialties for delivering holistic and integrated care.
Details of service
Day and frequency
The clinic was named as GMHC and was started on a once-a-week basis, i.e., every Saturday. This day was specifically chosen as Saturday is a public holiday in government offices in Chandigarh and it would facilitate the attendance of the elderly by allowing their caregivers to bring/accompany them on that day, keeping in mind that a reasonable majority of young/middle-aged people residing in the tricity (comprising Chandigarh and adjoining cities of Mohali and Panchkula) are from the public/government sector.
The personnel were a consultant psychiatrist (SD), a consultant clinical psychologist (MKB), an MD psychiatry trainee (by rotation), and an M. Phil clinical psychology trainee (by rotation). There is an additional facility of referral to the psychiatric social work faculty placed in the OPD for assessment and management of psychosocial issues.
Any new patient attending the psychiatry general outpatient clinic would be first screened by a senior resident (qualified psychiatrist; post-MD) in terms of suitability of age for referral to GMHC (i.e., age above 60 years), followed by a detailed assessment using a specially designed socioclinical pro forma (Instrument 1 under TOOLS) and making an initial working diagnosis based on the International Classification of Diseases-10 (ICD-10) (WHO) criteria, following which treatment and/or necessary investigations were advised accordingly. The senior resident makes the referral to the GMHC, wherein a patient comes for the subsequent (i.e., 2nd) follow-up visit to the GMHC is registered under the specialist clinic services and is allocated a GMHC number.
In the 2nd visit, a detailed assessment is carried out wherein the MD trainee conducts a detailed clinical assessment involving history taking, physical examination, and mental status examination to arrive at a diagnosis as per the ICD-10. In addition, a baseline assessment of cognitive function is done using the “Hindi Mental State Examination (HMSE),” and the level of functioning is assessed with the help of “Everyday Abilities Scale for India (EASI)” (Instruments 2 and 3 under TOOLS) by the M. Phil clinical psychology trainee under the direct supervision of consultant clinical psychologist (MKB). A detailed case discussion is conducted with the consultant psychiatrist I/C of GMHC (SD), and by adopting such a multidisciplinary approach, the ICD-10 diagnosis (along with associated dysfunction) is confirmed or refuted.
Management and follow-up
In terms of management, patients were provided with appropriate pharmacological intervention in keeping with their psychiatric diagnosis and medical comorbidities. In addition, nonpharmacological strategies/packages were formulated (pure psychological, pure psychosocial, mixed psychological, and social) as per identified needs of the patient and caregiver, and attempts were made to deliver the same. Overall, the attempt was to deliver management in an integrated model adopting a judicious mix of pharmacological and nonpharmacological strategies as per identified needs of both patients and their caregivers. Follow-up of patients was provided/advised in a pragmatic manner in order to ensure convenience for both patient and his/her caregiver. This was generally done at a variable period ranging from once every 2 weeks to once every few months and was influenced by a host of variables–nature of illness, severity of illness, distance of patient's home from hospital, functionality of patient, distress of caregiver, time constraints faced by caregiver, etc.
This study aimed to profile the initial 1st year cohort of patients utilizing the tertiary hospital-based geriatric mental health-care services from North India using the “service evaluation framework.”
The objectives of this study were:
- To outline the socioclinical profile of patients presenting to the GMHC in the 1st year of its inception
- To determine the short-term (18-month) functional and clinical outcome of patients seen during the 1st year of the GMHC
- To assess the satisfaction with GMHC services from patients presenting to the GMHC in the 1st year of its inception
- To compare the patients on various sociodemographic-, clinical-, functional-, and satisfaction-related parameters on the basis of diagnosis, i.e., by dividing them into broad categories of “organic” and “functional/nonorganic.”
| Materials and Methods|| |
All consecutive elderly patients, i.e., aged 60 years or more, who attended and were registered in the GMHC, Department of Psychiatry, Government Medical College and Hospital, Chandigarh, over a period of 1 year, i.e., from January 31, 2015 to January 30, 2016, were taken up for the study.
Patients not seen by the primary consultant in-charge of the clinic (SD) and where data were incomplete or missing due to various reasons (patients could not be contacted, absence of baseline data, patient refused to participate, etc.) were excluded.
Duration of follow-up
Patients were recontacted between November 2016 and July 2017, i.e., approximately within a range of 18–24 months, but with a view of keeping an average follow-up period of 18 months after the first contact with the geriatric services.
Service evaluation parameters
- Level of functioning (using GAF , and EASI scales)
- QoL (using WHO-QoL-BREF)
- Satisfaction with the services (using PAT-SAT).
As most of the elderly were frail with limited mobility and with associated physical comorbidities and many of them were from distant places, it was jointly decided by the two principal authors (SD and NG) that the follow-up assessment would be conducted telephonically. This would also cause minimal inconvenience to the patients and further ensured uniformity in the procedure of data collection.
An MD trainee in psychiatry (AD) was inducted into the study. AD was provided extensive training in the use of the assessment tool numbers 3–6 by SD and NG. Subsequently, AD administered tools 3–6 under the supervision of SD on ten admitted patients and their caregivers in order to familiarize herself with these instruments/scales. Thereafter, the same procedure was conducted by assessing ten patients and their caregivers telephonically. Verbal consent was taken from all these patients. Analysis of both sets of data by the supervising consultants revealed that there was near comparability in the assessment conducted across both settings and opined that assessment over phone can be done without major issues. Nevertheless, in order to ensure quality control, the first ten interviews by AD were again done under the supervision of NG. In addition, for all subsequent interviews, AD was randomly supervised during the interview process on a periodic basis. Hence, a robust system was put into place to ensure quality assurance for data collection.
AD would contact the patients telephonically and would explain the process to them in detail. Thereafter, verbal consent would be taken and be recorded in the patient pro forma. In situ ations where the patient would not be in a position to provide consent or be interviewed or refuse interview or be unavailable due to any reason, then the primary caregiver would be interviewed. The primary caregiver was defined as an individual who has the responsibility of meeting the physical and psychological needs of the dependent patient and also providing assistance or supervision in the daily activities of their patient with mental illness. Caregivers were taken as adequate proxy measure of patients as there is reasonable body of evidence from our center/this area to support this methodological issue., The interviews were carried out at a time, which was convenient for the participants. The complete interview lasted for about an average time of 40 (range = 30–50) min. For any given participant, at least three attempts were made to establish contact with them. If after three attempts, no contact could be established, then such a case was deemed to have dropped out from the study and was not recontacted.
Verbal consent was taken. Interviews were conducted as per convenience of the participants. Anonymity and full confidentiality were ensured. Approval from the Institute's Ethics Committee was not required as the study design and execution were done using the “service evaluation framework.”
Patient intake pro forma (for recording clinical and sociodemographic details)
This specially designed pro forma, which is routinely used in the GMH Clinic, contained patients' sociodemographic details such as name, age, gender, occupation, and address. In addition, it also contains information pertaining to clinical details such as comorbid physical illness, medications being used, family history of mental illness, past history of mental illness, substance use history, general physical and systemic examination, and mental status examination.
Hindi mental state examination (HMSE)
The HMSE is a 22-item scale, which tests different components of intellectual capacity. The items cover several areas of cognitive functioning such as orientation to time and place, memory, attention and concentration, recognition of objects, language function, both comprehension and expressive speech, motor functioning, and praxis. It is relatively simple to administer and provides a quick brief index of the participant's current level of functioning. It is a modified and Hindi version of Mini–Mental State Examination  which can be used in Hindi-speaking Indian population and can even be administered on illiterate people. Sensitivity and specificity of 81.3% and 60.2%, respectively, were reported from Ballabhgarh in North India. This is used routinely in the GMH Clinic during the initial detailed assessment and on follow-up visits.
Everyday abilities scale for India (EASI)
EASI is a 12-item unidimensional scale covering mobility, memory, instrumental, and personal care activities related to activities of daily living and can be used in Hindi-speaking Indian population. It is a brief and easy to use assessment tool about the functioning of patients where information is gathered from care givers. It has a sensitivity of 62.5% and specificity of 89.7%. Higher the score, more is the dysfunction. This is used routinely in the GMH Clinic during the initial detailed assessment and on follow-up visits.
Global Assessment of functioning (GAF)
The Global Assessment of Functioning (GAF) is a 100-point scale divided into intervals or sections, each with 10 points. The GAF covers the range from positive mental health to severe psychopathology, is a global measure of how a patient is doing, and is intended to be a generic rather than diagnosis-specific scoring system. The 10-point intervals have anchor points (verbal instructions) describing symptoms and functioning that are relevant for scoring. The scale is provided with examples of what should be scored in each 10-point interval. The present GAF is found as Axis V of the Internationally accepted Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revision.,
World Health Organization quality of life-BREF Hindi version (WHO-LO-BREF)
WHO-QoL-BREF is an abbreviated 26-item version of the WHO-QoL-100 scale and was developed using data from the field trial version of the WHO-QoL-100. It has been developed cross culturally and is available in over twenty different languages. This instrument places primary importance on the perception of the individual. It is one of the best known instruments to measure the generic QoL. It is a self-administered scale that measures the following broad domains: physical health, psychological health, social relationships, and environment. The Hindi version was developed and validated and is widely used in various mental illnesses.
Patient satisfaction scale (PAT-SAT)
The scale comprises 19 items subdivided into six domains – trust, communication, exploration of ideas, body language, active listening, and miscellaneous. It is rated on a 5-point Likert scale (strongly agree, agree, do not know, disagree, and strongly disagree). The PAT-SAT is easily readable and understandable even for people with few years of education. The scale quantifies the complex and multidimensional relationship between the clinician and the patient seen from the patient's perspective. The PAT-SAT scale can be used without prior training for the practitioner and with a minimum of instructions to patients. It has been translated into Hindi by one of the authors (NG) and who had demonstrated that this scale can be used in the Indian setting, albeit judiciously, and can serve as proxy assessment for patients if administered on caregivers.,
Statistical analysis was carried out using SPSS version 22.0 (Armonk, NY; IBM corp, USA). Data were analyzed in which frequency generation, percentages, mean, and SD were calculated. In addition, it was subjected to univariate analysis, where Chi-square analysis was done for nominal variables and Student's t-test (across-group comparison)/paired t-test (within-group comparison) was done for ordinal variables. For nonparametric comparison, Mann–Whitney U analysis was conducted. For correlational analysis, Spearman's Rho was calculated keeping in view the nonuniform distribution of the data when comparing the groups. Statistical significance was kept at P < 0.05 for all tests.
| Results|| |
A total of 105 patients comprised the sample for the study.
As shown in [Table 1], most of the cases (n = 105) were in the 60 to <65 years' age group, were married, males outnumbered females (male-to-female ratio being almost 3:2), and majority were Hindus. More than one-fifth of the patients were illiterate and a little over 40% were either homemakers or engaged in household work. Almost half of the patients stayed in a joint family setup, majority being from urban areas and only about 30% were from the union territory of Chandigarh.
|Table 1: Sociodemographic profile of whole sample presenting to geriatric mental health clinic (n=105)|
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[Table 2] summarizes a description on the clinical variables of the overall sample. About 70% of the cases had functional disorders such as depression and bipolar affective disorders (BPADs). One-fifth of the cases had duration of illness for >10 years followed by about 16% who had illness duration of 4–6 months. Medical morbidity was present in more than half of the cases, with hypertension being the most common, and one-fifth of the cases were afflicted by it. Three-fourth of the cases did not have any positive history of mental illness in the family. Baseline mean EASI score was 2.95 (range being 0–12), suggesting that overall there was less functional impairment in the cases. Mean HMSE score was 25.04, suggesting that overall very few patients had cognitive impairment.
|Table 2: Clinical profile of whole sample presenting to geriatric mental health clinic (n=105)|
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The mean duration of follow-up for all cases was 17.26 months [Table 3]. In the follow-up assessment, it was seen that there was a statistically significant reduction in the mean EASI score (from 2.95 to 1.64) during follow-up assessment, as shown in [Table 3] and [Table 4]. In addition, [Table 3] shows that the mean scores for WHO-QoL BREF and GAF were 45.42 (suggesting poor QoL) and 78.7 (suggesting slight impairment in socio-occupational functioning), respectively. The mean PAT-SAT scores in all the subcategories (PAT-SAT: D1, D2, D3, D4, D5, and D6, respectively, represents trust, communication, exploration of ideas, body language, active listening, and miscellaneous categories) were above average.
|Table 3: Functional outcome scores of sample (n=105) obtained at follow-up|
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|Table 4: Satisfaction scores on Patient Satisfaction Scale of sample (n=105) obtained at follow-up|
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Finally, the whole sample was subdivided into two groups namely “organic” diagnosis (i.e., dementia and delirium, etc.) and “functional” (depression, anxiety etc.). Details of the findings are summarized in [Table 5]. The mean baseline HMSE score in those with organic disorders was significantly less than those with functional disorders. On follow-up assessment, organic subgroup had significantly lower scores on GAF and WHO-QoL domain scores of social relationships (WHO-QoL-D3) and environment (WHO-QoL-D4) compared to the functional subgroup.
|Table 5: Comparison of organic (n=32) versus functional (n=73) cases on different assessment parameters at baseline and follow-up|
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[Table 6] shows the correlations among the various significant assessment parameters. It reflects that the GAF score was positively correlated with that of HMSE scores and WHO-QoL social relationship domain and WHO-QoL environment domain scores.
| Discussion|| |
This study has been planned using a “service evaluation framework” keeping in mind that (i) there is a lack of specialized geriatric mental health outpatient services across the country , and also there is a lack of monitoring of such services to the best of our knowledge. Due to these reasons, it was felt imperative to develop an understanding whether our newly setup outpatient geriatric services are patient friendly, adequately resourced, and being run in a satisfactory manner or not.
This was also felt essential in the existing scenario, as no such formal facility exists in the tricity of Chandigarh. More importantly, an evaluation of the existing structure and functioning was deemed necessary in order to put into proper perspective the current state of affairs of the GMHC so that planning for the future can be undertaken as Chandigarh is not only a city of senior citizens staying alone who may require special attention (as their children have migrated to different places), but also the elderly population is ever increasing, and it is a well-established fact that mental health issues of the elderly are often different from those of adults  which get commonly dealt in general psychiatry OPDs.
It may also be helpful to mention at the outset that based on the experience of the consultant in-charge (SD) and our departmental data, it was surmised that a significant proportion (60%–70%) of the clinic patients availing treatment would be from outside the union territory of Chandigarh. Hence, the study was designed in a manner so that maximum number of patients can be followed up without subjecting them to any inconvenience or putting any extra burden on the existing resources. In this way, from our perspective, this study was envisioned as being novel, pragmatic, and practically feasible.
Finally, the mean duration of follow-up for the entire sample was 17.26 (2.15) months, which was in keeping with the initial objective of the study. In addition, this period is not too short by which one cannot place confidence on the results obtained in terms of evaluation of the service at hand.
Last but not the least, all the patients (and their caregivers) who attended the GMHC in the 1st year and comprised the cohort (n = 105) were not only contactable, but also responded to the interviewer (AD).
Objective 1 was to outline the socioclinical profile of patients presenting to the GMHC in the 1st year of its inception [Table 1] and [Table 2].
The first objective was to determine the profile of patients attending the GMHC in the 1st year of its inception.
In the current study, most of the cases were in the age group of 60–64.9 years. Combining with the 65–69.9 years' age group, we get a cumulative percentage of 55% cases. Majority of the cases in the present study were males. A sizeable proportion were illiterate (22.8%) or had just primary level of education (21.9%). Similar findings were reported from a previous study conducted in Uttar Pradesh. This finding holds significance as low level of education has been associated with dementia.,
In our study, most of the patients were either engaged in household work or were homemakers, followed by people who were retired. In the study by Gupta (2006) from Uttar Pradesh, the occupation profile of the patients was similar. However in this study, most of the cases were from rural areas, unlike our study where majority were from urban areas. This is understandable as our clinic mostly caters to the surrounding regions of Mohali (Punjab) and Panchkula (Haryana), which has a large urban population.
In terms of psychiatric morbidity among the elderly in the current study, BPAD and depressive disorder were the two leading mental illness and together they were present in more than half of the sample followed by dementia due to Alzheimer's disease; on the other hand, psychotic spectrum disorders and delirium were relatively less. A study in a neighboring country like Nepal reported alcohol dependence followed by mood disorders (mania), and organic mental disorders to be the most prevalent in males whereas in females mood disorders (depression) were the most prevalent among the elderly in an inpatient setting. In an earlier inpatient study from our department over a 3-year period, mood disorders were the most common mental disorders, followed by anxiety spectrum disorders and then by organic mental disorders. In addition, similar to our study, in both these studies, a significant proportion of the sample had comorbid physical illness; >60% in males and 40% in females in the study from Nepal had comorbid physical illness, while in the earlier departmental study, more than half of the sample had comorbid physical illness. Thus, these two studies had findings similar to those in our study; not surprising for that conducted over a decade back in our department, nevertheless interesting to note that the diagnostic/clinical pattern has not changed significantly. We did not have documented cases with alcohol or other substance use disorders as these cases were seen in a separate specialty service, i.e., de-addiction clinic.
Objective 2 was to determine the short-term (18-month) functional and clinical outcomes of patients seen during the 1st year of the GMHC [Table 3].
We wanted to know whether the cases had improved with treatment over time. Apart from the thorough psycho-geriatric assessment and the pharmacological treatment, nonpharmacological treatment such as extensive psycho-education to the patients, psychotherapy, and behavior therapy were also provided to the patients. In addition, extensive psycho-education to the caregivers and tips on caregiving, especially in those cases where there was gross cognitive dysfunction along with difficulty in carrying out activities of daily living, were also an important part of the treatment package. In fact, the department had made a manual on caregiving which was provided to all caregivers whenever their family members were diagnosed to have dementia. Moreover, in several occasions (such as World Alzheimer's Day and World Mental Health Day), programs aimed at providing psycho-education and enhancing care giving skills have been conducted by the department. In the GMHC, efforts are always made to engage the caregivers, especially pertaining to treatment adherence. This is essential, as many a times the elderly patients had comorbid physical illness. Hence, a robust system of liaison with other departments such as Internal Medicine, Cardiology, and Endocrinology was also facilitated so that the patients have minimal discomfort and easy access to treatment. In a nutshell, all efforts were made to have the best possible care for the elderly with mental illness.
Any service provided to the service users should be able to benefit them and so it is important to assess the overall functional improvement of the patients while they received treatment in a mental health-care facility. By the same logic, improvement in functioning after receiving treatment will imply that the treatment has been effective. This in turn would result in positive reinforcement and the patients would be expected to comply with the treatment received, which in turn will benefit the patients in the long run. In addition, these patients will encourage other patients with similar problems to use the service, which in turn will facilitate the growth of that particular service, i.e., “snowball effect.”
To assess the functional changes during the course of treatment, EASI was used for evaluation of baseline function and then again at the time of follow-up. EASI is very easy to use and it can be an alternative to mental state examination to assess cognition in the elderly. This strategy seemed to have worked as the mean EASI score during follow-up assessment showed significant reduction compared to baseline scores (EASI-baseline: EASI-f/u = 2.95 [3.36]: 1.64 [2.57]; t = 5.345–104]; P < 0.001).
In addition, we assessed the composite occupational, psychological, and social functioning of the patients by measuring their GAF score. A mean GAF score of nearly 80 (78.77 + 16.92) is indicative of “transient symptoms with no more than slight impairment in social and occupational functioning.” This also, by itself, shows that the patients had shown a reasonable degree of improvement. Understandably, a stand-alone score is limited and not appropriate for interpretation with absence of a baseline score. However, if taken in conjunction with the EASI score change, this does assume significance, as this meant that there was improvement in the overall functioning of the patients following treatment intervention. This, despite the fact that a reasonable proportion of the patients (approximately 30%) had illnesses, were either chronic or degenerative in nature. In fact, some randomized trials have already mentioned that comprehensive geriatric assessment itself can lead to improvement in functional status and better QoL. Apart from the assessment, our clinic had incorporated several components of patient care as well as involving the caregivers. This itself may have resulted in the better functional outcome for the patients.
Finally, as functional capacity of an individual has association with the QoL, this area was also explored as research pertaining to this was scarce in the elderly people with mental illness. However, in terms of QoL, the total mean score of WHO-QoL-BREF was 45.42 at follow-up assessment, which suggested that overall the patients continued to have a poor QoL. However, this was not something unexpected as QoL in the elderly in general, especially in those suffering with mental illness such as dementia, depression, and psychosis, has been found to be unsatisfactory,,,,,, though those having better cognition are reported to have a better QoL.
Objective 3 was to assess the satisfaction with GMHC services from patients presenting to the GMHC in the 1st year of its inception [Table 4].
The present study explores the important dimension of patient satisfaction pertaining to the services that they had availed while getting treatment for mental illness. To the best of our knowledge, no such study has been carried out in the elderly anywhere in the country and hence this study provides some interesting insight into this unexplored issue.
Patient satisfaction surveys serve a dual purpose of improving patient care and also evaluating performance. There are numerous such satisfaction scales available, but only a few in the field of mental health and even fewer that are validated. One such scale that is quick to use, validated, applicable for a variety of diagnoses, popular, and having multiple domains for outpatient population is the PAT-SAT. It has also been earlier used by one of the authors (NG) in terms of assessing its validity and applicability in the Indian setting., Unfortunately, the previous study was conducted for a different objective and with respect to general adult outpatient setting; hence, the findings obtained here cannot be compared.
Nevertheless, it is important to note that the scores obtained on each of the six domains of PAT-SAT were above 60% of the possible mean scores that could be obtained. This reflects that the patients (and/or their caregivers) were not dissatisfied, if not overly satisfied, with the services provided. Examining in detail the PAT-SAT domains, the highest score was obtained for “body language” domain whereas near-equal scores were obtained for other five domains. The “body language” domain comprises two items, namely (i) did the medical practitioner appear interested in your concerns and (ii) did you feel that a good rapport was established. Looking at these questions, the high score so obtained is probably indicative of the fact that the patients and their caregivers found the consultant in-charge (SD) to be interested in listening to their concerns and more importantly, he was able to develop an excellent rapport with them during the course of the consultations (and follow-ups). It will probably not be wrong to say that this contributed to a near-perfect telephonic follow-up of the cohort; though without direct inquiry and confirmation, this will still remain conjectural.
In fact, it has additionally be mentioned elsewhere that measuring and responding to patient satisfaction can be therapeutic by itself as the clinician seems to be listening to the patients' and caregivers' needs and simultaneously showing respect too. However, this is a topic that will require further research using a different study design and is an area to study for the future.
Objective 4 was to compare the patients on various sociodemographic-, clinical-, functional-, and satisfaction-related parameters on the basis of diagnosis, i.e., by dividing them into broad categories of “organic” and “functional/nonorganic”[Table 5] and [Table 6].
In order to achieve this objective, we divided the sample into two subgroups, namely 'organic (comprising dementia, other dementias, and delirium) and “functional/nonorganic” (comprising schizophrenia and other psychosis, BPAD, depression-single/recurrent, and anxiety disorder). Of the total sample of 105 patients, 73 cases (69.5%) were having functional disorders and the remaining 32 cases (30.5%) were having organic disorder. During the follow-up assessment, 5 cases of the former and 12 cases of the latter had expired, the mortality being 6.8% and 37.5% in each group, respectively. The higher mortality rates in the “organic” subgroup were not un-understandable, especially keeping in mind that the duration of follow-up was approximately 18 months and that by concept this subgroup is supposed to have poorer outcome and prognosis. On comparison of the sociodemographic profile of these two subgroups, they were comparable except for the variable of age (20% organic were above 80 years, whereas 50% functional were between 60 and 65 years; χ2 = 17.74; df = 1; P < 0.01). This is also on expected lines wherein with increasing age, probability of organic pathology goes up.,
Correspondingly, as shown in [Table 5], the HMSE scores were significantly lower in “organic” subgroup. This is again logically as expected and in keeping with the diagnostic grouping.
On the parameters of functionality, mixed results were obtained wherein both subgroups being comparable on EASI scores (baseline and follow-up) but “organic” scoring significantly lower on GAF. Lower GAF scores in the “organic” subgroup are self-explanatory and indicative of the underlying pathology along with the inherent progressive, deteriorating course of the illness. However, the comparable EASI scores at both baseline and follow-up are not easy to explain.
Mixed results were also obtained on QoL; comparable on physical and psychological domains, but significantly lower scores on social and environmental domains in “organic” subgroup. [Table 6] shows correlations of HMSE with GAF, GAF with WHO-QoL social and environmental domains, and intercorrelation between social and environmental domains of WHO-QoL-BREF. Combining these results, one may hypothesize that the QoL results may be because the organic cases were likely to have significant dysfunction because of which they would be often lonely, keeping to themselves and not able to overcome certain environmental barrier from time to time. Indeed, there is more dysfunction in the organic cases as statistically significant difference in the GAF scores has been seen between the organic and functional groups and also the fact that GAF score has shown strong positive correlation with the social relationship and environmental domains of QoL. However, not much difference was seen in the other two domains between the organic and functional groups maybe because the caregivers in our study sample were actively involved in the treatment plan; in fact in comparison to the caregivers of the functional group, the caregivers of the organic group may have provided more care and support, knowing well that their relative now required more extensive help and support. As a result of this, the physical and psychological domains did not get much affected and were comparable in both the groups.
Despite being a service evaluation, there were numerous aspects, which still need addressing. These could have gone a long way in strengthening the robustness of our results and conclusions so drawn. To enumerate, face-to-face interviews were not conducted; evaluation of satisfaction with one's own doctor tends to introduce a lack of honesty in responses from patients; PAT-SAT is not completely a culture-free instrument, and the use of instruments at baseline and follow-up could have been “smarter.”
Nevertheless, this study had its own strengths that make the findings hard to ignore, i.e., taking the patients' and caregivers' convenience into account, pragmatic in design, perfect follow-up rate, structured tools for assessment and noting of service user responses, and long duration of follow-up period (18 months).
| Conclusions|| |
One of the key approaches of the WHO is to develop services that provide older person-centered and integrated care (including mental health care). Our findings have shown that the newly started GMHC, even though in its incipient stage, is attracting patients of all diagnostic categories, from expected catchment areas, is being able to deliver interventions which are bringing about clinical and functional improvement, and service users (and their caregivers) are not reporting dissatisfaction.
Hence, the future should focus on further strengthening of the service with resources and also integration with other services, development of interventions, and addressing the lacunae as identified in this “service evaluation frame work.”
As it was once said…in the Indian context, this article and evaluation is conceptually akin to “one small step for man, one giant leap for mankind” (Neil Armstrong, July 20, 1969).
The authors would like to thank the patients and their family members and faculty and staff of Department of Psychiatry, Government Medical College and Hospital, Chandigarh, for their support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]