CMD PAPER PRSENTATION PPT by Dr Bashar.pptx

The ppt describes my study assessing Prevalence and determinants of CMD among the rural population of North India

1. Prevalence & Determinants of Common Mental Disorder symptoms in rural Poulation of Haryana, North India Dr. MD. Abu Bashar, MD, DNB, PGDGM, DCMH, FSIOP, FRSPH Assistant Professor Department of CMFM All India Institute of Medical Sciences & Research, Gorakhpur(U.P.)

2. Introduction Common mental disorders (CMDs) are depressive and anxiety disorders that are classified in ICD-10 (1) as: “ neurotic, stress-related and somatoform disorders ” and “ mood disorders ; CMD s are regarded as “ invisible disorders ” as t hey are often overlooked by patients, caregivers, health professionals, and policymakers yet cause significant health burdens ; The public health significance of mental and behavioural disorders is demonstrated by the fact that they are among the most important causes of morbidity in primary care settings and produce considerable disability National Mental Health Survey (NMHS) estimated that about 150 million Indians need care for mental disorders, and about 10% suffer from common mental disorders (CMD) such as depression, anxiety, emotional stress and suicide risk, as well as alcohol and drug use. The report indicated that the prevalence of mental disorders was 2–3 times higher in urban areas, compared with rural areas

3. Introduction Around 70–80% of the population in India currently live in rural settings without access to good quality healthcare facilities ; However, relatively few studies have used standardised tools to assess the burden of CMD in rural settings ; Thus, there is a need to provide further evidence about the burden of mental disorders and its determinants , especially in rural communities ; In the absence of reliable disease prevalence estimates, planning an appropriate health system response is challenging ; With ths background, the current study was conducted to outlines the prevalence of CMD s such as depression, anxiety and suicidal ideation in arural population of North India and risk factors associated with those conditions ;

4. Objectives To assess the point prevalence of Common Mental Disorder (CMDs) symptoms among the rural population of Haryana, North India & To identify the various socio-demographic determinants of CMDs in the rural population of Haryana, North India

5. Study Design & Settings Study Design - C ommunity based cross sectional study Study A rea : Two villages of Raipur Rani block, a predominantly rural block, of district Panckhkula of Haryana, North India Study Participants : Adult residents of the selected villages not previuosly diagnosed or under treatment for any psychiatric illnessess Study Tool: A se mi-structured study quetionnaire containing details on socio-demographic detail and a screening tool for CMD

6. Sample size & Sampling strategy Sample Size : Using the formula for cross sectional studies, where prevalence was taken as 12.2% ( from a meta-analysis of studies from India and South Asia ) 2 , confidence Interval as 95% with margin of error of 5% and design effect (DEFF) as 1.5( for cluster sampling), the sample size arrived was 180. Sampling Strategy: Multistage random sampling technique, conducted in two phases: (i) household (ii) participant. A list of all households in the two selected villages was obtained using the family folders maintained by the female health worker which were numbered consecutively. The two villages, Kheri and Badauna Kalan, had 274 and 180 households respectively with a total adult population ( ≥ 18 years) of 824 and 524 respectively. A total of 180 households were selected using systematic random sampling technique with proportional number of households from each of the two villages. A list of all the adult family membersin each of the selected household was prepared and one member from each selected household was chosen through the Kish method.

7. Study Tool & Administration A pretested study questionnaire consisting of two sections : F irst part contained details on Socio-demographic characteristics such as age, sex, religion, caste category, marital status, education, employment status, occupation, monthly family income, type of family, presence of any mental illness in the family, presence of any chronic physical illness such as diabetes, hypertension, TB, HIV, cardiovascular diseases, chronic respiratory diseases such as asthma or COPD, H ypothyroidism, Osteoarthritis, Gout, Chronic kidney diseases etc. Hindi, the local language, version of Goldberg’s Short General Health Questionnaire (GHQ-12), a screening tool well validated in indian settings was used for detecting CMDs ; The scale asks whether the respondent has experienced a particular symptom or behaviour recently (in the past 2 weeks). Each item is rated on a four-point scale (less than usual, no more than usual, rather more than usual, or much more than usual) The questionnaire was administered through face to face interview by the investigator

8. Statistical Analysis Data were entered in MS Excel sheet and analysis was performed using SPSS IBM Corp. for Windows, Version 21.0. Armonk, NY: IBM Corp. B i-modal method(0-0-1-1), the most common scoring method with score ranging from 0 to 12, was used for calculating the GHQ-12 score of each participants . The threshold for screening positive for CMDs was taken as a score of 4 and above 3 Categorical comparisons across various Socio-demographic variables between individuals who were screened positive and negative for CMDs were made using the Chi-square or Fischer exact test s . Relative differences in being screened positive for CMDs between these two groups were also compared using odds ratios and 95% confidence interval. The level of significance was set at p-value < 0.05.

9. Ethical considerations Ethics approval was obtained from the Institute Ethical Committee (IEC), Post graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India (vide Letter No. IEC/243/2017). Written informed consent was obtained from all the participants before the interview. All consenting selected adults who understood the questions and instructions, and were not limited by any severe illness that prevented them from giving the interview, were only included. The interview was conducted in a place which offered privacy and efforts were taken to ensure that no other family members were present at the time of the interview. Study participants screen ed positive for CMDs were referred to the Psychiatrist in the team for Psychiatricfor further diagnosis and management. Prior to the start of the study, approval was also obtained from local village administrative body to ensure their co-operation in the study.

10. Results- Sociodemographic Characteristics A total of 180 community dwelling adult individuals were interviewed for the study. The age of the participants ranged from 18 to 76 years with a mean of 42.5± 23.4 years. Majority were aged between 31-50 years (52.3%) , were females (60.0%), educated only up to primary level (22.2%), living in joint family (55.5%), currently married (85 .0 %), unemployed (57.3%), working as housewives (44.4%) and having monthly family income below INR 10,000 (63.2%) (Table 1). Presence of any chronic physical illness such as diabetes, hypertension, coronary artery disease, stroke, asthma, COPD, arthritis etc. were reported by 28.8% of the study participants whereas presence of any psychiatric illness in family members was found in 7.7% of the participants. (Table 1).

11. Results-Sociodemographic Chracteristics Variables Frequency (N) Percentages (%) Gender Male Female 72 108 40.0 60.0 Age-group (in years) 18-30 31-40 41-50 51-60 >60 20 48 46 33 33 11.1 26.7 25.6 18.3 18.3 Religion Hindu Muslim Sikh 150 10 20 83.3 5.6 11.1 Marital status Unmarried Currently Married Widowed/Divorced/Separated 17 153 10 9.4 85.0 5.6 Type of Family Nuclear Joint/extended 107 73 59.4 41.6

12. Results- Sociodemographic Characteristics Variables Frequency N Percentages (%) Level of Education Illiterate/No formal education Up to Primary level (5th class) Up to Middle level (8th class) Up to Matriculation 10+2/Intermediate Graduate and Above 44 39 39 33 18 07 24.4 21.7 21.7 18.3 10.0 3.9 Employment status Employed/Retired with pension Unemployed 77 103 42.7 57.3 Occupation Farming Unskilled labour Skilled worker Govt. Job Private Job Housewife Not working/retired 18 22 20 12 18 80 10 10.0 12.7 11.9 6.7 10.0 44.4 5.6 Total monthly family income (in INR) ≤5,000 5,001-10,000 10,001-15,000 15,001-20,000 >20,000 17 97 41 13 25 9.4 53.8 22.7 7.2 13.8 Presence of any chronic physical illness Yes No 52 128 28.8 61.2 History of any psychiatric illness in family Yes No 14 166 7.7 92.3

13. Result- GHQ-12 scores Common mental disorders(CMDs) Symptoms Present (GHQ score≥4) Absent (GHQ score<4) N (%) 36 (20.0) 144 (80.0) GHQ-12 scores Mean ±SD 1.77±0.54 1-3 4-8 9-12 72(40.0) 72(40.0) 34(18.8) 02(1.2)

14. Results- Association between Socio-demographic characteristics and CMDs. Variables CMDs present n(%) CMDs absent n(%) OR(95%CI) p-value Gender Male Female 14(19.4) 22(20.4) 58(81.6) 86(79.6) 1(Reference) 1.05(0.50-2.23) 0.88 Age-group (in years) 18-30 31-59 60 & Above 40(22.2) 104(57.8) 36(20.0) 03(7.5) 15(14.4) 18(50.0) 1(Reference) 2.07(0.56-7.61) 12.33(3.21-47.38) <0.00001 * Religion Hindu Muslim Sikh 32(21.3) 2(20.0) 2(10.0) 118(78.7) 8(80.0) 18(90.0) 1(Reference) 0.92(0.19-4.56) 0.41(0.09-1.85) 0.61 Marital status Single Currently married Widowed/Divorced/Separated 2(11.8) 29(18.9) 5(50.0) 15(88.2) 124(81.1) 5(50.0) 1(Reference) 1.75(0.38-8.10) 7.50(1.09-51.52) 0.03 * Level of Education Literate Illiterate 16(11.8) 20(45.4) 120(88.2) 24(54.6) 1(Reference) 6.25(2.84-13.77) <0.0001 * * Statistically significant

15. Results- Association between Socio-demographic characteristics and CMDs. Variables CMDs present n(%) CMDs absent n(%) OR(95%CI) p-value Employment status Employed/retired with pension Unemployed 12(16.2) 24(22.6) 62(73.8) 82(77.4) 1(Reference) 1.5(0.70-3.26) 0.29 Type of family Nuclear Joint/extended 20(26.8) 16(20.8) 87(73.2) 57(1.92) 1(Reference) 1.22(0.58-2.55) 0.59 Monthly family income (in INR) <10,000 ≥10,000 24(30.8) 12(11.8) 54(69.2) 90(88.2) 3.33(1.54-7.20) 1(Reference) 0.002 * Presence of chronic physical illness Absent Present 12(9.8) 24(46.2) 116(90.2) 28(53.8) 1(Reference) 8.28(3.70-18.56) <0.0001 * History of psychiatric illness in family Absent Present 30(17.7) 6(54.5) 139(72.3) 5(45.5) 1(Reference) 5.56(1.52-19.42) 0.007 * * Statistically significant

16. Limitations As the study was restricted to a single block of a single district, hence may not be representing the whole rural adult population of the region of North India. However, the results can be generalized to other rural populations in the province, but its generalizability beyond similar rural populations may be difficult. Another limitation is that, as this was a cross-sectional study, no causal inference can be drawn from the results, and only associations can be established. Suicidal ideation was captured using the single GHQ-12 question, which only provides insight into one's thoughts; this is a risk indicator, but not a definitive clinical assessment of suicide risk, which requires further clinical assessment. Although alcohol and tobacco use may be potential risk for CMDs, we did not assess these in our study. More men have gone out of the village for seasonal work in factories and farms located in nearby villages and towns, and hence were unavailable for interviews during the daytime when the data collection took place. This led to a higher proportion of women being included in the study which is again one of the potential source of bias.

17. Conclusion The CMDs symptoms was found to be present in 1 out of studied 5 adult individuals from rural population which is alarmingly high and concerning. The findings provides evidence to recognize CMDs as a significant public health problem in rural population of North India Our findings showed that CMDs are closely linked with Socio-demographic characteristics (age, marital status, education, type of family, income, presence of any chronic physical illness and positive family history of psychiatric illness) among the rural population There is a need to assess, screen, diagnose and manage CMDs in primary healthcare and community-based settings in India to address the huge and growing burden of CMDs in the rural population. Interventions should focus on early detection in primary care, appropriate pharmacological and nonpharmacological interventions, greater accessibility to the community, and lesser health care costs to the public

18. Implications Given the higher prevalence of CMDs compounded with lower accessibility to mental health care and services, there is an urgent need to improve psychiatric care in India through its National Mental Health Programme ; NMHP ’s operational arm, the District Mental Health Programme should focus more on CMDs apart from traditional S evere M ental D i s orders; The is a need on the task-shifting to primary care in general healthcare settings with impactful, innovative telemedicine on-consultation training methods ; There is also a need for national guidelines for the management of CMDs in primary, secondary, and tertiary healthcare delivery systems ; Given the higher prevalence of CMDs among individuals with NCDs , It is recommended to include CMDs in the management of NCDs for a better course and prognosis .

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