|Ahead of print
|Anxiety, Depression and Barriers to Mental Health Services among patients with Neurological disorders: Brief report from a tertiary care centre in South India
Raviteja Innamuri1, Arnab Mukherjee2, Bhuvaneshwari Sethuraman3, Arun Rachana4, Vivek Mathew4
1 Assistant Professor, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
2 Consultant, Department of Palliative Care and Psycho-oncology, Tata Medical Center, Newtown, Kolkata, West Bengal, India
3 Assistant Professor, St John's Medical College and Hospital, Bengaluru, Karnataka, India
4 Professor, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
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|Date of Submission||27-Nov-2021|
|Date of Acceptance||18-Apr-2022|
|Date of Web Publication||17-Jun-2022|
There is high prevalence of psychological distress in patients diagnosed with neurological disorders. A cross-sectional study was done among inpatients from the department of neurology in a tertiary care centre in South India to assess prevalence of anxiety, depression, and barriers to mental health-care utilization. Anxiety and depression were estimated using the Hospital Anxiety and Depression Scale (HADS). There is a high prevalence of psychological distress among the study participants. Proactive inquiry and screening of distress by the treating team may help identify psychological distress. Patients are more conforming and open to treating doctor. Barriers to mental health-care utilization included stigma, patient perception regarding treating doctor's attitude, patients' perception regarding distress, and doctor's perception regarding patient distress. There is a need for measures to alleviate stigma.
Keywords: Anxiety, depression, mental health barriers, mental health-care utilization, mental health needs, patients of neurology
|How to cite this URL:|
Innamuri R, Mukherjee A, Sethuraman B, Rachana A, Mathew V. Anxiety, Depression and Barriers to Mental Health Services among patients with Neurological disorders: Brief report from a tertiary care centre in South India. Arch Ment Health [Epub ahead of print] [cited 2022 Jun 26]. Available from: https://www.amhonline.org/preprintarticle.asp?id=347735
| Introduction|| |
A general estimate in patients seeking neurological treatment is that 40% of neurology outpatients and 34% of neurology inpatients have psychiatric disorders. Recognition and treatment of comorbid psychiatric disorders significantly improve the treatment outcome, overall health status, and rehabilitation. Primary treating physicians may have difficulty to recognize the symptoms of depression and anxiety more than 50% of the time. Hence, psychiatric comorbidities may not be adequately addressed in primary neurological facility.
Many other factors additionally influence mental health-care utilization among patients of neurology. Studies in developed nations showed that majority of surveyed patients reported felt need for mental health intervention. However, almost half of those needing help were not formally referred to mental health professionals (MHPs) and one-third of them remained untreated. The most commonly found barriers to utilization of mental health services in developed countries are inadequate screening and detection of psychiatric complications by medical care providers, availability of services, accessibility of services, and acceptability of mental health-care treatment.
To the best of our knowledge, this is the first Indian study that assessed barriers to utilization of mental health services in patients who are receiving treatment at a neurological setting.
| Materials and Methods|| |
We followed a cross-sectional design. Participants were adults with a primary neurological condition admitted under the Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India. They were recruited over a period of 3 months. Patients with severe cognitive impairment were excluded from the study.
The clinical research form had questions on sociodemographic variables, primary neurological condition, medical comorbidity, mental well-being, and barriers to mental health care. The questions on barriers were based on available literature and inputs from the institute's neurologists and psychiatrists, who have clinical experience in the area. The Hospital Anxiety and Depression Scale (HADS) was used for screening anxiety and depression. The scale is widely used in nonpsychiatric population and provides anxiety score and depression score. A score of 8 or above in anxiety subscale indicates anxiety and a score of 8 or above in depression subscale indicates depression. A score of 8 or above in either of the subscale indicates psychological distress.
The study obtained institutional review board clearance (IRB No. 12247 dated 25-09-2019). Research ethical principles were followed during data collection and analysis. Informed consent was obtained from all participants. Data analysis was done using SPSS 16.0 version (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc).
| Results|| |
A total of 40 consecutive patients were recruited of which 30 completed the study. The details of those who completed the study are as follows:
The mean age of the sample was 39.8 ± 18.1 years. Majority were male (n = 22, 73.3%), married (n = 20, 66.7%), from urban background (n = 26, 86.7%), living in nuclear families (n = 23, 76.7%), belonging to Hindu religion (n = 21, 70.0%), with a graduate or postgraduate degree (n = 18, 60.0%), and employed (n = 22, 73.3%).
Clinical profile (medical)
The details of primary neurological diagnosis among participants were classified. 76.7% had central nervous system disorders and 23.3% had peripheral nervous system disorders. 33.3% were disorders of the brain and 20% were degenerative disorders. Most (n = 20, 66.7%) of the disorders had an insidious onset. The mean duration of neurological disease was 2.7 ± 2.3 years with a mean duration of treatment (1.7 ± 1.9 years). Seventeen participants (56.7%) had comorbid medical illness. The mean duration of medical comorbidities was 5.5 ± 4.5 years.
Based on the HADS scoring, the mean anxiety score was 6.6 ± 4.4 and mean depression score was 6.0 ± 4.1. Ten (33.3%) of the patients had screened positive for anxiety score and ten (33.3%) screened positive for depression. The prevalence of psychological distress (either anxiety or depression) was 50.0% (n = 15). Among the participants, eight (26.7%) reported suicidal ideas and one (3.3%) had a history of suicidal attempt. More than half (n = 17, 56.7%) reported to have or were described to have anxious personality traits. Four participants (13.3%) were already taking psychotropics and they all had HADS anxiety/depression score above cut off. Eleven participants (36.7%) reported perceived stress. The details on barriers are provided in [Table 1].
Barriers in mental health-care utilization
The following results are based on those who had subjectively felt anxious, depressed, or tense (n = 19). Among those 19 participants, help-seeking was seen in 13 (68.4%). Twelve (63.2%) of them informed about their distress to either their neurologist or when they consulted a mental health professional. Among those 12 who informed treating doctor, 11 (92.3%) participants reported that the treating doctor took action on their concern (viz., listened with empathy, prescribed medicine, and referred to psychiatrist). All patients referred by the treating doctor to MHP complied with the referral, and all of them reported benefit with the treatment offered by the MHP. However, 50% of them (n = 4) stopped treatment from MHP later on. The details on barriers are provided in [Table 2].
|Table 2: Barriers to mental health utilization among the study participants|
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Factors associated with mixed anxiety-depression
Those with anxious trait, perceived stress, and medical comorbidity were found to have greater prevalence of mixed anxiety depression when compared to those without those risk factors. However, the associations were not statistically significant on Chi-square analysis. Other factors could not be analyzed for the association since the sample was too small to provide a meaningful result.
| Discussion|| |
This study revealed a higher prevalence of psychological distress. Half of the patient population had objective distress. As noted in other studies, mixed anxiety depression is one of the common presentations among nonpsychiatric population. The impact of not recognizing and not dealing with this is high. It can translate into negative costs such as years lived with disability, disability-adjusted life years, loss of life due to suicide, burden on health system, worsening of underlying condition, and noncompliance with the treatment of primary condition.
In spite of this huge burden, the study revealed a treatment gap in terms of not seeking help and/or the distress being not explored. It is common in developing countries to have treatment gap in common mental disorder. The study attempted to explore the reasons for this gap. The barriers identified can be grouped into societal and individual. Societal level barrier was the stigma associated with mental illness. Individual-level barriers were the misperception from those involved in the therapeutic process of primary condition.
The study also revealed some strengths in the therapeutic system. The finding that patients are more likely to disclose their distress to the treating doctor than a MHP opens up avenues for alleviating stigma and addressing patient distress. The finding that patients are more likely to follow the treating doctor's instruction to consult MHP reveals that the therapeutic relationship can be utilized to overcome the barrier. Psychological distress screening could include proactive inquiry by the treating team that may help in the identification of psychiatric comorbidities.
Strengths and limitations
The study explored a neglected area in mental health, psychological distress, and barriers among those with neurological disorders. Cross-sectional design limits the judgment on direction of relationship between factors. Small sample size and consequent absence of higher-order analysis are major limitations of the study.
We would like to thank GL Assessment, London, for providing permission to use HADS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Sociodemographic|| |
1. Name of the Patient:
2. Contact details: District State Phone
3. Hospital No: CMC-H- MHC-
4. Age:…………. Years
5. Gender: 1. Male 2. Female 3. Other
6. Religion: 1. Hindu 2. Muslim 3. Christian 4. Sikh 5. Jain 6. Buddhist 7. Others (specify)
1.Profession or Honors 4.High school certificate
2.Graduate or postgraduate 5.Middle school certificate
3.Intermediate or post high school dip 6.Primary school certificate
1.Profession 4. Skilled worker
2.Semi-Profession 5.Semi-skilled worker
3.Clerical, Shop-owner 6.Unskilled worker
9. Marital status: 1. Single 2. Married 3. Separated 4. Divorced 5. Widowed
10. Place: 1. Rural 2. Urban
11. Family type: 1. Nuclear 2. Joint
12. Family income: INR ____________ per month
| Clinical|| |
13. Neurological Diagnosis:
14. Duration of Neurologic illness:
15. Rapidity of onset of current Neurologic illness: 1. Sudden 2. Insidious
16. Duration of treatment for Neurologic illness: ………………….months
17. Compliance of treatment (as reported): 1. Good 2. Average 3. Poor
18. Comorbid physical illnesses: 1. Yes (specify)………………. 2. No
19. If yes, 1. Specify illness ……………………………….2. Duration……. months
20. Family history of Physical illness: 1. Yes (specify)………………. 2. No
21. Family history of mental illness: 1. Yes 2. No
22. If yes, Relation to you: Type of mental illness:
23. Premorbid anxious personality traits (as reported): 1. Yes 2. No
24. Current Functionality:
1.Profession 4. Skilled worker
2.Semi-Profession 5.Semi-skilled worker
3.Clerical, Shop-owner 6.Unskilled worker
25. Presence of perceived stress other than current neurologic illness before the onset of psychiatric illness: 1. Yes 2. No
26. Have you ever had suicidal ideation: 1. Yes 2. No
If yes, please specify, 1) Before the onset of current neurological illness
2) After the onset of current neurological illness
27. Have you ever-attempted suicide: 1. Yes… (year/month)
| Questionnaire|| |
28. Since the time you have developed neurological symptoms, have you ever felt that you needed help in managing stress, tension or depression? 1. Yes 2. No
29. Since the time you have developed neurological symptoms, have your family members ever mentioned that you are looking tensed or depressed?
1. Yes 2. No
30. Since the time you have developed neurological symptoms, have your primary physician/neurologist ever told you that you are anxious or depressed?
1. Yes 2. No
| If All Three Responses are 'No', Go To Hads.|| |
31. Since the time you have developed neurological symptoms, have you ever reported to your physician/neurologist that you are feeling tensed or sad? 1. Yes 2. No
| IF “NO”, GO TO Q No. 34|| |
32. If you have reported to your physician/neurologist that you are feeling tensed or sad,
i) Did your doctor give adequate importance to that? 1. Yes 2. No
ii. Did he prescribe medicine for that problem? 1. Yes 2. No
iii. If yes, details of medication.
iv. Did your doctor refer you to a psychiatrist? 1. Yes 2. No
| IF ''YES'', GO TO Q No. 35|| |
33. Did you ever visit a Psychologist/Psychiatrist for your psychological problems on your own? 1. Yes 2. No
34. If you haven't reported to your physician/neurologist that you are feeling tensed or sad, what are the reasons? (Please tick whichever is applicable)
- I felt if I visit a psychiatrist, people would look down upon me
- I felt if I visit a psychiatrist, I would get labeled as “mentally ill”
- I couldn't accept I had a mental illness
- I felt my physician/neurologist would not be sensitive enough to my emotional struggles
- I felt anyone in my situation would be struggling
- Other reasons (mention
35. If your physician/neurologist had referred you, did you go to a psychiatrist/psychologist?
1. Yes 2. No (Mention: psychiatrist/psychologist)
36. If you didn't visit a psychiatrist/psychologist, what were the reasons? (Please tick whichever is applicable)
- I felt that if I visit a psychiatrist, people would look down upon me.
- I felt that if I visit a psychiatrist, I would get labeled as 'mentally ill'.
- I couldn't accept I had a mental illness.
- I could not afford the treatment since I am already spending on my neurologic illness.
- Unavailability of psychiatrist/psychologist in my reach.
- My neurologic illness prevents me from traveling to the doctor.
- I visited a traditional healer/magico-religious healer instead.
- Other reasons (mention
37. If you had visited a psychiatrist/psychologist
i) What was the time lag between the referral/recognition and your visit?……….Weeks
ii) Details of treatment/medications given:
Psychotherapy received: Yes/No
iii) Has the psychiatrist/psychologist consultation helped you? 1. Yes 2. No
iv) If yes, domain: a) Biological functions
v) Do you think the psychiatrist/psychologist was able to understand the problems specific to your neurological condition? 1. Yes 2. No
v. Did you continue following up? 1. Yes 2. No
38. If you did not follow up with psychiatrist/psychologist, what were the reasons? (Please tick whichever is applicable)
- I felt better
- I felt if I continue to visit a psychiatrist, I would get labeled as 'mentally ill'
- Psychiatrist/psychologist didn't understand the problems specific to my neurological condition
- I could not afford the added cost of treatment.
- The psychiatrist/psychologist was located too far from my reach.
- Following up with multiple doctors was too difficult with my physical condition
39) Current psychiatric diagnosis (if known):
40) Stability of psychiatric diagnosis: 1. Yes 2. No
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Room No. 202, Office of Unit 2, Department of Psychiatry, Mental Health Centre, Besides Bagayam Police Station, Bagayam, Vellore - 632 002, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]
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