Psychiatric Morbidities in Patients with Non-communicable Diseases among Inpatients of Medicine Department in a Tertiary Care Hospital: A Descriptive Cross-sectional Study

ABSTRACT Introduction: Psychiatric morbidities are common among patients with chronic non-communicable diseases. These diseases have high morbidity, mortality, and higher health costs. However, psychiatric conditions are often underdiagnosed and undertreated in our country. This study aimed to find out the psychiatric morbidities among patients with non-communicable diseases admitted in inpatients units of medicine department. Methods: A descriptive cross-sectional study was conducted in inpatients of medicine department of a tertiary care hospital among 926 patients with chronic non-communicable diseases. Ethical approval was obtained from Chitwan Medical College Institutional Review Committee (Ref. No. CMC-IRC: 2074/75: 38). Convenient sampling technique was used. Patients were interviewed using the Patients Health Questionnaire. Data analysis was performed using Statistical Package for Social Sciences version 16. Results: Among 926 non-communicable diseases patients, psychiatric morbidities observed were somatization 612 (66.1%) anxiety 319 (34.4%) and depression 379 (40.9%). Patient with multiple non-communicable diseases had higher psychiatric morbidities compared to patients with a single disease. Conclusions: Psychiatric morbidities are common among admitted patients suffering from non-communicable diseases in Nepal. Hence, regular screening services are needed in all level of health care centres to identify and treat the risk groups on time.


INTRODUCTION
Non-communicable diseases (NCDs) are the leading cause of deaths globally. 1 It accounts for more than 85% of premature deaths occurred in low and middleincome countries. 2 Psychiatric morbidities such as depression and anxiety are high in NCDs patients. 3,4 They are collectively responsible for 72% of all deaths. 5 The co-existence of psychiatric disorders with NCDs has important implications on quality of life, general well-being, cost of treatment and general longevity of the patient. 3,6 In Nepal, NCDs accounts for 66% of deaths in 2016. 7 The prevalence of mental disorders is higher among physically ill patients (31.7%) 8 compared to healthy adults (13.2%). 9 These conditions are underdiagnosed and undertreated in our country due to social stigma. Also, there is limited literature on the prevalence of mental disorders among patients with NCDs. The sample size of 925 patients was calculated considering the confidence level of 95%. Convenient sampling technique was used for recruiting the desired number of samples in the study. Structured interview schedule for the socio-demographic and diseaserelated information and Patient Health Questionnaire (PHQ) for the screening of psychiatric morbidities were used for the data collection. PHQ contains 3 parts: PHQ-15 to assess somatic functions, Generalized Anxiety Disorders-7 (GAD-7) to assess anxiety and PHQ-9 to assess depression. The PHQ questionnaire is a validated questionnaire, which found to be useful in the screening of patients for psychiatric illness worldwide. 4,6,10,11 It assesses the symptoms experienced by participants during the 2 weeks before they take the survey. Each item of GAD-7 and PHQ-9 was rated 0 to 3 scores where 0-not at all, 1-several days, 2-more than half of the days, and 3-nearly every day, with higher scores indicating patients' increased self-report of anxiety and depression severity. Scores obtained in GAD-7 was classified into mild (5-9), moderate (10)(11)(12)(13)(14), and severe anxiety (≥15). Likewise, scores of PHQ-9 was divided into mild (5-<10), moderate (10-<15), moderately severe (15-<20) and severe (≥20) depression.
To maintain the rights of patients, further evaluation was done for those patients who were found to be positive on PHQ by psychiatrists using Standard Beck Anxiety Scale 12 and Hamilton Depression Scale 13 for the confirmation and further treatment. Written informed consent was obtained from the patients ensuring their confidentiality of the information. Collected data were entered into Epi data 3.1 and exported to IBM SPSS version 20. Then data were analyzed in terms of descriptive statistics such as frequency, and percentages.

RESULTS
A total of 926 patients participated in the study. Among them, 548 (59.2%) were female and the mean age was 61.12 (±17.79) years. More than two-thirds of the patients were residing in the urban area 624 (67.4%), married 677 (73.2%) and belonged to the joint family 682 (73.7%). Nearly half of the patients were illiterate 461 (49.8%), involved in agriculture 453 (48.9%) and reported that their family income was just sufficient for the daily expenses. However, more than twothird 627 (67.7%) of the patients reported the illness impact on their job as a result they quitted their job. Regarding the behavioural pattern, nearly half 451 (48.7%) of the patients were never smoker, and 122 (13.2%) of patients were still smoking a cigarette. Only 203 (21.9%) of patients had a habit of alcohol use. Regarding clinical variables, more than one-quarter of patients had multiple NCDs 356 (38.4%) followed by COPD 188 (20.3%), diabetes mellitus 110 (11.9%) and HTN 102 (11.0%). More than half 535 (57.8%) of the patients' duration of diagnosis was less than 5 years and 532 (64.3%) of patients had a history of hospital admission in the last year (Table 1).   (Table 3).   (Table 5).  4 These studies finding might be varied due to the use of different data collection tool, characteristics of patients and data collection settings which might influence the prevalence of anxiety among patients.
In this study, the prevalence of depressive symptoms among NCDs patients was 41.0% which was found to be higher than the study done by Rijal et al. in 2016 in the general population of Nepal which showed 11.7% prevalence. 15 It indicates that depression is higher among NCDs cases. However, available evidence showed varied results regarding the prevalence of depression among NCDs cases. The prevalence observed in our study is higher compared to other study done in India in which 29.1% of patients had depressive symptoms 6 whereas lower than the study conducted in the urban slum of East Delhi which found depression among more than half (56.4%) of NCDs patients. 4 The difference in findings might be due to difference in characteristics of samples included in the study. In our study included five types of NCDs patients whereas these two studies excluded patients with COPD and CKD in their studies. 4 Our country is also giving priorities for noncommunicable diseases and mental health through implementing sustainable developmental goal in national health policy. Nepal health research council, university grant commission and other NGOs have also mentioned NCDs and mental health as a priorities area for funding. Exploring psychiatric morbidities in patients with major non-communicable diseases using standard screening tool is the strong point of this study. Despite this, our study has certain limitations like-it was conducted in only one study setting and hospital admitted patients only, which may limit the generalizability of the study and it did not exclude the patients with other health problems which might have influenced the study findings.

CONCLUSIONS
Psychiatric morbidities i.e. anxiety, depression and symptoms of somatization, is common among the patients suffering from non-communicable diseases such as diabetes, hypertension, chronic obstructive pulmonary disease, cardiovascular diseases and chronic kidney disease in Nepal. Anxiety and depression are proportionally higher in patients with DM and CKD than other NCDs patients. Likewise, patient with multiple NCDs tends to have higher psychiatric morbidities compared to patients with a single disease. Hence, there is a need to develop an integrated care model to manage these morbidities to the vulnerable groups at all level.