STUDY OF PSYCHIATRIC MORBIDITY OF PATIENTS ATTENDING FREE MENTAL HEALTH CHECK UP CAMPS IN FAR WESTERN RURAL NEPAL Dr C P Sedain Department of psychiatry Chitwan Medical College, Bharatpur,Chitwan,Nepal

 STUDY  OF   PSYCHIATRIC MORBIDITY  OF PATIENTS ATTENDING   FREE MENTAL HEALTH  CHECK UP CAMPS IN  FAR WESTERN RURAL  NEPAL

Dr C P Sedain

Department of psychiatry Chitwan Medical College, Bharatpur,Chitwan,Nepal

Abstract

Introduction:

The hilly area of far western development region is the most remote area of Nepal. This is the region of less health facility. The aim of the  study was  to find out psychiatric morbidity  of patients   attending   free check up clinic of far western development region  Nepal.

Methods:           

A prospective cross-sectional   study comprised of all consecutive patients attending   free check up psychiatric  clinic of  far western development region  Nepal. All the patients  attending  the free clinics for four days  were taken as case. The study was performed  in  the month  of June, 2013. Demographic data and disease profile of 287 patients attending the  clinic were analyzed. The ratios and proportions were used for statistical analysis.

Conclusions

Most of Patients attended of far western development region free mental health clinic  are farmer  of  age group 20-29 .   The commonest incidence of psychiatric illness attending the free clinic is depressive disorder and (tension/migraine) headache.

Key words: diagnosis profile, socio-demographic characteristics, BPAD

Correspondence

Prof Dr.C P Sedain

Department of Psychiatry

Chitwan Medical College Bharatpur ,Chitwan,Nepal

Email-drcpsedai@yahoo.com

Phone:9779855056666

Introduction

 The hilly area of far western development region is the most remote area of Nepal. This is the region of less health facility. The majority of people of this region are poor. The psychiatric problems in the far western development region are high as compare to other part of the country. HIV  positive cases are found in Acham, Doti and Bajura districts. These people still believes traditional healers. The status of mental  health is low in far western development region. The free mental health check up was done in Daduldhara, Doti, Acham and  Bajura districts. Many patients came from neighboring districts  for free check up. Most of the patients are poor, low educational status. No single psychiatrist posted in these areas. Most of  the people  go to India for treatment of mentally ill patients.

 The Far Western Region covers 19,539 km2 and comprises two zones, the Seti and Mahakali. It has nine districts with the regional headquarters at Dipayal, Doti district. The Far Western Region is remote and developmentally challenged. Forty four percent  of people in the Far West Hills and 49% in the Himalayan districts live beneath the poverty line. The region has limited access to basic services and increasing services is challenging due to the difficult topography.

The region has complex socio-economic structures and there is both widespread gender and caste based discrimination. Traditional systems associated with religion, culture and customs also have a great impact on overall development. Major Challenges  are prevalence of gender and caste based discrimination; lack of employment and high seasonal migration to India; High prevalence of HIV/AIDs among migrants;  a legacy of socio-economic exploitation, such as bonded labour and the Kamaiya/Haliya systems;  Widespread child labour.1

Studies regarding psychiatric morbidity are scare in Nepal. The pattern of psychiatric illness has been described to similar across the country.  Regmi et al. found that majority of cases were neurotic stress related  and somatoform  disorder (42.46%) followed by mood disorder(37.23%). Still that the culture plays an important role on morbidity pattern in the community is known as an acknowledged fact. Thus the studies in this aspect becomes important, mainly to formulate any plan regarding mental illness 2. There are few studies on mental illness e.g. by Nepal et al , Wright , Shrestha  and Sharma . About half of the patients in all studies were of the age group 20-40 years and more than half were males. However the diagnostic distribution differed among the studies. Nepal et al  found that the patients mainly suffered from neurotic and related disorders. Majority of the patients in Wright’s study were epileptic (32℅), Shrestha found most of the patients suffering from psychosis (63℅), while Sharma described as many as 41℅ suffered from depression. The inconsistencies may be because of the difference in the setup, population studied and the criteria used. Shrestha  had studied the patients attending a Mental Hospital valley; Sharma  conducted the study in private clinic setup in Pokhara, whereas Wright studied the patients attending the health posts in a rural community. Thus despite the inconsistencies in the diagnostic distribution, the findings in the different setup have their own importance 3. The Quality Adjusted Life Year(QALY) losses  in  primary care is highest is  in pain related physical condition   followed by mood disorder4.

Major depression is the most common psychiatric problem seen in primary care. Prevalence figures for major depression vary substantially between surveys 5. The reasons for increased rates among women are uncertain. Depression is more common among the unemployed; divorced, all medical illness and their treatment can act as non-specific stress, which may lead to mood disorder in predisposed subject. The present study was conducted to find out psychiatric morbidity  of patients   attending  far western development region  of  Nepal. The  free mental health check up camp was performed  four places Dadeldhura, doti ,acham and bajura district  one day each continuously.

 

Methods

           A prospective cross-sectional   study comprised of all consecutive psychiatric  patients attending   far western development region  of Nepal. All the patients  attending  the  psychiatric  free check up  clinics were taken as case.   The study was performed month of   June 2013. A brief explanation about the study was offered to the subjects and written or verbal consent was obtained either from them or guardians. A continuous sequential number was given to each subject and available necessary information was kept confidential in a separate file. The socio demographic profile which contains name, age, sex, caste, address, marital status, occupation, and other information also filled. The diagnosis was done on the basis of I.C.D. - 10 diagnostic research criteria 6. Data were entered in to a computer and analyzed using Statistical Package for Social Studies (SPSS) software. The free psychiatric patients check up  camp was completed in four days.

Results

A total of 287 patients were included in the study. Out of them male were 151(52.61%) and female were 136 (47.39%). Data shows highest numbers of patients were age group 20-29 (N-68, 23.69%) followed by age group 30-39 (N-63, 21.95%). Data shows highest numbers of patient were married (N-191, 66.55%) and most of cases were farmer (N-162, 56.44 %). Distribution on the basis of  ICD 10 diagnosis, highest number of cases were depressive disorder  (N-98,33.45 %) followed by tension/migraine headache (N-44, 15.33%) ,  epilepsy (N-25, 8.01 %)  and  alcohol use disorder (N-24, 7.67 %). Similarly Schizophrenia (N-19, 5.92 %) , anxiety disorder (N-18, 5.57 %), somatoform disorder (N-16, 5.57 %),  mania/BPAD (N-15, 4.52 %) and  conversion disorder (N-7, 2.44 %) .

Table 1

DISTRIBUTION ON THE BASIS OF AGE GROUP

AGE	N
		%
10-19	43	14.98
20-29	68	23.69
30-39	63	21.95
40-49	53	18.47
50-59	36	12.54
60-69	20	6.97
70-79	4	1.39
TOTAL	287	100

Table 2

DISTRIBUTION ON THE BASIS OF SEX

SEX	CASE
	NO	%
MALE	151	52.61
FEMALE	136	47.39
TOTAL	287	100

Table –3

DISTRIBUTION ON THE BASIS OF MARIETAL STATUS

MARITAL STATUS N % MARRIED 191 66.55 UNMARRIED 77 26.83 WIDOWED 19 6.62 TOTAL 287 100

 

 

 

 

 

 

 

 

 

 

 

Table-4

DISTURIBUTION ON THE BASIS OF OCCUPATION

OCCUPATION	N	%
FARMER	162	56.44
BUSINESSMAN	13	4.53
SERVICE HOLDER	24	8.36
HOUSEWIFE	27	9.41
LABOUR	28	9.76
UNEMPLOYED	17	5.92
STUDENT	16	5.57
TOTAL	287	100

Table-5

DISTURIBUTION ON THE BASIS OF DIAGNOSIS (ICD-10 DCR)

DIAGNODIS-ICD,10	MALE	FEMALE	TOTAL	%
DEPRESSIVE DISORDER(F32)	36	62	98	33.45
SCHIZOPHRENIA (F20)	11	8	19	5.92
EPILRPSY (G40)	12	13	25	8.01
MANIA/BPAD (F30-31)	10	5	15	4.52
ANXIETY DISORDER (F4O-41)	6	12	18	5.57
ALCOHAL USE DISORDER (F10)	21	3	24	7.67
SUBSTANCE USE DISORDER (F11-19)	1	1	2	0.69
CONVERSION DISORDER (F44)	2	5	7	2.44
ADHD	1	1	2	0.69
PTSD (F43)	3	0	3	1.04
SOMATOFORM DISORDER (F45)	9	7	16	5.57
ORGANIC PSY DISORDER	2	4	6	2.09
MENTAL RETARDATION (F70-79)	2	2	4	1.39
(TENSION/MIGRAINE) HEADACHE (G43-44)	33	11	44	15.33
OTHER	2	2	4	1.39
TOTAL	151	136	287	100

Discussion:

Far western region are prevalent of  high infant and maternal mortality rates due to a lack of basic health services and high malnutrition; low literacy rate, insufficient school facilities and limited access to quality education. There are lack of medical facility and different health problems  including acute respiratory tract infection, headache, gastritis (APD), pyrexia, diarrhoea, intestinal worms and amoebic dysentery are among the most common diseases. The Far West also has high maternal and child mortality rates and a high prevalence of HIV/AIDS. Hygiene and sanitation in the region are poor , more than 70% of people living in the region do not have access to toilets but use ‘open defecation areas’. There is also a strong preference, particularly among those living in rural areas, to visit religious healers (Dhami, Jhakri) when they are sick, rather than visit formal health institutions.

The life style is becoming complex day by day, thus the patients consulting the psychiatrist is increasing than previous decade. Depressive disorder is the commonest psychiatric disorders worldwide. A review of anxiety disorder surveys in different countries found  that average lifetime prevalence estimates of 16.6%, with women having higher rates on average7.A review of mood disorder surveys in different countries found that  lifetime rates of 6.7% for major depressive disorder (higher in some studies, and in women) and 0.8% for Bipolar I disorder  In the United States the frequency of disorder is: anxiety disorder (28.8%), mood disorder (20.8%), impulse-control disorder (24.8%) or substance use disorder (14.6%)8.A 2004 cross-Europe study found that approximately one in four people reported meeting criteria at some point in their life for at least one of the DSM-V  psychiatric disorders assessed, which included mood disorders (13.9%), anxiety disorders (13.6%) or alcohol disorder (5.2%). Approximately one in ten met criteria  within a 12-month period. Women and younger people of either gender showed more cases of disorder. A 2005 review of surveys in 16 European countries found that 27% of adult Europeans are affected by at least one mental disorder in a 12 month period 9. Psychiatric disorder like schizophrenia, BPAD, alcohol & drug addiction problems are also equally challenging to us. A ten-year perspective study in Zurich,  estimated the life time prevalence of major depression is about 16 percent. The rates of depressive disorder seems to be higher in industrialized countries¹⁰. They are consistently increased in woman across different cultures. Nepal et al Regmi et al reported that patients attending to psychiatric OPD of TUTH were commonly neurotic and stress related disorder. Similarly Sharma’s study shows 41℅ patients were depressive disorder only.

 Pokhrel et al reported that mood disorder (35℅) followed by schizophrenia and related disorder (28℅) and neurotic and stress related disorder (17 ℅) respectively. The percentage distribution of depressive illness reported by Sharma is similar to our finding. Major depression is the commonest psychiatric problem seen in primary care center. Depression is more common among the unemployed and divorced people. If we look at our finding the depressive illness was observed among the patient of SLC and intermediate education level. All medical illnesses and their treatment can act as non-specific stress factor which may lead to mood disorder in predisposed subject. Prevalence of psychiatric disorders among general hospital population is higher than in community. Sedain  found  Maryknoll  free mental   health check up clinic Simara, Bara,Nepal  shows depressive disorder is the commonest psychiatric disorder (18.93%).11

Data on current study shows that total of 287 patients were included in the study. Out of them male were 151(52.61%) and female were 136 (47.39%). Data shows highest numbers of patients were age group 20-29(N-68, 23.69%) followed by age group 30-39 (N-63, 21.95%). Data shows highest numbers of patient were married (N-191, 66.55%) and most of cases were farmer (N-162, 56.44 %).Distribution on the basis of  ICD 10 diagnosis, highest number of cases were depressive disorder  (N-98,33.45 %) followed by tension/migraine headache (N-44, 15.33%) ,  epilepsy (N-25, 8.01 %)  and  alcohol use disorder (N-24, 7.67 %). Similarly Schizophrenia (N-19, 5.92 %) , anxiety disorder (N-18, 5.57 %), somatoform disorder (N-16, 5.57 %),  mania/BPAD (N-15, 4.52 %) and  conversion disorder (N-7, 2.44 %) .

 

 

Conclusions

The hilly area of far western development region is the most remote area of Nepal. This is the region of less health facility. Data   shows depressive disorder ( F-32 ) is the commonest psychiatric disorder. Similarly other disorders include tension/migraine headache( G-43 ,G-44) , epilepsy (G -40), alcohol use disorder (F- 10 ),   schizophrenia ( F-20), mania/BPAD(F-30),  anxiety disorder(F-40,F-41), somatoform disorder (F-45) and conversion disorder (F-44). Most of the patients were farmer of age group 20-29 .

REFERENCES

1          Far-western regional health directorate Dipyal ,Nepal, annual report 2014.

2 Pokhrel et al. Sociodemographic characteristics and diagnostic profile of patients admitted in psychiatric ward of TUTH, Katmandu. Nepalese Journal of psychiatry 1992;(2):13-17.

3  Regmi et al. Studies of sociodemographic characteristics and diagnostic profile in psychiatric outpatient of TUTH. Nepalese Journal of psychiatry 1999; 1: 26-33.

4         Fernandz,A.,Sammeno.J.B.Printo-Meza.A.,Luciano,V.J.etal, Burden of chronic condition and mental disorder  in primary care, British jurnal of psychiatry,2010;196:302-309.

5         Smith AL,Weissman,M.M,Smith. Cross national epidemiology of major depression and bipolar disorder. Journal of American medical association. 1992;

6         World Health Organization. International Classification of disease and related heath problems, Tenth revision: Clinical description and diagnostic guideline; Geneva: World Health Organization. 1992

7         Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE . "Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication". Arch. Gen. Psychiatry  2005;62 (6): 593–602.

8         Waraich P, Goldner EM, Somers JM, Hsu L . "Prevalence and incidence studies of mood disorders: a systematic review of the literature". Can J Psychiatry 2004; 49: (2): 124–38.. 

        9 Alonso J, Angermeyer MC, Bernert S, et al.. "Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project". Acta Psychiatr Scand Suppl  2004;109: (420): 21–7. 

      10  Angst. J. How recurrent and predictable is depressive illness. In long term treatment of depression, eds S. Montgomery and F Rouillon.Wiley, Chichester; 1992:1-3 .

      11 Sedain C P study of psychiatric   morbidity  of  patients attending  free  mental health check up  camp, Simara, Bara district of Nepal JCMC 2012:3,15-17.