PSYCHIATRIC MORBIDITY AND ATTITUDES TOWARDS MENTAL ILLNESS AMONG PATIENTS ATTENDING PRIMARY CARE CLINIC OF HOSPITAL UNIVERSITI KEBANGSAAN MALAYSIA

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1 PSYCHIATRIC MORBIDITY AND ATTITUDES TOWARDS MENTAL ILLNESS AMONG PATIENTS ATTENDING PRIMARY CARE CLINIC OF HOSPITAL UNIVERSITI KEBANGSAAN MALAYSIA Riana AR*, Osman CB**, Ainsah O** ABSTRACT The prevalence of psychiatric morbidity among patients attending primary care clinics is high and their attitudes towards psychiatry are often negative. The objectives of this study were to assess the prevalence of psychiatric morbidity and attitudes towards mental illness in relation to socio-demographic factors among primary care patients. A cross-sectional study was conducted on 245 patients attending the primary care clinic of Hospital Universiti Kebangsaan Malaysia at Bandar Tasik Selatan. A two-stage case identification process was used to detect psychiatric morbidity. The Malay translation of General Health Questionnaire 30 (GHQ-30) was used for screening and the Structured Clinical Interview for DSM-IV (SCID) was used to generate Axis-1 diagnosis. The Attitudes Towards Mental Illness Questionnaire was used to assess their attitudes towards mental illness. 8.2% of patients were found to have psychiatric morbidity, and they were significantly associated with the younger age group (p<0.05). Nevertheless, there was no significant association between psychiatric morbidity and sex, race, marital status, educational level and social class of patients. The attitudes towards mental illness were significantly associated with age, race, marital status, educational level, social class and the presence of family history of psychiatry illness (p<0.05). There was no significant association between attitudes towards mental illness and patients' sex. Primary care doctors need to be equipped with psychiatry knowledge in order not to miss patients with psychiatry morbidity. Patients with psychiatric morbidity significantly believed in supernatural causes of mental illness compared with those without psychiatric morbidity. Keywords: primary care, psychiatric morbidity, attitude towards psychiatry 1

2 INTRODUCTION Like many other countries, primary care setting has been the first-line provider for health services in Malaysia. This has been in line with the introduction of community psychiatric services and the move towards decentralization of psychiatric services. The study of psychiatric disorders in primary care largely evolved from the work of Professor Michael Shepherd (1,2). Since then, many studies had been published on the topic. Most studies had applied the two-phase design or the twostage case identification process in which, an initial sample was screened for psychiatry morbidity followed by and a full Structured Clinical Interview. Among the screening tools used was General Health Questionnaire (3,4,5). The prevalence rate of psychiatric illness in the primary care was found to be between 25% to 35% (3,4,5,6). In Malaysia, to the investigator's best knowledge, there has not been any large study done on psychiatric morbidity in primary care settings. However, a few authors had published their findings on psychiatric morbidity in the community. Amin S.M. et al. (1997) had studied the heads of household in five villages in a district of Kota Samarahan in Sarawak using General Health Questionnaire 30 (GHQ-30) and noted that 24.7% fall into those groups with probable psychiatric morbidity (7). Rashid Y.N et al. (2000) had conducted a psychiatric morbidity assessment on students from three different secondary schools and a university in Kelantan. It was found that the university students had a higher GHQ-30 score than the school students (8). Varma S.L and Azhar M.Z (1995) had conducted a study on psychiatric symptomatology in a primary health setting in two districts in Kelantan i.e. Bachok and Tumpat. Patients, who attended the primary care centres, as well as a key family member, were screened using a mental health item sheet to determine the presence of psychiatric symptomatology. They reported that 13.2% had depressive symptoms, 8.2% had hypochondriacal symptoms, 6.1% had anxiety symptoms and 5.1% had sleep disturbance (9). Razali S.M. et al. (1996) had studied the concept of aetiology of mental illness in 134 Malay patients in Kelantan, Malaysia. About 53% of the patients attributed their illnesses to supernatural agents whereby witchcraft and possession by evil spirits were regarded as the common causes (10). This belief was not significantly associated with age, gender, level of education or occupation of the patients. The number of patients who believed in the supernatural cause of mental illness was significantly higher among those who had consulted bomoh (traditional healer) than among those who had not consulted them. The patients who believed in the supernatural cause of mental illness were also found to show poor drug compliance (10). In Singapore, Kua E.H. et al. (1993) studied the illness behaviour among 100 Chinese psychiatric patients. He reported that 22% of the patients believed that they were possessed by spirit (11). A study on community health workers in South India using a case vignette reported that a significant proportion of them did not recognize chronic 2

3 psychosis as a disease condition, believing that it was caused by black magic, evil spirits and poverty, and felt that doctors could not help (12). Negative attitudes towards mental illness will not only influence treatment seeking behaviour, but also interfere with the implementation of community-based care. A popular belief among the public is that mentally ill people are aggressive. Therefore, the family or caregivers would insist for the patient to be admitted to the ward. Many studies had reported the association between sociodemographic factors and attitudes towards mental illness (13,14,15). Female, those with high education and those from high social status were reported to be more sympathetic and more tolerant towards the mentally ill. A group of workers had done a study to examine the effects of a lecture on mental health on public attitudes towards mental illness in Japan. They concluded that an educational lecture on mental health and welfare was effective in reducing stigma attached to mental illness and disorder (16). In this study, patients attending the primary care clinic of Hospital Universiti Kebangsaan Malaysia in Bandar Tasik Selatan were screened for psychiatric morbidity and their attitudes towards mental illness were assessed. The relationship between having psychiatric morbidity and the attitudes towards mental illness was looked into. The findings obtained could be used to assist managers plan the psychiatric services at primary care levels. The managers could also identify the target population and the content of the awareness program. METHODOLOGY Study setting and design This study was conducted at the primary care clinic of Hospital Universiti Kebangsaan Malaysia (HUKM) which is located in Bandar Tasik Selatan, Cheras, Kuala Lumpur. This is a cross-sectional study conducted from the first week of February 2004 to the first week of June The sample size calculation was based on the formula; sample size = n/(1- (n/population)) with power of study equivalent to 80% and the standard error was The calculation was done by using Epi-Info 6 software. The calculated samples were 246. All consecutive patients underwent the initial screening and all subjects who fulfilled the inclusion criteria were selected for this study. The patients were explained about the study and written permission was obtained. They were assured of their anonymity and the confidentiality of the data. A coding system was used to identify the subject. Inclusion criteria include all patients between 18 to 65 years and those who have a sufficient command of the Malay or English language. The exclusion criteria include those who could not understand the Malay or English. Data collection This study applied a two-stage case identification process i.e. a screening instrument followed by a structured psychiatric interview. In the first stage, the Malay version of General Health 3

4 Questionnaire (GHQ-30) (17) was used to screen the selected patients for the presence of probable psychiatric morbidity. At the same time, they were interviewed using a standard form containing sociodemographic variables and a questionnaire for assessment of their attitudes towards mental illness. All patients with a screening score of eight or greater (Abdul Hamid A. R. and Mohamed Hatta S, 1988) (17) or with a history of psychiatric illness proceeded to the second stage where they were interviewed for the psychiatric diagnosis. The investigator used the Structured Clinical Interview for DSM- IV (SCID) (18) to make the diagnosis. The investigator was trained to use SCID by a senior consultant psychiatrist who was trained to use the diagnostic instrument. In this study, a psychiatrist was called in to assess the patient together in the ratio of one in four. It was found that the diagnosis made by the investigator was similar to the diagnosis made by the psychiatrist. Instruments Sociodemographic Data Sociodemographic data were assessed using a brief questionnaire to obtain information on names, age, sex, marital status, educational level, employment status, monthly family incomes, family history of psychiatric illness and patient's history of psychiatric illness. The Malay version of General Health Questionnaire 30 items (GHQ-30) Structured Clinical Interview for DSM-IV (SCID). Attitudes Towards Questionnaire Mental Illness This is a 10-item guided questionnaire assessing the attitudes towards local psychiatric practice and mental illness. There are four questions that are related to psychiatric practice and another six are linked to mental illness. The participants were required to answer all the questions based on four scales i.e. never true, seldom true, often true and always. This questionnaire was devised by Razali S.M. (1998) (19), a local psychiatrist who had used the questionnaire in a local setting. The permission to use the questionnaire was obtained from him. Definition of variables Psychiatric morbidity The subject is said to have a psychiatric morbidity if the GHQ-30 score is eight or more, or if the subject has a history of psychiatric illness. Educational level 1. No education was referred to those who never had any formal education. 2. A primary school level was referred to standard one to standard six. 3. A lower secondary level was referred to those who had education, 9 years or less that was from form one to form three. 4. An upper secondary level was referred to those who had education, 11 years or less. 5. A higher secondary level was referred to those who had education, 13 years or less. 6. A tertiary education level was for those who obtained a degree or diploma. 4

5 Monthly family income Monthly family income was referred to a combination of husband and wife monthly income. For those who were still single and studying, monthly family income was referred to the parents' total income. For unemployed widows or divorcee, it was referred to the income of the children that she was staying with. Based on the incomes, the patients' social class can be classified (Abdul Kadir A. B., 1991) (20). Social class I RM 2000 and more II RM RM 1999 III RM 500 RM 999 IV RM 200 RM 499 V Less than RM 200 Race Others were referred to the minority ethnic group i.e. Kadazan. Marital status For statistical analysis, the marital status was divided into two groups only. 1. Married 2. Non-married were referred to the subjects who are single, divorced or widowed. History of psychiatric illness The patient was said to have a history of psychiatric illness when: 1. they have a history of consulting a medical doctor for a psychiatric disorder in the past and present. 2. the past history suggestive of psychiatric disorder (based on clinical interview) but had never consulted a psychiatrist. Statistical analysis Analysis of the data was done by using the computer program, Statistical Package for Social Studies (SPSS) Version 11.5). The relationship between the studied parameters were analysed using the appropriate statistical test. The parametric test was used to determine the significant difference between two groups for data that is normally distributed, this include t-test and Chisquare while non-parametric test was done for data which was not normally distributed i.e Mann-Whitney U-test and Kruskal-Wallis test. Ethical consideration This research project was approved by the Research Committee, Faculty of Medicine, Universiti Kebangsaan Malaysia. The purpose of this study was explained to the subjects and written permission was obtained from them. Those who were found to have psychiatric disorder were referred to the psychiatric clinic for further evaluation RESULTS 250 patients who attended the primary care clinic of HUKM in Bandar Tasik Selatan, Cheras, Kuala Lumpur were invited to participate in the study. However, five patients were unable to complete the study because of reasons such as unable to make the time (three patients) and did not feel comfortable with the questions (two patients). Therefore, the response rate was 98% with total subjects of

6 Sociodemographic data Table 1 shows that 29.8% (n=73) of the respondents were in the age group of years old, 22.9% (n=56) in the group of and 18.8% (n=46) in the group of years. The mean age was 44.8 (sd=12.4) years. Majority of the patients were female (n=156, 63.7%). 69.4% (n=170) were Malays, 20.8% (n=51) were Chinese and 9% (n=22) were Indians. Majority of the patients were married (n=204, 83.3%).33.9% (n=83) of respondents had their education until upper secondary level and 24.5% (n=60) until tertiary level (Table 2). 61.7% (n=151) of them were employed and most were government servants. Half of the patients (n=132, 53.9%) had monthly family income of RM2000 and more. 4.5% (n=11) of patients had a history of psychiatric illness. Majority of the patients (n=234, 95.5%) did not have any psychiatric morbidity. The mean GHQ score was 1.94 (sd=3.46). Psychiatry diagnosis among patients with psychiatry morbidity The 20 patients who were found to have psychiatric morbidity based on the initial screening were further interviewed for psychiatric diagnoses using Structured Clinical Interview for DSM-IV (SCID). Majority of the patients had mood disorder. 10% (n=2) of the patients were diagnosed to have major depressive disorder and 15% (n=3) had dysthymia. 5% (n=1) had major depressive disorder with dysthymia. 35% (n=7) were diagnosed to have lifetime major depressive disorder. Only 5% (n=1) were found to have anxiety disorder i.e. generalized anxiety disorder. 30% (n=6) of patients were diagnosed to have adjustment disorder relating to family, job or financial problems. 10.3% of female patients had psychiatric morbidity as compared to only 4.5% of male patients. However this finding was not statistically significant. The distribution of the race of the patients with psychiatric morbidity. For statistical analysis, the Chinese, Indian and the others groups were combined as non-malay and when this was compared with Malay, they were no significant difference. 18.3% of the married patients were found to have psychiatric morbidity whereby only 7.3% of the non-married group (single, divorcee, widow) had psychiatric morbidity. However, statistical test revealed no significant difference in the marital status of the patients with psychiatric morbidity. There was no significant difference in the level of education of the patients with psychiatric morbidity and without psychiatric morbidity. There was also no significant difference in the monthly family incomes of patients with psychiatric morbidity and without psychiatry morbidity. The attitude towards mental illness Table 3 shows the frequency and percentage of responses of all the respondents to each of the questionnaire. Majority of them did not think that consulting a psychiatrist is a stigma (no.1), and they would not bring their relatives to bomoh (traditional healer) first for their mental illness (no.2), and majority of them also thought that chronic schizophrenia cannot be managed at home (no.3). 6

7 Table 1: Sociodemographic characteristics of the patients Variables Characteristics Number Percentage (%) Age < Sex Male Female Race Malay Chinese Indian Others Marital status Single Married Divorced Widow Educational level No education Primary Lower Secondary Higher Secondary Upper Secondary Tertiary Employment Private Government Self-employed Labourer Student Housewife Unemployed History of Present Psychiatry illness Absent

8 Table 2: Distribution of the mean age, sex, race, education level, marital status and family income among patients with or without psychiatry morbidity Sociodemographic Psychiatric morbidity N (%) Profile Present Absent Total N(%) t-test Chi-Square Number of Patients Mean age ± ± (100) t=2.051p =0.04* Sex Male 4 (4.5) 85 (95.5) 89 (100) Female 16 (10.3) 140 (89.7) 156 (100) p=0.113 Race Malay 13 (7.6) 157 (92.4) 170 (100) Non-Malay 7 (9.3) 68 (90.7) 75 (100) p=0.657 Educational level No education & Primary 1 (20) 50 (98) 51 (100) Secondary 11 (8.2) 123 (91.8) 134 (100) Tertiary education 8 (13.3) 52 (86.7) 60 (100) p=0.093 Marital status Married 17 (18.3) 187 (91.7) 204 (100) Non-married 3 (7.3) 38 (92.7) 41 (100) p=0.828 Family income < RM (7.1) 105 (92.9) 113 (100) RM (9.1) 120 (90.9) 13 2(100) p=0.567 *p<0.05 8

9 Table 3: The frequency and percentage of response to the 10-item questionnaire Questionnaire no. Never true n (%) Seldom true n (%) Response Often true n (%) Almost always true n (%) (86.9) 24 (9.8) 6 (2.4) 2 (0.8) (81.6) 26 (10.6) 18 (7.3) 1 (0.4) (42.9) 105 (42.9) 30 (12.2) 5 (2.0) 4 74 (30.2) 137 (55.9) 30 (12.2) 4 (1.6) 5 69 (28.2) 127 (51.8) 43 (17.6) 6 (2.5) (60) 94 (38.4) 3 (1.2) 1 (0.4) (55.5) 89 (36.3) 18 (7.3) 2 (0.8) 8 47 (19.2) 115 (46.9) 78 (31.8) 5 (2.0) 9 79 (32.2) 31 (12.7) 127 (51.8) 8 (3.3) (9.8) 25 (10.2) 184 (75.1) 12 (4.9) Relationship between sociodemographic characteristics and attitudes towards mental illness a. Age and attitudes towards mental illness The higher percentage of young patients would bring their relatives to bomoh first and they believed that hysteria was caused by possession of evil spirit as compared with the middle-aged and elderly. These findings were found to be significantly different by the Mann- Whitney test (p<0.05). b. Sex and attitudes towards mental illness There was no significant difference between male and female patients in any of the items when tested using the Mann-Whitney test. b. Race and attitudes towards mental illness By using the Mann-Whitney test there was a significant difference between the Malays and non-malays in questionnaire number 2, 5, 7 and 9 (p<0.05). Higher percentage of the Malays would bring their relatives to bomoh first for their mental illness. They believed that charming or witchcraft can cause mental illness. They believed that bomoh is more competent than psychiatrists in treating hysteria, and they would see a psychologist rather than psychiatrist to solve their problem. 9

10 c. Marital status and attitudes towards mental illness There was a higher percentage of the non-married respondents did not think that schizophrenia was aggressive and dangerous to family members compared with the married respondents. This was significantly different with the Mann- Whitney test (p<0.05). d. Monthly family incomes and attitudes towards mental illness By using the calculation of Mann- Whitney test the difference between those earning RM2000 or more and those earning less than RM2000 in items 2, 3 and 5 was found to be significant (p<0.05). Higher percentage of those who earned RM2000 or more would not bring their relatives to bomoh first for their mental illness than those who earned less than RM2000 and they also did not think that hysteria was caused by possession of evil spirit. They did not believe that charming or witchcraft could cause mental illness. e. Level of education and attitudes towards mental illness Higher percentage of patients with secondary and tertiary education would see a psychologist rather than psychiatrist to solve their problems. This was significantly different by using the Kruskal-Wallis test (p<0.05). f. Family history of mental illness and attitudes towards mental illness There was a higher percentage of patients with a family history of mental illness thought that chronic schizophrenia only at times cannot be managed at home, and this was significantly different by the Mann- Whitney test (p<0.05). Relationship between psychiatric morbidity and attitudes towards mental illness By using Mann-Whitney test, the only significant difference (p<0.05) found in the patients with and without psychiatric morbidity was their beliefs that charming or witchcraft can cause mental illness. There was a higher percentage of those with psychiatric morbidity believed that charming or witchcraft can cause mental illness comparing to those without psychiatric morbidity. DISCUSSION This study made an attempt to examine at the presence of psychiatric morbidity and the attitudes towards mental illness at the primary care setting. At the same time, the relationship between sociodemographic factors and psychiatric morbidity as well as the attitudes towards mental illness were examined. It was conducted in only one centre i.e. primary care clinic of Hospital UKM. It is a semi-government clinic that charges a higher pay for the consultation fee, laboratory 10

11 investigations and medications compared with government clinics. Thus, not many people from lower socioeconomic status attended this clinic and this might affect our findings related to sociodemographic variables and the lower prevalence rate of psychiatry morbidity. Previous studies have shown that the prevalence of psychiatric illnesses is higher in lower social class (3,6). Several sampling bias were identified in this study. Due to the investigator s tremendous clinical workload, the samples were collected only from two sessions of the clinic i.e. Tuesday morning and Wednesday morning in a week. the study design does not allow discrimination of cause and effect. In this study, patients were detected to have anxiety-depressive disorder ranging from major depressive disorder, generalized anxiety disorder and adjustment disorder. This demonstrated the need for the primary care doctors to be able to identify patients with psychiatry disorders and to treat them accordingly. By increasing the number of doctors in the primary care clinics, it could reduce the heavy workload and they could spend more time to elicit psychiatric symptoms in patients. In addition, adequate budget should be allocated for new medications used in the primary care clinic. Only patients who entered one particular consultation room in the clinic during the day of the sample collection were invited to join this study and only those patients who could either understand English or Malay were selected for the diagnostic interview using SCID. Even then, there is a possibility of misinterpretation of the questions and giving incorrect information. But this was minimized by having an interpreter whenever possible. Some patients did not take the questionnaire seriously. Some rushed to complete the study because of the time factor. It is suggested that in the future, home visit should be done to interview these subjects who could not provide longer time during the clinic session. Being a cross-sectional study, it is not possible to identify factors that are truly predictive of psychiatric morbidity and attitudes towards mental illness because Whilst the previous local studies were done on health personnel who were familiar with the technical terms, our study s respondents were from the patients attending the primary care clinic. Razali S.M. (1998) (19) had compared the attitudes towards mental illness between the medical students and nursing students using a self-devised 10- item questionnaire. Ahmad H. et al. (2004) (21) had used a case vignette depicting a man with schizophrenia, and two dependent measures i.e. social distance scale and dangerousness scale to look into the attitudes of paramedics (nurses and medical assistant) towards the mentally ill. Study on public attitudes towards mental illness and the mentally ill done abroad had used the Community Attitudes towards Mentally Ill (CAMI) inventory (15), the Star Vignettes (22) and selfconstructed vignettes (23). Link B.G. et 11

12 al (1999) had created a set of vignettes based on DSM-IV criteria. The vignettes depicted people with schizophrenia, major depressive disorder, alcohol dependence, drug (cocaine) dependence and a troubled person with sub-clinical problems and worries. They were used to assess (1) recognition of mental illnesses, (2) beliefs about the causes of mental illnesses, (3) beliefs about how dangerous people with mental illnesses, and (4) the amount of social distance desired from people with mental illnesses. The questionnaire and vignettes did not use medical or technical terms, and thus, should be easily understood by the public. The authors had decided to use the 10- item questionnaire on attitudes towards mental illness devised by Razali S.M. (1998) (19) because it was easier and less time-consuming. Furthermore, it had been used locally. Though, it contained some technical terms such as hysteria, ECT, schizophrenia and psychologist; those terms can be explained easily to the public. The questionnaire is however, has it s limitations in assessing the public attitudes towards mental illness. Generally, it was not comprehensive and the questions were limited to only two disorders i.e. hysteria and schizophrenia. There was no specific question on major depression or anxiety though they are common disorders. It was noted that certain sociodemographic factors had an effect on the attitudes towards mental illness. Thus, any intervention to improve the public attitudes should be aimed towards those with these identifiable factors. It was also noted that there were some aspects of the mental illness that were viewed most negatively by them. Therefore, emphasis should be made on these particular aspects when dealing with the public. In this study, majority of patients, regardless of their sociodemographic factors, believed that chronic schizophrenia could not be managed at home. Therefore, a more intensive action should be taken to introduce them to the availability of community mental health service and to provide continuous education from time to time. This study had also shown that patients with psychiatric morbidity did not have better attitudes towards mental illness compared to patients without psychiatric morbidity. Any educational or awareness program should pay more attention to them, as their attitudes will have an effect on the outcomes of the illness. ACKNOWLEDGEMENT Authors would like to thank all patients who have agreed to participate in this study. REFERENCES 1. Acheson ED. Introduction. Shepherd M, Wilkinson G, Williams P. (editors). Mental Illness in Primary Care Setting. First Edition London: Tavistock Publications Buszewicz M, Mann A. Psychiatry and Primary Care (Social, Community And Public Health Psychiatry). Current Opinion in Psychiatry, 1997:10:2:

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