Assessing the Proportion of Anxiety and Depression prevalent in patients visiting a Homoeopathic Hospital Outpatient Department in a Rural area of Miyagam-Karjan using the Hospital Anxiety and Depression Scale: A Cross-sectional Survey

Pooja M Shah¹, Vidhi R Pethani², Dilip G Nandha*MD (Hom)³, Prashant P Tamboli, MD (Hom)⁴  Devangini R Broker, MD (Hom)⁵

¹, ² Interns,

³Professor and Head, Department of Medicine, Hospital Superintendent and Head Clinical Services,

Smt. Malini Kishore Sanghvi Homoeopathic Medical College and Hospital, Miyagam – Karjan, Gujarat.

⁴  Associate Prof, Department of Repertory and Head, Department of Research,

⁵Assistant Prof, Department of Repertory and Senior Research Fellow, Department of Research

Dr. M. L. Dhawale Memorial Homoeopathic Institute (MLDMHI)

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*Address correspondence to: Dr Dilip G Nandha

Email: dgnandha@gmail.com

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How to cite this article:

Shah PM, Pethani VR, Nandha DG, Tamboli PP, Broker DR. Proportion of anxiety and depression prevalent in patients visiting homoeopathic hospital OPD in rural area of Miyagam – Karjan using Hospital Anxiety and Depression Scale (HADS) : a cross sectional survey. Journal of Integrated Standardized Homoeopathy (JISH) 2018; 01(02):

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Received on: November 12, 2018

Accepted for Publication: December 22, 2018

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INTRODUCTION

In India, 44% of adults have at least one chronic illness.¹ The presence of chronic illness influences the quality of life, as measured in terms of disability-adjusted life years.² Chronic illnesses require long-term treatment, which is often sought in the outpatient department (OPD) of a hospital. Chronic conditions include hypertension, diabetes mellitus, endocrine diseases, heart diseases, stroke, chronic respiratory diseases, gastrointestinal (GIT) diseases, autoimmune conditions, and degenerative diseases. These patients are often referred to Homoeopaths seek Homoeopathic treatment.³

As defined by the World Health Organization, health is “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.”⁴ Approximately 200 years prior, Dr Samuel Hahnemann introduced the same concept in the Organon of Medicine as a core principle of Homoeopathy, stressing on the holistic approach to treating illness. The mind and body are not two separate entities, but form an indivisible whole; although inseparable in fact, they are distinguishable by the mind for easy understanding.⁵⁶ It has been observed that chronic illnesses affect the psycho-emotional state as well. Several studies show a strong association between chronic diseases and the emergence of depression and anxiety symptoms. Anxiety and depression may affect the patient’s ability to control their condition, quality of life, and overall health levels.⁷

 

Table 1. Studies showing the presence of anxiety and depression with medical conditions

No	Study / year of publication and reference	Study site	Findings
1	Anxiety and depression in patients with acne vulgaris 8 / 2010	Rasht, Iran	68.3% – anxiety 39.1% – depression
2	Depression and Anxiety Disorders among Patients with Psoriasis 9/ 2012	Dermatology department, Sari, Iran	45% – anxiety trait 67% – depressive trait
3	Prevalence of Unrecognized Depression among Outpatient Department Attendees of A rural Hospital in Delhi 10/ 2013	Rural Hospitals, Delhi, India	23.8% – undiagnosed depression
4	Prevalence and predictors of depression and anxiety in patients of diabetes mellitus11 / 2016	Tertiary care centre, North India	27.6% – anxiety 26.3% –  depression 21.0% co morbid depression and anxiety;
5	A systemic review on impact of Anxiety and Depression on Osteoarthritis patients12 / 2016	A systematic literature search was performed using the OVID Medline and EMBASE databases	19.16% – 21.3%. – anxiety and depression
6	Occurrence of Anxiety and Depression in COPD13 / 2017	Tertiary care hospitals, India	42.6% – Comorbid anxiety and depression
7	Assessment of Anxiety and Depression  in COPD14 / 2017	Tertiary care hospitals, India	57.02% – depression 36.37% – anxiety
8	Anxiety and Depression  in IBS15 / 2017	Kolkata. India	44% – anxiety 84% depression
9	Anxiety and Depression among Hypertensive Outpatients16/ 2018	Outpatient department,  Afghanistan	42.3% – anxiety 58.1% – depression 28.2% comorbid   anxiety – depression

Expressions of anxiety and depression are prevalent in various chronic conditions; in the long-term, they influence the quality of life¹⁷, amplify the chronic disease symptoms^18,19, or result in persistence of the physical symptoms of chronic illness²⁰. It is essential to understand the comorbid expressions of anxiety and depression in patients with chronic illness to understand the somatic symptom burden; it is easy to overlook these symptoms as they may not manifest overtly.

Early identification of these underlying states will help in comprehensive management of both patient and illness. ^5,21 The current survey was aimed to identify the proportion of comorbid expressions of anxiety and depression among a rural population visiting a Homoeopathic hospital to enable implementation of an individualized multidisciplinary approach.

The Hospital Anxiety and Depression Scale (HADS), a 14-item self-administered questionnaire, was originally designed by Zigmoid and Snaith (1983) to provide a simple yet reliable tool to assess the grades of depression and anxiety in medical practice. It gives clinically meaningful results as a screening tool and can assess the symptom severity of anxiety and depression. Although only a screening tool, it can help identify patients who need further psychiatric evaluation and assistance.^22,23 The HADS is commonly used in hospital practice and primary care, and for the general population. Seven items each assess anxiety and depression. Each item has four possible responses (scored 0–3); the anxiety and depression subscales are independent measures. Patients with anxiety scores (HADS–A) >8 are diagnosed with anxiety disorders (sensitivity: 0.89; specificity: 0.75), and patients with depression scores (HADS–D) >8 are diagnosed with depression disorders (sensitivity: 0.80; specificity: 0.88).

A recent review of literature on the validity of HADS indicates that the questionnaire helps to assess symptom severity and type in somatic, psychiatry, primary patient care, and in the general population. ²³ The HADS is also used to measure psychological morbidity in patients with cancer (especially those with breast, GIT, gynaecological, head and neck, urological, and lung cancers), chronic renal failure, and chronic heart disease. Further validity in other clinical conditions is recommended. ²³

 

AIM:

• To explore the proportion of anxiety and depression in patients visiting the Homoeopathic OPD in a single hospital using the HADS.

 

OBJECTIVES:

• To determine the proportion of anxiety and depression according to age and sex in patients visiting the Homoeopathic hospital.
• To determine the differences in the proportion of anxiety and depression in educated and illiterate patients.
• To determine the association of physical illness with anxiety and depression.

 

RESEARCH METHODOLOGY:

• Study Type: Observational – Descriptive
• Study Design: A cross-sectional survey
• Sample Size: 272
• Sampling Methodology: Simple random sampling
• Method of study / Procedure:
• The study was conducted in the Homoeopathic OPD of the Smt. Malini Kishore Sanghvi Homoeopathic hospital.
• Informed consent was obtained from the patients for the survey
• Preliminary information (name, age, sex, and mode of treatment) was recorded along with the questionnaire
• The HADS was administered in English for patients familiar with the English language
• Those not familiar with English language were administered the Gujarati version, which is not validated. However, the content reliability of the language was ascertained by a language expert and medical expert.
• The HADS^19,2522,23 was used to analyse scores obtained on three subscales: Non-case: 0 – 7, Borderline case: 7 – 11, Case – 11+

Duration of study:

• Three months (January to March 2018)
• On selected days/week – Monday, Wednesday, Friday, Saturday

1. Inclusion criteria:

• Patients who were registered in the hospital OPD
• Patients who provided voluntary consent

2.  Exclusion criteria:

• Patients who are taking both Homoeopathic and allopathic simultaneously

OBSERVATIONS & RESULTS:

The analysis included data obtained from 272 patients being treated in the Hospital. Statistical analyses were performed with IBM SPSS (Statistical Package for the Social Sciences) version 24.0. All the tests were two-sided, with alpha 0.05.

 Table 1: Overall proportion of anxiety and depression prevalent in OPD patients

	Anxiety		Depression
	Count	Percentage	Count	Percentage
Case	58	21%	23	8%
Borderline Case	78	29%	57	21%
No Case	136	50%	192	71%

 

Table 2: Sex-wise distribution of anxiety and depression in OPD patients

Anxiety	Case	Borderline Case	No Case	Total
Male	16 (14%)	31 (28%)	65 (58%)	112
Female	42 (27%)	47 (29%)	71 (44%)	160

The chi square statistic was applied; the chi square value is 4.917. The p-value is 0.0265. This result is significant at p< 0.05

Table 3: Age-wise distribution of anxiety and depression in OPD patients

Age group (in years)	Sex	Anxiety				Depression
		Case	Border line	Non-case	Total	Case	Border line	Non-case	Total
11 – 20	Male	0	1	5	6	0	0	3	3
	Female	1	0	2	3	0	1	5	6
21 – 30	Male	4	5	26	35	1	5	28	34
	Female	11	10	13	34	3	9	22	34
31 – 40	Male	4	2	9	15	1	0	12	13
	Female	7	10	18	35	1	8	28	37
41 – 50	Male	4	5	11	20	3	2	15	20
	Female	8	13	16	37	6	9	22	37
51 – 60	Male	4	7	7	18	1	8	9	18
	Female	8	6	8	22	3	5	14	22
61 – 70	Male	0	8	9	17	0	2	15	17
	Female	2	4	7	13	2	4	6	12
71 – 80	Male	1	2	4	7	2	1	4	7
	Female	2	4	4	10	1	2	7	10
81 – 90	Male	0	0	0	0	0	0	0	0
	Female	1	0	0	1	1	0	0	1

 

Figure 1: Comparative line graph representing age-wise trends in anxiety among patients visiting the hospital

 

Figure 2: Comparative line graph representing age-wise trends in depression among patients visiting the hospital

Table 4: The proportion of anxiety and depression according to level of education

Education	Anxiety	Borderline	Non-case	Total
Illiterate	8	10	13	31
Primary education	16	21	22	59
Secondary education	34	47	101	182

The chi-square statistics is 0.9102. The p – value is 0.3400. The result is not significant at p < 0.05

Education	Depression	Borderline	Non-case	Total
Illiterate	4	7	20	31
Primary education	8	18	33	59
Secondary education	11	32	139	182

The Chi square test applied – The chi-square statistics is 0.621. The p value is 0.430. There is no literacy wise difference statistically.

Table 5: Village-wise proportion of anxiety and depression among patients visiting OPD

	Anxiety				Depression
Village	Case	borderline	Non-case	Total	Case	borderline	Non-case	Total
Karjan	31	35	53	119	13	24	45	82
Amod	1	4	10	15	0	2	11	13
Ankleshwar	4	1	1	11	1	0	9	10
Miyagam	2	3	4	9	2	1	1	6
Sarbhan	3	4	2	9	1	4	9	14

 

Table 6: Department-wise distribution of anxiety and depression among patient visiting the OPD

Department	Anxiety	Borderline	Non-case	Total
Homoeopathic	49	55	89	193
Allopathic	3	18	57	78

The chi – square statistic is 21.53. The p – value is 0.000. The result is significant at p < 0.05

Department	Depression	Borderline	Non-case	Total
Homoeopathic	16	45	132	193
Allopathic	7	12	59	78

Chi square test applied – chi-square statistics is 2.106. The p value is 0.34. There is no department wise difference statistically

Table 7: System-wise distribution of anxiety and depression among patients visiting the hospital

Disease	Anxiety	Borderline	Non-case	Total
Gastrointestinal disease	14	22	14	50
Skin disease	12	18	14	44
Joint & muscle disease	10	17	7	34
Hypertension + Diabetes mellitus	8	11	3	22
Renal disease	4	7	3	14

 

Disease	Depression	Borderline	Non-case	Total
Joint & muscle disease	8	10	34	52
Hypertension + Diabetes mellitus	2	6	23	31
Skin disease	0	8	19	27
Gastrointestinal disease	2	2	12	16
Renal disease	2	2	6	10

 

DISCUSSION:

This study was carried out in the OPD of the Homoeopathic College at Miyagam, Karjan. The proportion of anxiety (Case: 21%, Borderline: 29%) was found to be higher than depression (Case: 8%, Borderline: 21%). Kohli et al reported a prevalence of 23% of undiagnosed cases of depression in a study performed in a rural area of North India.²³ Our study reports a similar prevalence of probably underdiagnosed proportion of borderline depression in a rural area of Gujarat at the OPD level.

Regarding the differences between the sexes, the expression of anxiety was higher in women (Case: 27%, Borderline: 29%) than in men (Case: 14%, Borderline: 28%). Similarly, depressive expression was higher in women (Case –10%, Borderline – 24%) than in men (Case – 6%, Borderline – 16%). Various studies have shown a higher prevalence of depression and anxiety among women^.8-11,15

Regarding age-related differences, anxiety was more prevalent in the age group 51-60 years whereas depression was more prevalent in the age group 41-50 years. Various studies have shown increased prevalence of these cases in the elderly, which may be due to chronic illness.^12,18

The unique finding of our study is that significant numbers of patients presenting anxiety expressions do seek Homoeopathic treatment i.e. 25% as compare to 4% visiting to Allopathic OPD.. Anxiety is mainly seen in patients suffering from GIT complaints followed by skin ailments, endocrine disease, hypertension, and joint and muscle complaints. In comparison, depression is mainly seen in patients with joint and muscle conditions, hypertension, and endocrine diseases such as diabetes mellitus. This finding corresponds with the results of earlier studies, which have shown a higher prevalence of anxiety and depression in patients with these chronic illnesses.^24,25

The study shows that the proportion of expressions of Anxiety and Depression are independent of the education level.

 

CONCLUSION

Proportion of Anxiety and Depression is more among

• Women
• Those visiting the Homoeopathic OPD
• Middle-aged patients suffering from chronic illnesses such as GIT ailments, skin ailments, joint and muscle complaints, and hypertension.

 RECOMMENDATIONS

            Similar types of studies should be undertaken in other Homoeopathic teaching hospitals to generalise the findings of presence of comorbid anxiety and depressions along with other medical conditions in the OPD of Homoeopathic hospitals. The diagnosis can be confirmed by evaluating patients’ symptoms using the DSM-V criteria.

 LIMITATION OF THE STUDY

The English version of the HADS was used. However, for those who could not read English, the locally translated scale was used. This may have had some influence on the data.

ACKNOWLEDGEMENTS:

We are thankful to the Principal of MKSHM college and the patients who participated in this study

CONFLICT OF INTEREST: No funding was received for this study. The authors have no conflict of interest to declare.

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