RESEARCH
Psychiatric morbidities in patients with pulmonary tuberculosis
Adya Shanker Srivastava, Netranee Anju Ramdinee1, SC Matah2, Maheshwar Nath Tripathi3, Balram Pandit4, Jai Singh Yadav5
Associate Professor, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
1Ex-Resident, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2Professor, Department of Tuberculosis and Respiratory Diseases, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3Assistant Professor, Department of Psychiatry, Narayan Medical College & Hospital, Rohtas, Bihar, India
4Assistant Professor in Psychiatry, Department of Medical Sciences, College of Medicine, Nursing & Health Sciences, Fiji National University, Fiji
5Assistant Professor, National Drug De-addiction Center, All India Institute of Medical Sciences, New Delhi, India
Abstract
Aims and objectives: Tuberculosis continues to be a major health problem in India. Psychiatric illnesses are common subsequent to tubercular infection. The emergent stress contributes to psychiatric morbidity. The aim of the study was to find out the associated psychiatric co-morbidities in patients of tuberculosis so that effective comprehensive management of physical and mental health of these patients can be planned to have a better outcome.
Methodology: Hundred patients, between age ranges of 20 to 60 years of confirmed pulmonary tuberculosis were taken into study for evaluation of presence of associated psychiatric morbidities. The diagnosis was made according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and severity was assessed on the basis of the Brief Psychiatric Rating Scale (BPRS), the Hamilton Rating Scale for Depression (HDRS) and the Hamilton Anxiety Rating Scale (HARS). Statistical analysis was done using chi-square test, t-test, p-value for significance, and correlation co-efficient for correlation between different variables.
Result: Male:female ratio was 7:3. The mean age of study group was 36.66 (±14.02) years and majority (66%) of the patients belonged to lower socioeconomic group. Psychiatric morbidities detected were major depressive disorder (84%), brief psychotic disorder (six per cent), and generalized anxiety disorder (two per cent).
Conclusion: Major depressive disorder is the most common psychiatric morbidity in patients with pulmonary tuberculosis. The evaluation of mental health of patients of tuberculosis must be done for a comprehensive health care of these patients.
Srivastava AS, Ramdinee NA, Matah SC, Tripathi MN, Pandit B, Yadav JS. Psychiatric morbidities in patients with pulmonary tuberculosis. Dysphrenia. 2014;5:133-7.
Keywords: Depression. Anxiety. Psychotic Disorders. Mental Health.
Correspondence: dr.maheshwar@gmail.com, adya_shanker@yahoo.com
Received on 26 March 2014. Accepted on 27 June 2014.
Introduction
India, with its population of over 1000 million, is estimated to account for nearly 30% of global tuberculosis burden.[1] In patients with tuberculosis, functionality may be severely impaired due to chronic psychogenic and somatic pain, frequent hospital admissions, and dependency on medical and nursing personnel.
Both tuberculosis and psychiatric illnesses are social stigmas, at least in India.[2] Tuberculosis results in adverse psychological reaction about life, tension or anxiety, and patients are neglected by the family and society.[2]
Among psychiatric disorders, depression has a lifetime prevalence of ten per cent.[3] Out of these, about 80% cases of depression are either treated by non-mental health professionals or receive no treatment at all.[3] Untreated mental illness is associated with the patient’s probability of suffering from complications, even lethal in patients with poor drug compliance.
Review of literature
Study of the associations of tuberculosis and psychiatric disturbances is of great practical value. Patients suffering from tuberculosis show a higher degree of psychiatric morbidity.[4] In a study of 150 patients of tuberculosis,[3] 40% patients were diagnosed as suffering from depression using the Beck Depression Inventory.[5] The severity of depression was directly related to the duration of illness.
A survey of 100 hospitalised patients of tuberculosis in South Africa indicated that 68% had some degree of clinical depression: 22 patients were mildly depressed and eight patients had severe depression.[6] Another study of 272 patients of pulmonary tuberculosis at Agra, India[7] reported that 80 patients were found to have mental illness; 53 were diagnosed as depressive disorder, 18 as anxiety disorder, four as paranoid reaction, and two as hysterical conversion reaction.
The relationship between anxiety, depression, and illness perception was studied in Pakistan.[8] Out of 108 patients, 50(46.3%) patients were depressed and 51 (47.2%) had anxiety. Recent study by Chandrashekar et al.[9] on 100 patients of pulmonary tuberculosis has reported psychiatric morbidity in 46% of patients, majority of these were diagnosed as depressive disorder followed by anxiety disorder.
Methodology
This study was conducted at Sir Sunder Lal Hospital of Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India. A written informed consent was obtained before inclusion in the study. Patients attending the outpatient department of Tuberculosis and Respiratory Diseases were screened for pulmonary tuberculosis under supervision of consultant.
One hundred consecutive confirmed Category I patients of untreated pulmonary tuberculosis, between 20 to 60 years of age, were selected for inclusion in the study. Confirmation of diagnosis of pulmonary tuberculosis was based on specific constitutional symptoms and signs, radiological examination (x-ray chest), examination of pleural fluid and sputum examination for acid fast bacilli. Patients with other co-existing lung disease and any other medical illness including impaired sensorium were not included in the study.
Psychiatric evaluation was done on the basis of structured proforma under supervision of consultant in psychiatry and diagnosis was based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria.[10] Patients with past history of psychiatric illness were excluded from the study. Severity of psychiatric illness was assessed on the basis of the Hamilton Anxiety Rating Scale (HARS),[11] the Hamilton Rating Scale for Depression (HDRS),[12] and the Brief Psychiatric Rating Scale (BPRS).[13]
Analysis of data was based on statistical methods using chi-square test, t-test, p-value for significance, and correlation co-efficient for correlation between different variables.
Result
Mean age was 36.64±14.02 years. Majority of the patients were male (70%), married (76%), and belonged to lower socioeconomic group (66%). Patients were grouped in lower, lower middle, middle, upper middle, and upper class. Among females (30%), most of them were housewives (83.33%).[Table 1]
|
Table 1: Socio-demographic variables (N=100) |
|
|
Age |
|
|
Range |
20-60 years |
|
Mean |
36.64±14.02 years |
|
Sex |
|
|
Male |
70 |
|
Female |
30 |
|
Marital status |
|
|
Married |
76 |
|
Unmarried |
24 |
|
Education |
|
|
Illiterate |
37 |
|
I-V |
24 |
|
VI-XII |
9 |
|
>XII |
30 |
|
Socioeconomic status |
|
|
Lower |
66 |
|
Lower middle |
30 |
|
Middle |
4 |
Mean duration of tuberculosis was 1.13±0.579 months in 36% of patients followed by 2.9±0.7 months in 37% of patients. Majority of the patients had duration of illness within six months.
The evaluation of psychiatric morbidity revealed a high percentage of psychiatric co-morbidity in patients with pulmonary tuberculosis. Out of 100 patients, 92 patients (92%) had a mental illness. Eighty four (84%) patients had major depressive disorder, six (six per cent) patients had brief psychotic disorder, and two (two per cent) patients had generalized anxiety disorder.[Table 2]
|
Table 2: Distribution of psychiatric morbidity in study group |
||||
|
Diagnosis |
N |
% |
Mean age±SD |
Mean score±SD |
|
MDD |
84 |
84 |
36.23±13.75 |
18.21±5.07 |
|
BPD |
6 |
6 |
36.33±13.15 |
24.50±3.332 |
|
GAD |
2 |
2 |
32±2.8 |
17.00±1.414 |
|
No disorder |
8 |
8 |
36.44+13.34 |
- |
|
N=number, SD=standard deviation, MDD=major depressive disorder, BPD=brief psychotic disorder, GAD=generalized anxiety disorder |
||||
Major depressive disorder: Mean Hamilton depression score was highest (20.53±3.06) in age group 20-30 years as compared to other age groups, and higher (18.59±5.411) in males as compared to females (17.32±4.140). Similarly, mean Hamilton depression score was higher in unmarried (21.09±4.451) as compared to married (17.13±4.901), lower socioeconomic group (19.18±4.301) as compared to lower middle socioeconomic group (15.00±5.657), and uneducated persons (19.47±3.784) as compared to educated persons (18.53±3.672). The correlation of severity of depression with duration of tuberculosis was positive and showed an increasing trend in severity of depression with increase in duration of tuberculosis.
Brief psychotic disorder: Six (six per cent) patients were diagnosed as brief psychotic disorder. M:F ratio was 2:1 and all of them belonged to lower socioeconomic group. Five patients had only primary education and one patient was illiterate. An increasing trend in BPRS score was observed with increase in duration of tuberculosis.
Generalized anxiety disorder: Only two (two per cent) patients were diagnosed as generalized anxiety disorder. Both were male, married, from lower socioeconomic group, and had seven months’ duration of illness. The mean Hamilton anxiety score was 17.00±1.414.
Eight (eight per cent) patients had no psychiatric illness.
Discussion
In patients of pulmonary tuberculosis, psychiatric co-morbidity often remains undetected and untreated, thus affecting treatment response, compliance, recovery rate, and final outcome.
There was male preponderance in the study (M:F=7:3). The studies by Borgdorff et al.[14]and Hamid Salim et al.[15] have also reported higher number of males. Mean age was 36.64±14.02 years. Aydin and Uluşahin[16] and Husain et al.[8] have reported mean age as 37.8 and 37.3 years respectively which is in concordance with our study. Majority of the patients (60%) belonged to lower socioeconomic group. Yadav et al.[7] have also reported majority (78%) of the patients from weaker socioeconomic background.
Studies by Natani et al.[3] and Yadav et al.[7] have also reported depression as the most common psychiatric morbidity and majority of the patients of tuberculosis were suffering from depression. Maximum number of patients (39.28%) belonged to age group 20 to 30 years. This finding is similar to the finding reported by Purohit et al.[17] who also reported 34.7% cases between the age group 20 to 30 years. Mean Hamilton depression score was 18.59±5.411 in males as compared to 17.32±4.1140 in females, and higher in unmarried (21.09±4.451) than married (17.13±4.901) persons. However, Natani et al.[3] had reported no difference in score between unmarried and married persons.
Lower socioeconomic group had higher mean depression score as compared to middle socioeconomic group. Bagadia et al.[18], and Natani et al.[3] have also reported higher level of depression in lower socioeconomic group. Financial stress and poverty contributing to the development of depression is a well-established fact.
The level of educational status and literacy has profound effect on the contribution of developing depressive features and reality of perception of the morbid state. In present study, depression was more common and greater in severity in uneducated as compared to educated group. This finding is in concordance with the findings of Natani et al.[3] who reported higher level of depression in non educated persons.
When analysed among various occupational groups, among females most of them were housewives and had moderate to severe depression. Similarly moderate to severe depression was observed among maximum patients in unskilled labours (43/46) and students (15/16) group.
The study showed a positive correlation between duration of illness of pulmonary tuberculosis and severity of depression. Similar observation has also been reported by Purohit et al.[17], Tandon et al.,[19] and Natani et al.[3].
The socioeconomic status, level of education, and occupation has significant contribution in development of stressor, and subsequently predisposing the individual to morbid state of depression. As the patients were not taking any anti-tubercular treatment (ATT) prior to inclusion in the study, the possibility of contribution of drug to the development of depression in these patients was ruled out.
Brief psychotic disorder was detected in six (six per cent) patients. All of them belonged to lower socioeconomic group. Three were married, one was illiterate, and five had education up to primary standard only. Mean BPRS score in patients having duration of illness up to three months was 22.67±5.56, and a patient with duration up to six months was 26.33±6.14.
Yadav et al.[7] have reported paranoid reaction in four out of 80 patients in their study. Prasad et al.[20] have reported psychotic episodes following administration of isoniazid and alleviation of psychosis after withdrawal of drug. Not much has been reported about prevalence of psychotic episode in patients who were not on ATT. In our study, since all the patients were treatment naïve cases of pulmonary tuberculosis, the brief psychotic disorder reported was not related with drugs. Also, the possibility of tubercular meningitis/delirium was ruled out before diagnosing them as functional psychosis on the basis of clinical history and available reports.
Nath et al.[21] studied the socio-demographic and clinical variables of patients diagnosed with organic mental disorders. 10.625% cases were of delirium in their study, and the causes were infections, metabolic, traumatic, drug induced, etc. Kumar et al.[22] found that 46% patients presented in psychiatry emergency with coexistent medical illness. Among these, the commonly associated medical illnesses were anaemia, peptic ulcer, diabetes mellitus, hypertension, tuberculosis, injury and poisoning, and menstrual complaints.
Only two patients (two per cent) fulfilled the DSM-IV criteria for generalized anxiety disorder. One was male and other was female, mean age being 36.23±13.75 years. Both were married and belonged to lower socioeconomic status. Male was working as labour and female was housewife. Mean Hamilton anxiety score was 17.00±1.44.
Yadav et al.[7] have reported 18 (6.61%) cases of anxiety disorder out of 272 patients of tuberculosis in their study, and Husain et al.[8] have reported 51 (47.22%) cases of anxiety disorder out of 108 patients of tuberculosis in Pakistan.
Conclusion
Psychological factors are important in tuberculosis treatment. The chest physicians and mental health professionals should be aware of the possibility of co-morbid psychiatric illness. Considering the high prevalence of mental illness in patients with pulmonary tuberculosis, a proper evaluation of mental health and comprehensive care of physical and mental health will lead to better outcome in respect to treatment and quality of life of these patients.
Source of support: Nil. Declaration of interest: None.
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