الفهرس 
Epidemiology of Psychiatric Morbidities in Primary Health CareOnly 14 pages are availabe for public view
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Abstract
Introduction
Mental disorders affect a large percentage of population and constitute important cause of morbidity, mortality, and disability (Ormel et al., 2008).
Nevertheless, two-thirds of all patients with psychiatric disorders are seen exclusively in primary care settings. Thirty percent of all primary care patients meet DSM-IV-TR criteria for a psychiatric disorder, but many of these patients go underdiagnosed and missed by the primary care practitioners (PCPs) (Badamgarav et al., 2003). A number of reasons have been adduced for this. Patients seeing their primary care doctors tend to somatise their emotional distress, presenting with physical symptoms rather than overt psychological symptoms (Scicchitano et al., 1996). Medical history is often taken in conditions of little privacy thereby discouraging patients from sharing sensitive aspects of their distress (Goldberg, 1985). PCP may also not be confident in diagnosing and treating psychiatric disorders (Pini et al., 1997). Moreover, PCP tends to have limited time in which to obtain a psychiatric history (Spitzer et al., 1994).
The long-term consequences of psychiatric morbidity such as depression when it is not identified and treated can be severely harm the patient health and functioning. These include reduced quality of life, stigmatization, suicide, increased rates of hospital admission, loss of jobs and relationships, and deterioration in physical health including higher risk of myocardial infarction and chronic physical illnesses. Major depression is among the leading causes of disability-adjusted life-years worldwide. In addition, the economic burden of depression is considerable: in Canada alone, the estimated annual productivity losses owing to depression were $4.5 billion in 1998 (Joffres et al., 2013).
Concurrent physical illnesses increase the vulnerability to psychiatric disorders. On the other hand, psychiatric problems may decrease the adherence to medical treatments and lead to poorer health outcomes of the chronic diseases (Prakash et al., 2007).
The choice and effectiveness of intervention by primary care doctors for psychiatric morbidities can have a profound effect on the quality of life of the patients and the demand for services. However, many challenges exist in providing optimal care, including difficulties in recognizing patients with psychiatric morbidities, developing an adequate diagnostic initial assessment, implementing treatment and management strategies, and integrating care of psychiatric morbidities with that of co-existing chronic illnesses (Culpepper, 2002).
Rationale of the work:
Psychiatric disorders are commonly existing with chronic general medical illnesses and this have a significant impact on the physical and psychiatric quality of life of the patients. However, they are always underdiagnosed and undertreated. Primary health care setting is the access point into the health system for most patients especially in rural areas, and primary care clinicians are ideally placed to serve as the central health care provider for patients with psychiatric disorders, and these mandates using thorough structured screening tools for psychiatric disorders and early treatment to reach optimum clinical outcome.
Aim of the work:
To assess the rate of occurrence of psychiatric morbidities with general medical illnesses among patients attending primary health care outpatient clinics.
To study the relation and possible risk between psychiatric morbidities and both the socio-demographic data and clinical profile data of the patients attending primary health care outpatient clinics.
Hypothesis:
Our hypothesis is that there is a significant occurrence of psychiatric morbidities among patients attending PHC with apparent impact of both the socioeconomic stress and the general medical condition on them.
Methodology:
Subjects and Methods:
• Type of Study: This is a cross sectional study.
• Study Setting: The study included 300 adult patients selected from the outpatient clinics of four primary care centers by convenient sampling on the working days from 9 am till 12 pm, these centers are located in Damanhour and serve a catchments area for about 118 thousand Egyptian citizens. Two centers of them (Ezbet Saad – Nasser) serve urban areas while the other two centers (El-Zawiah – Mansheyat Al-Awkaf) serve rural areas.
• Study Period: The study was carried out after the approval of the protocol by the department of Neuropsychiatry, Faculty of Medicine, Ain Shams University. The data were collected during the period from 3/2019 till 7/2019.
• Study Population:
- Inclusion Criteria:
- Age from 18 to 55 years old.
- Male and female patients.
- Egyptian nationality.
- Exclusion Criteria:
- Age below 18 and above 55 years old.
- Patients who refused to give informed consent.
- Patients with previous history of any psychiatric disorders.
- Patients with severe general medical disease states or with major complications that can interfere with their ability to participate in the study.
• Sampling Method: Patients were selected by convenient sampling from outpatient clinics of four primary care units located in Damanhour.
• Sample Size: Sample size was calculated using Epi Info® version 7.1.5 Program (CDC, Atlanta, USA, 2018). Calculation produced a minimum sample size of 300 cases.
Ethical Considerations:
All personal data of the participants were confidential and will not be participated in another research. Participation was voluntary after giving a written informed consent. Participants had the right to withdraw from the research anytime and for any reason. There was no any discrimination in conduction of health service between the participants and the patients who refused to participate in the research.
Study Tools:
* All subjects were assessed using the following measures:
• Clinical History Sheet of Internal Medicine Department of Ain Shams University Hospital.
• The 28-item General Health Questionnaire (GHQ-28) (Goldberg, 1978).
* Subjects who suggested to be had a psychiatric illness by GHQ, were evaluated by:
• The general screening part of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (First et al., 1994).
Statistical Package: All data were entered, recorded and analyzed using the Statistical Package of Social Sciences, version 25 (SPSS, 2015).
Statistical Analysis: Descriptive and analytical procedures were conducted.
Results:
A. The socio-demographic characteristics of the studied population:
Females constituted 85.67% of the total sample size. The cause of having more females is probably due to that the cultural notion that females have higher care seeking behavior and higher self-reported health status than males as well as the nature of their chronic illnesses related to their physiology of pregnancy and hormonal processing.
62.33% of the total sample were found to be unemployed and some have non-fixed income. The mean age of participants of the current study was 35.87 (31-45 middle-aged adult group).
B. The rate of distribution of chronic general medical illness data in the studied population:
The distribution of chronic illness data in the current study was: 79.3% with no chronic illness, 7.67% with HTN, 2% DM and 6.67% having multiple chronic illnesses. Although 60.3% of our sample doesn’t receive any medications, this is actually doesn’t represent the subjects who were with no chronic illness, because many of chronically ill patients are not compliant on their treatments. Moreover, some individuals in our study were receiving medications without being had a chronic general medical illness: like females receiving OCPs for family planning or others who take OTC drugs as multi-vitamins.
C. The complaint data in the studied population:
The main complaints of patients in the current study sample were: headache 43.4% followed by GIT symptoms 16%, then multiple complaints 6.3%, orthopaedic pain6%, and back pain 5.6% respectively. There is growing evidence that stressful life events are implicated in the development, exacerbation and maintenance of chronic pain syndromes, including abdominal and low back pain, while headache is acknowledged as a multi-factorial disease.
D. The potentiality of psychiatric disorders in the studied population:
36% of our sample was GHQ positive while 64% was negative.
E. The rate of distribution of psychiatric disorders in patients with GHQ positive score:
25% was with no psychiatric diagnosis, 25% depression, 26.6% GAD, 20% dysthymia and 16% multiple psychiatric diagnoses. Most studies reporting comorbidity have found depressive disorders to be the most frequent, followed by anxiety and substance abuse disorders.
F. Bivariate analysis of the relation between GHQ score data and demographic data:
Our results found that positive GHQ scores are higher among female gender, living in urban residence, being unemployed or with non-fixed income.
G. Bivariate analysis of the relation between GHQ data and general medical illness data:
While negative GHQ score was more among patients reporting a single complaint, our results detected no significant relation between positive GHQ score and chronic illness.
H. Bivariate analysis of the relation between the rate of distribution of psychiatric disorders and demographic data:
Our results found that depression and multiple psychiatric diagnoses were significantly more in the middle-aged adult group. However, there was no statistically significant relation between the absence of psychiatric diagnosis (although with GHQ positive score), GAD and dysthymia with any age group.
With regards to gender, our results found that the rate of occurrence of psychiatric disorders is higher in women than in men, and also found that depression and multiple psychiatric diagnoses were significantly more in unemployed and in non-fixed income groups. Both “no psychiatric diagnosis group” and “multiple psychiatric diagnoses group” showed statistically significant high rate of occurrence in urban group than rural group.
I. Bivariate analysis of the relation between the rate of distribution of psychiatric disorders and general medical illness data:
Our results found significant relation between depression, GAD and multiple psychiatric diagnoses with CNS complaint (headache), while they had no relation with other complaints.
Our results found no significant relation between psychiatric illness by SCID-I screening and patients with HTN, DM, hypothyroid, hyperthyroid, gastritis or both HTN and DM together.
J. Logistic Regression of the relation between psychiatric disorders, general medical illnesses and demographic variables:
In this study, no significant relations were found between psychiatric disorders according to the effect of demographic factors (Age, Gender and Residence) with chronic illness occurrence and complaint type variables, except in case of depression, the residence factor and the chronic illness showed significant relation. Additionally, another exception was found in case of dysthymia in which the residence factor and the complaint showed significant relation. Nevertheless, these significant relations are not strong enough according to the linearity equation to be defined as a predictor for depression or dysthymia due to the small sample size of our study.