PSYCHIATRIC MORBIDITY AMONG PATIENTS ATTENDING

THE INTEGRATED COUNSELLING AND TESTING CENTRE

(ICTC) FACILITY OF TERTIARY CARE HOSPITAL
IN SOUTH INDIA

A dissertation submitted to
JIPMER
In partial fulfilment of the requirements for the award of degree
M.Sc. Nursing- Psychiatric Nursing
BY

Mr. SRINIVASAN C
Reg. no. 121877D05

Jawaharlal Institute of Postgraduate Medical Education and

Research
(An Institute of National Importance under the Ministry of Health and
Family Welfare, Government of India)
Puducherry- 605 006

July 2020
जवाहरलालस्नातकोत्तरआयर्ु ानश न ा थान
वज्ञ िक्ष स नस
ाएवअ ध स्
JAWAHARLAL INSTITUTE OF POSTGRADUATE MEDICAL
 EDUCATION & RESEARCH
(स्वास््यएवपररवारकल्याणमत्रालय,भारतसरकारके
अधीनराष्ट्रीयमहत्वकासस्थान)
(An Institution of National Importance under Ministry of Health & Family welfare)
भारतसरकार / GOVERNMENT OF INDIA, धन्वतरर नगर, पदच्चेरी /
DHANVANTARI NAGAR, PUDUCHERRY- 605 006
Website: www.jipmer.edu.in Email: [email protected]
Phone: 0413 – 2296002, 2296022 Phone : 0413 – 2279357, 2297161/56
Fax: 0413 – 2272067- 2272735 Fax : 0413 – 2279357

BONAFIDE CERTIFICATE

This to certify that the project entitled “Psychiatric morbidity among patients
attending the Integrated Counseling and Testing Center (ICTC) facility of a
tertiary care hospital in South India” is a bonafide record of work done by
Mr. SRINIVASAN C under our guidance and supervision in the College of Nursing,
Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER),
Puducherry during the period of her postgraduate study for the degree of M.Sc.
(Nursing) in Psychiatric Nursing from August 2018 to July 2020.

Nursing Guide:
Dr. Padmavathi Nagarajan,
Assistant Professor,
College of Nursing, JIPMER

Co-Guides:
Dr. Vikas Menon, Dr. Rakesh Singh,
Additional Professor, Additional Professor,
Department Of Psychiatry, JIPMER Department of Microbiology, JIPMER

Principal (Ag.), Dean – Research, Dean – Academic,

College of Nursing, JIPMER. JIPMER JIPMER
 DECLARATION

I hereby declare that this dissertation entitled “Psychiatric

morbidity among patients attending the Integrated Counselling and

Testing Center (ICTC) facility of a tertiary care hospital south India”

submitted to the Jawaharlal Institute of Postgraduate Medical Education

and Research (JIPMER), Puducherry for the fulfillment of the

requirements for the Master of Science in Nursing is a bonafide record of

original research work carried out by me under the guidance and

supervision of Dr. Padmavathi Nagarajan, Assistant professor, College of

Nursing as my Nursing guide and Dr. Vikas Menon Additional Professor,

Department of Psychiatry, Dr. Rakesh Singh, Additional Professor,

Department of Microbiology, as Medical co-guides JIPMER, Puducherry.

This study represents the independent work conducted by me and has not

previously formed the basis for the award of any degree, diploma,

associateship, fellowship or any other similar title.

Mr. SRINIVASAN C

Place: Puducherry

Date:
 ACKNOWLEDGMENT

I thank God Almighty for the bountiful graces bestowed upon us and for his

enlightenment at every step which gave us the support to complete this study.

It is my privilege to be a part of JIPMER and we extend our sincere

gratitude to Dr, Rakesh Aggarwal, Director, JIPMER of the institution for allowing

me to conduct the study.

I extend my warm gratitude to Dr. Pankaj Kundra, Dean (Academics) and

Dr. R. Raveendran, Dean (Research), JIPMER for allowing me to conduct the study.

I owe a deep sense of gratitude to Dr. M. J. Kumari, M.Sc.(N), M.Phil.

(N), Ph.D.(N), Professor cum Principal (Ag) for her remarkable support throughout

the study.

Words are powerless to express my gratitude to my guide Dr. Padmavathi

Nagarajan, M.Sc. (N) Ph.D. (N), Assistant Professor, College of Nursing, JIPMER,

for her patience, motivation, enthusiasm and immense knowledge.

I have no words to express my sincere thanks and gratitude to my co-guides

Dr. Rakesh Singh, Additional Professor, Department of Microbiology and Dr. Vikas

Menon, Additional Professor, Department of Psychiatry, JIPMER, for their valuable

suggestions and guidance throughout the study.

I also extend my thanks to Dr. Rajeshwari, Assistant professor, Department

of Biostatistics, JIPMER for her statistical guidance and meaningful interpretation of

data.
 I convey my gratitude to Dr. David V. Sheehan, M.D., M.B.A, Professor of

Psychiatry, Director of Psychiatric, University of South Florida, for permitting me to

use my research tool and Mr. Dhinagaran A, ICTC counselor for given support

during my data collection time.

And my sincere thanks to all our teachers and non-teaching staff for their

timely support and cooperation. A word of appreciation to our seniors, friends, and

juniors for the help provided to us.

I also express my thanks to all the participants in the study and I am greatly

indebted for their patience, co-operation and valuable acceptance to be participants of

the study.

My parents watched me from a distance while I worked towards my degree.

The completion of this thesis will mean a lot to them, particularly ‘seeing more of

me’. So I dedicate this project to my loving family, without whose love, affection and

encouragement this work would not have been possible.

I also place on record, my sense of gratitude to one and all, who directly or

indirectly, have lent their hand in this venture.

Mr. SRINIVASAN C
 ABSTRACT

Introduction

The burden of mental disorders is expected to rise significantly over the next
20 years. Psychiatric symptoms are becoming increasingly evident in infected with
HIV people. It is estimated up to 70% of people with HIV suffer from an acute
psychiatric condition, and people undergoing HIV testing also have distress due to the
stigma and the fear associated with the disease. So, early screening of psychiatric
illness helps to manage the symptom effectively. The purpose of the study is to assess
the psychiatric illness among patients undergoing HIV testing in the Integrated
Counselling and Testing Centre (ICTC) facility, JIPMER.

Methodology

A cross-sectional, descriptive design was adopted for this study. Purposive

sampling technique was used and the sample consisted of 384 patients who were
utilizing the Integrated Counselling and Testing Centre (ICTC) in JIPMER. M.I.N.I
Neuro-International psychiatric questionnaire was used to screening for psychiatric
morbidity. Data analysis was done with descriptive and inferential statistics.

Results

The study showed that out of 384 patients, 91 (24%) had the psychiatric
illness, the distribution remained single psychiatric morbidity of 62 (68%) and rest
had at least two psychiatric co-morbidity, I also revealed that there was no significant
association between selected socio-demographical variables and psychiatric morbidity
among patients utilizing ICTC center.

Conclusion

Early screening of psychiatric morbidity among patients utilizing the ICTC

center may help identify and treat the illness at an early stage. The screening tool used
in this study was found to be useful in identifying the psychiatric symptoms and easy
to administer with minimum training.

Keywords: Psychiatric morbidity, HIV testing, ICTC.

 TABLE OF CONTENT

PAGE
CHAPTERS CONTENT
NO.
I  INTRODUCTION 1-9

1.1 Significance and need for the study 3

1.2 Novelty of the study 3-4
1.3 Statement of the problem 4
1.4 Aim and objectives of the study 4
1.5 Operational definitions 5
1.6 Delimitation 5
1.7 Expected outcome 5
1.8 Conceptual framework 6-9
II  REVIEW OF LITERATURE 10-15

2.1 Recognition and management of common mental 10

disorders in primary care.
2.2 Prevalence of mental disorders 10
2.3 Prevalence of major depressive disorder (MDD) 12
2.4 Prevalence of generalized anxiety disorder (GAD) 13
2.5 Prevalence of alcohol use disorder (AUD) 13
2.6 Psychological distress among PLWH 13
2.7 Fear and stigma associated with HIV testing 14
2.8 HIV testing and common mental disorders 15

III  METHODOLOGY 18-25

3.1 Research Approach 18
3.2 Research design 18
3.3 Variables 20
3.4 Research setting 20
 3.5 Population 20
3.6 Sample 21
3.7 Sampling technique 21
3.8 Sample size calculation 21
3.9 Sampling criteria Data collection procedure 21
3.10 Description of instruments and technique 22
3.11 Content validity 23
3.12 Reliability 23
3.13 Ethical consideration 23
3.14 Pilot study 24
3.15 Data collection procedure 24
3.16 Plan for data analysis 24

IV  DATA ANALYSIS AND ITS 26-33

INTERPRETATION
V  DISCUSSION 34-38
VI  SUMMARY, IMPLICATIONS, 39-41
RECOMMENDATIONS, AND
CONCLUSION
6.1 Summary 39
6.2 Conclusion 41
6.3 Implementation & Recommendations 41

VII  REFERENCES 44-50

 LIST OF TABLES

TABLE NO. CONTENT PAGE NO.

1. Description of socio-demographic variables of 27

study participants utilizing the ICTC facility
JIPMER.

2. Psychiatric co-morbidity among patients 30

attending the ICTC.

3. Association of psychiatric morbidity among 32

patients attending ICTC facility with selected
socio-demographical variables
 LIST OF FIGURES

FIGURE NO. CONTENT PAGE NO.

1. A conceptual framework based on the Betty 9

Neuman systems model

2. Schematic representation of research design 19

3. Psychiatric morbidity among patients utilizing 29

ICTC facility of a tertiary care hospital

4. Psychiatric co-morbidities among patients attending 31

the ICTC facility.

 LIST OF APPENDIXES

APPENDICES TITLE PAGE NO.

I Data collection instrument English and Tamil (socio- I

Demographic Performa and M.I.N.I plus
neuropsychiatric interview questionnaires)

II Nursing Research and Monitoring Committee certificate LXXVI

III Institute Ethical Committee certificate LXXVII

IV Plagiarism verification certificate LXXIX

V Permission letter for research tool (M.I.N.I. interview LXXX

questionnaires)

VI Consent form English and Tamil. LXXXVI

 LIST OF SYMBOLS AND ABBREVIATIONS

SYMBOLS ABBREVIATIONS

ADS Alcohol Dependence Syndrome

AIDS Acquired Immune Deficiency Syndrome

HCSUS Cost and Services Utilization Study

HIV Human Immunodeficiency Viruses

ICTC Integrated Counseling and Testing Center

IEC Institute Ethical Committee

JIPMER Jawaharlal Institute of Postgraduate Medical Education & Research

M.I.N.I MINI International Neuropsychiatric Interview

MDD Major Depressive Disorder

NACO National AIDS Control Organization

NRMC Nursing Research Monitoring Committee

OCD Obsessive-Compulsive Disorder

PTSD Post-Traumatic Stress Disorder

SPSS Statistical Package for Social Sciences

STD Sexually Transmitted Disease

TASACS Tamil Nadu State AIDS Control Society

VCTC Voluntary Counseling and Testing Center

WHO World Health Organization

 CHAPTER I

INTRODUCTION

The World Health Organization defines health as a state of comprehensive

physical, social, and mental well-being and not only the absence of disease. Stigma

and discrimination are the major drawbacks of mental health care in world wide.

However, globally 450 million people suffer from a mental or behavioral disturbance.

One in four families has at least one person with a mental disorder. Neuropsychiatric

disorders like depression, schizophrenia, and bipolar disorder, alcohol use disorder are

the one out of six leading causes of disability causing the problem worldwide.1

Mental or psychiatric morbidity generally refers to the incidence of both

physical and psychological deterioration as a result of a mental or psychological

condition it causes impairment in occupational and social functioning. Screening is

usually recommended as a way to identify individuals with “psychiatric morbidity”

that would otherwise be undetected or untreated.2

More than 80% of mental disorders are residing in low and middle- income

nations, with substance abuse disorders and mental illness performing since an

important cause of disease burdening approximately 16.6% and 8.8% of the total

overwhelming of disease in low-income and lower-middle-income nations,

respectively.3, 4 In India Bihar, the number of people suffering from schizophrenia is

higher than that in the entirety of North America..5

Asper mental health survey of NIMHANS, mental health morbidity was

10.6%. The distribution of Mental and behavioral problems due to psychoactive

substance use

1
was 22.44%, Schizophrenia, and other psychotic disorders were 0.42 %, Mood and

affective disorders were 2.84 %, Neurotic and stress-related disorders 3.5%.

The World health organization reported (2015), disability causing conditions

are neuropsychiatric problems 13 % and internal injury 3.3%, and HIV/AIDS and

other problems were 6%. Comorbidity results in lower adherence to medical therapy,

an increase in disability and mortality, and increasing the health care costs.6

HIV infection is one of the important global public health problems, more than

37.9 million peoples are living with HIV infection so far worldwide. However,

expanding the early HIV diagnosis, treatment, and identification of co-morbidities

may lead to long and healthy living for patients with HIV infection and it was

estimated that

21.40 lakh people living with HIV infection in India (by NACO, 2017).7

Mental and behavioral symptoms are becoming more evident in people

infected with HIV. It is estimated that up to 70% of people with HIV suffer from an

acute psychiatric condition related to HIV infection at some point during their

ailment.8

Thus, restricting screening for HIV in Sexually Transmitted Infection clinics

will not help in identifying the flowing HIV infected population. So, the National

AIDS control organization of India has established the Integrated Counselling &

Testing Centre (ICTC) is a gate-way, entry point for a host of HIV/AIDS-related

services in prevention and care.

The need for ICTC is early diagnosis and treatment of disease, mostly who all

are risk populations like sex workers and homosexual practice peoples and who have

multiple sexual partners. Those people were referred to ICTC for diagnosis.
1.1 Need for the study

In many public health clinics in India, HIV testing has become an increasingly

routine practice. The higher level of anxiety, depression, and distress was commonly

observed in HIV test- seekers, more among repeat test-seekers. Screening for AIDS

anxiety at ICTC and providing appropriate intervention might help the quality of life

and empower them to practice safer behavior of the individual who attends the ICTC

center.9

Individuals undergoing HIV tests are expected to experience significant

distress due to the stigma and the fear of the disease.10

Mental health disorders, particularly mood change have been shown to negatively

influence HIV test-seeking behavior, start on treatment, and adherence to antiviral

treatment.11

The testing for HIV infection may cause a significant amount of distress

because of the fear of the fatality of the disease as well as the stigma associated with

the diagnosis. Comorbid mental illness and substance abuse are also found to be at

higher levels among HIV infected individuals in comparison with the general

population.12

1.2 Novelty of the study

Hence, identifying and managing these distressing states could be an effective

interventional approach. So, early screening of psychiatric illness among HIV test

seekers may support better case management, appropriate clinical care, slowing the

disease progression and building quality of life. Since there is a paucity of the data in

this area, the proposed study is expected to portray the reality of the situation in a
meaningful way. The ICTC facility of JIPMER hospital is catering services to a wide
population from all over South India, the present study would add to the literature on

the current prevalence of the psychiatric morbidity among patients attending the ICTC

facility of JIPMER.

In this study, the investigator intended to find out the psychiatric morbidity to

screen following psychiatric illness, depressive episode, major depressive disorder,

suicidal ideation, manic episode, bipolar disorder, panic disorder, phobic disorder,

social anxiety disorder, post-traumatic stress disorder, alcohol use disorder, other

substance use disorder, eating disorder, generalized anxiety disorder, anti-social

personality disorder, medical, organic, drugs cause the psychiatric disorder.

1.3 Statement of the problem

Psychiatric morbidity among patients attending the Integrated Counselling and

Testing Center (ICTC) facility of a tertiary care hospital in South India.

1.4 Objectives

Primary objective:

 To assess the psychiatric morbidity among patients utilizing the ICTC

facility of JIPMER hospital

Secondary objectives:

 To identify the association between the socio-demographic variables

and the psychiatric morbidity among individuals who are attending the

ICTC facility of JIPMER hospital.

 To determine the presence of comorbidity with multiple psychiatric

disorders in patients utilizing the ICTC facility of JIPMER hospital.

1.5 Operational definitions

Psychiatric morbidity:

Psychiatric morbidity refers to the incidence of both physical and

psychological disturbances as a result of a mental or psychological condition that

causes impairment in occupational and social functioning during the time of attending

ICTC facility, JIPMER hospital a psychiatric condition as assessed by MINI. In this

study, it refers to positive for one or more modules of the MINI.

ICTC:

Integrated Counselling and Testing Center is a place where the person who is

at risk for HIV infection is counseled and tested for HIV infection, of his/her own free

will or as recommended by a medical health professional. In this study, it refers to the

center (ICTC) connected with JIPMER hospital.

1.6 Delimitations.

 The data collection was limited to the patients attending the Integrated

Counselling and Testing Center (ICTC), JIPMER.

 The data collection period was only 6 weeks.

 Non – probability sampling technique was identifying samples.

1.7 Projected outcome

The study was carried out to identify the prevalence of psychiatric morbidity

among patients attending the ICTC facility of JIPMER hospital. Based on the results,

those participants who were found to have some psychiatric illness were referred to

the Psychiatric Department for further management and follow-up.

 CONCEPTUAL FRAMEWORK

BETTY NEUMAN’S SYSTEM MODEL

1.8 Conceptual framework (Betty Neuman’s system model).

The central components of Betty Neuman systems model

are: Whole person

There are physiological, psychological, sociocultural, developmental and

spiritual variables. Each of these variables contributes to the reaction to stressors in

each individual.

The patients who are all coming for HIV testing have distress due to perceived stigma

and serious illness, disease prognosis.

Stressors

Neuman in 1995 defined stressors as “stimuli that produce tension and have

more potential for causing instability”. The system always has to deal with one or the

other stressor at any point in time. Here the researcher has identified that the major

stressor affecting the individual as a whole was patients attending the ICTC center for

HIV testing that contributed to the social stigma, fear about physical symptoms, and

prognosis of illness the impact of it within and around the client system.

The normal line of defense

According to Neuman’s theory, it describes a solid circle that that refers to the stability

of the individual (Neuman 1995). Any stressor can invade the normal line of defense.
In this study, the stressors that invaded the normal line of defense can be identified as

distress due to HIV infection and physical problems.

Flexible line of defense

It is the outer and initial response of an individual towards the stressors which

act as a protective buffer that alters over some time. If the individual can maintain a

well build a flexible line of defense, that can result in the strengthening of his system.

In this study the role of study to acknowledge the psychiatric disorder in patients

attending ICTC center by devoid the risk of threats to the client by a poor prognosis,

and increase change to spreading the infection.

Lines of resistance

For the study participants, prompt and early screening of psychiatric illness

improving the client's health status and better prognosis.

Level of interventions

These are actions that help an individual out to regain their state of wellness

equilibrium. These interventions have to be provided to patients based on the

available resources and the degree of stressor the client experiences. Through the

study, the researchers have identified the patients attending ICTC center also having a

psychiatric illness, so early screening and referral improving the patient’s quality of

life.
Primary prevention

This mode of intervention is carried out when any stressor is identified by the

client system. The rectification of these stressors helps to strengthen the line of

defense of an individual.

The study was focused on identifying psychiatric illness patients who are attending

the ICTC center.

Secondary prevention

Secondary prevention results when the stressor has already affected the client

by breaking the line of defense and the individual has initiated symptoms. It focuses

on the early detection of psychiatric disorders and referral and prompt treatment to it.

Tertiary prevention

This mode refers to the adjustment of the client to attain stability through the

treatment process. It helps to strengthen the individual’s response to a stressor and to

acquire wellness by strengthening the line of defense. Tertiary prevention invariably

focusing on bringing back the stable system, after identification of psychiatric illness

treats the psychiatric illness will reduce the isolation behavior and good treatment

adherence, come back to normal life.

 Stressors
Primary prevention Basic structure
 Early screening  Social stigma
of patients  Age, Immune system
 Fear about positive
attending ICTC  Genetic factors
result and
facility  Positive mental health
prognosis of illness
 Referral to  Adaptive behavior
 Anxiety about
psychiatric unit for
appropriate treatment illness
symptoms

Secondary Prevention
Degree of
 Early treatment reaction Basic
like Antipsychotic Structure
energy
& psychological source
Stressors
intervention
 Reduction of symptoms Reaction  Comorbidities like
through appropriate  Anxiety physical disorders
clinical intervention  Psychological distress  Poor
 Increase the risk treatment adherence
of behavior due to lake of family
alteration and social supports
 Financial problem and
fear of rejection in
Tertiary prevention family and society
 Rehabilitation of  Psychological support
patient and family
 Improve social and
occupational
function Intervention
 Prevention of
complication  Early screening of
and remission psychiatric disorders
 Health education

Fig.1.Conceptual framework – Betty Neumans system model (1970)

 Intra
Inter Personal
Reconstitution  Motivation to
 Improving quality of life factors Extra treatment adherence

Intra
Inter Personal
factors Extra

9
Fig.1.Conceptual framework – Betty Neumans system model (1970)
 CHAPTER II

REVIEW OF LITERATURE

The researcher conducted an extensive literature review for the present study.

The reviewed literature has been organized in the following headings.

Recognition and management of common mental disorders in primary care

Lusskin et al found that common mental disorders were undetected and

untreated at primary care facilities because of poor screening routines and the scarcity

of resources.13

Similarly Tomson et al also found that the inadequate treatment of common

mental disorders can result in significant social and economic burden for families,

friends and superiors. Several reasons have been suggested for the inadequate

treatment of CMDs, which include physician-related factors, patient-related factors,

and challenges associated with clinics.14

Prevalence of mental disorders

Kessler et al reported that the lifetime prevalence rate of mental disorders was

a range between 12.0% and 47.4% across 17 countries.15

A cross-sectional study was conducted by Naresh et al on psychiatric

morbidity in HIV positive subjects using the general health questionnaire (score 28.0,

p=.093) and structure clinical interview for DSM-IV. The study result showed that

prevalence of psychiatric disorders 45%, including major depressive disorder 19%,

adjustment disorders 7%, anxiety disorder 1 %, and substance use disorders 17%.16

10
 Similarly, Ghuloum et al estimated in a Qatari population attending a primary

healthcare setting, the overall prevalence of mental disorders was 36.6%.17

The first population-based study of psychiatric morbidity was conducted

among 4351 adults, the South African Stress and Health Study (SASH) Herman et al.

The SASH study had shown that approximately 30.3% of the sample has been

diagnosed with a psychiatric disorder in their life that has gone untreated. The SASH

further showed that 16.5% of the sample has experienced common mental disorders

over twelve months, but only 25% of the adults were treated for this condition.18

Pothen et al indicated that among primary care patients, 33.9% were

diagnosed with common mental disorders. The authors found that depression was the

most common diagnosis with a high prevalence rate of 83.8%.19

Subsequently a study conducted by Cwikel et al on the prevalence of

psychiatric disorders among primary care patients (n = 976). These authors found that

depression was the most prevalent disorder (20.6%) followed by generalized anxiety

disorder (11.2%) and panic disorder (7.2%).20

Pauline et al investigated the prevalence of undetected psychiatric morbidity

among HIV/AIDS patients. Results showed that there was no statistically significant

association between the overall psychiatric morbidity and social determinants such as

gender, marital status, level of education, and occupation or employment status.21

Prevalence of major depressive disorders (MDD).

Kessler et al conducted a 12 months study among the general population to

assess the prevalence of the major depressive disorder. The study results showed that

6.7 % of American had major depressive disorder.22

Stuart et al conducted a study on the prevalence of major depressive disorder

among the general population. The study result showed that 26.2% of the women and

16.4% of the men had major depression.23

Anderson et al conducted a cross-section study among 977 individuals aged

between 18 and 40. In this study, it was found that 31.4% of the sample met the

criteria for a lifetime depression using the MINI international neuropsychiatric

interview questionnaire.24

Similarly Olley et al. also reported that using the MINI, the prevalence of

MDD was 34.9% among HIV-infected individuals. The authors found that 6 months
25
later, 26% of their sample met the diagnostic criteria for depression.

The MINI was utilized among people with HIV/AIDS to assess the prevalence

of dysthymia by Sulyman et al. The prevalence of dysthymia was found to be 26.1%

among 300 (PLHIV) individuals.26

Munjal et al conducted a study in India. The Centre for Epidemiological

Studies Depression (CES-D) scale was utilized to determine the levels of depression

among 160 people living with HIV and receiving ART treatment. The results

indicated that 58.75% of the sample met the criteria for depression. Furthermore,

more females (61.3%) than males (58.1%s) and transgender persons (50%) were

depressed.27
Prevalence of generalized anxiety disorder (GAD)

Wittchen et al conducted a study, in a national representative sample of

primary care practices in Germany using the Generalized Anxiety Screening

Questionnaire (GAS-Q), a modified version of the Anxiety Screening Questionnaire

(ASQ), the prevalence of GAD was 5.4%.28

Berger et al assessed the prevalence of GAD among an American sample of

HIV infected individuals used SCID. The study result showed that a lower rate of

3.6% for GAD among HIV-positive outpatients in the USA.29

Heuvel et al reported using the MINI international neuropsychiatric interview

questionnaire, the prevalence rate of GAD among HIV-infected individuals in Zambia

was 13.3%. 30

Prevalence of alcohol use disorders (AUD).

In a recent study in Zambia, Connell et al assessed the prevalence of alcohol

dependence was assessed among TB and HIV-positive men and women making use

of the MINI. The study reported that the prevalence of alcohol dependence of 27.2%

among men was higher than for women, with a rate of 3.9%.31

Psychological distress among PLWH

Coyne et al investigated the level of psychological distress among people

living with HIV. The study revealed that high prevalence rate of clinically significant

distress is a cause for concern as it may harm the quality of life of HIV-positive

individuals.32
Fear and stigma associated with HIV testing

Nannozi et al conducted a qualitative study on fear of HIV positive results and

knowledge about HIV counseling and testing among couples attending HIV

counseling and testing center. The structured interview showed that fear of positive

HIV test results strongly as the most significant barrier to couple HIV counseling and

testing.33

Similarly, Annemarie et al conducted a qualitative study among the University

students to asses the fear of stigmatization as a barrier for HIV counseling and testing

through a focus group interview. Results showed that participants had a different level

of knowledge about HIV/AIDS and the main barriers for testing were fear of being

stigmatized and fear of knowing the HIV positive status.34

Wit et al evaluated the psychological barriers for HIV testing in high-income

countries. Results indicated that the fear of consequences of testing positive -mainly

worries related to discrimination and rejection - also hindered HIV testing. Finally,

individuals appear more likely to test for HIV when they perceive more benefits from

testing.35

The multi-country study understanding HIV related stigma and discrimination

revealed that people who believe it is important not to stigmatize PLHA do.

Individuals maintain correct and incorrect knowledge about the transmission of HIV

simultaneously, but even those who know that HIV is not transmitted through casual

contact continue to have doubts and behave as if it is. People expressed both

sympathetic and stigmatizing attitudes about PLHA.36

HIV testing and common mental disorders

Kagee et al investigated psychological distress, depression and anxiety

symptoms among persons undergoing for HIV test using the mean scores of 45.78

(SD=16.81) on the Hopkins Symptom Checklist, 12.44 (SD=13.00) on the Beck

Anxiety Inventory and 15.8 (SD=12.4) on the Beck Depression Inventory. Out of 485

persons, one-third of persons had depressive symptoms and clinically significant

distress was at least moderate and in some cases severe.37

Seema et al conducted a study among 150 HIV test seekers to assess the

anxiety, depression, and distress using the hospital anxiety depression scale. This

Study showed that repeat test seekers exhibited significant distress (AOR: 2.5; 95%

CI: 1.2–5.3; p = 0.017) and depression (AOR: 2.9; 95% CL: 1.4-6.1: p=0.004).

Education levels influenced the level anxiety (p = 0.033; 0.008). The repeat test seeker

who was HIV positive they had more anxious (p=0.035) and depressed (p=0.037).9

Ashraf et al concluded after a structured clinical interview with 485 HIV test

seekers, the prevalence of common mental disorders was 26 %. Common mental

disorders were major depressive disorder 14.2%, alcohol use disorder (19.8%),

generalized anxiety disorder (5.0%), posttraumatic stress disorder (4.9%), and also

suggested that integration of screening and referral improving HIV test seeker mental

health care.38

Mayston et al assessed the common mental disorders and cognitive morbidity

among people coming for HIV testing. The result showed that prevalence of common

mental disorder was 5.3%, hazardous alcohol use disorder 12.8% and around a one-

fourth of people scored below the educational norm on two cognitive tests of delayed

recall (22.8%) and verbal fluency (25.6%).39

 Landon et al assessed the relationship among common mental disorders and

HIV testing, HIV-related fears, perceived risk, and preventive behaviors, the study

result showed that any depressive disorder 4.9%, anxiety disorder 8.1%, posttraumatic

stress disorder 0.6%, agoraphobia 4.8%, panic disorder 0.8%, substance-related

disorders 5.8% and the perceived risk of HIV infection was significantly higher

among individuals with an anxiety disorder and those with a substance-related

disorder, and also revealed there were no associations between depression, anxiety,

and substance abuse disorders and appropriate forms of behavior change toward HIV

risk reduction.40

Baligh et al conducted a study on HIV Testing among Adults with Mental

Illness in the United States. Through the surveys from 21,785 respondents; 15 %

percent reported at least one mental illness. Of these, 2.6% had schizophrenia

spectrum disorder, 8.5% had bipolar disorder, and 88.9% had symptoms of depression

and/or anxiety. Overall, 36.9% of adults reported ever having had an HIV test.41

Perry et al assessed the severity of psychiatric symptoms after one year among

HIV testing individuals (328) by Hamilton Rating Scale for Depression, Beck

Depression Inventory, State-Trait Anxiety Inventory, and Brief Symptom Inventory.

The final result showed that mean scores on all measures of psychiatric symptoms

were lower at follow-up among both 106 HIV-positive and 222 HIV- negative adults.

One year after HIV testing, 121 (37%) of the 328 subjects had scores associated with

psychopathology. These elevated scores were not predicted by seropositive but by

initial psychopathological scores (N = 150), annual income less than +15,000 (N =

114), being female (N = 46), and history of injection drug use (N = 32) and

heterosexual risk factors (N = 60) as compared to males having sex with males (N =

236).42
 Chauhan et al assessed the psychiatric morbidity among asymptomatic

patients and compared them with seronegative control. The study concluded that

depression was found significantly higher in asymptomatic HIV seropositive patients

when compared with the seronegative control group.43

 CHAPTER III

METHODOLOGY

This chapter deals with the methodology adopted for this study to assess the

psychiatric morbidity among patients utilizing an ICTC facility of a tertiary care

hospital and its association selected socio- demographical variables. This chapter

deals with the research approach, research design setting, population, sample and

sampling technique, duration of the study, tool and technique, data collection

processes and plan for data analysis.

3.1 Research Approach

The approach used in the study was the quantitative approach.

3.2 Research design

A cross-sectional descriptive design was used to achieve the objectives of the

study.
 Research approach
Quantitative approach

Research design
Cross sectional descriptive survey design

Research setting
Integrated Counselling and Testing Center (ICTC), JIPMER.

Population
Patients utilizing the ICTC facility of JIPMER.

Sample size and technique

384 Patients utilizing ICTC facility of JIPMER& Convenience sampling technique.

Data collection
Assessment of socio-demographic data and M.I.N.I. plus neuro- interview questionnaires

Data analysis and interpretation

Findings and report

Figure 2: Schematic representation of the research design

3.3 Variables

a. Independent variables

 Socio-demographic variables

 Age, gender, education, marital status, occupation, and income

b. Outcome variables

 Psychiatric morbidity as assessed by MINI plus interview

questionnaires.

3.4 Research Setting

The study was conducted in JIPMER (Jawaharlal Institute of Postgraduate

Medical Education and Research), Puducherry. JIPMER is a tertiary care teaching

hospital with a bed strength of 2114 and has various specialty departments. One of the

departments is the Department of Microbiology. Under this Department, the regional

Integrated Counselling and Testing Center (ICTC) facility isdoing an excellent service

in South India. More than 150 individuals are utilizing the ICTC facility every day.

3.5 Population

Target population

The population selected for the study was patients who are utilizing the

ICTC facility of JIPMER.

Accessible population

o Patients who all are utilizing ICTC centre either voluntary or refered

from STD clinic and who consented to participate in this study..

3.6 Sample

The sample consisted of 384 patients utilizing ICTC facility care in JIPMER

and who fulfilled the inclusion criteria.

3.7 Sampling techniques

The sampling technique was non-probability purposive sampling

3.8 Sample size calculation

The sample size was estimated using the formula for estimating a single

proportion. The expected proportion of patients attending ICTC having psychiatric

morbidity is 50% and the sample size was estimated at a 5% level of significance and

5%absolute precision. The total sample size was 384 persons.

3.9 Sampling criteria for sample selection

Inclusion criteria

o Patients who all are utilizing ICTC centre either voluntary or refered

from STD clinic

o Aged above 18 years and both gender

Exclusion criteria

o Patients who had already diagnosed with some psychiatric illness.

o Patients already diagnosed with HIV /AIDS

3.10 Description of data collection instruments

3.10.1 Socio-demographic questionnaire

A questionnaire containing socio-demographic details was

administered to each study respondent. The socio-demographic data contained

in the questionnaire included information on gender, age, occupation, marital

status, income, level of education and family history of psychiatric illness.

3.10.2. M.I.N.I

The M.I.N.I. is a short structured diagnostic interview developed

jointly by psychiatrists in Europe and America to diagnose psychiatric

disorders according to ICD-10 and DSM-IV. The short structured interview

fills the gaps between short screening instruments and detailed diagnostic

assessments. It is easy to administer and takes only 15 minutes if the subject is

‘well’ and around 40 minutes if he/she is ‘psychologically unwell’. In this

study M.I.N.I. 7.0 current version used. The MINI international

neuropsychiatric interview questionnaire is divided into 16 modules identified

by the letters A-P, each corresponding to a diagnostic category. At the

beginning of each diagnostic module, screening questions corresponding to the

main criteria of the disorder were asked. The remaining questions of each

diagnostic module were asked based on the positivity of the screener

questions. If the screener was negative, the researcher automatically turned

into the screening questions corresponding to the next module for further

interviewing. Only symptoms occurring during the time frame indicated were

considered in the scoring of the responses. The rating for each question was

done at the right hand- side of each question by entering the codes as Yes or
No.
3.12 Content Validity

The tool used in the study is a standardized tool that has been used in many

previous studies in the Indian and Western countries. The tool was translated into

Tamil and its validity and reliability were established. A study conducted by Sheehan,

et.al on development and validity assessment, shows that tool has good validity for

assessing the psychiatric disorder.44

3.13 Reliability

The M.I.N.I. was designed as a brief structured interview for the major

psychiatric disorders in DSM-5 and ICD-10. Validation and reliability studies have

been done comparing the M.I.N.I. to the SCID-P for DSM-III-R and the CIDI (a

structured interview developed by the World Health Organization). The results of

these studies showed that the M.I.N.I. has similar reliability and validity properties,

but can be administered in a much shorter period (mean 18.7 ± 11.6 minutes, median

15 minutes) than the above-referenced instruments. Clinicians can use it, after a brief

training session. This tool has been previously used successfully in other studies

carried out in the general population in our Institution.45

3.14 Ethical considerations

Permission was obtained from the Nursing Research Monitoring Committee

and Institute Ethics Committee (IEC) before starting the study. The investigator

introduced himself to the study participants and explained the study in their local

language and informed consent was obtained. Privacy was provided during the data

collection and confidentiality was maintained throughout the study. The participants

had the freedom to withdraw from the study without assigning any reason.
3.15 Pilot study

A Pilot study was conducted to check the feasibility of the tools used in the

present study. Socio-demographic proforma and data collection scales were

administered to 10 patients utilizing the ICTC facility of, JIPMER. The tools were

found to be feasible.

3.16 Data collection procedure

Participants were recruited at the time of attending the ICTC for pre-test

counseling and testing, as ‘walk-in’ clients (self-referrals, or primary care physician

referrals) or those formally referred for testing by doctors from other general medical

departments. Individuals whose purpose for attending the ICTC was to undertake pre-

test counseling and HIV blood tests were eligible to take part. Other inclusion criteria

were fluency in Tamil or English and a lower age limit of 18 years. Upon entering the

ICTC, attendees were approached by personally and informed about the study. If they

were interested in participating in the study, written informed consent was obtained

from participants and privacy was provided. After baseline demographical data

collection, a structured clinical interview held on using M.I.N.I. International

neuropsychiatric interview scale to identifying the prevalence of psychiatric

morbidity. The study was approved by the Nursing Research Monitoring Committee

and the Institutional Ethical Committee. Data was collected between the periods of

September 2019 to October 2019.

3.17 Plan for Data Analysis

The collected data was organized and scored after which, the analysis was

done with SPSS version 23. The distribution of categorical variables such as gender,
socio-
demographical characteristics were expressed as frequency and percentages. The

continuous variables such as age etc. were expressed as mean with standard deviation

or median with range. The comparison of the psychiatric morbidity between different

subgroups was carried out by using chi-square test and Fisher's exact test. All

statistical analysis was carried out at 5% level of significance and P < 0.05 was

considered as statistically significant.

 CHAPTER IV

ANALYSIS AND FINDINGS

This chapter deals with the analysis and interpretation of the data collected.

Both descriptive and inferential statistics were used to analyze the data. The findings

of the study were organized and presented in the following sections.

Section I: Socio-demographic profile of study participants

Section II: Psychiatric morbidity among patients utilizing the ICTC facility of

tertiary care hospital.

Section III: Psychiatric morbidity and multiple psychiatric comorbidities in

patients utilizing the ICTC facility of JIPMER hospital.

Section IV: Association of Psychiatric Morbidity with selected demographic

variables.
 SECTION 1: DESCRIPTION OF SAMPLE CHARACTERISTICS

Table 1: Socio-demographic profile of study participants

(N=384)

Variables Categories Frequency (n)

Percentage (%)
Male 254 (66.1 )
Gender Female 130 (33.9 )
Single 89 (23.2)
Married 287 (74.7 )
Divorced 01 (0.3)
Marital status Widowed 07 (1.8%)

Formal education 246 (64.1)

Education status Non-formal education 138 (35.9)

Employed 275 (71.6)

Employed status
Un-employed 109 (28.4)
Skilled 114 (29.7)
Occupation
Unskilled 235 (61.2)

Student 35 (9.1)

< 3000 202 (52.6)

Income > 3000 182 (47.4)

Yes 13 (3.4)
Family history of psychiatric
No 371 (96.6)
illness
 The distribution of the socio-demographic variables among patients attending

the Integrated Counselling and Testing Center (ICTC) facility of a tertiary care

hospital in south India is shown in table 1. The majority of the subjects 254 (66.1%)

were males,

13 (33.9%) were females. Regarding educational status 246 (64.1%) had formal

education. Coming to marital status most of them 287 (74.7%) was married.

Regarding the employment status 275 (71.6%) subjects were employed but 235

(61.2%) subjects were unskilled workers. A family history of psychiatric disorder

revealed that 371 (96.6%) participants had no family history of any psychiatric

disorders; 202 (52.6%) of the participant’s income was less than 3000 rupees.
 SECTION II: PSYCHIATRIC MORBIDITY AMONG PATIENTS

ATTENDING THE ICTC FACILITY OF A TERTIARY CARE HOSPITAL

(N-384)

Psychiatric Morbidity 24%

No Psychiatric Morbidity 76%

Psychiatric Morbidity No Psychiatric Morbidity

Fig 3: Distribution of Psychiatric morbidity among patients attending the ICTC

facility of a tertiary care hospital:

Psychiatric morbidity among patients attending the ICTC facility is depicted in

Figure 2. Out of 384 participants, 91 (24%) subjects were having psychiatric illness

and 293 (76%) participants did not have any psychiatric illness.
 SECTION III: PSYCHIATRIC CO-MORBIDITIES AMONG PATIENTS

ATTENDING THE INTEGRATED COUNSELLING AND TESTING

CENTER (ICTC) FACILITY OF A TERTIARY CARE HOSPITAL

(N-384)

Psychiatric co-morbidity Frequency (n) Percentage

(%)

Major depressive disorder 64 16.67

Suicidality 31 8.0

Manic Episode 2 0.5

Panic disorder 26 6.8

Social anxiety disorder 7 1.8

Obsessive compulsive disorder (OCD) 1 0.3

Posttraumatic stress disorder (PTSD) 12 3.0

Alcohol use disorder (ADS) 15 3.9

Generalized anxiety disorder 1 0.3

Organic disorder 4 1.0

Psychiatric co-morbidities among patients attending the Integrated

Counselling and Testing Center (ICTC) facility has been listed in Table 2. Out of 384

patients, 64 (16.7%) had major depressive disorder, suicidality were presented in 31

(8.0 %) and panic disorder 26 (6.8%); ADS 15 (3.9%) & 1 (0.3%) was found in OCD,

Generalized Anxiety disorder.

 Psychiatric Co morbidity
80 70

70 60
60
50
50
40
40
30
30
20 20

10 10

0 0
Single co-morbidityMultiple co-morbidity

Frequency Percentage %

Fig 4: Multiple psychiatric comorbidities in patients attending the ICTC facility

of JIPMER hospital-(N-384)

Distribution of single and multiple co-morbidity of patients attending the

ICTC facility is shown in the bar diagram. Out of 384 patients, the distribution of

single psychiatric morbidity of 62 (68%) and rest had at least two psychiatric co-

morbidity (Depression with suicidality, ADS with Depression)

 SECTION IV: ASSOCIATION OF PSYCHIATRIC MORBIDITY

WITH SELECTED DEMOGRAPHIC VARIABLES

Table 3: Association of Psychiatric Morbidity with selected demographic

variables
(N-384)

Psychiatric morbidity among patients attending ICTC facility

Demographic Variables Psychiatric No psychiatric
parameters morbidity morbidity X2 p-value
N % N %
Male 58 22.8 196 77.2
Gender Female 33 25.4 97 74.6 0.309
0.578

Single 19 21.3 70 78.7

Marital Married 70 24.4 217 75.6

Status 0.750 0.861

Divorced 0 0 1 100
Widowed 2 28.6 5 71.4
Education Formal 57 23.2 189 76.8
education
0.105 0.419
Non-formal 34 24.6 104 75.4
education
Employed Yes 67 24.4 208 75.6
0.237 0.626
No 24 22.0 85 78.0
Skilled 33 28.9 81 71.1 4.178 0.098
Occupation Unskilled 54 23.0 181 77.0
Student 4 11.4 31 88,6
Monthly Less than 3000 44 21.8 158 78.2
0.865 0.352
Income More than 3000 47 25.8 135 74.2
Family history Yes 4 30.8 9 69.2
of psychiatric No 87 23.5 284 76.5
0.372 0.542
illness
 The association between selected socio-demographical variables and patients

attending the ICTC facility is shown in Table 3. Results of the above table showed

that there was no significant association between the selected socio-demographic

variables (gender, marital status, education, employed status, occupation, monthly

income, family history of psychiatric illness) and psychiatric morbidity among

patients attending the ICTC facility of JIPMER, hospital.

 CHAPTER V

DISCUSSION

The study assessed the prevalence of psychiatric morbidity among patients

utilizing the ICTC facility of tertiary care hospital, South India.

Demographic characteristics of the study participants

In this study, the mean age of subjects was 40 years and ranged between 18-60

years. Similarly, a study conducted by Ashraf et al also founded that HIV testing

subjects mean age was 39 years.38 One study reported that HIV test seekers mean age

was 28.7 years and followed by a Kenyan (Pauline et al) study which shows that

patients attending the comprehensive care clinic mean age was 37.3 years.9, 21
The

national mental health survey reported that the age group between 40 to 49 years was

predominantly affected by a psychiatric disorder.5

We found that 91(24 %) of our sample of patients attending ICTC facility met

the criteria for at least one of the mental disorders that we assessed, with the non-

significant selected demographic difference in prevalence rates. The most common

psychiatric morbidity found among the samples was major depressive disorder 64

(16.4%), followed by panic disorder 26(6.8%), suicidality 31(8.0%), alcohol use

disorder 15 (3.9%), posttraumatic stress disorder 12 (3.0%). In this study the observed

prevalence rate of psychiatric morbidity among the sample was higher than expected

given what is known about the prevalence of psychiatric morbidity among the general

population of India. For example, a national mental health survey study investigating

the prevalence of the psychiatric condition using MINI International Neuropsychiatric

Interview among the general population found that the prevalence of current mental
morbidity was 10.6%. Alcohol use disorder was 4.7%, while rates for Depressive

Disorder, PTSD and Phobic anxiety disorders were 2.7%, 0.2%, and 1.9%

respectively.5

After participating in the MINI international neuropsychiatric interview, all of

our participants received an HIV test. In the study reports, in a minimum number of

cases, psychiatric disorders existed before receipt of the HIV test.

Psychological literature has assumed that HIV positive result may cause the

infected person to become more psychologically disordered and that psychiatric or

psychological treatment is indicated following receipt of HIV positive test result. 47, 48

Indeed, psychiatric conditions such as major depression and generalized anxiety

disorder appear to be common among persons living with HIV.49, 50

In a study among South African HIV infected persons, 34.9% had major

depression while 21.5% had dysthymic disorder as assessed by the MINI International

Psychiatric Interview.51 In a study conducted with 465 patients enrolled in HIV care

and treatment services in a major South African city ( mean age of the sample was 33

years, 75% were female, 74.4% were unemployed), the prevalence of depression as

assessed by the MINI was 14%.47 Indian study also showed that Psychiatric morbidity

is higher in asymptomatic HIV patients when compared to HIV seronegative controls.

This study further revealed that psychiatric morbidity was 24 % in patients

irrespective of HIV status.52 The above studies recruited samples after they had

diagnosed with HIV and thus it was indeterminable whether these mental health

problems were precipitated due to HIV diagnosis or if they were already evident

before receiving an HIV positive test result. Our study helped to evaluate the

relationship between HIV testing and psychological disorders.

 The study among primary health care patients who received an HIV test

depression was a validation of PHQ against the MINI as a gold standard conducted by

cholera et al. the study showed that depression was assessed by PHQ only 1% had

very severe depression, 5% had severe depression, 18% had moderate depression and

32% of the study sample reported no depression. On the MINI 11.8% met the criteria

for a current major depressive episode.53 In this study, the results showed that MINI

international neuropsychiatric interview 13.8% (53) had a major depressive episode,

indicating a non-trivial rate of mood disturbance among this sample.

We also found that none of them had psychiatric morbidity such as

Agoraphobia, Anorexia nervosa, Bulimia nervosa, Anti-social personality disorder. A

similar study showed that patients with HIV infection had a lower prevalence rate of

generalized anxiety disorder, alcohol dependence syndrome, and post-traumatic stress

disorder.

The second objective of the study was to find out the association between the

psychiatric morbidity and the selected socio-demographic variable of patients

attending the ICTC facility:

This study results showed that there was no association between selected

socio- demographical variables and psychiatric morbidity among patients utilizing the

ICTC center, similarly, Seema et al also reported that there was no association

between depression and anxiety among HIV test seeker age, marital status,

occupation, domicile, family type, HIV infection, and behavioral history.9

Followed by a South African study Ashraf et al reported that non-significant

differences between males and females in the prevalence estimates among the

disorders assessed, except generalized anxiety disorder.35 Kenyan study showed that
there was
no statistically significant association between the overall psychiatric morbidity and

social determinants such as gender, marital status, level of education, and occupation

or employment.46

Psychiatric comorbidities

Out of 91 patients with psychiatric illnesses 62 (68.1%) were diagnosed with

single psychiatric morbidity and the remaining had at least two psychiatric

comorbidities. The occurrence of comorbid psychiatric disorders is common in both

the general population and HIV positive person. Patients attending HIV primary care

clinic in South Africa were found to have a high prevalence of distress; the authors

identified 52% of their participants as having significant depression and 65.6% had a

history of a substance use disorder.54

Given our finding of non-trivial rates of mental disorders among this sample, it

may be argued that patients attending the ICTC facility should be the focus of targeted

psychological interventions. Yet, such an approach is potentially controversial as it

was not clear that screening instruments were able to accurately identify individuals

who met the diagnostic criteria for mental disorders under routine care. 55 Given the

logistical, financial and capacity limitations in the Indian public health system, it may

be difficult to integrate routine mental health screening procedures in HIV testing.

Hence, ensuring that staff working in HIV testing sites can recognize individuals in

need of a psychiatric referral and are informed about appropriate psychiatric referral

pathways.
Limitations of the study

Non-probability sampling technique and onetime assessment were done with

no follow-up.

Strength of the study:

Despite these limitations, we believe our study demonstrates specific

strengths. First, we used a gold standard method of making determinations of

caseness, namely the MINI International Neuropsychiatric Interview, which in the

context of HIV and mental health research, is rare. Second, participants were before

rather than following HIV testing, which also unique in terms of the existing body of

research.
 CHAPTER VI

SUMMARY, CONCLUSION, IMPLICATIONS

AND RECOMMENDATIONS

This chapter deals with the summary, conclusion, implications, and

recommendations for future research.

6.1 Summary

The purpose of the present study was to assess the psychiatric morbidity in

patients attending the ICTC center, and its association with the selected socio-

demographical variable. A cross-sectional descriptive study was used to achieve the

objectives of the study.

The conceptual framework of the current research was based on the Betty

Neuman systems model. The instruments used for the data collection consists of the

socio-demographic profile, M.I.N.I neuro international psychiatric interview.

Participants were selected after obtaining informed consent. A total number of 384

participants from the patients attending the ICTC facilities were selected and

interviewed. Based on the interview, subjects were considered psychiatric morbidity.

Descriptive statistics (frequencies, percentages, and means) and inferential statistics

(Chi-square test and Fisher's exact test) were used to analyze the data. The findings

and descriptions were presented in the form of tables and figures.

Major findings of the study

Out of 384 samples, attending the ICTC facility, 91 (24%) subjects had

psychiatric morbidity, the distribution remained single psychiatric morbidity of 62

(68%) and rest had at least two psychiatric co-morbidity (depression with suicidal

behavior, ADS with depression, anxiety and substance use disorder), it also revealed

that no significant association was found between the selected socio-demographical

variables and the psychiatric morbidity among patients utilizing ICTC center.

Demographic characteristics

The subjects were selected based on the age ranging from 18 to 60 years. All

384 participants were between the given age group, and the average mean age was

patients with psychiatric morbidity 40.74 years and the remaining people had an

average mean age was 37.98 years. The prevalence of psychiatric morbidity among

male and female was 58 (22.8%), 33 (25.4%), concerning educational qualification,

the majority of subjects 44(78.5%) had formal education

287 (74.7%) of the subjects were married and 275 (71.6%) had employed.

Concerning the monthly income of the individual, the majority had a monthly income

of more than 3000 rupees.

6.2 Conclusion

About one fifth had psychiatric morbidity among patients attending the ICTC

facility. Out of one-fifth of psychiatric morbidity, 30% (29) had multiple co-

morbidity.

The findings of the study are supported by the literature and have strong support

from other studies conducted in India and worldwide. The same methodology of
assessment
is widely supported by many studies and thus can be generalizable to common men in

community settings. The present study also suggests that it could be useful to

introduce screening psychiatric morbidity among patients attending the ICTC facility.

Early screening of psychiatric morbidity among patients utilizing the ICTC center

may help identify and treat the illness at an early stage. The screening tool used in this

study was found to be useful in identifying the psychiatric symptoms and easy to

administer with minimum training.

6.3 Implications for Nursing

Practice Nursing education:

In the field of nursing education, nurses should be prepared to do a screening

of alcoholic patients for cognitive impairment, motivational state, and violence. The

nurses should be taught to give health education regarding the ill effects of HIV

infection and motivational interventions to a public screening of HIV infection. In the

community, students should be trained to identify psychological distress, the stigma

associated with HIV infection and screening of HIV in rural areas and provide health

education regarding the HIV infection and psychological problems for reducing the

stigma about HIV screening and HIV infection.

Nursing service:

Nurses can easily identify their risk behavior for the client’s depression,

suicidal behavior, anxiety, unhealthy substance use behaviors by various screening

methods and referral to psychiatric counseling and treatment units. Ongoing health

teaching and assessment of health risk levels can help patients to retrieve their

normal life.
Community health nurses also can screen the psychiatric disorder from HIV infected

people and refer to psychiatric care that may improve the patient's quality of life.

Nursing administration

Nursing administrators at a managerial level can arrange staff development

programs for improving the knowledge level of nurses in the screening of HIV/AIDS

for patients with psychiatric disorders and screening of psychiatric disorders in

patients living with HIV infection. They should be given health education regarding

the prevention of sexually transmitted diseases.

Nursing research

Nurse researchers can undertake a variety of researches in the area of the

prevalence of HIV infection in patients with a psychiatric disorder. They can screen

psychiatric patients earlier which will improve the quality of care and prevention of

sexually transmitted diseases.

6.4 Recommendations for further research

Based on the findings of the present study, it is recommended that

1. A similar study can be carried out with larger sample size.

2. A community-based study can be conducted on the prevalence of psychiatric

morbidity among patients with HIV infection.

3. A comparative study can be conducted among patients with risk behavior and

patients living with HIV infection

4. A similar study can be conducted in the outpatient Department of Psychiatric.

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26. Sulyman D, Abiodun O, Yussuf AD. Psychiatric disorders among people
living with HIV/AIDS attending outpatient clinics at the University of Ilorin
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27. Bathia MS & Munjal S. Prevalence of depression in people living with

HIV/AIDS undergoing ART and factors associate with it. J Clin Diagn Res.
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28. Wittchen H, Zhao S, Kessler RC, & Eaton WW. DSM-III-R generalized
anxiety disorder in the National Comorbidity Survey. Archives of General
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29. Berger JA, Cuevas CA, BradySM, Trezza G, Richardson MA & Keane TM.
Major depression in patients with HIV/AIDS and substance abuse. AIDS
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30. Van den Heuvel L, Chishinga N, Kinyanda E, Weiss H, Patel V, Ayles H.

Frequency and correlates of anxiety and mood disorders among TB- and HIV
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31. Connell R Chishinga N, Kinyanda E, Patel V, Ayles H, Weiss HA, Seedat S.

Prevalence and correlates of alcohol dependence disorder among TB and HIV
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32. Coyne JC, Palmer SC, Shapiro PJ, Thompson R & DeMichele A. Distress,
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121-128.
33. Nannozi V et al. fear of an HIV positive test result: an exploration of low
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39. Mayston R, Patel V, Abas M, Korgaonkar P, Paranjape R, Rodrigues &

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 APPENDIX I

RESEARCH INSTRUMENT (ENGLISH & TAMIL)

SOCIO DEMOGRAPHIC PERFORMA

QUESTIONNAIRE Study No.

Date

1) Gender

a). Male b). Female

2) Age in years: ……………………..

3) Marital status

a). Single b). Married c). Separated

d). Divorced e). Widowed

4) Level of education:

a). Formal education b). Non formal education

5) Are you employed?

a). Yes b). No

6) Occupation:

a). Skilled b). Unskilled c). Student

8) Monthly income

a). Less than 3000 b). More than 3000

9) Family history of psychiatric illness

a) Yes b) No

I
 r%f kf;fs; njhif fhuzpfs;

Njjp: ………….

1. Ma;T vz; :…………….

2. ghypdk;
(m) Mz; (M) ngz;

3. taJ (tULq;fspy;):…………………..

4. jpUkz epiy
(m) jpUkzkhfhjth; (M) jpUkzkhdth;

(,) jpUkzkhfp gphpe;J tho;gth; (<) tpthfuj;jhdth;

(c) tpjit

5. fytp epiy
(m) Kiwahd gs;sp top fy;tp fw;wth; (M) gpwtop fy;tp fw;wth;

6. ePq;fs; Ntiy nry;gth;uh?

(m) Mk; (M) ,y;iy

7. njhopy;
(m) Kiwahd (m) Njh;r;rp ngw;w njhopy; (M) rhjhuzkhd njhopy;

(,) fy;tpgapy;gth;

8. khj tUkhzk;
(m) 3000 mjpfk; (M) 3000 Fiwthd
XL
L
 APPENDIX II
NURSING RESEARCH MONITORING COMMITTEE CERTIFICATE
APPENDIX III
 APPENDIX IV
PLAGIARISM VERIFICATION CERTIFICATE
 APPENDIX V
PERMISSION LETTER FOR RESEARCH TOOL
 APPENDIX VI
CONSENTFORMS (ENGLISH/ TAMIL)

PATIENT / PARTICIPANT INFORMATION SHEET

INFORMATION FOR PARTICIPANTS OF THE STUDY

Dear participants,

I am going to conduct a study on ‘A comparative study on psychiatric morbidity among

patients utilizing the Integrated Counselling and Testing Center (ICTC) facility and

general population of tertiary care hospital in South India and those who do not’. The

details of the study are given below;

Title of the project

Psychiatric morbidity among patients attending the Integrated Counselling and Testing

Center (ICTC) facility of a tertiary care hospital in south India

Name of the Student Researcher/Guide/Co-Guides

Student Researcher:
Srinivasan C
M.Sc. Psychiatric Nursing I year,
Mob No: 9944910092
Email ID: [email protected]
Guide:

Dr. Padamavathi Nagarajan,

Assistant Professor, JIPMER.

Mob no: 9487984637

Email ID: [email protected]
Co-guide:

Dr. Rakesh Singh, Dr.Vikas Menon

Additional Professor, Additional Professor,

Department of Department of Psychiatry,

Microbiology, JIPMER, JIPMER,

Mob. No: 9751173425 Mob no: 91-9894410296

Email ID: [email protected] Email ID: [email protected]

Purpose of this project/study

To identify the prevalence of mental illness problems among patients attending

the ICTC facility of JIPMER hospital and referring the psychiatric clinic for further
management.

Procedure/methods of the study

You have been enrolled in this study since you have came to ICTC for undergoing
some test. Here, you will be counselled regarding the purpose of the test. I will be asking
you some details such as age, education status, occupation and income, I will be
assessing you whether you are having any psychological/mental disturbance. If you
found to have some symptome related to any unusual evidence, you will be referred to
the psychiatric clinic for further management.

Expected duration of the subject participation

One-time interview for each patient. It may take 30-45 minutes for you to
respond.
The benefits to be expected from the research to the participant or to others and the
post-trial responsibilities of the investigator.

I will be asked questions regarding the symptoms experienced in certain

psychological /mental disturbance in order to found your having any symptoms related to
mental illness. You will be referred to the psychiatric clinic for further management.

Any risks expected from the study to the participant

Since the study involves only interview and question. You can feel free to
express you concerns and please let us know if you feel uncomfortable.

Maintenance of confidentiality of records.

We ensure that the personal information obtained from you will remain
confidential throughout the study period and up to three years of publication. If the
results are published in a journal, your name and other details will not be disclosed. The
study records will be kept confidential for a period of three years.

Provision of free treatment for research related injury

Since this is a descriptive study, we do not except any injury to you. But in the
event of foreseen or unforeseen research related injury, free treatment will be provided as
per JIPMER guidelines.

Reimbursement for participating in the study

No reimbursement will be given in this study. Since, you came for your treatment
purpose only.

Compensation to the participants for foreseeable risks and unforeseeable risks

related to research study leading to disability or death.

You are eligible for compensation in the event of any unforeseen study related
risk or injury as per JIPMER guidelines
Freedom to withdraw from the study at any time during the study period without
the loss of benefits that the participant would otherwise be entitled

You will have freedom to withdraw from the study at any time during the study
period without assigning any reason and without loss of benefits that you would
otherwise be entitled. Withdrawal will not affect standard medical care provided from
JIPMER

Possible current and future uses of the biological material to be generated from the
research and if the material is likely to be used for secondary purposes or would be
shared with others, this should be mentioned.

No. Biological materials will not be collected in this study

Possible current and future uses of the data to be generated from the research and if
the data is likely to be used for secondary purposes or would be shared with others,
this should be mentioned.

Yes. Data to be generated and the result will be used as secondary data by future
researchers for their study without disclosure of your identity.

Thank you taking time to read this information sheet. If you have any study
related queries you contact.

Address and mobile number of the Student Researcher and Guide:

Student Researcher:
Srinivasan C
M.Sc. Psychiatric Nursing I year,
Mob No: 9944910092
Email ID: [email protected]
Guide:

Dr. Padamavathi Nagarajan,

Assistant Professor, JIPMER.

Mob no: 9487984637

Email ID: [email protected]

Signature of the investigator: Signature of the participant:

Date:

Place:

XC
 INFORMED CONSENT DOCUMENT (ICD) PART-2

INFORMED CONSENT FORM

Title of the project:

Psychiatric morbidity among patients attending the Integrated Counselling and

Testing Center (ICTC) facility of a tertiary care hospital in south India

Participant’s name:
Address:

The details of the study have been provided to me in writing and explained to me in
my own language. I confirm that I have understood the above study and had the
opportunity to ask questions. I confirm that I have understood about the compensation
and the risks and benefits involved in this research. I understand that my participation in
the study is voluntary and that I am free to withdraw at any time without giving any
reason, and without my routine medical care in this hospital being affected. I understand
that confidentiality of my identity will be maintained during the research period, after its
completion as well as during publication of the results. Only investigator, ethics
committee, institutional or regulatory authorities may have access to my information
when required.
I have been given a copy of information sheet giving details of the study. I volunteer to
participate in the above-mentioned study.
(I also consent/ do not consent to use of my stored biological samples or related data for
future scientific purposes, if applicable)

(I also consent / do not consent to be contacted over telephone for study purposes/
knowing the results – if applicable)

Name and Signature/thumb impression of the participant: Date:

Signature of the witness with date: Date:

Name and address of the witness for illiterate participants:

Signature of the investigator with date: Date:
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kw;Wk; kdNehAw;w jd;ikia mwpa rpy tiuaWf;fg;gL;L Nfs;tpfs;
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xU Kiw kL;LNk jfty; Nrfhpf;fg;gLk;. ,e;j Ma;tpd; gq;Fnfhs;s
vjph;ghh;f;fg;gLk; fhy msT 30-45 epkpLq;fs;.

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mwpFwpfs; fz;Lwpag;gLkhapd;> cq;fspd; eyd;fUjp ePq;fs; jFe;j
MNyhrid ngw kdey gphptpw;F ghpe;Jiuf;fg;gLtPh;fs;.
7. Ma;tpy; gq;F ngWgth;fSf;F Ma;tpdhy; vjph;ghh;f;fg;gLk; Mgj;Jfs; :
,e;j Ma;thdJ rpy tiuaWf;fg;gL;L tpdhf;fs; %ykhf kL;LNk jfty;
Nrfhpf;fg;gLk;. ,Ug;gpDk; cq;fSf;F VNjDk; mnrsfhpaq;fs; Vw;gL;Lhy;
ePq;fs; vd;dpLk; njhptpf;fyhk;.

8. Ma;T Fwpg;NgLfspd; ,ufrpak; guhkhpj;jy; :

,e;j Ma;tpy; gq;Nfw;gth;fspLk; ,Ue;J ngwg;gL;L jdpg;gL;L
jfty;fs; Ma;Tfhyk; KOtJk; ,ufrpakhf ,Uf;Fk;. vd;W Ma;thsh; cWjp
nra;fpwhh;> NkYk; Ma;tpd; KbTfis gj;jphpf;ifapy; ntspapL;LhYk;
ngah; kw;Wk; jdpg;gL;L tptuq;fs; ntspapLg;gLhJ. Ma;tpd; gjpTfs; 3
tULfhyj;jpw;F guhkhpf;fg;gLk;.

9. Ma;tpd; njhLh;GiLa fhaj;jpw;F ,ytr rpfpr;ir gw;wp :

Ma;tpy; ve;j fhaKk; vjph;ghh;f;fg;gLtpy;iy. Mdhy;
vjph;ghuhtifapy; Muha;r;rp njhLh;ghf fhak; Vw;gL;Lhy; [pg;khpd;
topKiwfspd;gb ,ytr rpfpr;ir toq;fg;gLk;.

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,e;j Ma;tpy; ePq;fs; gq;Nfw;gjw;F ve;j rd;khdKk; toq;fg;gLhJ.

11. Ma;tpdhy; gq;F ngWgtUf;F njhpe;Njh my;yJ njhpahkNyh Vw;gLk;

Cdk;my;yJ ,wg;gpw;F toq;fg;gLk; ,og;gPL :
,e;j Ma;tpy; gq;Nfw;gjhy; Mgj;JfNsh fhaq;fNsh vw;gLhJ. vjph;ghh;j;j
kw;Wk; vjph;ghuhj Ma;T njhLh;ghd Mgj;J my;yJ fhaq;fNsh
Vw;gL;Lhy;> [pg;khpd; topfhL;Ljypd;gb ,og;gPL toq;fg;gLk;.
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ePq;fs; cq;fs; RatpUg;gjpd; NghpNyNa ,e;j Ma;tpy; gq;Fnfhs;fpwPh;fs;.
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toq;fg;gLk; jukhd kUj;Jt guhkhpg;gpy; ve;j ghjpg;Gk; ,Uf;fhJ.
13. Ma;tpd; %yk; ngwg;gL;L caphpay; nghUs;fs; kw;Wk; Muha;r;rp
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nghUis kw;w gad;ghL;bw;F cgNahfg;gLj;Jjy; my;yJ kw;wth;fSLd;
gfph;e;Jnfhs;Sjy;>
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Ma;T Nkw;nfhs;gth; topfhL;bapd; ngah;

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Njjp: Muha;rpahshpd; ifnahg;gk;

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kdNeha; ghjpg;G jd;ikia fz;Lwpjy; gw;wpa Ma;T”

gq;;Nfw;gtupd; ngau;: Kftup:

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gq;fspg;G vdJ KO tpUg;gj;jpdhy; kL;LNk vd;Wk; ahnjhU fhuzKkpd;wp
ve;j Neuj;jpYk; ,e;j Ma;tpy; ,Ue;J tpyfpf;nfhs;s KO Rje;jpuKs;sJ
vd;Wk; Gupe;J nfhz;Ls;Nsd;. mt;thW tpyfpf;nfhs;tjhy; vdf;F
mspf;fg;gLk; kUj;Jt Nritfs;ghjpf;fg;gLhJ vd;gijAk;> tpupthf Gupe;J
nfhz;NLd;. ,e;j Ma;tpy; fpiLf;Fk; KbTfis mwptpay; Nehf;fj;jpy;
gad;gLj;Jk; gL;rj;jpy; vdf;F ML;Nrhgid
,y;iy. ,e;j Ma;it gw;wpa KOjfty; gbtk; vdf;F
toq;fg;gL;Ls;sJ. Ma;tpdhy; Vw;gLk; rpf;fy;fs; kw;Wk; gyd;fs; vdf;F
tpsf;fg;gL;LJ. ,e;j Ma;tpy;gq;Fngw ehd; KO xg;Gjy; nfhLf;fpd;Nwd;.

gq;Nfw;ghsh; ifnahg;gk; : Njjp

rhL;rpahsupd; ifnahg;gk;: Njjp:

rhL;rpahsupd; ngau; kw;Wk; Kftup:

Ma;thsupd; ifnahg;gk; : Njjp :