Introduction
Psychological distress is defined as a state of emotional suffering characterized by low mood, loss of interest, biological dysfunctions, feeling of helplessness, losing hope and anxiety, the construct is also viewed as a strong indicator for major or minor psychiatric disorders.(1-6) The prevalence of psychological distress varies across population. For example it is reported between 5% to 27% among general populations, 15% to 20% among workers from Africa and Europe, 27% among tertiary students of Australia, 31% among rural Australian communities, 28% and 19% among the low income and non-low income groups of Canada respectively and 54% and 66% respectively among native and immigrant patients in Dutch.(7-12) The severity of psychological distress is found to be associated with many factors, as those who have an increased risk for any serious illness, serving as care taker of any physically or mentally ill person, migration, adverse socio economic conditions, stressful social and family environment, life events, schooling and academic stress, working conditions and so on.(8,10,12-20)
The psychological distress and various physical and mental health problems are found to have a bi-directional relationship. Psychological distress is a risk for many physical and psychological disorders and at the same time it can be precipitated by physical and psychological problems.(21-26) Previous studies reported that psychological distress can trigger various psychiatric disorders, behavioural problems and substance abuse problems in individuals.(27-29) It is important in the context that often there is a significant delay in seeking help by individuals around the globe for all kind of mental illnesses and in such a way a significant portion of individuals who need treatment and support remain untreated and happened to live with their difficulties for a long time or even life time.(30) A proper strategy is needed to screen and identify those individuals who are in need of support and to motivate them to avail and accept supportive services.
The mental health problems and psychological distress are more prevalent among the relatives and care takers of mentally ill persons. A number of reasons have been attributed for this, such as an increased family burden, perceived stigma, disturbances due to active psychopathology of the patient and other adverse socio economic factors. The level of psychological distress is found to be associated with untreated mental illness among the relatives’ of individuals with mental disorders.(31-41) The relatives of the individual with mental illness may not approach for treatment because of many reasons. In this context the brief screening instruments can be used for assessment to rule out the presence of a mental illness and would guide the authorities to decide future plan of management in face of positive findings. The screening instruments of psychological distress like Kessler Psychological Distress Scale- version 6 and 10 are found to have good sensitivity and specificity to serious mental illnesses. A higher score in such instruments indicates a high probability of serious mental illnesses.(42)
Jharkhand is one among the least developed states in India with a lower literacy rate than the national average, poor health status and very poor utilization rates of health infrastructure. The state is significantly affected by naxalite movements and the extremist movements raise a big challenge for the government to bring growth oriented changes and developments in the area. Many often government officials and health workers perceive it to be unsafe while working in these areas. The mental health scenario of Jharkhand has not been explored properly so far because of such issues. Although there are limited facilities available they all are concentrated to the major cities and those who are living far away from the city remain unaware or unable to reach to the centres.(43-46) There are very few studies conducted from India to assess the prevalence of psychological distress among general population and also among the relatives with mentally ill people and no such study are found from Jharkhand. In this context a study about the prevalence of psychological distress among the individuals who never approached for professional help and increased risk of psychological distress for the individual living with a mentally ill person would be relevant. This study expected to give inputs to the policy makers and mental health researchers to plan future strategies and more systematic researches in future.
Methodology
The present study was a community based cross sectional study conducted in Hazaribag district of Jharkhand state in India, during the time period of July 2014 to February 2016. The study conducted by the 2014-2016 batch of MA Social Work students and faculties of Dr. Guislain Svastha Education Trust, Ranchi, India which is established by Fracarita International with the academic support of Tata Institute of Social Sciences, Mumbai, India. A total sample of 480 individuals consisted of 240 individuals living with a mentally ill person (Group 1) and 240 individuals from general population (Group 2) were participated in the study. The study used convenient sampling technique because of many limitations such as poor accessibility in many geographical areas, unavailability of transport facilities and safety issues. Individuals living with a mentally ill person for at least last two years and who are either related with blood relations or marriage included in the group 1. The individuals with no family history of mental illness, not living with a mentally ill spouse, or a mentally ill child or any other person with mental illness were included in the group 2.
Individuals with any kind of known mental illness, mental retardation, epilepsy, physical disability, chronic physical illnesses, unable to give a valid response due to any kind of physical limitation and age below 18 years and above 60 years were excluded from both groups. Informed written consent obtained from all participants. The study is carried out with the support of Nav Bharat Jagriti Kendra (NBJK), a non-profit organization working for the development of underprivileged and individuals with various disabilities in different part of Jharkhand. The organization shared a data base of more than 1400 individuals with mental illnesses in Hazaribag district, which helped the research team to identify the relatives of mentally ill. The location for data collection decided on the basis of the concentration of the samples, availability of transport and safety. The data collected at the door step of the individual respondent. A semi structured profile used for recording the socio-economic details of the respondents. Kessler Psychological Distress Scale version 10 used for recording the psychological distress.(42) Kessler Psychological Distress Scale is a simple scale consisted of ten questions with five levels responses to each question about the emotional status of the respondent from ‘none of the time’ to ‘all of the time’. A higher score in the measurement indicates higher levels of psychological distress ranging from 10 to 50 which can be given to the respondent to complete or can be read to them by the practitioners.(42) As per cut offs adopted by the 2001 Victorian Population Health Survey, a score between 10 to 19 indicates likely to be well, a score between 20 to 24 indicates likely to have a mild disorder, a score between 25 to 29 indicates likely to have a moderate disorder and a score between 30 to 50 indicates likely to have a severe disorder.(47) In the present study individuals who have scored less than 25 are categorized as having no or low level of psychological distress and a score above 25 has been categorized as having moderate or severe psychological distress. The questionnaire used in its original form in English language and the individuals who are unable to read and comprehend the questionnaire were helped by the trained volunteers. Descriptive statistics used for comparing the socio-demographic variables and odd ratio used for analysing the risk between groups.
Results
As Table 1 shows, large number of respondents of both groups was from the age category of less than 30 years (33% and 51% respectively). Females (56%) were majority in group1 and males (68%) were in group 2 and most of them were from Hindu religion (84% and86% respectively). Majority of the respondents were from rural back ground (63% and 80%) belonged to nuclear families (59% and 53%) and married (65% and80%). In group 1 majority were low educated or illiterate (38% and 27%) whereas largest (40%) number of respondents had an education of matriculation or intermediate in group 2. In group 1 large number (40) of respondents were unemployed and were earning income less than 25000 Indian rupees annually (44%). In group 2 largest (41%) number of people engaged in business or professional works and were reported annual earning income between 25000 to 1 lack Indian rupees (53%). Largest number (27%) of the respondents in relative group were mothers of the individuals with mental illnesses followed by any other blood relatives (25%), spouses (18%), siblings (18%) and fathers (13%).
Table 1: Socio-demographic characteristics (N-480) |
| Variable |
Group 1 Relatives of mentally ill (n=240) |
Group 2 General Population
(n-240) |
Age in years (between 18 to 60 years) |
Less than 30 years |
79 (32.9) |
122 (50.8) |
31 -40 years |
61 (25.4) |
55 (22.9) |
41- 50 years |
56 (23.3) |
44 (18.3) |
51 and above |
44 (18.3) |
19 (7.9) |
Gender |
Male |
106 (44.2) |
163 (67.9) |
Female |
134 (55.8) |
77 (32.1) |
Religion |
Hindu |
202 (84.2) |
207 (86.2) |
Others |
38 (15.8) |
33 (13.8) |
Residence |
Rural |
193 (80.4) |
151 (62.9) |
Urban |
47 (19.6) |
89 (37.1) |
Family type |
Nuclear |
127 (52.9) |
141 (58.8) |
Joint / extended |
113 (47.1) |
99 (41.2) |
Marital status |
Married |
191 (79.6) |
157 (65.4) |
Unmarried |
40 (16.7) |
78 (32.5) |
Education |
Illiterate |
65 (27.1) |
25 (10.4) |
Low educated |
90 (37.5) |
71 (29.6) |
Matriculation and intermediate |
59 (24.6) |
95 (39.6) |
Graduation and above |
26 (10.8) |
49 (20.4) |
Occupation |
Unemployed |
97 (40.4) |
16 (6.7) |
Daily wagers |
48 (20.0) |
72 (30.0) |
Farmers and self employed |
53 (22.1) |
53 (22.1) |
Business, professionals and others |
42 (17.5) |
99 (41.2) |
Family income in Indian rupees |
Less than 25000 |
105 (43.8) |
29 (12.1) |
25000 to 1 lack |
96 (40.0) |
127 (52.9) |
1 lack and above |
39 (16.2) |
84 (35.0) |
Relationship with mentally ill person |
Mother |
64 (26.7) |
|
Father |
30 (12.5) |
|
Sibling |
43 (17.9) |
|
Spouse |
44 (18.3) |
|
Any other blood relative |
59 (24.6) |
|
Table number 2 shows the comparison of prevalence of psychological distress and odd ratio between two groups. As the table shows nearly half of the respondents from group 1 and almost 15% of respondents from group 2 reported to have psychological distress at moderate or severe levels and difference between groups is found to be significant at a P-value less than 0.001 levels in chi-square test. The odd ratio shows 5.3 times higher probability for psychological distress among the group 1 who are living with a mentally ill person for not less than last two years in comparison to group 2 in present study.
Table 2: Showing comparison and odds ratio between groups (N=480) |
|
Presence of psychological distress |
Odds ratio |
95% confidence interval |
Chi-square value
(DF) |
P value |
Moderate / severe psychological distress
N (%) |
No / low levels of psychological distress
N (%) |
Group 1 Living with a mentally ill person (N=240) |
118 (49.2) |
122 (50.8) |
5.31 |
3.44- 8.18 |
62.52
(1) |
0.000*** |
Group 2- Not living with a mentally ill person (N=240) |
37 (15.4) |
203 (84.6) |
Total (N=480) |
155 (32.3) |
325 (67.7) |
| *** Significant at less than 0.001 level |
Discussion
The result of the present study shows the prevalence of psychological distress among nearly 50 % of the respondents living with a mentally ill person and around 15% prevalence among the general population. It has found that there was significant higher prevalence of psychological distress among the respondents who are living with a mentally ill person compared to the respondents who are not living with mentally ill. The odd ratio shows more than 5 times increased probability for higher level of psychological distress among the respondents who are living with a mentally ill compared to the other group. The findings corroborated with previous studies in which they reported a range of prevalence of 5% to 27% of psychological distress in general populations and up to 66% found among specific populations.(11,12) The prevalence of mental disorders are found to be more common among individuals with high levels of psychological distress.(22,23,42) The Kessler Psychological distress scale reported to have high sensitivity and specificity toward serious mental illnesses as per DSM 4 criteria, most importantly towards depressive and anxiety disorders. The scale found to have inconsistent bias towards gender, culture, language, educational status etc., and is recommended by many researchers for screening serious mental illnesses in different populations.(2-6,42,48,49) Taking from this perspective one can assume that the individuals scored high in Kessler 10 probably have some kind of serious mental illness. In that case each alternative person in group 1 (living with mentally ill) and one among seven people in group 2 (not living with mentally ill) can have some mental health problem which needs serious attention.
The psychological distress can be the outcome of many factors and it is often associated with the psychosocial difficulties of each individual. There are certain specific vulnerabilities for a person living with a mentally ill person to have psychological distress compared to other individuals. The increased burden and adversely changed psychosocial situation of the family increases the vulnerability of the caretakers for psychological distress. The problems may arose due to various factors such as the demand for compensation for day to day household chores resulting from the functional impairment of individual with mental illness, an added responsibility to take care of the individual with mental illness and help them in carrying out their daily activities especially personal hygiene. Defective coping of family members, poor social support to the family, taking up a new role in the family, difficulty in maintaining the daily routines and timing for work along with care taking, financial difficulties due to loss of income from the mentally ill person and also because of additional cost of treatment, other socio cultural factors such as labelling and stigma are all important. The psychopathology of the individuals with mental illness such as delusions, hallucinations, obsessions and suicidality and associated behaviours may also disturb family members.(31-33,35-37,40,41,50-54) Although, all the above mentioned factors certainly affect the individual’s emotional and psychological status, studies also argue that this higher level of distress can be an indicator for their own untreated mental illnesses. Earlier studies found a higher prevalence of mental illness among the caretakers of individuals who scored higher psychological distress compared to the caretakers with low psychological distress. Following the biopsychosocial models it can be supported as the biopsychosocial milieu is mostly common among the blood relatives whereas the spouses are hypothesized to share common psychosocial milieu.(30-34,36-38,55,56) The same stressors might have affected the individuals in a different way and form and also may exacerbate the degree of distress. But in either of the case the most important fact is that the individuals and families living with a mentally ill person need additional support to cope up. There should be focused interventions for early identification and promoting treatment. The anxiety and depressive disorders which are also called as common mental health disorders are often distressful for the sufferer and in comparison to psychotic disorders the burden and distress on others are low. In presence of psychotic features the distress is usually passed on to the caregivers as it can be sensed as well as affect others equally whereas in face of anxiety and depression the perceived distress by others remain at the threshold and is often confined within to become snowball reaction after a considerable time period which delays the treatment. Factors like stigma, labelling and discrimination may also force the individual with psychological distress to suppress their problems as they themselves do not want to give acceptance for such (mental illness) happenings to oneself.(57)
With respect to the present study both the groups of individuals living with a mentally ill person and not living with mentally ill person with high score on psychological distress are not receiving any help from any sources. They never approached any one for help and less likely to plan so. In that case if no preliminary steps of intervention is taken, they will remain untreated and continue with their sufferings, which will affect the future of entire family members and most importantly the younger ones.(58,59) Jharkhand is a state with very poor health infrastructure and poor utilization rates compared to other parts of India. The remote areas of Jharkhand do not have proper transport facility and connectivity. The state belongs to one of the least developed in India and people from interior places are struggling with their survival needs. The community based mental health services have been started in Jharkhand by some government organizations but are limited to very few districts. The higher rate of possible psychiatric morbidity among the referred population suggests the insensitivity and inadequacy of the present strategies to identify the individuals with the need of mental health services in the area. These observations can be generalised to other developing countries too.(44-46,60)
The authors observed following limitations in the present study. The study included all the relatives without considering a relationship through marriage and blood relations. However there can be differences in outcomes between groups based on genetic and no-genetic relationships. Also gender, the quality of the relationship, family atmosphere, education, occupation, and health status etc. may have significant impact on psychological distresses which are not addressed in the present study. The study used convenient sampling, which limits the generalization of the findings.
Despite having the limitations mentioned above this study made an effort to explore the mental health scenario of Jharkhand. The study strongly indicates the insensitivity and inadequacy of the services delivered in the area by various government and non-governmental agencies. The participants of the study requires a more systematic, strategic and affordable support to deal with their mental health needs. There is also a need for more comprehensive studies by using more representative samples and more number of respondents to understand the issues with more clarity.
In conclusion, the study reveals that the presence of significant level of psychological distress among the population of Jharkhand. The risk for psychological distress is found to be very high among the individuals living with a mentally ill person compared to the individuals not living with a mentally ill person. The findings indicate the need of more organized support for the people living developing countries in general and more focused support for the families and cares of mentally ill peoples. The current support systems found to be out of reach to most of the natives and inadequate to fulfil the mental health needs of the individuals.
Conflict of interests: On behalf of all authors the corresponding author states that there is no conflict of interest
Acknowledgements: We are thankful to all our participants and Nav Bharath Jagrithi Kendra (a non-profit organization based in Hazaribag, Jharkhand) for their support and cooperation to complete this study. We also thank Dr. Ronald C. Kessler for permitting us to use ‘Kessler psychological distress scale-version10’ for current study. Heartful thanks to our batch mates and friends for extending their support in data collection.
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