Open Access

Psychiatric morbidity among adult patients in a semi-urban primary care setting in Malaysia

  • Ruzanna ZamZam1Email author,
  • Maniam Thambu1,
  • Marhani Midin1,
  • Khairani Omar2 and
  • Pervesh Kaur2
Contributed equally
International Journal of Mental Health Systems20093:13

https://doi.org/10.1186/1752-4458-3-13

Received: 17 February 2009

Accepted: 18 June 2009

Published: 18 June 2009

Abstract

Background

Screening for psychiatric disorders in primary care can improve the detection rate and helps in preventing grave consequences of unrecognised and untreated psychiatric morbidity. This is relevant to the Malaysian setting where mental health care is now also being provided at primary care level. The aim of this paper is to report the prevalence of psychiatric illness in a semi-urban primary care setting in Malaysia using the screening tool Patient Health Questionnaire (PHQ).

Methods

This is a cross-sectional study carried out in a semi-urban primary healthcare centre located south of Kuala Lumpur. Systematic random sampling was carried out and a total of 267 subjects completed the PHQ during the study period.

Results

The proportion of respondents who had at least one PHQ positive diagnosis was 24.7% and some respondents had more than one diagnosis. Diagnoses included depressive illness (n = 38, 14.4%), somatoform disorder (n = 32, 12.2%), panic and anxiety disorders (n = 17, 6.5%), binge eating disorder (n = 9, 3.4%) and alcohol abuse (n = 6, 2.3%). Younger age (18 to 29 years) and having a history of stressors in the previous four weeks were found to be significantly associated (p = 0.036 and p = 0.044 respectively) with PHQ positive scores.

Conclusion

These findings are broadly similar to the findings of studies done in other countries and are a useful guide to the probable prevalence of psychiatric morbidity in primary care in other similar settings in Malaysia.

Introduction

Most of the psychiatric morbidity in the community is seen at the primary care level [15]. Studies using screening instruments have reported prevalence rates ranging from 16 to 43% of general practice attenders [1, 68]. A study of psychiatric morbidity using the General Health Questionnaire (GHQ) reported rates up to 30% [1]. In a Malaysian primary health setting the prevalence of psychiatric morbidity using GHQ-30 item version was 26.7% [9]. In the general population, as measured by GHQ-12 in the Malaysian National Health and Morbidity Survey, the prevalence of psychiatric disorder was 11% [10].

It has been reported that primary care practitioners miss about one third of psychiatrically ill people [4, 11, 12]. A number of reasons have been adduced for this. Patients seeing their primary care doctors tend to somatize their emotional distress, presenting with physical symptoms rather than overt psychological symptoms [13]. Medical history is often taken in conditions of little privacy thereby discouraging patients from sharing sensitive aspects of their distress [6]. Primary care practitioners (PCP) may also not be confident in diagnosing and treating psychiatric disorders [14, 15] Moreover PCP tend to have limited time in which to obtain a psychiatric history [15].

The consequences of psychiatric morbidity such as depression when it is not identified and treated can be severe. These include suicide, loss of jobs and relationships, and deterioration in physical health including higher risk of myocardial infarction [1618]. Early detection is important because it would reduce not only the above mentioned consequences but also unnecessary suffering for the patients [19, 20]. In view of the serious consequences of psychiatric morbidity it would be useful for us to explore the prevalence of psychiatric morbidity in our own local setting.

The use of self-report screening tools in primary care settings is potentially helpful in view of the impediments to recognition and treatment of mental disorder in primary care. A number of screening tools exist, including GHQ, Self-rating Questionnaire (SRQ) and the Patient Health Questionnaire (PHQ) [2123]. The aim of this paper is to report the prevalence of psychiatric disorder in a semi-urban primary care setting using the PHQ.

Methods

This is a cross-sectional study carried out in a semi-urban primary healthcare center located south of Kuala Lumpur. The center is a government run healthcare facility which is easily accessible by public transport. The center caters for the health needs of a population of 603,800 people of whom a majority are from the lower middle socioeconomic group. The center provides general medical outpatient care, emergency services and special clinics for antenatal, diabetes, hypertension, psychiatric illnesses and HIV-related diseases. The average attendance in a month is about 5,000 cases (100 to 150 patients per day), a majority of whom are antenatal cases seen by nurses and midwives. Other facilities include laboratory investigations, ECG, radiography and ultrasound. The clinics are run by a primary healthcare physician, one medical officer, eight nurses, two midwives, two health attendants, two assistant pharmacists and one laboratory technician.

Patients aged from 18–70 years were selected based on their registration number and subjected to a systematic random sampling. Exclusion criteria were patients who did not consent and those who were not literate.

Instruments

The PHQ was translated into Bahasa Malaysia and back translated. It was pre-tested to ensure that the original meanings were retained. The questionnaire consists of items that enable identification of eight psychiatric diagnoses including somatoform disorder, major depressive disorder, panic disorder, binge eating disorder, bulimia nervosa, alcohol abuse, other anxiety disorders and other depressive disorders.

The PHQ was validated against the GHQ-30 which has previously been validated for a Malaysian population [24]. The results of the validation will be reported in a subsequent paper. The respondents were also requested to complete a data form consisting of sociodemographic data, psychiatric history and recent life events.

Procedure

The patients completed the forms while waiting to see the doctor. Once they were in the consultation room, the doctor verified positive responses and applied the diagnostic algorithm. The time taken by respondents to complete the questionnaire was 5 to 15 minutes. The ethics approval for the study was obtained from the Research Committee of the Department of Family Medicine, National University of Malaysia.

Results

The sociodemographic characteristics of the sample are shown in Table 1. A total of 267 subjects returned questionnaires during the study period. Four questionnaires were incomplete and were excluded from analysis. The sample consisted of 97 (36.9%) young adults aged 18 to 29 years, 91 (34.6%) aged 30 to 39 years, and 75 (28.5%) aged 40 to 70 years.
Table 1

Demographic data of respondents

Demographic Data

 

Respondents (n = 263)

  

No.

Percentage (%) against total

   Age group

18 ~ 29 years

97

36.9

 

30 ~ 39 years

91

34.6

 

40 ~ 49 years

51

19.4

 

50 ~ 59 years

15

5.7

 

60 ~ 70 years

9

3.4

   Sex

Female

188

71.5

 

Male

75

28.5

   Race/Ethnic

Malay

199

75.7

 

Chinese

29

11.0

 

Indian

31

11.8

 

Others

4

1.5

   Education Level

None/Primary

27

10.3

 

Secondary

170

64.6

 

College/Tertiary

66

25.1

   Marital Status

Single

26

9.9

 

Married

233

88.6

 

Widow/Divorced

4

1.5

   Occupation

Professional, tech. & rel. work

78

29.7

 

Clerical & Sales

69

26.2

 

Production workers & laborers

35

13.3

 

Economically inactive

81

30.8

Income Group

≤ RM1, 000

39

14.8

 

RM1, 001 ~ RM1, 999

121

46.0

 

RM2, 000 ~ RM2, 999

57

21.7

 

≥ RM3, 000

46

17.5

Clinical Data

 

Respondents (n = 263)

  

No.

Percentage (%) of total respondents

   PHQ

Positive

65

24.7

   GHQ

Positive

71

27.0

   Previously known medical illness

Yes

52

19.8

   Previous history of psychiatric illness

Yes

1

0.4

   Family history of psychiatric illness

Yes

1

0.4

   History of stresses in the last 4 weeks

Yes

18

6.8

   History of menstrual problems

Yes

25

9.5

Of the 263 respondents who returned completed questionnaires, 233 (88.6%) were married. The majority of the respondents were female (n = 188, 71.7%). Malays formed the majority ethnic group (n = 199, 75.7%), followed by Indians (n = 32, 12%), Chinese (n = 29, 11%) and other races (n = 3, 2%).

Most of the respondents had at least secondary school education (64.6%) and 69% were employed. Almost half (46%) were from the lower income group.

About twenty percent had a previously known medical illness (including diabetes mellitus, hypertension, coronary heart disease or bronchial asthma). One respondent had previous psychiatric illness while another reported a family history of psychiatric illness (0.4%). Only 6.8% reported having a history of stress or losses in the previous four weeks.

It was found that 24.7% of respondents had at least one PHQ positive diagnosis. Some had more than one diagnosis. The diagnoses included depressive illness (n = 38,14.4%), somatoform disorder (n = 32, 12.2%), panic and anxiety disorders (n = 17, 6.5%), binge eating disorder (n = 9,3.4%), alcohol abuse (n = 6, 2.3%) (Table 2).
Table 2

Clinical data of respondents

PHQ Diagnosis

 

Respondents (n = 263)

  

No.

Percentage (%) of total respondents

Somatoform disorder

Positive

32

12.2

Major depression & other depressive Syndrome

Positive

38

14.4

Panic Syndrome & other anxiety syndrome

Positive

17

6.5

Binge eating disorder

Positive

9

3.4

Alcohol abuse

Positive

6

2.3

To analyze the association between PHQ positive status and sociodemographic and clinical characteristics, chi-square test was done with p < 0.05 taken as statistically significant.

Table 3 shows that age group was the only sociodemographic factor significantly associated with positive PHQ. It was significantly associated with young age group between 18 to 29 years. (p = 0.036)
Table 3

Association of demographic data with PHQ score

  

Respondents (n = 263)

Demographic Data

 

PHQ positive

PHQ negative

P

  

(% of total respondents)

(% of total respondents)

 

Age

18 ~ 29 years

25 (9.5)

72 (27.5)

 
 

30 ~ 39 years

17 (6.5)

74 (28.1)

0.036

 

40 ~ 49 years

20 (7.6)

31 (11.8)

 
 

50 ~ 59 years

1 (0.4)

14 (5.3)

 
 

60 ~ 70 years

2 (0.8)

7 (2.7)

 

Sex

Female

47 (17.9)

141 (53.6)

0.865

 

Male

18 (6.8)

57 (21.7)

 

Race/Ethnic

Malay

47 (17.9)

152 (53.6)

 
 

Chinese

5 (1.9)

24 (9.1)

0.230

 

Indian

11 (4.2)

20 (7.6)

 
 

Others

2 (0.8)

2 (0.8)

 

Education Level

None/Primary

8 (3.0)

19 (7.2)

0.822

 

Secondary

41 (15.6)

129 (49.0)

 
 

College/Tertiary

16 (6.1)

50 (19.0)

 

Marital Status

Single

7 (2.7)

18 (7.2)

0.472

 

Married

56 (21.3)

188 (67.3)

 
 

Widow/Divorced

2 (0.8)

2 (0.8)

 

Occupation

Professional, tech. & rel. work

18 (6.8)

60 (22.8)

 
 

Clerical & Sales

16 (6.1)

53 (20.2)

0.574

 

Production workers & labourers

12 (4.6)

23 (8.7)

 
 

Economically inactive

19 (7.2)

62 (23.6)

 

Income Group

≤ RM1, 000

8 (3.0)

31 (11.8)

 
 

RM1, 001 ~ RM1, 999

33 (12.5)

88 (33.5)

0.740

 

RM2, 000 ~ RM2, 999

12 (4.6)

45 (17.1)

 
 

≥ RM3, 000

12 (4.6)

34 (12.9)

 

Note: total % exceeds 24.7% because some patients have more than one diagnosis.

Having a history of stressors in the last four weeks was found to be significantly associated with PHQ positive (p = 0.044)

Discussion

Screening for psychiatric disorders in primary care is an important step to improve services. It should prompt physicians to consider further full diagnostic interview and referral to specialized psychiatric services whenever necessary [5]

An earlier study [25] used the GHQ-30 in detecting psychiatric morbidity in an urban Malaysian primary care population. In this study the PHQ is used because it is designed to provide diagnoses of mental disorders in primary care [15, 26]

In this study it was found that the prevalence of psychiatric disorder among adult patients attending a primary care center was 24.7%. This is similar to studies done in other countries which reported prevalence between 25% and 35% [2, 2729]. A study done in Taiwan showed a higher prevalence of 38.2% [30]

A previous Malaysian study of probable mental disorder in primary care, using GHQ, and carried out in an urban population attending private outpatient clinics in Kuala Lumpur, reported a prevalence of 29.9% [25].

The overall prevalence of psychiatric disorder (24.7%) and the prevalence of depressive illness (14.4%) are within the expected range in a primary care setting [2, 2729]. The prevalence of somatoform disorder (12.2%) and the lower than expected prevalence of anxiety disorders (6.5%) perhaps reflect the tendency of Asian patients to present their psychological distress in somatic symptoms [3133]. An interesting finding from this study is a finding of the higher than expected prevalence of binge eating disorder (3.4%) which is, to the best of our knowledge, the first estimate of prevalence of this disorder in a primary care setting in Malaysia.

Other studies found that being female, unemployed, separated or divorced is associated with a higher probability of psychiatric disorder [1, 2, 4, 10, 29, 3436]. However in this study, the only two factors found to be associated with psychiatric morbidity were age between 18 to 29 and a history of recent stressors.

Inferences from this study should be drawn with caution because of several limitations. The questionnaire was validated against the GHQ and not against a structured clinical interview which would have given better data on psychometric properties of the PHQ. There was a preponderance of Malays and women in this sample rendering the findings not applicable to primary care settings with different ethnic composition. It is more representative of semi-urban primary care centers with a preponderance of Malay attenders from the lower and lower middle income groups.

Systematic random sampling was carried out thereby reducing sampling bias. The sample size was adequate.

Conclusion

The healthcare centre in which the study was carried out shares common features with many other centres in rural Malaysia. Hence the study is potentially useful in estimating the prevalence of psychiatric disorder in similar settings.

Notes

Declarations

Acknowledgements

We would like to thank Prof. Robert Spitzer for permission to use the PHQ.

Authors’ Affiliations

(1)
Department of Psychiatry,Faculty of Medicine, Universiti Kebangsaan Malaysia
(2)
Department of Family Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia

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Copyright

© ZamZam et al; licensee BioMed Central Ltd. 2009

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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