Prevalence.html

Prevalence of psychological distress and associated factors in urban hospital outpatients in South Africa

Karl Peltzer, PhD

HIV/AIDS/STI and TB (HAST), Human Sciences Research Council, Pretoria, and Department of Psychology, University of Limpopo (Turfloop Campus), Limpopo

Supa Pengpid, DrPH

Linda Skaal, DrPH

Department of Health System Management and Policy, University of Limpopo (Medunsa Campus), Pretoria 

Objective. The aim of this study was to assess the prevalence of psychological distress and associated factors among outpatients in an urban hospital in South Africa.

Method. A sample of 1 532 consecutively selected patients (56.4% men and 43.6% women) from various hospital outpatient departments were interviewed with a structured questionnaire.

Results. Based on assessment with the Kessler Psychological Distress Scale, a measure of psychological distress, 17.1% of the patients (15.5% of men and 19.4% of women) had severe psychological distress. Logistic multiple regression identified no income, poor health status, migraine headache and tuberculosis as significant factors associated with severe psychological stress for men. For women the factors identified were lower education, no income, having been diagnosed with a sexually transmitted disease, stomach ulcer and migraine headache.

Conclusion. The study found a high prevalence of psychological distress among hospital outpatients in South Africa. Brief psychological therapies for adult patients with anxiety, depression or mixed common mental health problems treated in hospital outpatient departments are indicated. Accurate diagnosis of co-morbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and optimising the management of somatic symptom burden.

Common mental disorders such as depressive and anxiety disorders are classified in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10),1 as ‘neurotic, stress-related and somatoform disorders’ and ‘mood disorders’. Common mental disorders (CMDs), which include depression, anxiety and somatoform disorders, make a significant contribution to the burden of disease and disability in low- and middle-income countries (LMICs).2 , 3 These conditions are responsible for up to 10% of the total global disease burden.4 Based on recent findings from World Health Organization World Mental Health surveys on the global burden of mental disorders, the inter-quartile range (IQR: 25th - 75th percentiles) of lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV) disorder prevalence estimates (combining anxiety, mood, externalising and substance use disorders) was 18.1 - 36.1%.5 At least one-third of all patients seen in primary care in LMICs present with CMDs. The majority of these are not recognised or are ineffectively treated.4 Although depressive and anxiety disorders are classified as separate diagnostic categories in the ICD-10,1 the concept of CMDs is valid for public health interventions owing to the high degree of co-morbidity between these disorders in primary care and the similarity in epidemiological profiles and treatment responsiveness.6

Various studies have identified high prevalence rates of CMDs among primary healthcare patients in LMICs, e.g. 23% probable cases in Nicaragua,7 21.3% psychiatric disorders in Nigeria,8 23% major depression, 24% panic disorder and 29% generalised anxiety disorder in Lesotho,9 and a prevalence of generalised anxiety and depressive disorders of 23.9% in a community-based sample in South Africa.10

Factors associated with CMDs of primary care patients in LMICs include older age,8 , 10 female gender,8 being widowed, separated or divorced8 , 10 or unemployed,10 , 11 low socio-economic status,10 , 12 , 13 low social capital,13 substance use such as smoking14 and alcohol problems,15 and chronic medical illness16 such as type 2 diabetes mellitus,17 hypertension,18 peptic ulcer,19 lower back pain20 and communicable illnesses such as tuberculosis.21

Increasing emphasis has been placed on the detection and treatment of CMDs, particularly among patients seen in primary care settings.4 Hospital settings are a particularly valuable point of contact for the delivery of brief interventions, because large numbers of patients attend these facilities each year. The fact that little information exists about CMDs or psychological distress among hospital outpatients in South Africa prompted the study.

Aim of the study

The aim of this study was to assess the prevalence of psychological distress and associated factors among outpatients in an urban hospital in South Africa.

Methods

Sample and procedure

The sample included 1 532 subjects (56.4% men and 43.6% women) consecutively selected from different hospital outpatient departments. Universal screening of all presenting outpatients was utilised, whereby all consecutive clients visiting outpatient departments were interviewed. The study protocol was approved by the Research Ethics Committee of the University of Limpopo (Medunsa Campus). Informed consent was obtained from the patients who participated.

Measures

Demographic characteristics. A researcher-designed questionnaire was used to record demographic information on participants’ age, gender, educational level, marital status, income and place of residence (urban or rural).

The Kessler Psychological Distress Scale (K-10) was used to measure global psychological distress, including significant pathology that does not meet formal criteria for a psychiatric illness.22 , 23 This scale measures symptoms over the preceding 30 days by asking: ‘In the past 30 days, how often did you feel: nervous; so nervous that nothing could calm you down; hopeless; restless or fidgety; so restless that you could not sit still; depressed; that everything was an effort; so sad that nothing could cheer you up; worthless; tired out for no good reason?’ The frequency with which each of these items was experienced was recorded using a 5-point Likert scale ranging from ‘none of the time’ to ‘all the time’. This score was then summed, with increasing scores reflecting an increasing degree of psychological distress. The K-10 has been shown to capture variability related to nonspecific depression, anxiety and substance abuse, but does not measure suicidality or psychoses.24 This scale serves to identify individuals who are likely to meet formal definitions for anxiety and/or depressive disorders, as well as to identify individuals with sub-clinical illness who may not meet formal definitions for a specific disorder.22 It is increasingly used in population mental health research and has been validated in multiple settings25 including among pregnant women26 and HIV-positive individuals in South Africa.27 We examined the K-10 scale using ordinal categories for low, moderate, high and very high psychological distress (scores of 10 - 19, 20 - 24, 25 - 29 and ≥30, respectively) and as a binary variable comparing scores of 0 - 29 versus ≥30. The internal reliability coefficient for the K-10 in this study was Cronbach alpha = 0.89.

Alcohol consumption. The 10-item Alcohol Disorder Identification Test (AUDIT)28 assesses alcohol consumption level (3 items), symptoms of alcohol dependence (3 items), and problems associated with alcohol use (4 items). In South Africa a standard drink is 12 g alcohol. Because the AUDIT is reported to be less sensitive at identifying risky drinking in women than in men,29 the cut-off point of binge drinking for women (4 units) was reduced by one unit compared with men (5 units), as recommended by Freeborn et al. 29 Responses to items on the AUDIT are rated on a 4-point Likert scale from 0 to 4, for a maximum score of 40 points. Higher AUDIT scores indicate more severe levels of risk; scores of 8 or more indicate a tendency to problem drinking. Cronbach alpha for the AUDIT in this sample was 0.88, indicating excellent reliability.

Tobacco use. Two questions were asked about the use of tobacco products: (i) ‘Do you currently use one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)?’ (response options were ‘yes’ or ‘no’); and (ii) ‘In the past month, how often have you used one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)?’ (response options were once or twice, weekly, almost daily and daily).

Perceived general health. Participants were asked: ‘In general, would you say your health is: excellent, very good, good, fair or poor?’ This measure was categorised based on participant response (very good = excellent/very good, good = good, and poor = fair/poor).

Patients were also given a list of chronic and communicable illnesses such as hypertension, diabetes and sexually transmitted diseases (STDs), and asked to indicate which of them they had been diagnosed with.

Data analysis

Data were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows software application programme version 17.0. Frequencies, means and standard deviations (SDs) were calculated to describe the sample. Predictors of severe psychological distress were identified using logistic regression analyses. Following each univariate regression, multivariable regression models were constructed. Independent variables from the univariate analyses were entered into the multivariable model if significant at a level of p<0.05. Logistic regression was conducted for men and for women separately. Cases with missing data were excluded from the multivariable models. For each model, the R2 are presented to describe the amount of variance explained by the multivariable model. Probability below 0.05 was regarded as statistically significant.

Results

Sample characteristics

Of the 1 713 hospital outpatients approached, 1 532 agreed to participate (89.4% response rate). The final sample included
1 532 (56.4% men and 43.6% women) consecutively selected from different hospital outpatient departments. Their mean age was 36.1 years (SD 11.6, range 18 - 77 years). Almost two-thirds (63.8%) of the participants had never been married, almost half (48%) had grade 12 or higher education, 32.6% had a formal salary as main household income, and 80.1% lived in an urban area. Forty per cent of the hospital outpatients had chronic conditions and 60% were general hospital outpatients, 57.8% rated their health as excellent or very good, 24.2% used tobacco products daily or almost daily, and 34.9% scored 8 or more on the AUDIT indicating hazardous or harmful alcohol use. With regard to previously diagnosed conditions, 30.2% reported migraine headaches, 26.1% lower back pain, 19.3% hypertension, 17.3% arthritis, 17.3% stomach ulcer, 8.3% diabetes, 7.6% STD, 7.3% tuberculosis and 7.3% depression (Table 1).

Psychological distress

Overall 17.1% of the patients had scores on the K-10 indicating severe distress; this figure was significantly higher in women (19.4%) compared with men (15.5%). Moderate distress was reported by 14%, mild distress by 18.6% and no significant distress by 50.3% (Table 2).

Predictors of psychological distress

Univariate analyses showed that among men, lower education, no income, poor self-rated health status, daily or almost daily tobacco use, and having been diagnosed with a stomach ulcer, migraine headache, lower back pain, high cholesterol, arthritis or tuberculosis were associated with severe psychological distress; and among women, severe psychological distress was associated with older age, lower education, no income, being a chronic disease hospital outpatient, poor self-rated health status, and having been diagnosed with hypertension, a sexually transmitted disease, migraine headache, lower back pain, high cholesterol, diabetes or tuberculosis. Multivariable analysis showed that among men no income, poor self-rated health status, daily or almost daily tobacco use, and having been diagnosed with migraine headache or tuberculosis remained significantly associated with severe psychological distress, and that for women lower education, no income, and having been diagnosed with a sexually transmitted disease, stomach ulcer or migraine headache remained significantly associated with severe psychological distress (Table 3).

Discussion

A high prevalence of severe (17.1%) and moderate (14.0%) psychological distress was identified in this study of a large sample of hospital outpatients in South Africa. This finding is comparable with prevalence rates of psychological distress or CMDs in other LMICs (Nicaragua 23%,7 Nigeria 21.3%,8 Lesotho major depression 23%, panic disorder 24%, and generalised anxiety disorder 29%).9

In concurrence with other studies this study found an association between severe psychological distress and female gender.8 low socio-economic status (lower education, no income),10 , 11 , 13 daily or almost daily tobacco use,14 , 30 and having been diagnosed with chronic diseases including stomach ulcer,19 migraine headache,19 lower back pain,20 hypertension,18 and communicable diseases including tuberculosis21 and STDs.31 In a large Canadian community study, sexually transmitted infections (STIs) among women also increased the risk of depression.32 The diagnosis of an STI may contribute to the development of depression.32

Study limitations

Caution should be taken when interpreting the results of this study because of certain limitations. As this was a cross-sectional study, causality between the compared variables cannot be concluded. A further limitation was that all variables were assessed by self-report and desirable responses may have been given.

Conclusion

The study found a high prevalence of psychological distress among hospital outpatients in South Africa. Brief psychological therapies for adult patients with anxiety, depression or mixed common mental health problems treated in hospital outpatient departments are indicated.33 Accurate diagnosis of co-morbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and optimising the management of somatic symptom burden.34

Acknowledgement. The study was funded by the Directorate General for Development Cooperation (DGDC) through the Flemish Interuniversity Council (VLIR-UOS).

References
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Table 1. Sample characteristics

Sample characteristics

Men (N=864, 56.4%)

Women (N=668, 43.6%)

Total (N=1 532)

N

%

N

%

N

%

Age (yrs)

18 – 24

138

16.0

120

18.1

258

16.9

25 – 34

280

32.6

248

37.3

528

34.6

35 – 44

200

23.3

169

25.5

369

24.2

45 – 54

153

17.8

94

14.2

247

16.2

≥55

89

10.3

33

5.0

122

8.0

Marital status

Never married

520

61.8

435

66.2

955

63.8

Married/cohabitating

289

34.3

183

27.8

472

30.5

Separated/divorced/widowed

32

3.8

29

5.9

58

5.7

Education

≤ Grade 7

125

14.6

82

12.4

207

13.6

Grade 8 – 11

335

39.0

249

37.6

584

38.4

≥ Grade 12

399

46.4

332

50.1

731

48.0

Main household income

Formal salary

325

37.8

172

25.9

497

32.6

Family member contributions

235

27.4

250

37.7

485

31.8

Social grants

68

7.9

76

11.4

144

9.5

Other

128

14.9

63

9.5

191

12.5

No income

103

12.0

103

15.5

206

15.5

Urban residence

693

80.8

523

79.1

1218

80.1

Rural residence

165

19.2

138

20.9

303

19.9

Chronic hospital outpatient

304

35.3

311

46.8

615

40.3

General hospital outpatient

556

64.7

354

53.2

910

59.7

Very good v. poor health status

498

58.0

383

57.6

882

57.8

Daily or almost daily tobacco use

288

33.4

82

12.3

370

24.2

Hazardous or harmful alcohol use

401

46.6

131

19.7

532

34.9

Illness conditions (ever diagnosed)

Hypertension

148

17.2

145

21.9

293

19.3

High cholesterol

21

2.5

23

3.5

44

2.9

Diabetes

74

8.6

52

7.9

126

8.3

Cancer

17

2.0

31

4.7

48

3.2

Depression

57

6.7

50

7.6

107

7.0

Migraine headache

201

23.5

258

39.2

459

30.2

Stomach ulcer

125

14.6

138

21.0

263

17.3

Asthma

29

3.4

40

6.1

69

4.6

Arthritis

125

14.6

136

20.6

262

17.3

Tuberculosis

74

8.6

37

5.6

111

7.3

Lower back pain

207

24.4

187

28.4

394

26.1

STD

70

8.2

45

6.8

115

7.6

Table 2. Levels of psychological distress of male and female participants

K-10 score

Total ( N =1 532) (%)

Men ( N =864) (%)

Women ( N =668) (%)

No significant distress

10 - 19

50.3

53.5

46.0

Mild distress

20 - 24

18.6

17.8

19.6

Moderate distress

25 - 29

14.0

13.2

15.0

Severe distress

30 - 50

17.1

15.5

19.4

Total K-10 score (mean (SD))

21.5 (8.9)

20.9 (8.7)

22.4 (9.2)*


*t=-3.14; p<0.001.

Table 3. Predictors of severe psychological distress

Men

Women

Predictors

Crude OR (95% CI)

Adjusted OR (95% CI)

Crude OR (95% CI)

Adjusted OR (95% CI)

Age

1.01 (0.99 - 1.02)

-

1.03 (1.01 - 1.05)**

0.99 (0.96 - 1.02)

Married/cohabitating v. Not

0.97 (0.64 - 1.47)

-

1.11 (0.70 - 1.75)

-

≤ Grade 7 or less

Grade 8 - 11

≥ Grade 12

1.00

0.57 (0.34 - 0.97)*

0.40 (0.23 - 0.68)***

1.00

0.85 (0.47 - 1.55)

0.79 (0.42 - 1.47)

1.00

0.29 (0.16 - 0.52)***

0.22 (0.12 - 0.40)***

1.00

0.54 (0.26 - 1.13)

0.34 (0.16 - 0.74)**

No income

Formal salary

Family contributions

Social grants

1.00

0.42 (0.26 - 0.69)***

0.64 (0.39 - 1.05)

0.63 (0.28 - 1.45)

1.00

0.57 (0.33 - 0.99)*

1.08 (0.62 - 1.88)

0.69 (0.28 - 1.69)

1.00

0.34 (0.19 - 0.58)***

0.16 (0.09 - 0.27)***

0.28 (0.12 - 0.64)**

1.00

0.53 (0.28 - 0.98)*

0.25 (0.13 - 0.48)***

0.32 (0.12 - 0.83)*

Chronic v. general outpatient

1.14 (0.76 - 1.71)

-

1.55 (1.02 - 2.37)*

0.91 (0.55 - 1.49)

Very good v. poor health status

0.38 (0.26 - 0.58)***

0.51 (0.32 - 0.80)**

0.35 (0.23 - 0.54)***

0.60 (0.36 - 1.02)

Daily or almost daily tobacco use

1.79 (1.20 - 2.67)**

1.81 (1.17 - 2.80)**

1.69 (0.97 - 2.97)

-

Hazardous or harmful drinking

1.27 (0.86 - 1.89)

-

0.67 (0.38 - 1.18)

-

Hypertension

1.50 (0.92 - 2.45)

-

1.81 (1.13 - 2.90)*

1.04 (0.55 - 1.96)

Sexually transmitted disease

1.56 (0.84 - 2.93)

-

2.93 (1.50 - 5.70)**

3.97 (1.79 - 8.78)***

Stomach ulcer

2.26 (1.39 - 3.67)***

1.29 (0.69 - 2.43)

3.46 (2.20 - 5.42)***

1.80 (1.05 - 3.10)*

Migraine headache

3.86 (2.55 - 5.87)***

3.38 (2.08 - 5.48)***

3.57 (2.30 - 5.52)***

2.24 (1.33 - 3.76)**

Lower back pain

2.29 (1.50 - 3.49)***

1.32 (0.81 - 2.17)

3.00 (1.94 - 4.62)***

1.66 (0.97 - 2.83)

Asthma

1.98 (0.82 - 4.80)

-

2.00 (0.95 - 4.21)

-

High cholesterol

2.83 (1.04 - 7.66)*

1.83 (0.57 - 5.90)

3.97 (1.57 - 10.01)**

1.58 (0.46 - 5.44)

Diabetes

1.35 (0.71 - 2.57)

-

2.23 (1.16 - 4.31)*

2.00 (0.86 - 4.68)

Arthritis

2.16 (1.33 - 3.50)**

1.46 (0.84 - 2.53)

1.40 (0.86 - 2.28)

- -

Tuberculosis

2.37 (1.36 - 4.15)**

0.56 (0.32 - 0.80)**

2.87 (1.42 - 5.81)**

2.13 (0.92 - 4.95)

Cancer

1.84 (0.58 - 5.81)

-

0.94 (0.35 - 2.53)

-

*p=0.05; **p =0.01; ***p =0.001.

†Using forward logistic regression selection of variables.

‡For men Hosmer and Lemeshow chi-square = 10.77, p=0.215; Cox and Snell R2 =0.11; Nagelkerke R2 =0.19.

§For women Hosmer and Lemeshow chi-square = 17.16, p=0.029; Cox and Snell R2 =0.19; Nagelkerke R2 =0.31.

OR = odds ratio; CI = confidence interval.



 

Crossref Citations

1. Stress begets stress: the association of adverse childhood experiences with psychological distress in the presence of adult life stress
Mercy Manyema, Shane A. Norris, Linda M. Richter
BMC Public Health  vol: 18  issue: 1  year: 2018  
doi: 10.1186/s12889-018-5767-0