Running head: MENTAL ILLNESS IS MORE COMMON IN IN RURAL AREAS TOO

Mental illness is more common in rural areas

too

ANANYA SINGH, RASHI GUPTA

DAYALBAGH EDUCATIONAL INSTITUTE

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 ABSTRACT

BACKGROUND

about 10% of Indians suffer from stress, depression or substance use disorders.
Few receive care for these problems, especially in rural areas.

AIMS

As part of broader initiative to deliver technology-enabled mental health services

for rural communities (adults above 18 years), information was collected about the
prevalence of depression, anxiety and suicide risk.

METHOD

The study was conducted in 12 villages in the west Godavari district of Andhra
Pradesh. Depression and anxiety were assessed using the Patient Health
Questionnaire-9 and Generalized Anxiety Disorder-7, respectively. Additionally,
data were collected about sociodemographic factors and stressful events, among
others.

RESULTS

Anxiety, depression and suicide ideation 10.8, 14.4 and 3.5% of participants,
respectively. These were more common among women, and among those who were
aged 30-59 years, uneducated, or divorced/ separated/ widowed. Stress due to
financial loss was significant.

CONCLUSION

The study identified a significant number of people a risk of depression, anxiety

and suicide, and needing care.

DECLARATION OF INTEREST

None

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INTRODUCTION

Around 70-80% of the population in India currently live in rural settings without
access to good quality healthcare facilities. The establishments= of primary health
centres has helped improve affordability and accessibility of healthcare to some
extent, for some conditions, but it has been largely ineffective in addressing the
needs of people suffering from or at risk of non-communicable disorders including
mental disorders. It has been estimated that only in 27 receive care of mental
disorders such as depression. The national mental health survey estimated that
about 150 million Indian need care for mental health disorders, and about 10%
suffer from common mental disorders such as depression, anxiety, emotional stress
and suicide risk, as well as alcohol and drug use.

The report indicated that the prevalence of mental disorders was2-3 times higher
in urban areas, compared with rural areas. However, relatively few studies have
used standardized tools to access the burden of CMD, especially in rural settings.
Thus, there is a need to provide further evidence about the burden of mental
disorders, especially in rural communities and particularly using standardized
tools and methods. In the absence of reliable disease prevalence estimates,
planning an appropriate health system response is challenging. This paper reports
on the baseline data from the systematic medical appraisal, referral and treatment
(SMART) Mental Health Project. It outlines the prevalence of CMD such as
depression, anxiety and suicidal ideation, and risk factor associated with those
conditions. However, the SMART Mental Health Project had the broader objective
of conducting a study to access feasibility and acceptability, and gather
preliminary evidence about a mobile technology based mental health services
delivery model for rural India.

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METHOD

STUDY SETTINGS AND SAMPLE SIZE ESTIMATION

The study was conducted in 12 villages (with total population of about 40,000) in
the west Godavari district of Andhra Pradesh, southern, India. West Godavari is a
coastal district of Andhra Pradesh with a population of about 4 million. Telugu is
the predominant language in the region and agriculture and fishing are the main
sources of income. First, three Primary Health Centers (PHCs) within 50
kilometers of his field office were selected. All villages served by these PHCs are
listed. Prior to randomization, villages were assured that there were a sufficient
number of villages general health workers to care for the population. This was
necessary because later stages of the project involved the implementation of
complex mental health services delivery interventions involving ASHA.

SAMPLE SIZE ESTIMATION

Because the SMART Mental Health Project is essentially a mental health services
delivery project, the sample size estimates were made considering key outcomes of
mental health service use and the availability of ASHA. The population of the 12
villages the assumed was about 27,000 people over the age of 18. Based on our
extensive work to date, we expected a response rate of approximately 75%
representing approximately 19,500 participants. A conservative estimate was that
15% of consenting participants had her CMD at baseline as determined by the
screening tool. This equates to approximately 3,000 to 4,000 people. Studies
estimate that only 15-25% of people with severe mental disorders in developing
countries receive treatments, and an even smaller number of people with CMD.
There is one he-she ASHA for every 1000 population, and they are identified as
clusters for analysis. A previous study focused on primary care delivery of mental
health services India found an intraclass correlation of 0.03.11. Since this study
included a behavioral intervention, we assumed an ICC of 0.1. With these
assumptions, if there were 38 clusters containing 80 he in each cluster, this study
would have a power of 80% at a=0.05 and only 20% of mental health care
utilization at follow-up. A relative increase was detected.

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ETHICS APPROVAL AND CONSENT OF PARTICIPANTS

Ethical approval was obtained from the center for Chronic Disease Control, New
Delhi, India. Written informed consent was obtained from all participants. All
adults over age of 18 who were not handicapped by a serious illness that prevented
them from understanding the questions and instructions and conducting the
interview and who consented were included.

Approval was obtained with the assistance of the Health Department of the
government of Andhra Pradesh and the District Medical Health Officer of West
Godavari Region prior to the start of the study. they also obtained the consent of
all local village authorities.

BASELINE DATA COLLECTION

First, a formative phase was initiated to test and finalize the data collective tools.
Improve mental health and reduce negative perceptions associated with asking for
help. Baseline data were then collected by trained interviewers.

TOOLS USED AND GENERATION OF ELECTRONIC DATABASE

Depression and anxiety were assessed using Patient Health Questionnaire 9-item
(PHQ9) and the generalized anxiety disorder 7-item (GAD7) respectively. PHQ9
consists of 9 elements. 0, 1, 2, and 3 points are assigned to the response categories
‘never’, ‘a few days’, ‘more than half of the time’, and ‘almost every day’,
respectively. The 9-item total score ranges from 0-27, with scores 5to 9 indicating
mild depression, 10 to 14 moderate depression, and 15 to 27 severe depression. A
cut-off score of 10 or higher is recommended as indicating the possibility of
clinically relevant moderate depression requiring further evaluation. GAD7
consists of 7 elements. Values of 0, 1, 2, and 3 are assigned to the response
categories never, days, more than half of the time, and almost every day. Total
score range from 0-21, with scores 5-9 indicating mild generalized anxiety, 10-14
moderate generalized anxiety, and 15-21 severe generalized anxiety. A cut-off score
more than 10 is used as an indicator of clinically relevant moderate anxiety
requiring further evaluation and follow-up. 13-15 The Telugu national language

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PHQ9 has been validated in India. In this study, a score of 10 or greater on either
the PHQ9 or GAD7 and/or a score of 1 or greater on PHQ9 self harm question was
considered indicative of positive screening TMD: was considered to be a sign from
depression. Both PHQ9 and GAD7 have been used extensively in research and
have been shown to capture depression and anxiety in a variety of contexts.

Data were also collected on the following:

1. Socio-demographic factors – gender, education, marital status, occupation,

age.
2. Stressful life events – These were collected using a series of questions asking
about major life events in the past year and adapted from epidemiological
catchment surveys. Knowledge related to mental health, it is used to assess
attitudes, and behaviors.
3. Perception of stigma associated with seeking help for mental disorders – This
was assessed using the barrier to care assessment treatment stigma subscale,
which has 12 questions and uses like type responses.
4. Alcohol and drug use – This information was collected using the ASSIST
questionnaire.
5. Social networks and social support – questions were asked about the number
of family members, relatives, or friends that the person was in contact with
in the past 1 year, and about how helpful such people were when discussing
personal problems or lending money when needed.
6. Previous psychiatric disorders and treatment history of psychiatric disorders.

DATA MANAGEMENT AND DATA ANALYSIS

All data was captured electronically on seven-inch Android tablets and uploaded on
the go using cloud computing whenever network access was available. The data
was stored on secure servers. All data stored on the servers were initially cleaned
and errors were fixed. Clean data were downloaded and de-identified before being
made available to the research team. Descriptive analyzes are presented as
proportions and means. For those who reported a depression/anxiety score ≥10 or
an increased risk of suicide (score ≥1 on the question related to suicidal ideation in
the PHQ9), differences in proportions were analyzed by various sociodemographic
factors such as gender, age, and occupation and education. Univariate analysis and
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odds ratio (OR) were performed for each factor, and 95% CI and χ2 P values for
differences in proportion were calculated for each factor. Because all of our
predictors were categorical in nature, the pairwise association between sets of
predictors was checked using Cramér's V statistic prior to modeling to identify
collinearity that might have affected the relationship between predictors. Logistic
regression was then used to adjust for all sociodemographic factors that were
significant during univariate analysis. Adjusted ORs with 95% Wald confidence
intervals were determined along with P-values.

ETHICAL STANDARDS

The authors declare that all procedures contributing to this work are in accordance
with the ethical standards of the relevant national and institutional human
experimentation committees and with the 1975 Declaration of Helsinki, revised in
2008.

RESULTS

Data were collected from 22377 individuals (50.1% and 49.9% females)
representing 80.3% of the total eligible population contacted in the 12 villages. Of
the eligible individuals, 4848 (17.4%) were not available for the interview as they
moved out of the villages in search of seasonal work, about 71% of these were
males. Only 70 (0.001%) individuals refused to be interviewed.

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 Fig. 1

(Diagram showing population contacted and interviewed)

Sociodemographic details are provided in Table 1. The samples were

characterized by an overall higher proportion of females. In addition, a higher
proportion of women compared to men either had no education or had studied
up to primary level, and a higher proportion of men had completed high school
or college. Most of the participants worked in the unorganized sector and more
males were employed in both the organized and unorganized sectors. About 80%
were married (with similar proportions for both sexes) and the average age of
the population was 42.3 years.

TABLE 1

sociodemographic characteristics of baseline population

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 Percentages may not add up to 100% due to rounding.

a) under occupation includes the "other" category students, jobseekers and people unable to work due to illness
or old age.
b) Includes jobs that involve the payment of a regular wage.
c) Jobs that do not involve a regular salary, such as farming, working as contract labourers, fishing.
d) In the field of education, the category "other" includes vocational training.

Tables 2 and 3 outline the depression and anxiety characteristics of the population.
Overall, 5.3% of the population was identified as screen-positive (ie, either had a
score of ≥10 for depression or anxiety or a score of ≥1 on the suicidal ideation
question). The risk of depression and anxiety and suicidal ideation was more
common in women, and this was statistically significant for each condition (P <
0.001). Overall, 3.5% responded positively to the suicidal ideation question on the
PHQ-9, indicating an increased risk of suicide. Based on severity scores, 10.8%
were at risk for anxiety, of which 1.4% had moderate or severe anxiety, and 14.4%

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were at risk for depression, of which 2.5% had moderate/severe depression. Anxiety
and depression were more severe in women.

Table 2

Number of screen-positive cases at baseline

This test for any statistical difference between genders.

Table 3

Severity of anxiety and depression

Table 4 shows that gender, age, education, marital status, and occupation were all
significantly associated with the odds of a positive screening. Being female, aged

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18–29, unemployed (housewife/pensioner/other), having no education (vs. some
education) and currently married or divorced/separated/widowed (vs. never
married) sociodemographic characteristics associated with increased probability of
positive screening in univariate analysis.

Table 4

Univariate and multivariate models of the effect of sociodemographic variables on

screen-positive status

a) Score ≥10 on PHQ9/GAD7 and/or score ≥1 on the suicide-related question on

PHQ9.
b) The unorganized sector included work as laborers or shop assistants or
farmers or fisheries; the organized sector included working in offices or
schools or in the health sector for paid work.

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Using Cramer's V statistic to look for correlations, we found that only
occupation and gender were correlated at the 0.5 level (medium correlation).
Other predictors were poorly correlated. However, since both of these variables
were significant, we decided to keep them in the model. A logistic model
adjusted for all selected variables showed that the probability of a positive
screening was higher in women than in men (OR 1.40, 95% CI 1.20–1.64, P <
0.001). Compared with the 18–29 age group, those aged 30–59 years had
significantly increased odds of a positive screening and those over 60 years had
the highest risk (OR 2.81, 95% CI 2.23–3.53, P < 0.001 ). Compared with those
with some education, those with no education had increased odds of a positive
screening (OR 1.36, 95% CI 1.19–1.55, P < 0.001) and those who were
separated/divorced/widowed had an increased risk (OR 1 .68, 95% CI 1.16, 2.44,
P = 0.01).

Table 5 details the different stressful events experienced by those who had
moderate or severe depression/anxiety (scores ≥10 on the PHQ9 or GAD7)
compared with those who had no depression/anxiety or only mild
depression/anxiety ( score ≤10 on PHQ9/GAD7). "Suffering a financial loss" in
the past year was the most common stressful event experienced by 56% of
individuals with moderate/severe depression or anxiety. All stressful events
except "getting married," "having a child," "losing a job," and "leaving a job"
were significantly more common among those with moderate or severe
depression or anxiety.

Table 5

Number of stressful events between those with an anxiety/depression score of

≥10 and those with a lower score

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a) n = number of respondents who said yes.
b) N = number of respondents who answered a specific question.

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DISCUSSION

We found that about 5.3% of participants were at risk of CMD. To our

knowledge, this is the first study providing information on CMD from this
community and is the largest study providing such data from rural India. A
strength of the study was that standardized validated instruments were used to
assess CMD. Interviewers were trained and monitored during data collection. A
random data quality check was performed and any discrepancy was clarified
and corrected. Since the data were collected electronically, the chance of
transcription error was reduced. In line with recent calls for sex-segregated
analyses,24,25 we attempted to provide this in this work and found that women
were significantly at increased risk for depression, anxiety, and suicide.

A limitation of the study is that it is specific to one geographic area. The results
may be generalizable to other rural populations in the region, but generalization
beyond similar rural populations may be difficult. Results do not include data on
children and adolescents. Another limitation is that since this was a cross-
sectional study, no causal inferences can be drawn from the results and only
associations can be established. Suicidal ideation was captured using a single
question of the PHQ9, which only provides insight into one's own thoughts; this
is an indicator of risk, but not a definitive clinical assessment of suicidal risk,
which would require further clinical evaluation. Although alcohol use disorder
can be considered a CMD, we did not include it in this study because the
purpose of the larger study was to provide a depression/anxiety/suicide risk
intervention at the primary care level. There was a view that managing alcohol
use disorders is more complex and would be a challenge within existing
resources for targeted primary care settings and could be introduced at a later
stage.

Several of the men had moved away from the village for seasonal jobs in
factories and farms in other towns and were therefore unavailable for interviews
even after repeated attempts to contact them. This resulted in a higher
proportion of women in the villages surveyed by the interviewers. The higher
male employment rate and the fact that more men than women completed high
school or high school graduation may reflect the fact that this study was from
rural communities where men are traditionally employed in the field or other
unorganized sectors. in large numbers as workers, while women are often
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unemployed or housewives. District data
(http://www.westgodavari.ap.gov.in/Cencus.apo) indicates that males have a
higher literacy rate. Men are more likely than women to pursue further
education, especially in rural settings, which may be why more men have
completed high school or high school. The skewed dropout rate has led the
government to develop specific programs to increase school attendance among
girls in India (http://mhrd.gov.in/incentives).

The prevalence of adults at risk of CMD in this study was lower than the
prevalence reported by the NMHS. 6 One reason could be that we did not
include alcohol and substance use disorders, which showed a 5% prevalence in
the NMHS. In addition, this study was based on a rural population, which is
expected to have lower prevalence rates compared to urban populations,7,8,26
which may have led to lower estimates. Another reason may be the differences
in the instruments used in this study compared to the instruments used in the
NMHS. A modified version of the MINI International Neuropsychiatric
Interview was used in the NMHS, while the PHQ9 and GAD7 were used in this
study. Recent research has shown that when compared to the MINI, the PHQ9
has a sensitivity of 86% and a specificity of 78%.27 Given the differences in the
methods used in this study versus the NMHS, we believe that our results are
similar to those obtained in the NMHS and provide independent validation of
the NMHS findings. The differences in observed prevalence may be due to a
number of factors, as discussed above. The NMHS, although a significant
survey, had some methodological limitations, notably the use of a modified
MINI without currently available information on the validity of the modified
instruments and the selection of some states based on the "availability of
interested partners",6 which may be potential sources of bias. The value of data
collected from large studies using appropriate study designs, such as the
SMART Mental Health Project, will add to existing research from India
(including the NMHS) and should lead to more accurate aggregate estimates of
mental disorders across India in the future.

The adjusted model showed that female gender aged at least 30 years,
uneducated, and separated/divorced/widowed were associated with a higher risk
of CMD. Depression, anxiety and suicide risk were significantly higher in
women. This is similar to findings from other studies conducted nationally and

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internationally.6,26,28 The association between lower education and depression
has also been reported previously.26 In this study, the risk of CMD increased
with increasing age. Earlier research from India has also shown that depression
is higher in older individuals compared to younger individuals, but slightly
decreases in those over 60.6 The highest risk of CMD in those over 60 could
reflect the most common stressors identified in the community – financial loss,
death or illness of loved ones and lack of employment. Older individuals may be
less financially independent, leading to an increased impact of any financial
crisis on them compared to younger individuals who may be more financially
stable and have a job. This was seen in the unadjusted model, where use was
significantly associated with a reduced risk of CMD, but was not significant in
the multivariate model. With age, it is also more likely that family members and
friends will experience a higher rate of illness and death, especially if they are
also older individuals. However, more research, including qualitative
interviews, needs to be done to understand the reasons more clearly. Previous
research in both national26 and international20 populations has shown that
both the number and type of stressors are associated with mental disorders, and
the common stressors associated with depression and anxiety in this study are
similar to those previously found in India.

CMD should be manageable at the primary care level by non-specialist health

workers and primary care physicians and nurses according to World Health
Organization guidelines.29 However, even such basic training is currently not
provided to health workers and primary care physicians. While the National
Mental Health Policy30 and the World Health Organization's Mental Health
Action Plan31 recommend that community services be provided by primary care
workers, their implementation is not uniform across the country and, if present,
is not necessarily provided or evaluated. at regular intervals. The use of mental
health services, although part of the larger aim of the project, was not the focus
of this paper and data related to the use of mental health services are being
analysed. However, data collected using similar instruments and methods from
a predominantly tribal population from the same district showed a baseline
mental health service utilization of 0.8%, which increased to 12.6% after the
intervention.32,33 The study highlighted the low rate of mental health service
utilization in community, low awareness of CMD, lack of mental health services
and the effect of providing basic mental health services on increasing the use of
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mental health services. It is therefore important not only to expand the current
training of primary care health workers to include mental health training, but
also to provide them with skills and technical guidance that is evidence-based
and makes efficient use of their time to provide mental health care. One way to
do this is to use mobile technology, which is increasingly present in rural
communities in India, not only to deliver mental health services, but also to
facilitate training and monitoring. The SMART Mental Health project uses such
a paradigm and proposes to use it in a rural setting as described in this paper to
evaluate the feasibility of implementing such an intervention.

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 REFERENCES
 https://www.sciencedirect.com/science/article/abs/pii/S0022395614001423
 http://www.ap.gov.in/about-ap/districts/west-godavari/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034434/
 The WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need
for treatment of mental disorders in the world health organization world mental health
surveys.
 World Health Organization. WHO Mental Health Gap Action Programme (mhGAP). WHO,
2011. (http://www.who.int/mental_health/mhgap/en/
 World Health Organization. Mental Health Action Plan 2013–2020. World Health
Organization, 2013

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