Effectiveness of psychological intervention package on anxiety and wellness level among patients with anxiety disorders

ABSTRACT

Background of the Study:

Anxiety disorders are among the most common mental disorders in all age groups and they are associated with short-term and long-term impairment in social, academic, familial, and psychological functioning. The purpose of this study was to evaluate the impact of psychological interventions to decrease anxiety thereby improving the wellness level of patients with anxiety disorder.

Methods:

A quasi-experimental research design (a nonequivalent control group design) for evaluating the effectiveness of the psychological intervention on anxiety and wellness level among neurotic patients (n = 100). Psychological interventions consisted of psychoeducation and simple relaxation exercises was administered.

Results:

The study findings revealed that in pre-test, there is no significant difference between experimental and control groups, but in post-test significant difference is observed between experimental group and control group as depicted by the t values at first post-test was t = 2.04 at P = 0.04, df = 98, at third month post-test t = 6.32 at P = 0.001, df = 98 and at sixth month post-test t = 11.03 at P = 0.001, df = 98. The experimental group patients are having 20.3% anxiety reduction and 23.0% improved wellness score, whereas in control group anxiety reduction is only 1.4% and only 2.4% improved wellness score which shows the effectiveness of psychological intervention.

Interpretation and Conclusion:

The results demonstrated the importance of improving patient’s awareness of anxiety and how to manage and access help. Nurses can play a vital role in screening and managing anxiety, and educating people in strategies to prevent episodes of panic. This nurse-led intervention, increased perceived self-efficacy in patients with anxiety disorders, compared with control patients.

Introduction

For all individuals, mental, physical, and social health is vital strands of life that are closely interwoven and interdependent. As understanding of this relationship grows, it becomes even more apparent that mental health is crucial to the overall well-being of individuals, societies, and countries.[1] Mental illness is a leading cause of disability worldwide and an important public health issue (Baxter 2014).[2] Anxiety disorders, including generalized anxiety disorder, panic disorder, social phobia, and obsessive-compulsive disorder, are the most common mental health issues, with lifetime prevalence reported to be as high as 30% (Kessler 2005). The present treatment focuses on unnecessary investigations and costly medications that are not only inadequate and ineffective, but also produce widespread frustration in both seekers and providers of healthcare services Government of India (GOI). There are lacunae in psychiatric epidemiology due to intricacy related to defining a case, diagnosis, sampling methodology, underreporting, and stigma, lack of adequate findings and trained labor, and low priority of mental health in health policy.

Anxiety disorder is an umbrella term that covers several different forms of a type of common psychiatric disorder. The disorders once classified as neuroses are now considered anxiety/neurotic disorders and Common Mental Disorders (CMDs). CMDs are a functional clinical classification of the group of disorders that describe the deeper psychological distress states of an individual. They include anxiety disorders, somatoform disorders, dissociative disorders, phobia, and depression. For people with anxiety disorders, worry and fear are constant, overwhelming, and crippling. The condition turns their life into a continuous journey of unease and fear and can interfere with their relationships with family, friends, and colleagues. But all too often they are mistaken for mental weakness or instability and resulting social stigma can discourage people with anxiety/neurotic disorders from seeking help. Patients with these disorders experience high levels of distress and impaired social functioning. If untreated, their thinking, decision-making ability, perceptions of the environment, learning, and concentration get affected.[3]

Prevalence of CMDs in primary care settings has varied from about 11–34.6% in different Indian studies (Nambi et al.). A recent study from India reported a prevalence of 42% inpatients attending a clinic in a tertiary care hospital (Avasthi et al. 2008). Prevalence of generalized anxiety disorder in primary care settings is reported to be in the range of 5–16% (Wittchen 2002) and that of panic disorder is 1.5–1.3% (Craske et al. 2002). According to the National Mental Health Survey undertaken by NIMHANS across 12 selected states of India during 2015–2016, reported that CMDs, including depression, anxiety disorders, and substance use disorders are a huge burden affecting nearly 10.0% of the population. Neurosis and stress-related disorders affected 3.5% of the population and were reported to be higher among women (nearly twice as much as men). Neurosis and stress-related disorders are commonly encountered in primary care settings where they are usually missed or misdiagnosed. Among the major mental disorders that manifest predominantly during adulthood, the crude prevalence for both depressive disorders and anxiety disorders was 3.3% (3.1–3.6 for depressive disorders and 3.0–3.5 for anxiety disorders).[1] Psychosocial care is increasingly recognized as an essential component of the comprehensive care of neurotic disorders. Improving patients’ access to psychosocial care is important. Among the mental disorders that manifest predominantly during adulthood, the highest disease burden in India was caused by depressive and anxiety disorders, followed by schizophrenia and bipolar disorder (Kyu 2018) To give high-quality care, it is essential that mental health nurses have a solid grasp of the most common therapies and interventions used in mental healthcare. If nurses understand, what the various interventions involve then they will be much better equipped to support patients through their recovery.[4] A range of psychological and psychosocial treatments for depression and anxiety (including depression with a chronic physical health problem) have been shown to relieve the symptoms of depression and there is growing evidence that psychological and psychosocial therapies can help people recover from depression in the longer-term relaxation training is effective in reducing anxiety in all participants for anxiety disorders and increase the quality of life.[5,6] People with depression often prefer psychological and psychosocial treatments to medication (Prins et al., 2008) and value outcomes beyond symptom reduction that include positive mental health and a return to usual functioning (Zimmerman et al, 2006) management options for anxiety disorders include psychoeducation, psychological treatment and pharmacological treatments.[7] This improves health outcomes by optimizing self-care skills, engaging family and community supports, and promoting early recognition of problems and appropriate interventions.

Within the limitations placed on modern mental healthcare, it is a challenge for the nurses to take the responsibility of providing evidence-based holistic nursing interventions for anxiety disorder patients. Moreover, such studies are woefully inadequate in the Indian context. Although neurotic/anxiety disorders are the commonest mental disorders, they receive scant attention. It is useful to devote attention to the management of these mental disorders because they are the commonest mental disorders in the general population. Considering the above-stated factors, the investigator felt the need to address psychosocial aspects of anxiety disorders and the present investigation makes an earnest effort to plan psychological interventions to decrease anxiety thereby improving the wellness level of neurotic patients. The present study also helps to make society and government aware of the mental health needs of the population and take necessary steps for the development of the same.

The objectives of the study were to assess the socio-demographic profile of the neurotic patients, pre-interventional level of anxiety and wellness of the neurotic patients, and to evaluate the effectiveness of psychological interventions on the anxiety and wellness level among anxiety disorder patients.

Along with psychosocial approaches studies support that exercise, sleep, hygiene and self-care activities are effective means of treatment of such patient[8] psychoeducational intervention is based on cognitive behavioral principles and have better effect on worry symptoms and reduction of anxiety therefore due to multipronged nature, psychoeducation can be suited to any mental health setting.[9]

Materials and Methods

This study adopted a single-blind quasi-experimental study comprising of a group of 100 neurotic patients (50 experimental group and 50 control group) selected through purposive sampling from outpatient clinics in three mental hospitals in Chhattisgarh. The samples were fulfilling the criteria of age 20 years or more with no major visual or motor handicap or other chronic diseases, diagnosed with neurotic/anxiety disorders by psychiatrists of selected mental hospitals of Chhattisgarh, willing to cooperate, and provide consent for the study. The study was approved by the Institutional Ethics Committee of Jawaharlal Nehru Hospital and Research Centre, Bhilai Manopchar Hospital Mana Raipur, and CIIMHANS Anjora Durg. Both groups matched on various socio-demographic correlates. To judge the similarity of two groups, a pre-test or pre-measurement was made in the “before” time period. Consecutive eligible patients who scored more than 17 on Sinha’s Comprehensive Anxiety Test (SCAT) were randomly assigned to experimental group who was administered psychological intervention and to control group with standard care.

Data were collected using socio-demographic datasheet, Freeman et al. Wellness Assessment Tool, SCAT and Rathus Assertiveness Schedule, physiological parameters such as self checking of pulse and respiration before and after intervention and at 3 months and 6 months post-intervention. Socio-demographic datasheet included age and gender, education, family income, residence and marital status, main feature of illness, adherence to treatment, frequency of admission to hospital, participation in social activity, occupational status and frequency of change of employment, functional level of patient, year of onset of illness and type of family. Data were collected using face-to-face interview method.

Psychological interventions was administered to experimental group with routine care and control group is given only the routine care. Routine care included administration of anti-anxiety medicines and general advice by doctors and other health team members. Psychological intervention was planned in two sessions for 2 days in the experimental group. First session was held on Day 1 and second session on Day 2, that is, one session each on both days. First session on Day 1 comprised of administration of pre-test followed by group discussion on anxiety and its effects on the respondents, psycho-education on anxiety and its management. The session lasted for one and half hours. In the second session, review of the previous sessions, followed by simple relaxation therapy and checking of physiological parameters, that is, pulse and respiration were done. This was followed by feedback and post-test on second day after second session. This session lasted for one and half hours. So, total of 2 hours per group. Each group constituted of 10 respondents. In the control group, only one session was utilized. This session included the administration of pre-test followed by feedback and post-test. The time taken for the session was one and half hours. Post-test was done again at 3 and 6 months for both groups.

The collected data were analyzed using statistical package of social sciences (SPSS) 12. First, the socio-demographic characteristics were presented as frequency, percentage, average, and SD. Second, the general characteristics of the experimental and control groups were analyzed using t-test, and Chi-square test. Major variables such as anxiety and wellness were analyzed using independent samples t-test. Third, to test the effectiveness of the psychological intervention, the comparison of the differences before and after the intervention on anxiety and wellness was analyzed using repeated analysis of co variance (ANOVA) measurements.

Results

The analysis of data was organized and presented under the following headings:

 Section 1: Analysis of socio-demographic characteristics of study subjects.

 Section 2: Distribution of subjects according to the level of anxiety and wellness

 Section 3: Association between anxiety and selected socio-demographic variables

 Section 4: Association between wellness and selected socio-demographic variables

 Section 5: Evaluate the effectiveness of psychological intervention on level of anxiety and wellness.

Section 1: Analysis of socio-demographic characteristics of study subjects.

The socio-demographic profile is shown in Table 1. As per socio-demographic variables amongst two groups, it can be concluded that both the groups were comparable with regard to the age, educational status, and age of onset of illness, whereas it differed in other socio-demographic characteristics such as educational status, marital status, etc.

Table 1.

Distribution of Subjects according to socio-demographic variables n=50+50

Demographic profile	Variables	Group
		Experimental		Control
		n	%	n	%
		Gender	Male	21	42.0%	21	42.0%
	Female	29	58.0%	29	58.0%
Age	< 20 yrs	12	24.0%	12	24.0%
	20-30 yrs	13	26.0%	13	26.0%
	30-40 yrs	20	40.0%	20	40.0%
	> 40 yrs	5	10.0%	5	10.0%
Education	Primary/middle	21	42.0%	21	42.0%
	High school	14	28.0%	14	28.0%
	Under Graduate	11	22.0%	11	22.0%
	Post Graduate	2	4.0%	2	4.0%
	Professional	2	4.0%	2	4.0%
Occupation	Employed	11	22.0%	9	18.0%
	Self-employed	11	22.0%	11	22.0%
	Unemployed	28	56.0%	30	60.0%
Marital status	Married	32	64.0%	30	60.0%
	Separated	3	6.0%	3	6.0%
	Single/Unmarried	15	30.0%	17	34.0%
Residence	Pucca house in Urban area	36	72.0%	31	62.0%
	Pucca house in Rural area	3	6.0%	3	6.0%
	Kutcha house in Urban area	8	16.0%	13	26.0%
	Kutcha house in Rural area	3	6.0%	3	6.0%
Monthly income	No income	18	36.0%	18	36.0%
	< Rs. 2000	6	12.0%	7	14.0%
	Rs. 2000-5000	1	2.0%	1	2.0%
	Rs. 5000-10000	10	20.0%	7	14.0%
	>Rs. 10000	15	30.0%	17	34.0%
Changing Employment	Never	31	62.0%	32	64.0%
	1-3 times	7	14.0%	6	12.0%
	>3 times	2	4.0%	2	4.0%
	NA	10	20.0%	10	20.0%
Age of Onset of Illness	10-20 years	12	24.0%	12	24.0%
	20-30 years	13	26.0%	13	26.0%
	30-40 years	20	40.0%	20	40.0%
	> 40 years	5	10.0%	5	10.0%
Socialization of Patient	Not socialize and remain at home	13	26.0%	13	26.0%
	Talk when spoken to	22	44.0%	20	40.0%
	Normal	15	30.0%	15	30.0%
	Familiarity to unfamiliar	0	0.0%	2	4.0%
Main Feature of Illness	Not attending daily routine activities	4	8.0%	2	4.0%
	Anxiety/Apprehension	46	92.0%	48	96.0%
Adherence to Treatment	Complete adherence	17	34.0%	13	26.0%
	Non adherence, Very rarely	6	12.0%	10	20.0%
	Non adherence, Very often	0	0.0%	3	6.0%
	Not taking medicine	27	54.0%	24	48.0%
Frequency of Hospitalization	Once	47	94.0%	43	86.0%
	Twice	3	6.0%	7	14.0%
Functional Level of Patient)	Need supervision	4	8.0%	2	4.0%
	Independent	46	92.0%	48	96.0%
Type of Family	Nuclear family	18	36.0%	22	44.0%
	Joint family	28	56.0%	19	38.0%
	Extended family	2	4.0%	5	10.0%
	Single	2	4.0%	4	8.0%

Section 2: Distribution of subjects according to the level of anxiety and wellness

Pre-interventional level of anxiety and wellness score

Out of the 100 patients who participated in the study, majority i.e. 68% of the patients were having mild anxiety and, 88% of them were having moderate level of wellness in the experimental group, 88% of the patients were having mild anxiety, and 90% of them were having moderate level of wellness in the control group. Experimental group patients are having 123.36 wellness score of 200, whereas in control group it is 122.58 of 200. It is inferred that pre-interventional level of anxiety was higher in both control and experimental groups as depicted in [Figure 1] and pre interventional level of wellness score was low to moderate in experimental and control group as depicted in [Figure 2].

Figure 1.

Multiple Bar Diagram Showing Pre-test Level of Anxiety Score of Neurotic Patients

Figure 2.

Multiple Bar Diagram Showing Pre-test Level of Wellness Score of Neurotic Patients

Section 3: Association between anxiety and selected socio-demographic variables

Association between anxiety and selected socio-demographic variables

In the experimental group, the association between post-test level of anxiety and their demographic variables in [Table 2] depicted that elders, more educated, employed, and complete adherence patients are having more reduced anxiety than others. In the control group, none of the demographic variables are significantly associated with their post-test level of anxiety. In post-test considering level of anxiety, there is statistically significant difference between experimental group and control group as the Chi-square values at first post-test is (χ² = 8.31, P = 0.03***, df = 2), at third month post-test is (χ² = 34.03, P = 0.001***, df = 2), and at sixth month is (χ² = 52.73, P = 0.001***, df = 2). Statistical significance was calculated using Pearson Chi-square test. It was inferred that there was no significant difference in the pre-test anxiety between the experimental group and the control group, whereas in the experimental group there was significant difference in the post-test anxiety scores.

Table 2.

Association between post-test level of anxiety and demographic variables (Experimental group)

Demographic variable	Items	Posttest Level of Anxiety						Total	Chi square test
		Normal		Mild		Moderate
		n	%	n	%	n	%
Gender	Male	14	66.7%	6	28.6%	1	4.8%	21	χ2=0.51 P=0.77
	Female	22	75.9%	6	20.7%	1	3.4%	29	DF=2
Age	<20 yrs	5	41.7%	5	41.7%	2	16.6%	12	χ2=15.03
	20-30 yrs	8	61.5%	5	38.5%	0	0.0%	13	P=0.02* DF=6
	30-40 yrs	18	90.0%	2	10.0%	0	0.0%	20
	>40 yrs	5	100.0%	0	0.0%	0	0.0%	5
Education	Primary/middle	9	42.8%	10	47.6%	2	9.5%	21	χ2=16.27
	High school	12	85.7%	2	14.3%	0	0.0%	14	P=0.03* DF=8
	Under Graduate	11	100.0%	0	0.0%	0	0.0%	11
	Post Graduate	2	100.0%	0	0.0%	0	0.0%	2
	Professional	2	100.0%	0	0.0%	0	0.0%	2
Occupation	Employed	11	100.0%	0	0.0%	0	0.0%	11	χ2=13.80
	Self-employed	11	100.0%	0	0.0%	0	0.0%	11	P=0.01**
	Unemployed	14	50.0%	12	42.8%	2	7.2%	28	DF=4
Marital status	Married	21	65.6%	9	28.1%	2	6.3%	32	χ2=2.81 P=0.59
	Separated	3	100.0%	0	0.0%	0	0.0%	3	DF=4
	Single/Unmarried	12	80.0%	3	20.0%	0	0.0%	15
Residence	Pucca house in Urban area	24	66.7%	11	30.6%	1	2.8%	36	χ2=5.15 P=0.52
	Pucca house in Rural area	3	100.0%	0	0.0%	0	0.0%	3	DF=6
	Kutcha house in Urban	6	75.0%	1	12.5%	1	12.5%	8
	Kutcha house in Rural	3	100.0%	0	0.0%	0	0.0%	3
Monthly income	No income	10	55.6%	7	38.9%	1	5.6%	18	χ2=4.98 P=0.75
	< 2000	5	83.3%	1	16.7%	0	0.0%	6	DF=8
	Rs. 2000-5000	1	100.0%	0	0.0%	0	0.0%	1
	Rs. 5000-10000	8	80.0%	2	20.0%	0	0.0%	10
	>Rs. 10000	12	80.0%	2	13.3%	1	6.7%	15
Changing Employment	Never	23	74.2%	7	22.6%	1	3.2%	31	χ2=4.24 P=0.64
	1-3 times	6	85.7%	1	14.3%	0	0.0%	7	DF=6
	>3 times	2	100.0%	0	0.0%	0	0.0%	2
	NA	5	50.0%	4	40.0%	1	10.0%	10
Age of Onset of Illness	10-20 years	9	75.0%	3	25.0%	0	0.0%	12	χ2=5.12 P=0.52
	20-30 years	8	61.5%	5	38.5%	0	0.0%	13	DF=6
	30-40 years	15	75.0%	3	15.0%	2	10.0%	20
	> 40 years	4	80.0%	1	20.0%	0	0.0%	5
Socialization of Patient	Not socialize and remain at home	10	76.9%	2	15.4%	1	7.7%	13	χ2=2.12 P=0.71
	Talk when spoken to	16	72.7%	5	22.7%	1	4.5%	22	DF=4
	Normal	10	66.7%	5	33.3%	0	0.0%	15
Main Feature of Illness	Not attending daily routine activities	2	50.0%	2	50.0%	0	0.0%	4	χ2=1.69 P=0.42
	Anxiety/Apprehension	34	73.9%	10	21.7%	2	4.3%	46	DF=2
Adherence to Treatment	Complete adherence	17	100.0%	0	0.0%	0	0.0%	17	χ2=10.78 P=0.05*
	Non adherence, Very rarely	5	83.3%	1	16.7%	0	0.0%	6	DF=4
	Not taking medicine	15	55.5%	10	37.0%	2	7.4%	27
Frequency of Hospitalization	Once	33	70.2%	12	25.5%	2	4.3%	47	χ2=1.24 P=0.53
	Twice	3	100.0%	0	0.0%	0	0.0%	3	DF=4
Functional Level of Patient	Need supervision	2	50.0%	2	50.0%	0	0.0%	4	χ2=1.69 P=0.43
	Independent	34	73.9%	10	21.7%	2	4.3%	46	DF=4
Type of Family	Nuclear family	12	66.7%	6	33.3%	0	0.0%	18	χ2=9.97 P=0.13
	Joint family	21	75.0%	6	21.4%	1	3.6%	28	DF=6
	Extended family	1	50.0%	0	0.0%	1	50.0%	2
	Single	2	100.0%	0	0.0%	0	0.0%	2

Section 4: Association between wellness and selected socio-demographic variables

Association between wellness and selected socio-demographic variables

In the experimental group, the association between post-test level of anxiety and their demographic variables depicted that more education, occupation, and more income have significantly gained more wellness scores than others as shown in [Table 3].

Table 3.

Association between post-test level of wellness and demographic variables (Experimental group) n=50+50

Demographic variables	Variable	Post-test level of wellness				Total	Chi-square test
		Moderate		High
		n	%	n	%
Gender	Male	8	38.1%	13	61.9%	21	χ2=0.61 P=0.43 df=1
	Female	8	27.6%	21	72.4%	29
Age	<20 yrs	3	25.0%	9	75.0%	12	χ2=3.41 P=0.49 df=3
	20-30 yrs	6	46.2%	7	53.8%	13
	30-40 yrs	6	30.0%	14	70.0%	20
	>40 yrs	1	20.0%	4	80.0%	5
Education	Primary/middle	12	57.1%	9	42.9%	21	χ2=11.35 P=0.02* df=4
	High school	3	21.4%	11	78.6%	14
	Under Graduate	2	18.2%	9	81.8%	11
	Post Graduate	0	0.0%	2	100.0%	2
	Professional	0	0.0%	2	100.0%	2
Occupation	Employed	2	18.2%	9	81.8%	11	χ2=6.29 P=0.04* df=2
	Self-employed	1	9.1%	10	90.9%	11
	Unemployed	13	46.4%	15	53.6%	28
Marital status	Married	10	31.3%	22	68.7%	32	χ2=0.02P=0.98 df=2
	Separated	1	33.3%	2	66.7%	3
	Single/Unmarried	5	33.3%	10	66.7%	15
Residence	Pucca house in Urban area	14	38.9%	22	61.1%	36	χ2=3.59 P=0.30 df=3
	Pucca house in Rural area	0	0.0%	3	100.0%	3
	Kutcha house in Urban area	1	12.5%	7	87.5%	8
	Kutcha house in Rural area	1	33.3%	2	66.7%	3
Monthly income	No income	9	50.0%	9	50.0%	18	χ2=9.71 P=0.04* df=4
	<2000	2	33.3%	4	66.7%	6
	Rs. 2000-5000	1	100.0%	0	0.0%	1
	Rs. 5000-10000	0	0.0%	10	100.0%	10
	>Rs. 10000	4	26.7%	11	73.3%	15
Changing Employment	Never	11	35.5%	20	64.5%	31	χ2=4.95 P=0.17 df=3
	1-3 times	1	14.3%	6	85.7%	7
	>3 times	0	0.0%	2	100.0%	2
	NA	4	40.0%	6	60.0%	10
Age of Onset of Illness	10-20 years	3	25.0%	9	75.0%	12	χ2=2.41 P=0.49 df=3
	20-30 years	6	46.2%	7	53.8%	13
	30-40 years	6	30.0%	14	70.0%	20
	>40 years	1	20.0%	4	80.0%	5
Socialization of Patient	Not socialize and remain at home	4	30.8%	9	69.2%	13	χ2=0.02 P=0.98 df=2
	Talk when spoken to	7	31.8%	15	68.2%	22
	Normal	5	33.3%	10	66.7%	15
Main Feature of Illness	Not attending daily routine activities	3	75.0%	1	25.0%	4	χ2=3.69 P=0.06 df=2
	Anxiety/Apprehension	13	28.3%	33	71.7%	46
Adherence to Treatment	Complete adherence	7	41.2%	10	58.8%	17	χ2=1.37 P=0.50 df=2
	Non adherence, Very rarely	1	16.7%	5	83.3%	6
	Not taking medicine	8	29.6%	19	70.4%	27
Frequency of Hospitalization	Once	16	34.0%	31	66.0%	47	χ2=1.50P=0.22 df=1
	Twice			3	100.0%	3
Functional Level of Patient	Need supervision	3	75.0%	1	25.0%	4	χ2=3.69 P=0.06 df=1
	Independent	13	28.3%	33	71.7%	46
Type of Family	Nuclear family	6	33.3%	12	66.7%	18	χ2=0.76 P=0.82 df=3
	Joint family	8	28.6%	20	71.4%	28
	Extended family	1	50.0%	1	50.0%	2
	Single	1	50.0%	1	50.0%	2

*Significant at P≤0.05 ** highly significant at P≤0.01 ***very high significant at P≤0.001

The data presented in [Table 4 and Figures 3 and 4] show that the Karl Pearson correlation coefficient in the experimental group is r = −0.66 and in the control group is r = −0.30. The findings reveal that there is a fair negative correlation between sixth month post-test anxiety and wellness score. Results indicate that level of wellness increase when anxiety level decreases and vice versa.

Table 4.

Correlation between post-test anxiety and wellness n=50+50

Groups	Variables	Mean±SD	Karl pearson correlation coefficient	Interpretation
Experimental group	Anxiety & Wellness	12.02±4.87 169.94±6.87	r=-0.66, P=0.001***	Negative correlation between post-test anxiety and wellness score It means when wellness increases their anxiety decrease fairly.
Control group	Anxiety & Wellness	27.08±7.58 127.41±10.58	r=-0.30, P=0.02*	Negative correlation between post-test anxiety and wellness score It means when wellness increases their anxiety decrease fairly.

Figure 3.

Scatter Plot With Regression Estimate Shows the Substantial, Negative Correlation Between Post-test Anxiety Score and Wellness Score (R = −0.66) Among Experiment Group Patients

Figure 4.

Scatter Plot With Regression Estimate Shows the Fair, Negative Correlation Between Post-test Anxiety Score And Wellness Score (R = −0.30) Among Control Group Patients

Section 5: Evaluate the effectiveness of psychological intervention on level of anxiety and wellness.

The Tables 5 and 6 shows the comparison between experimental group and control group score was analyzed using students’ independent t-test. In pre-test, there is no significant difference between experimental group and control group, but in post-test significant difference is observed between experimental group and control group as depicted by the t values at first post-test was t = 2.04 at P = 0.04, df = 98, at third month post-test t = 6.32 at P = 0.001, df = 98, and at sixth month post-test t = 11.03 at P = 0.001, df = 98. Findings reveal that there is consistent significant difference between experimental and control group at third and sixth month which means that the treatment produced an effect on anxiety reduction and it is sustained even at sixth month post-test. Comparison of pre-test and post-test anxiety score was analyzed using one-way ANOVA F-test. In experimental group, there is a significant difference between pre-test and post-test and in control group, no significant difference was found. As the “F” value calculated for experimental group is 54.84 which is highly significant, that is, greater than the table value at P ≤ 0.001 level of significance at df = 98, the data signifies that the NIP was very effective in reducing anxiety level. The obtained F values were significant in experimental group.

Table 5.

Comparison of anxiety between experimental and control group, n=50+50

Anxiety	Experimental		Control		Student’s Independent t-test
	Mean	SD	Mean	SD
Pre-test	30.22	8.71	28.36	7.94	t=1.11 P=0.27 DF=98, not significant
Post-test	24.00	7.82	28.20	7.87	t=2.04 P=0.04* DF=98, significant
Third month	18.44	6.27	27.32	7.70	t=6.32 P=0.001*** DF=98, significant
Sixth month	12.02	4.87	27.08	7.58	t=11.03 P=0.001*** DF=98, significant
One-way ANOVA, F-test	F=54.84 P=0.001***, significant		F=0.33 P=0.77, not significant

Table 6.

Comparison of overall wellness between experimental group and control group, n=50+50

Wellness	Experimental		Control		Student’s Independent t-test
	Mean	SD	Mean	SD
Pre-test	123.36	12.54	122.58	12.90	t=0.30, P=0.76, df=98, not significant
Post-test	131.41	13.82	122.96	12.67	t=3.19, P=0.01**, df=98, significant
Third month	155.06	7.80	126.48	10.80	t=17.19, P=0.001***, df=98, significant
Sixth month	169.94	6.87	127.41	10.58	t=25.75, P=0.001***, df=98, significant
One-way ANOVA, F-test	F=215.84, P=0.001***, significant		F=2.04, P=0.10, not significant

*Significant at P≤0.05; **highly significant at P≤0.01; ***very high significant at P≤0.001

The experimental group patients are having 20.3% anxiety reduction, whereas in control group it is only 1.4% which clearly shows the effectiveness of NIP on anxiety reduction, experimental group patients are having 23.0% improved wellness score whereas in control group it is only 2.4%.

The Tables 5 and 6 presents the results of analysis based on variances based on the overall clinical symptoms of the study group. For this purpose, the study groups were divided into eight subgroups, the first four groups are the experimental groups at four levels of assessment, that is, group refers to nursing intervention baseline data, group 2 refers to first post-test after nursing intervention, group 3 refers to nursing intervention after 3 months, and group 4 refers to nursing intervention after 6 months. Likewise, the control group at the respective levels of assessments are represented by groups 5–8. The analysis of variance shows that there is a statistically significant difference among the groups in respect of clinical symptoms are more than differences within the groups as depicted in [Figures 5 and 6]. To find out which groups are significantly different, post hoc test Seheffe procedure revealed that there is a statistical difference among the groups at 0.05 level.

Figure 5.

Box Plot Compares Pre-test and Post-test Mean Anxiety Score Between Experimental and Control Group Patients

Figure 6.

Box Plot Compares Pre-test and Post-test Mean Wellness Score Between Experimental and Control Group Patients

Tables 5 and 6 also portrays the mean, SD, standard error, t value, and levels of significance of both groups in all four phases of assessment in relation to overall clinical symptom (anxiety and wellness level). It is observed that there is a difference between the mean score of experimental and control group. The difference is found to be statistically significant indicating the effect of nursing intervention in reduction of clinical symptoms in experimental group compared with control group.

The role of nurses in providing clinical care

Psychiatric nurses use a number of interpersonal and communication skills to help clients cope with their psychiatric problems. Psychiatric nurses have a unique role: they promote the psychological health of individuals, families, and communities and help people deal with grief, crisis, or developmental difficulties. They also care for those with intractable illnesses such as schizophrenia, depression, and posttraumatic stress disorder. The focus of caring for the client is also based on the continuum of psychiatric nursing care, from emergency units to inpatient units to the community, where the emphasis on contemporary psychiatric nursing, that is, caring for client and their families in the community and with helping them mobilize community resources.[10]

Psychiatric nursing can be seen as a dynamic interplay between the nurse and the patient that encompasses knowledge and skillful application of the concept of behavior, personality, the mind, psychopathology and most importantly, the process of interpersonal relationship. This implies that the nurse must have an awareness of herself, her behavior, her needs, and her ways of relating and handling stress whether she is to see clearly where her problems and responses end and where the patient’s begin. This is of prime importance because the identification and evaluation of patient’s behavior are paramount in establishing an effective nursing care plan approach. This implies the need for empathy qualities in mental health nurse and the importance of developing empathy-based nurse–patient relationship is perhaps one of the nurse’s most important therapeutic tools. The psychiatric nurse must use herself and her total personality as the main implement for effective care. Physical manipulative skills are limited here because the nurse meets the patient on a communication level, social and recreational activities serve as a bridge to open communication. Psychiatric nursing is comprehensive nursing care. This suggests the acknowledgment of the patient as a total person who possesses the needs concerning all inspects of life- physical, psychological, social, environmental, religions, occupational, and recreational. Thus, the role of psychiatric nurse of the day is far different from that of the psychiatric nurse of the past, whose job was to “take care” of the hospitalized mental patients.

Given its high prevalence and burden for anxiety disorders and existence of treatment barriers there is a clear need for brief inexpensive effective intervention such as psychoeducation.[7,11,12]

Psychiatric-mental health nursing has evolved into a unique discipline. It now combines the knowledge, experience, and skills of nursing and mental health. In actuality, the term psychiatric mental health nursing implies two different areas of nursing that often interact and overlap. Psychiatric nursing focuses on the care and rehabilitation of those with identifiable emotional disorders. Mental health nursing focuses on well populations; it intervenes in crises and with high-risk individuals or groups to prevent the development of mental illness or disorder.[13]

Functions include:

1. Collecting significant data that help identify problems (e.g., observing behavior, and recording observations.)

2. Making inferences and/or judgments based on these data and leading to action (e.g., interpreting the behavior of the patient and seeking to understand patients’ needs).

3. Acting or intervening based on inferences (e.g., clarifying with a patient the meaning of a procedure, discussing and acting to solve problems in work situations).

4. Evaluating the process based on whether identified problems have been solved (e.g., mutually evaluating experience and learning).

The American nurses association has identified nine major activities involved in the practice of psychiatric nursing. They are as follows:

1. Providing a therapeutic milieu.

2. Working with here and now problems of clients.

3. Using the surrogate–parent role.

4. Caring for some somatic aspects of the client’s health problem.

5. Teaching factors related to emotional health.

6. Acting as a social agent.

7. Providing leadership to other personnel.

8. Conducting psychotherapy.

9. Engaging in social and community activities related to mental health.

Importance in the practice by primary care physicians

The creation of a new primary care role for psychiatric nurses developed in liaison with community health nurses brought in a system of mutual referral and consultation. Primary are roles involved assessment, direct patient care, and case management.

The concept of primary, secondary, and tertiary prevention provides a framework for discussing psychiatric nursing activities primary prevention is a community concept. It is a concept that precedes disease and is applied to a generally healthy population. Nursing goal is to decrease the vulnerability of individuals to illness and to strengthen their capacity to withstand stressors.

In secondary prevention, the nursing goal becomes the reduction of actual illness by early detection and treatment of the problems. In tertiary presentation, nursing goal is to reduce the residual impairment or disability resulting from an illness.

Psychiatric nurses become members of multidisciplinary team, having members of different disciplines who each provide specific services to the patient and a member of interdisciplinary team, having members of different disciplines involved in a formal arrangement to provide patient services while maximizing educational interchange. In both the teams, nurses are accountable and responsible for the patient’s milieu and for implementing the nursing process, dealing with the daily activity of patients, and evaluating the outcome of nursing care.

The nurses play a vital role in psycho education and improves the psychological distress, pain and quality of life of anxiety disorder patients.[14]

Thus, nature of psychiatric nursing is conceptualized as an interpersonal process that strives to promote and maintain behavior that contributes to integrate functioning. The patient may be an individual, family, or community. Nurses would play an active role in team functioning through cooperation and collaboration both in the hospital and community.

Conclusion

The findings of the present study indicate that potentially evident anxiety in anxiety prone patients can be managed by nurse-led interventions. The results of this study suggest that NIP is effective. Patients who received psychological interventions comprising of psychoeducation, and relaxation therapy have achieved a significant improvement, with reduced severity of anxiety symptoms and improving the overall performance, faster than the control group treated only with the routine care. These improvements were clinically significant, as indicated by the positive response. Importantly, these effects were maintained and extended over a period of 6 months. This nurse-led intervention, increased perceived self-efficacy in patients with anxiety disorders, compared with control patients.

Projected outcome

The finding of this study also suggests that mental health nurses with appropriate education and supervision can provide an effective therapeutic approach to patients who are experiencing anxiety in the mental health settings. The results of the study demonstrated the importance of improving patients’ awareness on anxiety and how to access help when it occurs. The positive mental health nursing contribution should include teaching more productive coping techniques and relapse prevention. Working closely with patients and promoting hope for relatives is another area that services should focus on as it has been shown that involving patients and relatives is critical when planning appropriate and acceptable care for them. The results highlighted the contribution of nurses in assisting patients in coping with difficulties associate with anxiety and for patients to begin to understand their illness symptoms and prevent further deterioration. Giving patients a sense of optimism and control in the future management of their anxiety is a significant part of support. Empowering patients with mental health illness and specifically anxiety are central to their own coping. The importance of nurturing a sense of empowerment is the mental health nurses’ role by providing encouragement and support and developing connections with patients and family.

Key points

• Anxiety disorders are the most common and disabling psychiatric disorders. These disorders cause significant distress and disability like any other medical ailments such as hypertension and interfere with the ability to relax and experience a sense of enjoyment and wellbeing.

• The patients with these disorders visit primary healthcare and other practice settings.

• Nurses are in a vital position to identify symptoms of different types of anxiety disorders, start appropriate interventions, counsel, or refer these patients for treatment major nursing interventions include making an accurate diagnosis, initiating appropriate NIPs like the package by the research consisting of psychoeducation, focus group discussion, and relaxation therapies contributed to a higher level of wellness and quality of life. These person-centered interventions improve anxiety outcomes in the patient.

• Anxiety disorder can be managed effectively in the primary healthcare settings with access to the psychological interventions and therapies the nurse play a crucial role in assessment and collaborating with primary care physicians in early identification and management which is key to the patient recovery and can prevent secondary disorders such as depression and substance use disorders.[15]

Financial support and sponsorship

Self-funding.

Conflicts of interest

There are no conflicts of interest.