Abstract
Background:
Psychiatric disorders are among the leading contributors to disability in India and worldwide. The pattern, prevalence, and distribution of psychiatric disorders in the country and its regions need to be assessed to facilitate early diagnosis and treatment. No study on the epidemiology of psychiatric disorders has been conducted in the Chhattisgarh state. This paper, as part of the National Mental Health Survey (NMHS), discusses the prevalence and pattern of psychiatric disorders in Chhattisgarh state.
Methods:
A stratified random cluster sampling technique and random selection based on probability proportional to size (PPS) at each stage were adopted. Participants were from three selected districts of Chhattisgarh, such as Janjgir-Champa, Kabirdham, and Raipur. Adults (aged ≥18 years) residing in selected households were interviewed using Mini International Neuropsychiatric Interview (version 6.0), the Fagerstrom test for nicotine dependence, the WHO-SEARO screening questionnaire for generalized tonic-clonic seizures, and screening tools for intellectual disability and autism spectrum disorders.
Results:
A total of 2841 individuals were interviewed. The state’s lifetime and current prevalence of psychiatric disorders for adults were 14.06% [95% confidence interval (CI) = 13.83–14.29] and 11.66% (95% CI = 11.45–11.87), respectively. Prevalence of substance use disorders, tobacco use disorders, schizophrenia and related disorders, and mood disorders was 32.4% (95% CI = 32.09–32.71), 29.86% (95% CI = 29.56–30.16), 0.8% (95% CI = 0.75–0.86), and 4.44% (95% CI = 4.31–4.58), respectively. High risk for suicide was detected in 0.28% (95% CI = 0.25–0.31). Psychiatric disorders were twice more common in males than in females.
Conclusions:
The study gives authentic data on the prevalence of psychiatric disorders in Chhattisgarh. This shall pave the way for policymakers and planners to design state-specific plans for dealing with mental disorders and related issues.
Keywords: Chhattisgarh, Mental disorders, Population, Prevalence, Psychiatric disorders
Key Messages:
Prevalence of psychiatric disorders in Chhattisgarh is nearly the same as the national prevalence of psychiatric disorders.
The prevalence of substance use disorders, especially tobacco use disorders, is higher in Chhattisgarh compared to the national average.
A male preponderance of psychiatric disorders was noted, which was over and above the national average.
Psychiatric disorders and issues related to mental health are among the leading causes of disability- adjusted life years (DALYs) worldwide. 1 The contribution of psychiatric disorders to the DALYs is ever-increasing, and it is projected that they may climb to the top position in the list soon. 2 There is an urgent need to implement programs for early identification and treatment of psychiatric disorders, to limit the burden due to the same. This becomes even more important in a country like India, which is huge in terms of size and population and is known to contribute a major proportion of the global burden of psychiatric disorders. 3 Therefore, it is vital to understand the prevalence and pattern of distribution of psychiatric disorders in the country at a macro and micro level.
Several Indian studies have assessed the prevalence of psychiatric disorders in the community.4–14 Researchers have conducted reviews and meta-analyses based on data from different studies and tried to arrive at the best possible estimates of the epidemiology of psychiatric disorders in the country.15–18 However, a wide variation was seen in the epidemiology of psychiatric disorders across the studies. This could be due to different screening/diagnostic tools used in the studies, application of the varying definition of a “case,” recall bias, reliance on one informant only, and sampling technique and related factors.16,17 The estimates provided by these studies are believed to be far below the true prevalence of psychiatric disorders in the country.16,17 Also, all these studies were limited to small geographical locations and could not estimate the burden of psychiatric disorders across the country. Though India has been a center for World Mental Health Survey (WMHS), 19 despite being a nationwide study, due to certain serious limitations, the WMHS could not serve the intended purpose. 20
To fill the gap in knowledge regarding the epidemiology of psychiatric disorders in India, the Ministry of Health and Family Welfare, Government of India, decided to conduct a nationwide survey. The responsibility of planning and conducting this survey was given to the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. 21 The survey conducted for this purpose was titled the “National Mental Health Survey 2015–16” (NMHS). It was conducted across 12 states, in collaboration with participating institutes from each of the states. 21 This paper is part of NMHS and aims to discuss the findings of this survey from Chhattisgarh, limited to the objectives mentioned below:
Prevalence of psychiatric disorders in Chhattisgarh state.
Age, gender, residence, education, occupation, and income-specific prevalence rates of psychiatric disorders in the state.
Materials and Methods
The protocol and survey methodology of the survey has been described in detail in another paper 21 and shall be discussed here briefly. The master protocol was prepared by NIMHANS and implemented uniformly across all participating centers. The survey was implemented in Chhattisgarh by the Psychiatry and Community and Family Medicine Departments, All India Institute of Medical Sciences (AIIMS), Raipur. This study was approved by the Institutional Ethics Committees of NIMHANS and AIIMS, Raipur.
Study Design and Participants
The study used stratified random cluster sampling, and random selection was based on probability proportional to size (PPS) at each stage. The number of clusters chosen for sampling was in proportion to the state’s rural, urban non-metro, and urban metro population as per the Census of India, 2011. The state districts were rank-ordered and divided into three strata based on district-wise poverty estimates. One district was chosen from each stratum randomly. Using the PPS strategy, two talukas or community development blocks (CDBs) were selected within each district. Urban and rural clusters were selected from the CDBs/talukas in proportion to the urban–rural ratio in the state. Fifty adults from 15 randomly selected households within each cluster were interviewed to complete the sample size (discussed below). The flow of sampling is depicted in Figure 1. All adult members (aged ≥18 years) of a household were included. Consent was obtained from each of the participants. Wherever an eligible participant in a household was unavailable at the first visit, two more visits were done; the first on a holiday and the second with a prior appointment. An individual was declared a non-responder if he/she was not interviewed despite three visits. Temporary adult residents of a household (e.g., relatives or guests) were excluded. The districts selected in the state were Janjgir-Champa, Kabirdham, and Raipur. The rural and urban non-metro clusters were included in all three districts. The urban metro clusters were included from Raipur only. A total of 60 clusters were selected.
Figure 1. Recruitment of Participants.
*CDB, Community development block.
Sample Size
Before launching the survey throughout the country, a pilot study was conducted in Kolar district of Karnataka state. In the pilot study, the prevalence of any mental morbidity in adults was 7.5%. At an absolute precision of 2% and confidence level of 95%, with an estimated design effect of 3 and a non-response rate of 30%, the total sample size for the state was estimated at 3000 adults.
Study Tools
The sociodemographic data sheet collected information like age, sex, education, occupation, marital status, religion, domicile, and individual and family monthly income. Psychiatric disorders were assessed using the Mini- International Neuropsychiatric Interview, adult version (version 6.0). 22 For additional assessments, an expansion of the Fagerstrom test for nicotine dependence, 23 the WHO-SEARO screening questionnaire for generalized tonic-clonic seizures, 24 and a screening instrument developed by NIMHANS for screening for intellectual disability and autism spectrum disorders were used. 21 The study tools were translated in Hindi (following standard WHO protocol) and field-tested before use. The details of the process of translation have been mentioned in another paper. 21 The study tools were administered by trained interviewers (discussed below). The diagnoses of mental disorders were classified as per the International Classification of Diseases, Diagnostic Criteria for Research (ICD-10 DCR). 25
Procedure
The data were collected by seven field data collectors (FDCs) with master’s degrees in psychology or social sciences, who were supervised by a study coordinator. The FDCs underwent intensive training of 8 weeks in survey procedure, interviewing techniques, and handling of handheld digital devices. The training was conducted at the Department of Psychiatry, AIIMS, Raipur. Members of the survey team closely monitored the data collection process through a three-tier monitoring system, i.e., at the field levels, state, and center, by the field data supervisor, state team, and NIMHANS, respectively. The state team visited survey clusters in each district to supervise data collection. Re-interviews were conducted in 5% of cases, which showed satisfactory agreement. A team of supervisors from NIMHANS visited field survey sites and gave feedback through video-conferencing at regular intervals. The data were collected from December 2015 to May 2016.
Statistical Analysis
The data merging and cleaning were done using Red Gate MySQL data compare software. 26 Subsequent analyses were carried out using SPSS 22.0 for windows. 27 As the survey had adopted multistage sampling and a representative sample was taken, appropriate weights were used for data analysis. Weights were calculated by considering the probability of selecting districts, CDBs, and non-response rates. The method of application of weight has been explained in detail in the previous paper. 21 The findings have been summarized as the prevalence of disorders with 95% confidence intervals.
Results
During the survey, 2841 participants were interviewed among the 3079 eligible individuals approached. Thus, the response rate was 92.3%. There was nearly equal representation of males and females in the survey (Table 1). The maximum number of participants belonged to the age group of 18–29 years (38% approx.), almost 80% were from a rural background, the majority (72% approx.), had received formal education, and nearly a quarter of them were uneducated (28%). Nearly one-third were involved in agriculture and related work, and another one-third were involved in household duties. About 75% of the participants were married.
Table 1.
Sociodemographic Characteristics.
| Males n(%) | Females n(%) | Total n(%) | |
| Total | 1382(48.64) | 1459(51.35) | 2841(100) |
| Age group 18–29 30–39 40–49 50–59 60 and above |
506(36.61) 271(19.6) 231(16.71) 166(12.01) 208(15.05) |
564(38.65) 279(19.12) 259(17.75) 174(11.92) 183(12.54) |
1070(37.66) 550(19.35) 490(17.24) 340(11.96) 391(13.76) |
| Place of Residence Rural Urban non-metro Urban metro |
1117(80.82) 140(10.13) 125(9.04) |
1178(80.74) 146(10) 135(9.25) |
2295(80.78) 286(10.06) 260(9.15) |
| Education Illiterate Primary Secondary High School Pre-University Vocational Graduate Post Graduate Professional |
228(16.49) 295(21.34) 257(18.59) 280(20.26) 179(12.95) 10(0.72) 91(6.58) 40(2.89) 2(0.14) |
575(39.41) 252(17.27) 205(14.05) 231(15.83) 117(8.01) 5(0.34) 59(4.04) 14(0.95) 0(0) |
803(28.26) 547(19.25) 462(16.26) 511(17.98) 296(10.41) 15(0.52) 150(5.27) 54(1.9) 2(0.07) |
| Occupation Cultivator Agricultural Laborer Employer Employee and other workers Student Household duties Dependent Pensioner Other Not known |
400(28.94) 312(22.57) 18(1.3) 358(25.90) 152(10.99) 4(0.28) 84(6.07) 50(3.61) 3(0.21) 1(0.07) |
33(2.26) 190(13.02) 5(0.34) 78(5.30) 119(8.15) 834(57.16) 141(9.66) 59(4.04) 0(0) 0(0) |
433(15.24) 502(17.66) 23(0.8) 436(15.30) 271(9.53) 838(29.49) 225(7.91) 109(3.83) 3(0.1) 1(0.03) |
| Marital Status Never Married Married Widowed/Divorced/Separated |
300(21.7) 1048(75.83) 34(2.46) |
226(15.49) 1109(76.01) 124(8.49) |
526(18.51) 2157(75.92) 158(5.56) |
Tables 2 and 3 show the weighted prevalence of psychiatric disorders. The current prevalence of any psychiatric disorder among adults was 11.66% [95% confidence interval (CI) = 11.45–11.87], and the lifetime prevalence was 14.06% (95% CI = 13.83–14.29) (excluding tobacco use disorders, epilepsy, and intellectual disability). Tobacco was the most commonly used substance, followed by alcohol. The lifetime prevalence of schizophrenia and related disorders was 0.8% (95% CI = 0.75–0.86). Mood disorders were more common, with a lifetime prevalence of 4.44% (95% CI = 4.31–4.58). Anxiety disorders were less compared to mood disorders. The prevalence of psychiatric disorders was the least among the youngest group assessed, i.e., 18–29 years. The prevalence of psychiatric disorders in males was more than twice that of females. Place of residence or education did not seem to make a difference in the prevalence of psychiatric disorders. The working population was affected more. Also, a lower prevalence was seen among those who were never married. It was observed that 0.28% (95% CI = 0.25–0.31) were at high risk for suicide, while another 0.4% (95% CI = 0.39–0.48) had a moderate risk of suicide. About 0.2% (95% CI = 0.16–0.22) screened positive for epilepsy (generalized tonic-clonic seizures), and 0.7% (95% CI = 0.64–0.75) screened positive for intellectual disability.
Table 2.
Weighted Prevalence of Psychiatric Disorders as per ICD-10 DCR Criteria.
| ICD-10 DCR | Psychiatric disorder | Lifetime prevalence (95% CI) | Current prevalence (95% CI) |
| Any psychiatric disorder | 14.06 (13.83–14.29) | 11.66 (11.45-11.87) | |
| F10–F19 | Mental and behavioral problems due to psychoactive substance use (includes tobacco use disorders F17) | 32.4 (32.09–32.71) | |
| F10 | Alcohol use disorder | 7.14 (6.97–7.31) | |
| F11–F19 | Other substance use disorder (except F17) | 1.29 (1.21–1.36) | |
| F17 | Tobacco use disorders | 29.86 (29.56–30.16) | |
| F20–F29 | Schizophrenia and other psychotic disorder | 0.8 (0.75–0.86) | 0.43 (0.38–0.47) |
| F30–F39 | Mood (Affective) Disorders | 4.44 (4.31–4.58) | 1.81(1.72–1.9) |
| F30–F31 | Bipolar Affective Disorders | 0.51 (0.47–0.56) | 0.29 (0.25–0.32) |
| F32–F33 | Depressive Disorder | 3.99 (3.87–4.12) | 1.58 (1.5–1.67) |
| F40–F48 | Neurotic and stress related disorders | 2.42 (2.32–2.52) | 2.38 (2.28–2.48) |
| F40 | Phobic anxiety disorders | 1.86 (1.78–1.95) | |
| F40.0 | Agoraphobia | 1.5 (1.42–1.58) | |
| F40.1 | Social phobia | 0.41 (0.37–0.45) | |
| F41 | Other anxiety disorder | 0.33 (0.29–0.36) | 0.29 (0.26–0.33) |
| F41.0 | Panic disorder | 0.12 (0.09–0.14) | 0.08 (0.06–0.1) |
| F41.1 | Generalized anxiety disorder | 0.14 (0.12–0.16) | |
| F41.9 | Panic disorder with limited symptoms | 0.07 (0.05–0.09) | |
| F42 | Obsessive Compulsive Disorder | 0.45 (0.4–0.49) | |
| F42.0–F42.8 | OCD current | 0.29 (0.26–0.33) | |
| F42.9 | OCD NOS | 0.45 (0.4–0.49) | |
| F43 | Reaction to severe stress and adjustment disorders (PTSD) | 0.03 (0.02–0.05) |
ICD-10 DCR: International Classification of Diseases 10th edition Diagnostic Criteria for Research, CI: confidence interval, PTSD: post-traumatic stress disorder, OCD: obsessive compulsive disorders, OCD NOS: obsessive compulsive disorders not otherwise specified.
Table 3.
Weighted Prevalence of Psychiatric Disorders Among the Participants, Distribution as per Sociodemographic Characteristics.
| Characteristic | Life Time Prevalence (95% CI) |
Current Prevalence (95% CI) |
| Age group 18–29 30–39 40–49 50–59 60 and above |
10.21 (9.88–10.53) 16.53 (15.97–17.08) 16.62 (16.03–17.2) 17.21 (16.51–17.92) 15.2 (14.55–15.85) |
9.05 (8.75–9.36) 13.21 (12.71–13.72) 13.64 (13.1–14.18) 14.22 (13.57–14.87) 11.85 (11.26–12.43) |
| Sex Female Male |
8.6 (8.34–8.85) 19.91 (19.54–20.29) |
5.65 (5.44–5.86) 18.09 (17.73–18.46) |
| Place of Residence Rural Urban non-metro Urban metro |
13.38 (13.13–13.64) 15.94 (15.17–16.71) 16.54 (15.88–17.2) |
11.09 (10.85–11.32) 13.59 (12.87–14.32) 13.46 (12.86–14.07) |
| Education Illiterate Primary Secondary High School Pre-University and Vocational Graduate and above |
12.29 (11.87–12.7) 16.76 (16.16–17.35) 14.2 (13.63–14.76) 15.66 (15.12–16.2) 11.64 (11.03–12.26) 13.73 (12.94–14.51) |
9.94 (9.56–10.32) 14.45 (13.88–15.01) 12.19 (11.66–12.72) 14.16 (13.64–14.68) 8.81(8.27–9.36) 8.6 2(7.98–9.26) |
| Occupation Workers Non-Workers |
19.28 (18.91–19.65) 8.92 (8.66–9.19) |
16.93 (16.58–17.28) 6.46 (6.24–6.69) |
| Marital status Never Married Married Widowed/Divorced/ Separated |
9.57 (9.13–10) 15.28 (15.01–15.55) 13.64 (12.68–14.59) |
8.69 (8.28–9.11) 12.76 (12.5–13.01) 7.4 (6.67–8.13) |
Discussion
The current study is the first of its kind in psychiatry, where the prevalence of psychiatric disorders has been assessed in a representative sample of the country and Chhattisgarh state. None of the previous epidemiological studies in psychiatry (discussed in the Introduction section), including WMHS, were conducted in Chhattisgarh. Thus, NMHS is the first epidemiological study regarding psychiatric disorders in Chhattisgarh.
The current and lifetime prevalence of any psychiatric disorder in Chhattisgarh was 11.64% and 14.05%, respectively. These figures do not include tobacco use disorders, epilepsy, and intellectual disability. These figures are nearly comparable to the national prevalence of psychiatric disorders (current prevalence of 10.56% and lifetime prevalence of 13.67%). 28 Higher prevalence of psychiatric disorders was noted among males and the working population. These figures also follow the trend pointed out in the national data. While the country-wide data show a far more significant prevalence of psychiatric disorders in urban metros, Chhattisgarh does not have the same pattern. The prevalence of psychiatric disorders in urban metros of Chhattisgarh was only slightly higher than that in urban non-metros and marginally higher than that in rural areas. Both our and the national findings revealed that those who were never married had a lower prevalence of psychiatric disorders. However, widowed/divorced/separated people were more affected in the national data than in our state. 28
It is not justified to compare our findings with previous epidemiological studies, due to major differences in sampling technique and case definition. We shall compare the findings of the NMHS in Chhattisgarh with the other participating states. Among the 12 states that participated in the NMHS, a detailed report of the pattern and prevalence of psychiatric disorders has been published from three states, such as Punjab, Uttar Pradesh (UP), and Madhya Pradesh (MP).29–31 The distribution of psychiatric disorders in Chhattisgarh has various notable differences compared to these states. In Punjab, the total prevalence of psychiatric disorders (lifetime prevalence: 17.9%, 95% CI: 17.52–18.33) is higher than that in Chhattisgarh. 29 The prevalence of substance use disorders (2.48%, 95% CI: 2.31–2.64) and tobacco use disorders (5.50%, 95% CI:5.26–5.75) is less in Punjab. The prevalence of depression is higher in Punjab (lifetime prevalence: 7.26%, 95% CI: 6.99–7.54, current prevalence: 1.83%, 95% CI: 1.69–1.97). The level of morbidity is higher among the older adults in Punjab (lifetime prevalence: 24.51%, 95% CI: 23.42–25.60). In both the states, the working population has been affected by psychiatric disorders more than those who are not working. 29
In UP, the overall prevalence of psychiatric disorders (lifetime prevalence: 7.97%, 95% CI: 7.85–8.09, current prevalence: 6.08%, 95% CI: 5.97–6.19) was almost half of that in Chhattisgarh. 30 The prevalence of substance use (16.36%, 95% CI: 16.19–16.52) and tobacco use (16.06%, CI: (15.89–16.52) was also less in UP. Unlike Chhattisgarh, the male preponderance was not seen in UP. Rather, the prevalence of psychiatric disorders among males and females was nearly equal. In UP, people living in urban metros had higher prevalence. The burden of psychiatric disorders was nearly the same in working and non-working populations in UP. Also, the marital state affected the prevalence, with greater prevalence in widowed/divorced/separated people. 30
Coming to MP, the total prevalence was noted to be slightly higher than in Chhattisgarh (lifetime prevalence of any psychiatric disorder: 16.7%, 95% CI: 16.5–16.9%; current prevalence: 13.9%, 95% CI: 13.7–14.1). 31 Like Chhattisgarh, MP also suffers from a high prevalence of substance use disorders (10.33%, 95% CI: 10.19–10.46). The prevalence of tobacco use in MP (34.89%, 95% CI: 34.68–35.1) was higher than that in Chhattisgarh, and the prevalence of alcohol use in MP was highest among all the states surveyed.31,32 It is noteworthy that Chhattisgarh was once a part of MP. 33 Chhattisgarh was carved out of the erstwhile MP state in the year 2000 and shares a long border with MP. 33 The shared ethnic, historical, and cultural values among these two states could explain the observation of the high prevalence of substance use, especially tobacco, in this region. A detailed report of findings of NMHS of other states is not available, and hence, a comparison could not be drawn.
The report on the prevalence and pattern-related findings of NMHS (available online) has not discussed the regional variations in detail. 32 However, it is amply clear that significant regional variations exist among the various parts of the country in terms of the pattern and prevalence of psychiatric disorders. India is a large country and most of the states are larger than many of the small European nations and do not represent a homogenous population in true sense. There are numerous differences among the states in terms of population distribution, pattern of education and employment, per-capita income, historical and cultural background, climate, and other factors which could contribute to regional variation in epidemiology of psychiatric disorders in their own way. NMHS was not designed to determine the reasons for regional variations. Nevertheless, the differences in prevalence and their possible sociodemographic correlates indicate that this aspect needs further exploration, as this shall have an important bearing on policymakers and those who shall design and implement programs for the prevention and treatment of mental disorders. While India has a national policy for mental disorders, 34 special attention shall be required to deal with the specific needs of each state/region.
The key strength of this study is the implementation of a well-planned, uniform study protocol at all the centers in the country and rigorous multi-pronged monitoring of data collection in the field by the local and national supervisors, ensuring the collection of quality data and the maintenance of robust standards. A stratified sampling technique using the PPS-based approach ensured that the sample was truly representative of the studied population. The use of standard interview schedules and other well- established scales/tools helped maintain diagnostic accuracy. Recording the data using handheld devices helped maintain the purity of the captured information and minimized the possibility of errors due to the handling of data by multiple personnel at different levels.
Limitations
The study assessed people residing in households; the homeless mentally ill were missed. It did not assess a few commonly encountered psychiatric conditions such as dissociative disorders, somatoform disorders, and sexual dysfunctions. The diagnosis was dependent on the subjective reporting of the participants. It is possible that, due to highly prevalent stigma and prejudices regarding psychiatric disorders, some participants might have concealed their issues, leading to under-reporting.
Conclusions
The study provides first-hand information on the prevalence of psychiatric disorders in a representative population of Chhattisgarh. While the overall prevalence of psychiatric disorders in the state is nearly the same as in the country, the significantly higher prevalence of substance use disorder, especially tobacco, is noteworthy. In this state, the prevalence of psychiatric disorders is higher among males, the working population, and married people. The findings of this study shall provide the much-needed epidemiological data that shall help design region-specific programs and policies for the betterment of people with mental disorders.
Acknowledgments
The authors acknowledge the contribution and support of members of NIMHANS-NMHS team, National Technical Advisory Group, NMHS Expert Panel, NMHS publication group, State Technical Advisory Group for Chhattisgarh, and Field Data Collectors.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: This study was funded by Ministry of Health and Family Welfare, Government of India, New Delhi, India.
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