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A Prospective Study on Patterns of Psychiatric Morbidity in Patients with

Pulmonary tuberculosis at a tertiary care hospital in northern india

Article · July 2019

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Shabir Ahmad Dar Zaid Ahmad Wani

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Original Article

A Prospective Study on Patterns of Psychiatric Morbidity in Patients with

Pulmonary Tuberculosis at a Tertiary Care Hospital in Northern India
S.A. Dar1, Z.A. Wani1, N.N. Shah2, B.A. Bhat1, Y.H. Rather1 and M.A. Margoob1

Departments of Psychiatry1 and Chest Medicine2, Government Medical College, Srinagar, Jammu and Kashmir, India

Abstract
Background. An association has been described between tuberculosis (TB) and common mental disorders. We aimed to evaluate
the patterns of psychiatric morbidities in patients with pulmonary TB.
Methods. This was a prospective study which was conducted over a period of one-and-half year. A total of 198 patients were
recruited for the study. Baseline psychiatric morbidity was assessed after two weeks of diagnosis and at the end of intensive phase.
Psychiatric morbidity was assessed using Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV) based Mini-Plus.
Results. In the present study 62.1% of patients with pulmonary TB had morbid baseline psychiatric disorders. Major depressive
episode was the most common morbid psychiatric disorder (40.9%) followed by panic disorder (12.6%), agoraphobia (2.5%) and
generalised anxiety disorder (2%). The psychiatric morbidity dropped to (11.6%); major depressive episode (10.1%) followed by
panic disorder (1.5%) were the only diagnosis on follow-up.
Conclusion. In view of high burden of psychiatric morbidity associated with pulmonary TB, there is a need for psychiatric
services to be made available to these patients. [Indian J Chest Dis Allied Sci 2019;61:63-67]
Key words: Anxiety disorders, Morbidity, Depression, Pulmonary tuberculosis.

Introduction with those with other medical diagnoses.8,9 Studies report

that prevalence of depression significantly correlates with
Tuberculosis (TB) is one of the leading causes of mortality severity and duration of the TB.10
worldwide. It is a disease of poverty affecting mostly young Despite the fact that mental ill health has far reaching
adults in their most productive years. The vast majority consequences for the treatment adherence and health
of TB deaths are in the developing world.1 TB patients outcomes in the patients with TB, psychological distress has
have to face social rejection and isolation because they rarely been investigated among these patients, especially in
are considered to be a source of infection for the healthy low-resource countries.11
individuals.2 In a few studies; TB patients themselves
reported that they experienced negative emotions, such as Material and Methods
anxiety and fear.2,3 This study was a prospective, observational study
The socio-economic status of the patients deteriorates conducted in the Postgraduate Department of Psychiatry
due to functional impairment.4 Because of the chronic in collaboration with Department of Chest Medicine,
psychogenic and somatic pain, frequent admissions Government Medical College, Srinagar from April 2015
in hospitals and dependency on medical and nursing to August 2016. Written informed consent was obtained
personnel, severe functional impairment occur in patients from all the patients. Our study patients were the newly
with TB. In addition to that, in our country social stigma is diagnosed, treatment-naive pulmonary TB patients
associated with TB as well as psychiatric illnesses. So the attending the Department of Chest Medicine, Government
patients with TB are at increased risk of having anxiety, Medical College Srinagar. Confirmation of diagnosis
adverse psychological reaction about life and are neglected of pulmonary TB was based on specific constitutional
not only by the society but also by their care-givers.5 symptoms and signs, radiological examination (chest
Another reason for the frequent comorbidity is that there radiograph) and sputum examination for acid-fast bacilli.12
are commonly shared risk factors,6 for the development of The diagnosis of pulmonary TB was made by the
a variety of psychiatric and medical disorders (smoking, consultant Pulmonologist; 198 patients were included in
low socio-economic status, etc).7 Psychiatric illness may the study. Patients with hypertension, hypothyroidism,
develop subsequent to TB infection, and mood disorders diabetes mellitus, etc were excluded from the study. Detailed
seem to be particularly common in TB patients compared history, physical examination and relevant investigations
[Received: January 4, 2018; accepted after revision: May 2, 2018]
Correspondence and reprint requests: Dr Shabir Ahmad Dar, Department of Psychiatry, Government Psychiatric Diseases
Hospital Srinagar, G4, Residential Block, Srinagar-190 001, Jammu and Kashmir, India; E-mail: shabir1055@[Link]
 64 Psychiatric Disorders in Pulmonary TuberculosisS.A. Dar, [Link]

were done by the psychiatrist before screening for any statistically significant difference between baseline versus
psychiatric diagnosis. psychiatric morbidity at the end of intensive phase with a
All the cases were interviewed for socio-demographic p-value of 0.0001 (<0.05).
parameters, like age, gender, employment, educational
level, marital status, and socio-economic level. Baseline Table 1. Socio-demographic characteristics of the patients
assessment for the psychiatric morbidity was done after two
Socio-demographic Pulmonary p-value
weeks of the diagnosis of pulmonary TB, final assessment Characteristics Tuberculosis Cases
was done at the end of intensive phase. The socio-economic
Mean age 29.7±11.4 0.0001
status was established by the Kuppuswamy’s scale.13 The
study was approved by the Ethical Institutional Committee Male:Female ratio 111:87 0.088
of the college. For the diagnosis of psychiatric morbidity, Rural:Urban ratio 129:69 0.0001
MINI International Neuropsychiatric Interview Schedule
Nuclear:Joint:Extended family 136:35:27 0.0001
PLUS (MINI PLUS)14 was used.
Socio-economic status*
Statistical Analysis
Upper class 2 (1%)
Descriptive statistics are reported as mean ± standard
Upper middle class 20 (10.1%)
deviation for continuous variables; and percentage for
categorical variables. A p-value less than 0.05 was considered 55 (27.8%)
Lower middle class
statistically significant. Data were analysed using the 102 (51.5%) 0.0001
Upper low class
Statistical Package for the Social Sciences (SPSS, version 20.0).
19 (9.6%)
Lower class
Results
* as per Kuppuswamy’s scale
During the one-and-half-year study period, a total of 211
patients who were diagnosed with pulmonary TB from p-value was significant for all socio-demographic variables except
the Department of Chest Medicine were enrolled as per male to female ratio.
our inclusion and exclusion criteria. However, out of these
enrolled, 13 patients lost to follow-up and, therefore, were Table 2. Comparison of baseline versus final psychiatric diagnosis
excluded from the study. The socio-demographic and in the study patients
clinical variables of 198 studied patients were studied. Their
Initial Psychiatric Final Psychiatric Diagnosis t-test
mean age was 29.7±11.4 years. Males slightly outnumbered Diagnosis
females; two-third of our study patients belonged to No PD MDE Total
rural area and one-third to urban area. More than half Diagnosis
of the patients belonged to nuclear family followed by No diagnosis 83 0 0 83
joint and extended nuclear family. Maximum number of
Panic disorder 22 3 0 25
patients belonged to upper-low class followed by lower-
middle, upper-middle, lower and upper class, respectively Major depressive 62 0 19 81
(Table 1). Two-third 135 (68.2%) of the patients belonged to episode 0.0001
Category  1 and one-third 63 (31.8%) belonged to Category 2. Agoraphobia 5 0 0 5
In the present study, 123 (62.1%) out of 198 patients
with pulmonary TB which were studied had morbid Generalised 3 0 1 4
anxiety disorder
psychiatric disorders at baseline as compared to
23 (11.6%) of pulmonary TB patients at the end of Total 175 3 20 198
intensive phase.
Definitions of abbreviations: PD=Panic disorder; MDE=Major depressive
Most common psychiatric disorder in our patients at
episode
baseline was major depressive episode followed by the
panic disorder. Major depressive episode was seen in
41.9% of patients at baseline as compared to 10.1% at the Table 3. Initial and final psychiatric diagnosis of the study patients.
end of intensive phase. Panic disorder was second common
Variable Final Psychiatric Diagnosis (n=198) p- value
diagnosis in 12.6% of patients at baseline as compared 1.5%
at the end of intensive phase. Agoraphobia, adjustment No Yes
disorder, generalised anxiety disorder and mixed anxiety Initial No 75 0
and depression was present in 2.5%, 2.5%, 2% and 1.5%, psychiatric 0.001
respectively at baseline while as none of these patients meet diagnosis Yes 100 23
the diagnostic criteria for any psychiatric illness on follow-
Total 175 23
up at the end of intensive phase (Tables 2 and 3). There was
2019; Vol.61 The Indian Journal of Chest Diseases & Allied Sciences 65

Discussion 74% cases, respectively, which is quite high than the results
of our study. The reason for higher percentage seems to be
Tuberculosis often leaves its impact physically, socially
the difference in comorbidity of study participants, data
and mentally on patients. Patients tend to be worried,
collection, sensitivity of screening tool and the geographical
frustrated, or disappointed by their diagnosis, but it is not
differences in the study participants. The high prevalence
known how emotional health changes with the treatment.
of depression in this study seems to be the elderly group
Patients with TB may experience depression and anxiety,
which is more prone to depression, because of low social
both of which can make the overall burden of the disease
support, neglect and isolation.28
more difficult to carry.15 The lifetime prevalence of mood
Major depressive episode was the most common
disorder in patients with chronic diseases is 8.9% to 12.9%,
disorder in our study. Similar results were reported in
with a 6-month prevalence of 5.8% to 9.4%.16,17
several other studies,29,30 which also documented depressive
Majority of patients in our study were in the younger
disorders to be the commonest diagnosis. Most of the
age group which could be attributed to their age-specific
studies reported that in almost half of the patients with
role that would require them to have many social contacts.
pulmonary TB have concurrent major depressive disorders
This in turn could have increased their TB exposure risk.
at the time of evaluation which is in accordance with our
Published data also suggests that 80% of those infected in
study findings of 40.9% patients. Husain et al31 found that
industrialised nations are aged 50 years and above, while
75% of those in developing countries are less than 50 years.18 50 (46.3%) cases of pulmonary TB were depressed which is
In our study two-third of the patients belonged to rural similar to the results of the present study.
and one-third to urban areas. This can be explained by the Anxiety disorders were seen in 34 (17.1%) of patients
overall rural and urban divide of the population in Kashmir and panic disorder (12.6%) was the most common anxiety
valley where majority of the population still resides in rural disorder followed by agoraphobia (2.5%) and generalised
areas.19 Of the total population of Jammu and Kashmir, anxiety disorder (2%). Yadav et al30 reported 6.6% anxiety
around 72.6% live in the villages of rural areas.19 neurosis and Maikandaan et al32 report 10% anxiety
In our study, more than half of the patients belonged disorders. This is lesser than what we observed in the
to nuclear family 136 (68.7%), followed by joint family present study. However, most of the studies show anxiety
35 (17.7%) and extended nuclear family 27 (13.6%). As disorders much higher than our study results. Husain
per 2011 census of Jammu and Kashmir, prevalence of the et al31 had documented anxiety to be present in 47.2%
nuclear family was 73% and extended family was 13.5% patients. Our observations differ from the report by Kumar
which are similar to our results.19 It seems that urbanisation et al27 who found anxiety disorders to be the commonest
enhances nucleation of family systems and a decrease in psychiatric morbidity. The variation in results may be due
care and support for the patients with pulmonary TB. to the sensitivity of screening tool used, study design and
In community-based studies, 73% and 79% of the studies population. In our study, generalised anxiety disorder was
reported positive associations between number of poverty seen in 4 (2%) of cases, consistent with another study.33
measures and common mental disorders, 19% and 15% reported The negative emotions of fear, anxiety and frustration
no association and 8% and 6% reported negative associations, in our study at the time of diagnosis and at early stage of
using bivariate and multivariate analyses, respectively. In the disease declined considerably after the treatment. Some
facility-based studies (clinic- and hospital-based studies), trends of the positive emotions expressed by the respondents
were similar, with 76% and 69% of studies reporting positive included well-being and happiness. This positive outcome
associations, 22% and 31% reported no associations and 1% and may be due to the attitude of family members and health-
0% reported negative associations.20 care workers as shown in the responses given by the TB
In our study, two-third of the patients 135 (68.2%) patients. However, some studies have shown unfriendly
belonged to category 1 and one-third 63 (31.8%) of patients attitude of health-care workers that made some patients
to category 2. Similar results were found in another feel frustrated, threatened, or uncomfortable.3,35
study21 with 76.1% and 23.8% belonging to each category, In our study percentage of psychiatric morbidity
respectively. The reason for a higher frequency of category  1 at the end of the intensive phase of the treatment was
TB seems that most of the cases occur afresh and only a few 11.6%. Most common diagnosis was major depression
become defaulters or fail to respond to chemotherapy. episode in 20  (10.1%) cases followed by panic disorder in
Psychiatric disorders were seen in 62.1% of patients 3 (1.5%) cases. Our results are consistent with Atif et al35
with pulmonary TB. Our study results are concordant with who reported that at the start of the treatment more than
other Indian studies where approximately 39% to 70% of 67% patients had depression (MCS score ≤ 42 NBS point).
pulmonary TB cases have been found to have anxiety or Although, proportion of the patients with depression
depression.22,23 This is in unison with most of other studies.24,25 decreased with the treatment, 23.5% patients were still
In contrast to above facts, Duko et al26 and Kumar et al27 with depression after the completion of their treatment.
found psychiatric morbidity to be present in 84.9% and Similar findings were reported in a UK study.36
 66 Psychiatric Disorders in Pulmonary TuberculosisS.A. Dar, [Link]

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