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

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

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

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

Sample and procedure
The sample included 1 532 subjects (56.4% men and 43.6% women) consecutively selected from different hospital outpatient departments.Universal screening of all presenting outpatients was utilised, whereby all consecutive clients visiting outpatient

Prevalence of psychological distress and associated factors in urban hospital outpatients in South Africa
Objective.The aim of this study was to assess the prevalence of psychological distress and associated factors among outpatients in an urban hospital in South Africa.
Method.A sample of 1 532 consecutively selected patients (56.4% men and 43.6% women) from various hospital outpatient departments were interviewed with a structured questionnaire.
Results.Based on assessment with the Kessler Psychological Distress Scale, a measure of psychological distress, 17.1% of the patients (15.5% of men and 19.4% of women) had severe psychological distress.Logistic multiple regression identified no income, poor health status, migraine headache and tuberculosis as significant factors associated with severe psychological stress for men.For women the factors identified were lower education, no income, having been diagnosed with a sexually transmitted disease, stomach ulcer and migraine headache.

Conclusion.
The study found a high prevalence of psychological distress among hospital outpatients in South Africa.Brief psychological therapies for adult patients with anxiety, depression or mixed common mental health problems treated in hospital outpatient departments are indicated.Accurate diagnosis of co-morbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and optimising the management of somatic symptom burden.
departments were interviewed.The study protocol was approved by the Research Ethics Committee of the University of Limpopo (Medunsa Campus).Informed consent was obtained from the patients who participated.

Measures
Demographic characteristics.A researcher-designed questionnaire was used to record demographic information on participants' age, gender, educational level, marital status, income and place of residence (urban or rural).
The Kessler Psychological Distress Scale (K-10) was used to measure global psychological distress, including significant pathology that does not meet formal criteria for a psychiatric illness. 22,23This scale measures symptoms over the preceding 30 days by asking: 'In the past 30 days, how often did you feel: nervous; so nervous that nothing could calm you down; hopeless; restless or fidgety; so restless that you could not sit still; depressed; that everything was an effort; so sad that nothing could cheer you up; worthless; tired out for no good reason?'The frequency with which each of these items was experienced was recorded using a 5-point Likert scale ranging from 'none of the time' to 'all the time' .This score was then summed, with increasing scores reflecting an increasing degree of psychological distress.The K-10 has been shown to capture variability related to nonspecific depression, anxiety and substance abuse, but does not measure suicidality or psychoses. 24This scale serves to identify individuals who are likely to meet formal definitions for anxiety and/or depressive disorders, as well as to identify individuals with sub-clinical illness who may not meet formal definitions for a specific disorder. 22It is increasingly used in population mental health research and has been validated in multiple settings 25 including among pregnant women 26 and HIV-positive individuals in South Africa. 27We examined the K-10 scale using ordinal categories for low, moderate, high and very high psychological distress (scores of 10 -19, 20 -24, 25 -29 and ≥30, respectively) and as a binary variable comparing scores of 0 -29 versus ≥30.The internal reliability coefficient for the K-10 in this study was Cronbach alpha = 0.89.

Alcohol consumption. The 10-item Alcohol Disorder
Identification Test (AUDIT) 28 assesses alcohol consumption level (3 items), symptoms of alcohol dependence (3 items), and problems associated with alcohol use (4 items).In South Africa a standard drink is 12 g alcohol.Because the AUDIT is reported to be less sensitive at identifying risky drinking in women than in men, 29 the cut-off point of binge drinking for women (4 units) was reduced by one unit compared with men (5 units), as recommended by Freeborn et al. 29 Responses to items on the AUDIT are rated on a 4-point Likert scale from 0 to 4, for a maximum score of 40 points.
Higher AUDIT scores indicate more severe levels of risk; scores of 8 or more indicate a tendency to problem drinking.Cronbach alpha for the AUDIT in this sample was 0.88, indicating excellent reliability.
Tobacco use.Two questions were asked about the use of tobacco products: (i) 'Do you currently use one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)?' (response options were 'yes' or 'no'); and (ii) 'In the past month, how often have you used one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)?' (response options were once or twice, weekly, almost daily and daily).

Perceived general health.
Participants were asked: 'In general, would you say your health is: excellent, very good, good, fair or poor?'This measure was categorised based on participant response (very good = excellent/very good, good = good, and poor = fair/ poor).
Patients were also given a list of chronic and communicable illnesses such as hypertension, diabetes and sexually transmitted diseases (STDs), and asked to indicate which of them they had been diagnosed with.

Data analysis
Data were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows software application programme version 17.0.Frequencies, means and standard deviations (SDs) were calculated to describe the sample.Predictors of severe psychological distress were identified using logistic regression analyses.Following each univariate regression, multivariable regression models were constructed.Independent variables from the univariate analyses were entered into the multivariable model if significant at a level of p<0.05.Logistic regression was conducted for men and for women separately.Cases with missing data were excluded from the multivariable models.For each model, the R 2 are presented to describe the amount of variance explained by the multivariable model.Probability below 0.05 was regarded as statistically significant.

Sample characteristics
Of

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

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

Discussion
A high prevalence of severe (17.1%) and moderate (14.0%) psychological distress was identified in this study of a large sample of hospital outpatients in South Africa.This finding is comparable with prevalence rates of psychological distress or CMDs in other LMICs (Nicaragua 23%, 7 Nigeria 21.3%, 8 Lesotho major depression 23%, panic disorder 24%, and generalised anxiety disorder 29%). 9 concurrence with other studies this study found an association between severe psychological distress and female gender. 8low socio-economic status (lower education, no income), 10,11,13 daily or almost daily tobacco use, 14,30 and having been diagnosed with chronic diseases including stomach ulcer, 19 migraine headache, 19 lower back pain, 20 hypertension, 18 and communicable diseases including tuberculosis 21 and STDs. 31In a large Canadian community study, sexually transmitted infections (STIs) among women also increased the risk of depression. 32The diagnosis of an STI may contribute to the development of depression. 32

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

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