|Year : 2015 | Volume
| Issue : 1 | Page : 18-23
Identifying psychological distress in elderly seeking health care
Prafulla Shivakumar1, Shilpa Sadanand1, Srikala Bharath2, N Girish3, Mathew Varghese2
1 PhD Scholar, Centre for Public Health, Geriatric Clinic and Services (GCS), National Institute of Mental Health and Neurosciences, Bangalore, India
2 Professor of Psychiatry, Centre for Public Health, Geriatric Clinic and Services (GCS), National Institute of Mental Health and Neurosciences, Bangalore, India
3 Additional Professor of Epidemiology, Centre for Public Health, Geriatric Clinic and Services (GCS), National Institute of Mental Health and Neurosciences, Bangalore, India
|Date of Web Publication||9-Mar-2015|
Professor of Psychiatry, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore - 569 929, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Psychological distress in the elderly with various illness conditions often goes unrecognized. Since psychological distress is treatable, it is important to recognize it at the earliest to enhance recovery. This is an interim analysis of screening data of the elderly seeking health care in a hospital in India, with a focus on the 12-item General Health Questionnaire (GHQ-12), a screening instrument for psychological distress and a rationale for a higher cutoff score in help seeking elderly. Materials and Methods: A retrospective analysis of screening data of psychological distress using GHQ-12 in the elderly seeking care for neuropsychiatric conditions was carried out. Traditionally, ≥2 is considered positive for distress by GHQ-12. Receiver Operating Characteristic (ROC) curve was used to define new cutoff points for psychological distress. Results: At ≥2, 2443 (50%) of the elderly screened were recognized to be psychologically distressed. Using an ROC and optimum sensitivity and specificity measures, a cutoff score of ≥4 was observed to detect 30% of the elderly who had diagnosable mental health disorders. Female sex, illiteracy, and multiple co-morbidities were the factors that were associated with higher cutoff scores on GHQ-12 proposed here and psychiatric morbidity thereof. Conclusion: There is greater psychological distress among the elderly seeking health care. Hence, it is important to screen them and identify those at higher risk. Using a higher cutoff score with a standardized instrument like GHQ-12 indicated that it was statistically valid to identify those elderly with higher distress in a busy out-patient setting.
Keywords: Elderly, Psychological distress, Screening instrument
|How to cite this article:|
Shivakumar P, Sadanand S, Bharath S, Girish N, Varghese M. Identifying psychological distress in elderly seeking health care. Indian J Public Health 2015;59:18-23
|How to cite this URL:|
Shivakumar P, Sadanand S, Bharath S, Girish N, Varghese M. Identifying psychological distress in elderly seeking health care. Indian J Public Health [serial online] 2015 [cited 2020 Jan 25];59:18-23. Available from: http://www.ijph.in/text.asp?2015/59/1/18/152849
| Introduction|| |
India's elderly population in 2011 census was 86,028,327, contributing to 7.1% of the total population. This section of the population has grown steadily since 1951 and at a rate faster than the general population. Official projections indicate that the number of elderly persons in India would nearly double by 2030.  Given the rate of population aging, it becomes important to focus on aging issues related to poor health and to take effective measures to improve the quality of life in old age.  Increasing age is one of the most powerful risk factors for chronic illnesses.  The illnesses are not just physical, but also affect their psychological well-being, and this has a significant impact on their quality of life.  Hence, perceived health, especially psychological well-being, is an important indicator of health status in the elderly population. 
Psychological distress is defined as emotional suffering characterized by the symptoms of depression and anxiety, and sometimes could be tied with somatic symptoms.  Psychological problems go undetected for several reasons: Confusing the symptoms of psychological distress with those of co-morbid medical illness, the tendency of elderly persons to report physical symptoms and underreport distress, lack of time for the physician,  and importantly, sometimes, due to lack of systematic method/tool for detection of definite distress. 
Psychological distress is treatable.  Detection of psychological distress/morbidity and its appropriate management not only shortens the duration of suffering but also improves the overall quality of life and results in far less social impairment in the long term.  Therefore, the use of a good screening instrument to recognize the underlying psychological distress, especially in elderly with health issues, is essential.
The General Health Questionnaire-12 (GHQ-12)  is an instrument used in detecting psychological distress with a high sensitivity and specificity.  Developed in the 70s, it detects non-psychotic psychiatric problems such as depression, anxiety, and related psychiatric morbidity.  Studies of GHQ-12 have yielded high validity coefficients when administered in several languages and in countries including India. 
There are several studies in India that have looked into the physical morbidity profile in the elderly. , In all these, routine elicitation of psychological distress is scarce. Therefore, we aimed to analyze distress in the elderly who sought help in a tertiary care hospital. The examination of data over 2 years indicated the need to reexamine the cutoff scores of GHQ-12 in the elderly to diagnose syndromal distress.
| Materials and Methods|| |
The present work is an interim analysis of the records being routinely maintained in the Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, which is an ongoing service delivery. The available data from October 2008 to September 2010 were used for analysis in the current study. Consecutive people aged 60 years and above attending NIMHANS screening services were screened by four post-graduate research staff/PhD scholars trained in clinical work. The screening process is already reported in detail elsewhere. 
Socio-demographic details and screening instruments were administered to the patients or caregivers as appropriate. Information provided by the patients and/caregivers and the available medical records were used to collect data on the chronic medical conditions of the patients. All elderly people were provisionally diagnosed by medical personnel among the research staff and further treatment management was as per the routine clinical services protocol of the hospital. The present study focuses on the information available regarding GHQ-12 and the relevant socio-demographics.
Data were entered in Epi-info  and analyzed using Statistical Package for Social Sciences (SPSS, Version 15.0, Chicago, USA).  Proportions and measures of central tendency were used to summarize the data. Mean GHQ scores indicated the severity of distress. A score of ≥2 was considered positive for psychological distress.  The analysis of cutoff scores was done using Receiver Operating Characteristic (ROC) curve. Non-parametric tests and chi-square test were used as required.
| Results|| |
A total of 5260 elderly persons were screened; General Health Questionnaire-12 (GHQ-12) could be administered to 4890 patients (93%). The age of the respondents ranged from 60 to 96 years (mean 66.1, SD ± 6.5 years); majority were in the 60-69 years age group (72%) [Table1]. The male:Female ratio was 2:1. While 41.9% (n = 2049) did not have any formal education, 43.9% were literates [Table 1]. Nearly a third (33%) scored 0 on the GHQ and 2.4% scored positive on all 12 items.
|Table 1: Socio-demographic profi le and the GHQ scores of elderly at cutoff values of ≥2 and ≥4 (N = 4890)|
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Half of those screened (49.5%) had a recognized cutoff score of ≥2 (mean 5.2, SD ±3.0), indicating psychological distress and the need for further evaluation and intervention. The often used cutoff score of ≥2 in the ROC corresponded to a sensitivity of 88.0% and a specificity of 53% with respect to mood disorders. At a sensitivity and specificity of 71 and 72%, respectively, the cutoff score for psychological distress was ≥4 and was considered acceptable [Figure 1].
|Figure 1: Receiver operating characteristic (ROC) curve for GHQ-12 and ICD-10 diagnosis for mood disorders (area under ROC curve = 0.781)|
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Socio-demographics, illness profile, and psychological distress
More women and elderly without formal education had psychological distress [Table 1]. Majority (87%) of the elderly with mood disorders confirmed by subsequent detailed psychiatric evaluation just scored ≥2 on GHQ-12 and also had higher median scores (7.0) denoting higher distress levels, and a similar result was obtained even at a higher cutoff of ≥4 (median 8.0) [Table 2]. Similarly, greater proportion of elderly with co-morbid conditions, especially those with a definite psychiatric illness (80% with a diagnosis of psychiatric and medical illness and 74% with a diagnosis of psychiatric and neurological illness), scored ≥2 on GHQ-12 and also had higher mean scores (6.3 ± 2.7 and 5.7 ± 3.1, respectively) indicating more severe psychological distress [Table 3]. The pattern and trend were the same at the higher cutoff of ≥4 (6.7 ± 2.5 and 7.1 ± 2.6) for the diagnosis of psychiatric and medical illness and the diagnosis of psychiatric and neurological illness, respectively [Table 3]. The mean scores were statistically significant.
|Table 2: Psychiatric diagnosis and GHQ scores at cutoff values ≥2 and ≥4|
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|Table 3: Diagnosis and differential GHQ-12 Scores at cutoff values ≥2 and ≥4|
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| Discussion|| |
Majority of the elderly patients with physical illness are distressed. However, the mental health problems among the elderly are not routinely enquired into or recognized; when recognized, they are not documented and when documented, they are rarely diagnosed or treated.  Ignorance of the health service provider regarding geriatric mental health problems critically contributes to this significant gap in knowledge and practice. Hence, the need to screen elderly with physical illness using GHQ-12 as a screening tool with different cutoff scores is discussed.
Elderly and distress
The present study utilized GHQ-12 to detect distress in the elderly who sought treatment for various health problems in a tertiary care setting. The gender difference in GHQ-12 scores was statistically significant. As reported by other studies, more elderly women reported distress. , The higher scores among the elderly females and the lower ratio of male:Female (2:1) in those seeking treatment in this study reflect the discrimination and neglect of health of the female in our society. Widowhood, isolation, feeling of insecurity, poor education, sense of helplessness, substandard health, physical illness, and lack of attention contribute to greater distress among the women. 
As in the case of elderly women, significantly more elderly who had no education reported higher psychological distress. Other studies have also reported this. , Education would render the elderly to engage in cognitively stimulating activities, have better economic outcomes, and also make them physically more active that could help fight distress. 
In concurrence with other work among the elderly, there was no significant difference in the reporting of distress across the age groups. ,
Distress in elderly with various diagnosis
Physical ill health is one of the important causes of psychological distress among elderly. Lack of training and brevity of time  available to the physician for consultation make detailed assessment of psychological distress a challenge in routine practice. Moreover, elderly with a primary physical complaint do not report psychological distress spontaneously unless explored. Therefore, the use of a good screener by the busy physician (or his trained health aide) to detect distress becomes vital. Using GHQ-12, the present researchers found it feasible to detect distress in those elderly who came for various neurological, medical, and psychiatric conditions. Elderly with mood disorders scored high, in support of the validity of GHQ as a tool to detect non-psychotic psychiatric disorders such as depression and anxiety. ,
It stands to reason that elderly in the current study with more than one illness condition (co-morbidity) scored higher than those with a single condition, indicating higher distress. Studies from abroad and India indicate that increasing morbidities result in deterioration of psychological well-being and increase in disability. , Psychological distress may be a reflection of baseline physical illness and increase the mortality risk.  Clinicians, therefore, should elicit and identify distress in the elderly with multiple-morbidities that could further complicate the comprehensive management.  Since this could be challenging in a busy OPD setting, using a brief screening instrument like GHQ-12 to detect distress, followed by a structured interview when needed is the critical need of the hour.
Nearly 95% of the elderly who sought health care in NIMHANS could be administered the GHQ, thus proving the ease of using the instrument for screening by both the service seeker and the provider.  While selection of a screener is based on its sensitivity and specificity, the ease of administration is equally critical and in the present study, GHQ satisfied all the three requirements.
Using the conventional cutoff of ≥2,  50% scored positive on GHQ-12, indicating that every other elderly person seeking care was distressed. Undertaking a detailed assessment would overwhelm the health care system and compromise the delivery of quality care, especially in a busy OPD. Ensuring that scarce primary care resources are allocated to definite cases with high needs is both logical and relevant.  We attempted to identify those with greater need for care by looking at the associated factors and also reviewed the cutoff scores to identify those with greater and possibly definitive distress. Associated factors of female gender, illiteracy, co-morbidity, and mood disorders were some of the factors that indicated higher distress in the present study. Earlier studies have also indicated this. ,,
Receiver operating characteristics (ROC) curves enable determination of optimum cutoff points for the diagnostic tools in clinical purposes by providing information about all possible pairs of achievable sensitivity and specificity values.  We looked at the scores with increased specificity of GHQ-12 for mood disorders without compromising the sensitivity. At a cutoff value of ≥4, the ROC for GHQ-12 for this population showed a sensitivity of 71% and specificity of 72%, which corresponded to identification of 30% of the elderly with definite psychological distress. Using similar methods, Papassotiropoulos et al.  have also suggested a higher cutoff value (3/4) for case identification in the elderly compared to younger individuals. With a higher cutoff (≥4), the numbers of those requiring detailed assessment across different diagnoses were lesser by about one fifth. This greater targeting would help the clinicians to do a better assessment of the distress. This would also permit the clinician to factor psychological distress influencing other morbidities in the elderly and refer them to an appropriate member of the health team. Based on the above evidence, the Geriatric Screening Services, NIMHANS now uses a GHQ score of ≥4 as the cutoff score in a care-seeking elderly person for a more detailed psychological evaluation with a relative increase in the available time for evaluation of more definitive "caseness."
| Conclusion|| |
The growing number of elderly raises issues not just related to aging but also for ensuring healthy aging. While ill health among the elderly compromises their quality of life, psychological distress compounds the issues of management of physical ill health. As psychological distress is barely recognized, we used the simple and frequently used 12-item GHQ to address this challenge. Firstly, using the GHQ-12 and a conventional cutoff score of ≥2, we observed psychological distress in every other elderly seeking health care. Secondly, multiple co-morbidities, lack of education, and female gender were the key factors contributing to distress in the elderly. Thirdly, using a higher cutoff score of ≥4 was statistically valid toward identifying those elderly with more distress needing recognition in a busy OPD/clinic. This has larger implication for service delivery, especially in a busy OPD/clinic, as it has been to our services, more particularly in a primary care setting in the context of the recently launched National Programme for Health Care of the Elderly.
Other significant contributor in making the articles are: Mariamma Philip, Loganathan Santosh, Bagepally Shankara Bhavani, Kota Lakshminarayanan, Reddy Narayana Nalini, and Palanimuthu Thangaraju Shivakumar of Geriatric Clinic, National Institute of Mental Health and Neurosciences.
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[Table 1], [Table 2], [Table 3]