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Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 29-33

Prevalence of undiagnosed common mental disorders and its association with quality of life among patients attending the arrhythmia clinic of a large tertiary care hospital in Southern India

1 Department of Cardiology, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Electrophysiology, Christian Medical College, Vellore, Tamil Nadu, India
4 Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication22-Jan-2018

Correspondence Address:
Dr. Gopal Chandra Ghosh
Christian Medical College and Hospital Campus, Room No 310, Hospital Annexe, IDA Scudder Road, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_25_17

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Objective: Studies are available from high-income countries exploring the prevalence of depression and anxiety among patients with cardiovascular diseases such as coronary artery disease, heart failure, and atrial fibrillation. Similar data are limited from low- and middle-income countries, particularly India. Data on how the quality of life (QOL) parameters are affected by common mental disorders (CMD) such as depression and anxiety are lacking. The aim of this study is to explore the prevalence of undiagnosed depression and anxiety in patients attending the arrhythmia clinic of a tertiary care hospital in Southern India and to look at their association with QOL. Methods: This cross-sectional study involved 282 patients attending the arrhythmia clinic of a tertiary care hospital in Southern India. Depression and anxiety were assessed using the “Patient Health Questionnaire-9” scale and “Hospital Anxiety and Depression Scale for Anxiety” scale, respectively. Patient demographics and potential risk factors were also assessed. Quality of life was assessed using the “Short Form Health Survey” questionnaire. Results: The proportion of patients with undiagnosed CMD (depression or anxiety or both) in our study was 45.74%. This included 32.98% with undiagnosed depression and 32.62% with undiagnosed anxiety. The presence of depression and anxiety are important determinants of quality of life. Presence of hypertension, diabetes mellitus, or smoking is not significantly associated with a poor quality of life in our study. Conclusions: Depression and anxiety are important associations of a poor quality of life. They are commonly seen among those attending the outpatient arrhythmia clinic. Having a screening program for CMD may assist in early diagnosis and intervention in those attending arrhythmia clinics.

Keywords: Anxiety, arrhythmia, depression

How to cite this article:
Ghosh GC, George DE, Lahiri A, Samuel P, Chase D, Jacob JR. Prevalence of undiagnosed common mental disorders and its association with quality of life among patients attending the arrhythmia clinic of a large tertiary care hospital in Southern India. Res Cardiovasc Med 2017;6:29-33

How to cite this URL:
Ghosh GC, George DE, Lahiri A, Samuel P, Chase D, Jacob JR. Prevalence of undiagnosed common mental disorders and its association with quality of life among patients attending the arrhythmia clinic of a large tertiary care hospital in Southern India. Res Cardiovasc Med [serial online] 2017 [cited 2023 Mar 27];6:29-33. Available from: https://www.rcvmonline.com/text.asp?2017/6/4/29/223780

  Introduction Top

Depressive disorders would become the most common cause of DALY (disability-adjusted life year) by 2030.[1] Cardiovascular diseases such as coronary artery disease (CAD) and congestive cardiac failure are commonly associated with common mental disorders (CMD) such as depression and anxiety.[2],[3] The association of CMD with arrhythmias has however not been well-studied. Patel et al. showed that 28% of atrial fibrillation patients had anxiety disorders, whereas 38% met criteria for major depression.[4] Besides, a certain proportion of patients attending the arrhythmia clinic with cardiac symptomatology lack underlying cardiovascular pathology. The aim of this study was to investigate the prevalence of CMD in patients attending the arrhythmia clinic. We also wanted to look at the association of CMD with the quality of life (QOL) in the same group of patients.

  Methods Top

This cross-sectional study was performed in patients aged 18 years or more who attended the arrhythmia clinic of Christian Medical College (CMC), Vellore between January 01, 2016 and August 31, 2016. Patients diagnosed to have a prior psychiatric illness were excluded from the study. Written informed consents were obtained from all patients before inclusion. The study was approved by the Institutional Review Board and the Ethics committee of CMC, Vellore. The study protocol conforms to the ethical guidelines of the 1975 declaration of Helsinki as reflected in a prior approval by the Institutional Review Board and the Ethics committee of CMC, Vellore.

After obtaining informed consent from eligible candidates, depression and anxiety were objectively assessed using “Patient Health Questionnaire-9” (PHQ-9) and “Hospital Anxiety and Depression Scale for Anxiety” (HADS-A) questionnaire. Quality of life was assessed using “Short Form Health Survey” (SF-36) questionnaire in all patients. All enrolled patients were evaluated for the presence of cardiovascular disease. This helped us to determine the proportion of patients who lacked underlying cardiovascular disease; although, they presented with related symptomatology. Differences were studied between the group of patients with CMD and those without. Diagrammatic algorithm of the study as shown in [Figure 1].
Figure 1: Diagrammatic algorithm of the study

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Cardiovascular disease (CVD) was diagnosed in those who had any one or more of the following:

  1. History of typical angina
  2. Documented CAD by coronary angiogram or exercise stress test or echocardiography
  3. Documented bradyarrhythmia
  4. Documented tachyarrhythmia
  5. Positive electrophysiological study
  6. Diagnosed case of heart failure
  7. Structural heart disease diagnosed by echocardiography.

Short Form-36

This questionnaire has been validated in India by Sinha et al. and consists of 36 items which are divided into eight domains.[5] For each domain, the items were coded and transformed into a scale from zero (worst QOL) to 100 (best QOL), according to the standardization in the questionnaire manual.

Patient Health Questionnaire-9

A simple, quick, and reliable instrument to diagnose depression, made keeping in mind the busy clinicians.[6] PHQ-9 is validated in India with high sensitivity, specificity, and accuracy for screening and diagnosis of depression.[6]

Hospital Anxiety and Depression Scale for Anxiety

HADS-A questionnaire is also validated in India for the screening of psychological morbidities in patients with cancer.[7] Optimal cutoff value for the screening of any anxiety disorder if taken as ≥8, confers a sensitivity of 82% and specificity of 79%.[8]

Statistical analysis

Sample size

A total sample size of 250 patients was required to estimate the prevalence of CMD within a precision of 5% for a 95% of confidence interval (CI).

Analysis of variables

Prevalence of depression was calculated with 95% of CIs. Continuous study variables were summarized using mean with standard deviation and frequency with a percentage for categorical data. Association between baseline characteristics and study outcome (depression, anxiety, and quality of life) were assessed using an independent t-test for continuous variables and Chi-square test for categorical data. All analyses were performed using STATA 11.0 (StataCorp, College Station, Tx, USA).

  Results Top

Socio-demographics and basic clinical characteristics of participants are presented in [Table 1]. The mean age was 50.783 ± 15.10 years. 101 (35.82%) out of 282 participants were female. Nearly 75.53% of participants were educated to higher secondary level or beyond. Around 65.19% of participants were either from middle or higher socioeconomic class.[9]
Table 1: Sociodemographic and clinical characteristics of participants by common mental disorder category

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The proportion of participants with undiagnosed depression using PHQ-9 score >10, was 32.98% and undiagnosed anxiety using HADS-A score >8 was 32.62%. Overall, 129 (45.74%) participants had either depression or anxiety or both [Figure 2].
Figure 2: Column chart showing prevalence of common mental disorder

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The mean QOL score by using the SF-36 questionnaire in our population was 56.67 ± 15.98. The mean score was significantly different between the groups of patients with CMD as compared to those without (49.23 ± 14.71 vs. 62.89 ± 14.27, P < 0.001). Among the QOL parameters, all scores were significantly inferior for patients with CMD than without, except for physical functioning [Table 2].
Table 2: Quality of life parameters of participants by common mental disorder category

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Multivariate analysis showed that after adjusting for age, sex, socio-economic status, and alcohol consumption, those with CMD had a significantly lower QOL (beta coefficient = −12.61 [95% CI: −16.09, −9.12]) [Table 3].
Table 3: Multivariable analysis of factors associated with quality of life

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In this study, 65 (23.05%) patients presented to the arrhythmia clinic with cardiovascular symptoms; although, they did not have any cardiovascular diagnoses [Table 4]. Out of these 65 patients, 19 (29.23%) patients had anxiety, 19 (29.23%) patients had depression and 27 (41.53%) patients had both anxiety and depression. Mean QOL was 49.5 ± 13.23 for these group.
Table 4: Distribution of patients and quality of life scores, with respect to cardiovascular disease and common mental disorder

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A total of 139 (49.3%) patients had underlying cardiovascular disease. In this subgroup, the mean QOL by SF-36 in patients with CMD was 48.97 ± 16.16 versus 62.71 ± 14.57 in those without. The difference was statistically significant with a P < 0.001. In the sub-group of patients with CMD, the QOL was not significantly different in patients with and without CVD – the same was true for the sub-group without CMD. This implies that the QOL was probably affected more by the presence of CMD than by the presence of CVD.

  Discussion Top

To the best of our knowledge, this is the first cross-sectional study from India to document the prevalence of CMD like depression and anxiety in patients attending the arrhythmia clinic of a tertiary care hospital.

A large population-based urban study from Chennai revealed the prevalence at 15.1% in the general population.[9] A study from Vellore showed the prevalence of CMD among primary care attendees was 33.9%. Depression (83.8%) was the most common mental disorder diagnosed.[10] Prevalence studies from India showed that depression (prevalence 23%–33.8%) was one of the most common mental disorders among patients attending outpatient department in secondary care level hospitals.[11],[12] There is, however, a dearth of data on the prevalence of CMD in the tertiary care setting.

Prevalence studies on anxiety disorders are severely lacking in the Indian context. Salve and et al. have reported a prevalence rate of 14% among patients attending the psychiatric outpatient department in northern India.[11] A meta-analysis revealed the prevalence of anxiety disorders in both rural and urban India to be around 20.7% (18.7%–22.7%).[13] In our study, the prevalence of depression and anxiety were 32.98% and 32.62%, respectively, which were higher than epidemiological population-based studies reported in different primary and secondary care centers in India.

Depression is associated with decreased adherence to medications, prevents successful modification of other cardiovascular risk factors, reduces participation in cardiac rehabilitation programs and is associated with higher healthcare utilization. It poses a higher cost burden for patients besides reducing their quality of life.[14] Patients with high screening scores (PHQ-9 score of 10 or higher) should be referred for a more comprehensive clinical evaluation by a psychiatrist to determine an individualized treatment plan. Such patients should also be evaluated for other mental illnesses like anxiety.[14]

The medical outcome survey SF-36 has been widely validated as a QOL assessment tool. Albrecht and Fitzpatrick have suggested that QOL be an outcome measure in clinical trials to assess the health needs of a population.[15],[16] In this study, patients with CMD have significant impairment in all QOL parameters (SF-36 score: 49.23 ± 14.71 in CMD group vs. 62.89 ± 14.27 in patients without CMD) [Table 4]. After adjusting for age, sex, socioeconomic status, and alcohol consumption, the presence of CMD was significantly associated with poor QOL (beta coefficient = −12.61 [95% CI: −16.09, −9.12]) [Table 3].

Indian studies have revealed that depression is an important determinant of poor quality of life in patients with type II diabetes mellitus, people living with HIV and AIDS, and patients with the chronic obstructive pulmonary disease.[17],[18],[19] The study suggests that the presence of CMD in patients with underlying CVD is associated with moderate impairment in QOL (SF-36 score: 48.97 ± 16.16 vs. 62.71 ± 14.57, P < 0.001, in patients without CMD) [Table 3].[20] The presence of CMD impaired all QOL parameters as depicted in [Table 2]. Not only mental dimension parameters but also physical dimension parameters were also equally affected by the presence of CMD. This implies that CMD have a negative impact on physical functioning as well.

Nearly 23.05% of patients (65 patients) presented to arrhythmia clinic with symptomatology related to the cardiovascular system such as palpitations and dyspnea, but they did not have any underlying cardiovascular disease. All these patients had underlying depression or anxiety and poor QOL (mean QOL score 49.5 ± 13.23). Hence, our study revealed that almost one-fourth of our arrhythmia clinic patients had CMD without underlying cardiovascular diseases. Depression and anxiety disorders can commonly masquerade as a cardiovascular disease with symptoms like palpitations.[21],[22] Hence, patients in an arrhythmia clinic may need simultaneous screening for CMD as well.

Strengths and limitations

To the best of our knowledge, this is the first study from India to document the prevalence of CMD in patients attending the arrhythmia clinic. We objectively measured QOL of patients and looked for the association of common mental disorders with the quality of life. Very few studies from India have data on objective quality of life measurement by SF 36 questionnaire. Hence, it will help further studies in this field.

The study has limitations. This was a cross-sectional study from a single center; thus, we may not be able to generalise this data widely. Also being an institutional survey, referral bias remains. We did not compare our results with a normal population cohort, and the sample size could have been larger.

  Conclusions Top

  1. Undiagnosed CMD like depression and anxiety are quite prevalent in patients attending the arrhythmia clinic. Around one-fourth of our outpatients have undiagnosed CMD without any underlying cardiovascular disorder, although they presented with cardiac symptomatology. Hence, having a high index of suspicion coupled with routine screening will help identify these conditions early and optimise their treatment
  2. Patients with CMD have poor QOL and irrespective of the presence of cardiovascular disease, and the presence of CMD is an important determinant of the same.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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