Outlook Regarding Mental Illness In Patients And Caregivers In Eastern Nepal

Introduction: Mental health is an integral component of overall health. Various factors along with stigma affect knowledge, perspectives and behavior of the people ultimately affecting help seeking and treatment. The patient and their caregivers are directly involved in overall management and outcome. Hence ascertaining those aspects among them is important and so are aims of this study. Material And Method: A cross sectional comparative study was carried out among 160 participants (80 patients and 80 caregivers) visiting neuropsychiatry outpatient department of a tertiary care hospital. Data was collected through semi-structured proforma and Attitude towards mental illness questionnaire (modified). Data were analysed by using SPSS version 25 and Microsoft excel. Results: The socio-demographic profiles between both groups were similar. About 75% from both the groups had good knowledge about mental illness. Almost 60% from both groups had positive perception/attitude regarding mentally ill and mental illness with an only significant difference in relation to rights to mentally ill. More than 70% from both groups had positive attitude regarding help-seeking with only significant difference in view about people with mental illness seeking help from psychiatrist. About 50% from both groups had positive attitude regarding care and treatment. Conclusion: With good knowledge and positive attitude/perception regarding mental illness, self-stigma persisted regarding some domains. Despite positive attitudes for help-seeking, ambivalent views regarding care and treatment into both groups necessitate easy accessibility and upgrading of mental health services


INTRODUCTION
According to the World Health Organization (WHO), Mental health is "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community". 1 Mental, neurological, and substance use disorders make up 10% of the global burden of disease and 30% of non-fatal disease burden. Nearly 25% of individuals, in both developed and developing countries, develop one or more mental or behavioral disorders at some stage in their life. 2 Mentally ill people are labeled as "different" from other people in society and are viewed negatively, even by their own family. Many often take mental health for granted and don't worry about the components of mental wellbeing until problems surface. 3 Various studies regarding knowledge, attitude, and helpseeking behavior regarding mental health were conducted in different subgroups of the population worldwide. Most studies have concluded knowledge being poor and attitude being mixed based on various factors. The stigma, discrimination, and social exclusion related to mental illness are recognized as a major public health concern. 2 These affect the knowledge, perspective, and behaviour of the

ORIGINAL ARTICLE
people directly or indirectly involved in mental health issues and will also impact help seeking, treatment, and overall management. The extent to benefit from mental health services is influenced not only by the quality and availability of services but also by the knowledge and belief systems of the people. 4 Better knowledge is often reported to result in favorable attitudes towards mental illness and a belief that mental illnesses are treatable can encourage early treatment-seeking and promote better outcomes. 5 Assessing public knowledge and attitude would be the pre-requisite as their practices are influenced accordingly. Studies involving the affected individual and their caregiver are scarce and assessing their perspectives about mental health is important as they are involved directly in treatment and this may influence the ultimate outcome. The purpose of the study was to assess and compare the knowledge, perspectives, and practices regarding the mental illness of patients and caregivers visiting the Neuropsychiatric outpatient department. This study would be useful in making strategies for improving mental health awareness, tackling stigma, and emphasizing mental health promotion at the hospital setting and also at community levels.

MATERIAL AND METHOD
Design and sampling: This was a prospective open-label cross-sectional study conducted in the Neuropsychiatry department of Tertiary care hospital in the easternmost part of Nepal from July to December 2019. Cases coming to Neuropsychiatry OPD were included. The inclusion criteria were-i. Age: 18-60 years ii. Willing to give written consent. The exclusion criteria were -i. severe mental illness (schizophrenia, bipolar disorders, severe depression, etc) ii. Clinical diagnosis of mental retardation iii. Last psychoactive substance use within 1 month (except tobacco). The sampling method was convenience sampling. The total duration of sample collection was three months and three weeks (10 th august-30 th November 2019). Out of 180 participants, 160 participants (80 patients and 80 caregivers) met the criteria in the study. Procedure: The study was approved by the Institutional review board. After ascertaining inclusion for the study, written informed consent was taken from the patient as well as the caregiver stating their willingness to participate in the study after they were informed about the nature of the study and its purposes. They were also ensured that all information would be kept anonymous and used for research purposes only. A face to face interview was conducted with the patient and immediate caregiver for demographic profiles followed by Attitude towards mental illness questionnaire which were given to them to assess their understanding of mental health and mental illnesses. In cases of uneducated participants, interpretation and marking was done by the interviewer.

Materials:
The following tools were used: Semi-structured proforma: consisted of sociodemographic variables as age, gender, marital status, ethnicity, occupation, income, and religion.

Attitude towards mental illness questionnaire (modified):
It is a self-administered questionnaire with 47 items. The tool was originally adapted from Weller and Grunes's Attitudes to Mental Illness Questionnaire 6 . It was revised later to reflect more of the sociocultural aspects in different societies. It has a reliability of 0.79. The questionnaire was translated into Nepali and independently backtranslated by professional translators. It consists of 5 sections: a. knowledge about mental illness with 9 items. In this section, the mean percentage score of favourable response will be calculated and qualitative descriptions assigned as good knowledge to them. b. Perceptions toward mentally ill people with 8 items. c. Attitudes toward mental illness with 13 items d. Attitudes toward mental health help-seeking with 6 items e. Care and treatment of mental illness with 11 items. For all other sections agreeing for favourable statement and disagreeing for an unfavourable statement was taken as positive perception\attitude whereas agreeing for unfavourable statement and disagreeing for a favourable statement was taken as negative perception\attitude. The mean percentage score of both perception\attitude will be calculated. The first section items were dichotomous questions whereas rest all sections were in 5 points Likert scale with respective scales as very much agree, agree, have no opinion, disagree, very much disagree. Later for brevity three scales were used, both degrees of agreeing as one and both degrees of disagree as one. The obtained data were fed and analyzed by Microsoft excel and Statistical Package for the Social Sciences software (SPSS) version 25. They were analyzed by descriptive statistics as frequency, Percentage, Mean ± standard deviation. For inferential statistics student t-test, chi-square test, and Fischer exact test with 95% confidence intervals were used appropriately. As shown in Table 1, there were no significant differences between patient and caregiver groups in terms of baseline socio-demographic variables.     Table 2, more than three fourth from both the groups believed mental health is an essential component of health, mental illness is caused by a brain disease, anyone can suffer from a mental illness, and mental illness is not caused by God's punishment \ghost -spirits. More patients than caregivers (85% vs 71.3%) think all mental disorders are caused by stressors and mental illness is caused by a personal weakness ( 56.3% vs 40%) but was not statistically significant. Almost two-third of the patients and more than two-thirds of caregivers (63.7 vs 67.5) don't think mental illness is caused by poverty. More than two-thirds (almost75%) of the participants from both groups had good knowledge about mental illness with no significant difference. As shown in Table 3, majority of patients had positive perception for items 3,5,7,8 and negative perception for items 1, 2, 6. However, regarding item 4, positive and negative perceptions were almost equal (42.5% vs 45%). The majority of caregivers had positive perceptions for all items except item 6. The overall majority of the patients (59%) and the majority of caregivers (62.5%) had positive perception towards mentally ill with no significant difference between the two groups. As shown in Table 4, the majority of patients had positive attitudes for all items except item 6,8,9,10. Almost equal patients (42.5 vs 37.5) had both positive and negative attitudes regarding item 6.The majority of caregivers had positive attitude for all items except item 8. Regarding item 8, the almost equal caregiver had a negative attitude (35.0%), followed by don't know response (33.7%) and positive attitude (31.3 %).

RESULT
There was a significant difference in attitude between two groups about people with mental illnesses having the same rights as anyone else. The overall majority of the patients (58%) and majority caregivers (60%) had positive attitude towards mental illness with no significant difference between the two groups. As shown in Table 5, the majority of participants (more than 70% ) from both the groups had a positive attitude toward mental health helpseeking and less than 25% had a negative attitude toward mental health help-seeking from each group. There was only a significant difference in attitude between two groups regarding help-seeking from psychiatrists by mentally ill people. As shown in Table 6, the majority from both groups had a negative attitude for items 1, 2, 3, 4 and 10. The majority of both groups had a positive attitude on items 5,6,7,9. The majority of the patients and the caregiver agreed on item 8. Almost equal patients and caregivers (44% and 40% vs 45% and 44%) were divided in their views regarding mentally ill people should be in an institution where they are under supervision and control. The overall majority had a positive attitude (47.7% vs 48.6%) whereas (41.7% vs 40.3%) in the respective group had a negative attitude to care and treatment.

DISCUSSION:
The concept of no health without mental health priorities mental component of overall health 7 but the understanding and acceptance of this concept is lacking worldwide. Knowledge and belief system are the utmost in determining the perspectives and practices of an individual towards mental health issues. Studies from Western societies have shown that biological factors were regarded as causal for mental illness 5,8,9 , while in African countries stress, drug/substance abuse 10, 11 supernatural causes were considered. 12,13 Not only in Africa, but the considerations of supernatural causes are also worldwide and similar views are from our part of the world also. 14-16. The concept toward mental illnesses and its causal factor seem to change towards biological factors in the last decades 17,18 which was also reflected in our study. The knowledge was good among both the groups with most identifying mental health as a component of health and no one being immune to mental illness which points to acceptance similar to other physical illnesses. Most attributed mental illness as brain diseases and least pointing ghosts and spirit as a causal factor. More than two-thirds of patients believed stressor was causal factor for mental illnesses which was almost significantly different than of caregivers. One of the reasons for better understanding in our study may be direct or indirect involvement of the participants in the management and the other may be easy accessibility of information in multimedia.
The majority of patients and caregivers had positive attitude and perception regarding mentally ill people and mental illness, more in caregivers (62.5% and 60.6%) than in patients (59% and 58%). This contrast many previous studies where negative views were prominent 10,11,19,20 and studies where the views were mixed. 18,21 Majority patients had negative perceptions of blaming themselves for mental health condition, physical appearance as determinant of mental illness, and been usually dangerous. The majority patients disagreed marrying mentally ill and agreed not wanting to let others know about their mental illness which points to negative views about social participation in the community. These points toward self-stigma been high regarding those domains in patients themselves. Regarding caregivers majority had a negative perception about people with mental illness being dangerous similar to previous studies 14,22,23 while regarding marriage almost equal had a negative attitude (35.0%) followed by an uncertain response(33.7%). The only difference in view between the two groups was regarding similar rights to mentally ill person where majority patients (95%) believed they should have same rights as others and this points to a positive attitude towards counteracting selfstigma whereas almost one-fifth caretakers did not believe so reflecting stigma within the family. The positive help-seeking attitude was in more than two-thirds of participants from both the groups. The majority of participants from both groups had a positive attitude to seek help with professional as would do for a physical illness which points that public attitudes towards helpseeking for mental issues had positively changed over the last decade. 14,24,25 The difference existed between two groups regarding seeking psychiatric help. The majority of patients were aware to go for psychiatric help if they recognize they had mental health problems but still identifying symptoms as of mental illness remains a major challenge. Most choose to go for treatment as they interpret symptoms initially or depends on suggestions from others. Majority caretakers also believed the same but almost one-third caretakers didn't believe they would approach psychiatrists but prefer other ways of treatment which may be due to similar reasons or they tend to avoid psychiatric help due to fear of being labeled as mentally ill. Normalization of help-seeking and knowledge about timely professional help and treatment can be an effective means that had been growing. Social acceptance can prove vital to further increase in help-seeking attitude. Still, more than one fifth felt going to a traditional healer in case of mental illness which reflects the dominance of cultural and religious healing persist in this group. The majority believed that information and services for mental health are lacking at the local level which was similar to previous study 18 and even lack of sufficient services at higher levels of care. This reflected the low priority of mental health and its scarce treatment resources. The majority believed mental illness was treatable and more than two-third considered mental illnesses can recover. Positive attitude towards treatment and outcome whereas negative attitude towards services may impact treatment behaviour 26, 27 and a similar scenario had been in our study which may be the reason for the treatment gap. The majority from both groups still think treatment outside the hospital is not possible which reflects care at lower level centers and other places beyond the hospital without professional was not possible supporting hospital-based treatment. The other way of interpretation may reflect inpatient care needed in severe mental illnesses in which treatment outside the hospital may not be feasible and might be dangerous for the public. Whereas views regarding treatment under institutional supervision and control were divided reflecting almost two-fifth believing in care at community and family level was still possible. The overall perception of care and treatment was almost equally divided into both groups.

LIMITATIONS:
This was a hospital-based study involving patients and caregivers involved in treatment. More extensive studies in larger samples representing most subgroups of the population are needed for generalization. In uneducated cases, there may be a possibility of bias in interpretation and marking of responses.

CONCLUSION:
This study showed there was a good understanding of mental illness and its causes.
The majority in both groups had a positive attitude and perception regarding mentally ill and mental illness whereas self-stigma persisted in some domains. Thus there is a need to promote mental health education focusing on those aspects to reduce self-stigma among patients. More than two-thirds had a positive attitude for help-seeking and recovery but views regarding care and treatment were almost equally divided. The information regarding the availability of mental health services should be easily accessible and referral should be encouraged at local health centers. Furthermore, the recommendation for upgrading mental health services should be advocated.