Warning: include_once(../article_type.php): failed to open stream: No such file or directory in /home/suxhorbncfos/public_html/ijoprs/IJOPRS.MS.ID.555579.php on line 80
Warning: include_once(): Failed opening '../article_type.php' for inclusion (include_path='.:/opt/alt/php56/usr/share/pear:/opt/alt/php56/usr/share/php') in /home/suxhorbncfos/public_html/ijoprs/IJOPRS.MS.ID.555579.php on line 80
Detecting Psychiatric Comorbidity in Persons
with Respiratory Diseases Using the New Free for
Use Nimhans Screening Scale
Gayatri Saraf1, Santosh K Chaturvedi2*, Harish T2, Uma Buggi3 and Shashidhar Buggi3
1Maharashtra Institute of Mental Health, India
2National Institute of Mental Health and Neuro Sciences, India
3Rajeev Gandhi Institute of Chest Diseases, India
Submission: May 19, 2017; Published: July 27, 2017
*Corresponding author: Santosh K Chaturvedi, National Institute of Mental Health and Neuro Sciences, Bangalore, India
How to cite this article: Jolanda N, Hasan H, Roland H.Lung Function in Combined Pulmonary Fibrosis and Emphysema Syndrome, What to Expect. Int
002 J Pul & Res Sci. 2017; 2(1): 555578. DOI:10.19080/IJOPRS.2017.02.555578
Background: Despite the high prevalence and morbidity of respiratory disorders, the psychological aspects have not received the same attention as other areas of general medicine such as heart diseases or cancer.
Aim/Objectives: To assess the psychiatric morbidity in outpatients with respiratory diseases using the NIMHANS screening scale.
Methods: Patients were consecutively selected from outpatient services of a tertiary care respiratory disease hospital over a period of 9 months. Patients were screened by a qualified psychiatrist for psychiatric morbidity using a 21-item screening scale. The 21 item screening scale has screening questions to assess for depression, anxiety, psychosis, substance use and chronic pain.
Results: A total of 85 patients were assessed. Majority of the patients were males (68%), with a mean age of 42.6 (±16.0) years, belonged to lower socio-economic strata (89%), were married (83%) and came from an urban background (73%). The most common respiratory diagnosis was pulmonary tuberculosis (52%), followed by chronic obstructive pulmonary disease (27%). 48% had a concomitant psychiatric diagnosis, 9% had been referred by the chest physician for psychiatric evaluation. 43% had substance abuse, the commonest being nicotine (25%). Mean score on NIMHANS screening questionnaire was 10.0±6.1. The tool was found to have a sensitivity of 0.71 and specificity of 0.77 in this population
Conclusion: NIMHANS 21 items scale is useful in detecting psychiatric co-morbidity in patients with respiratory diseases. Though psychiatric comorbidity including substance use in respiratory diseases is high, the rates of psychiatry referrals are quite low. Our study highlights the need to screen for psychiatric disorders in respiratory disease patients. Development and validation of short screening instruments for use by chest physicians and psychiatrists in medical settings would help in early detection and prompt treatment of psychiatric disorders in these settings.
Keywords: NIMHANS: National Institute of Mental Health and Neuro Sciences; ATT: Anti Tuberculosis Treatment
Respiratory diseases are common, disabling and have far-reaching impact on an individual’s ability to perform the vital function of respiration independently. In respiratory disorders, functioning is impaired because of chronic pain breathlessness, dependence on nursing personnel and frequent hospitalisations .
Psychiatric issues are common in patients with respiratory disease . Prevalence rates of as high as 19-40% for depression and 28-36% for anxiety have been reported in patients with COPD [3,4]. In a study, subclinical depressive symptoms that do not meet the diagnostic criteria were found to afflict as high as 25% of patients having COPD . Studies also indicate significant comorbidity between asthma and anxiety, especially an elevated prevalence of generalised anxiety disorder and panic disorder [5,6]. Tuberculosis is also associated with a high rate of depression and anxiety [7,8]. In addition, psychiatric disorders and substance use lead to poor adherence to Anti Tuberculosis Treatment (ATT) and are associated with poor outcomes . Comorbid psychiatric conditions also lead to greater disability .
There is a paucity of literature in the area of prevalence and
correlates of psychiatric disorders in respiratory diseases. Most
screening scales for psychiatric morbidity are very expensive.
The objective of this study was to assess the pattern of psychiatric
comorbidity in respiratory diseases using the National Institute
of Mental Health and Neuro Sciences (NIMHANS) screening
NIMHANS screening scale is a 21-item scale, with questions
aimed at assessing for psychiatric caseness. It was reduced from
28 items. Item reduction and analysis was done on the developed
28 NIMHANS screening tool for psychological problems. It was
administered on 50 normal subjects above 18 years of age. The
tool was developed in English, Hindi and Kannada languages
using back to back translation. Split half reliability of the tool
is 0.84. Score of 11 and above indicates presence of psychiatric
distress in normal populations. Discriminate validity has been
developed with sensitivity of 0.76 and specificity of 0.82 .
It is free of any charges and can be obtained by writing to the
All patients then underwent a detailed psychiatric evaluation
to assess for psychiatric morbidity. Psychiatric diagnosis was
given after a psychiatric interview as per the ICD-10 classificatory
system. Appropriate interventions were done for patients
including pharmacotherapy and psychological interventions.
The study was approved by the institutional ethics committee
of Rajeev Gandhi Institute of Chest Diseases, Bengaluru, India.
Majority of the patients were males (68%), with a mean
age of 42.6 (±16.1) years, belonged to lower socio-economic
strata (89%), were married (83%) and came from an urban
background (73%). The mean years of education were 6.5 (±4.8)
years, and the mean duration of the respiratory disease was 41
(±66) months. The most common respiratory diagnosis was
pulmonary tuberculosis (52%), followed by chronic obstructive
pulmonary disease (27%). 21% of the subjects had diagnosis
such as infection, allergy, malignancy and pleural effusion. 19%
of them also had a comorbid medical diagnosis such as diabetes,
hypertension or dyslipidemia. Though 48% had a concomitant psychiatric diagnosis as per clinical assessment, only 9%
had been referred by the chest physician for evaluation. The
commonest psychiatric diagnosis as per ICD-10 classificatory
system was adjustment disorder (32%), followed by major
depression (25%) and anxiety disorders (25%). 43% had
substance abuse, the commonest being nicotine (25%).
Of the 31 patients who were smokers, 14(45%) qualified
for a psychiatric diagnosis (p-0.822%). Half (50%) of the 30
patients with tuberculosis qualified for a psychiatric disorder,
however this was not statistically significant (p-0.824). A total of
33 patients scored above the cut-off score of 12 on the NIMHANS
screening instrument of which 25 had a psychiatric diagnosis
by clinical interview. Mean score on NIMHANS screening
questionnaire was 10.0±6.1. The tool was found to have a
sensitivity of 0.71 and specificity of 0.77 in this population at a
cut-off score of 12 (Table 2).
The study demonstrates a high prevalence (48%) of
psychiatric disorders in patients with respiratory diseases. This
is in line with previous studies which have demonstrated a high
prevalence of depression [12,13], anxiety [3,14], panic attacks
 and substance use  in respiratory diseases. Perhaps due
to the high comorbidity between respiratory and psychiatric
disease, the Global Initiative for Chronic Obstructive Lung
Disease guidelines recommend that all COPD patients should be
assessed for feelings of depression and anxiety .
Half of the patients with tuberculosis were found to have
a psychiatric disorder. This confirms previous studies which
have found a high psychiatric morbidity in tuberculosis. Factors
such as stigma, isolation, psychological reaction to disclosure
of diagnosis and side effects of Anti Tuberculosis Treatment
(ATT) are said to explain higher rates of psychiatric morbidity.
Psychiatric disorders when present may adversely impact
adherence, leading to relapse and multi-drug resistance.
We found a high prevalence of substance use disorders
(43%) in patients with respiratory disease, the commonest being
nicotine (25%). Close to half (45%) of smokers in this study
qualified for a psychiatric disorder. Approximately 10-15% of
smokers develop COPD . Smokers are also at a higher risk of
developing lung cancer, interstitial lung diseases and bronchial
asthma . Moreover, smokers also benefit from quitting in
terms of improvement in lung parameters . Towards that
effect, smoking cessation programs have been found to be useful
in respiratory diseases .
Recognising psychiatric disorders in general hospitals
becomes difficult because Psychiatric services may not always be
available. Moreover, even in hospitals where liaison services are
present, it is not feasible to screen all patients due to cost, time
and manpower involved. Hence screening instruments validated
for use in the respiratory disease populations are needed in
order to rapidly assess and detect psychiatric disorders [11-14].
These screening instruments need to be simple, effective and
easy to use by physicians and general practitioners in primary
care and chest medicine settings where a qualified psychiatrist
might not always be available. There is a need for setting upconsultation-
liaison services in chest medicine hospitals.
Psychiatric morbidity is common in patients with respiratory
disorders, however most are not detected or referred by the
physicians. The NIMHANS screening scale is an effective, way of
rapid assessment and screening in respiratory diseases, at no
cost. The tool also has a good sensitivity and specificity in this
population, which render it useful in these settings.