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CHAPTER 1

INTRODUCTION
Depressed individuals in silence, waiting for nearly one year before seeking
professional help:
Health in partnership with Eli Lilly and Company and Boehringer Ingelheim, showed
that people with major depressive disorder, on average, waited more than 11
months to see a doctor and were May 2005 An international survey,
conducted by The World Federation of Mental only diagnosed with
depression after five visits to the doctor, further delaying treatment. The
survey also revealed that nearly 72% of people with major depression did not
believe, prior the diagnosis, that painful physical symptoms such as,
unexplained headache, back ache, gastrointestinal disturbances and vague
aches and pains, when a common symptoms of depression

Health has been defined in the World Health Organization (WHO) Constitution
as a "State of Complete Physical, mental and social well-being". Yet the
provision of an adequate psychiatric care has usually been given a low priority
in developing countries including Nepal. Nepal has largely focused on the
physical aspects of health, hardly, care of physical illness and problems.
.

Depression is an illness, which is for beyond the usual feeling of being sad or
unhappy. This is fact a clinical syndrome, which comprises of various
psychological, biological and behavioral symptoms, which persist of minimum
duration of two weeks. Depression symptoms are feeling persistently low,
decreased interest even to carry out routine activities, easy fatigability,
decreased drive and energy, decreased sense of cocentration, pessimistic ideas
a, heaviness/pain over different body parts, decreased appetite, sleep
disturbances etc. About 6% of general population suffers from it. Females are
more prone to depression as compared to male.

Attitude is the concept or preparation and belief that one has about certain
things, which are not genetically transmitted. Attitude can be learnt socially
transmitted.
The attitude of the person influences various aspects of human life. A person's
attitude also influences people's health and hygiene. However, many people are
not aware that the attitude of a person can affect mental health.

Depression is the oldest and has frequently described psychiatric illness


(Belcher and Hold craft, 2001). The existence of depression has been
documented since biblical period and has been defined by religious writers,
philosophers and scientists (Mahendra, 1986). Depression and mental illness is
an emerging issue in health problem. It has been affecting to many people such
as young and old, rich and poor, men and women. It is reported that the 15 per
cent of the general population are victimized at any one time (Austera,
(http://www.studenthealth.co.uk/leaflets/depression.htm, 21.02.2005).
It is estimated that 5 to 10 per cent of the population in the communities at any
given times suffer from identifiable depression needing psychiatric or
psychological interventions. The lifetime risk of developing depression is 15 to
17 per cent in females and slightly less than in males (South East Asia region,
2001). Depression is undiagnosed and untreated among the community people
in both rural and urban due to certain misconception about mental illness,
which affect them in seeking medical treatment and such misconceptions are
directly concerns to its causative factors. No single cause is accountable for
depression causing depression. It is reported that the depression emerges during
childhood (Upadhaya, 2002). Depression is recognized as major cause of heart
disease and rank fourth position. Much evidence reveals that depression rates
are likely twice as high in women as that of men. The women is more likely

chances of being depressed as a result of physical and sexual abuse, domestic


violence, poverty, family burden and workload and single parenthood.
Similarly, it has also been reported that hormonal, genetic, biological and
reproductive systems of women also contribute to be depression higher than for
men. Furthermore, women are most likely to be depressed as a result of
infertility, miscarriage and menopause. This means there is a higher chance of
depression in married women than single (http://www.add-adhd-helpcenter.com/Depression/Women.htm, 2/21/2005).
The study also reveals that the use of drugs, alcohols and violence particularly
in men are common factors for causing depression in men. Similarly, there is a
high practice of hiding depression weaknesses by men as compared to women.
The majority of people who commit to suicide are mainly due to unhappy,
isolation, sadness and emotional feeling. The suicidal rate is reported to be
high,

in

male

than

for

female

(http://www.add-adhd-help-

center.com/Depression/Men.htm 2/21/2005). And 44, however the rates of


occurring depression during childhood among boys and girls are equal.
In Nepal, it is estimated that over seven million people are need of mental
health services and 50 per cent of them under age of 35 (The Rising Nepal, 20
February 2005). The depression is responsible to weaken the immune systems
making the body more susceptible to physical illness. Depression is also linked
with the age of individuals. It is reported that depression in women most likely
occurs between the ages of 25
Depression is the leading cause of disabilities in women and suicide is the most
common among men who are separated, widowed, divorced and one in seven
men will develop depression within six months of becoming unemployment. In
elderly people, depression occurs in about 15 per cent of those over the age of
65 and elderly people with depression have about 50 per cent higher health care

costs

(http://www.add.adhd-help-center.com/Depression/statistics.htm,

21.02.2005).
.
1.2

Statement of the problem.


A study of socio- demographic aspects and attitudes of family members
towards depressive patient.

1.3.

Objective of the study.


General objective: The overall all objective of this study is to assess the
attitude of family members towards depressive patients.
Specific objectives:
To assess the socio demographic characteristics of the family
members of depressive patents/ and depressive cases as well.
To study the attitudes of family members of depressive patient.
To find out family members involvement in the care of depressive
patient.

1.4.

Significance/Importance of the study.


Depression is an illness, and it is very common psychiatric problem. It
affects about 10 to 15 % of all men, and 20 to 30 % of all women at
same time during their lives. It hurts families and carriers; it destroys
people. Mental health is an important part of the health, and also mental
health is the second leading cause of global burden in the world. Among them
depression is the most common illness and about six per cent of the total
population of Nepal is suffering from major depressive disorder. Every year
30,000 people commits suicide, suicide is the third leading cause of the death
in adolescents. In our society mentally ill patients are stigmatize socially.

Many family members think that mentally ill patents are no longer
productive and they are not equal like human beings are before, so there
is no need to show love, concern and sympathy.

Depression runs in families, which may be either the result of genetics


of family socialization. Those with close family members who are or
have been depressed are about twice as likely as the average individuals
to become seriously depressed themselves. Still, just because a person
has family members week depression does not garneted that he or she
develops it. Similarly a person may get depression even if no one else in
his or her family has experienced it. Depression in women-Contrary to
popular belief, clinical depression is not a "normal part of being a women" nor
is it a ' female weakness", Depressive illness are serious medical illness that
affect more than 19 million American adults age 18 and over each year.
Nepal is developing countries with few mental health professionals and
resources this is due to the lack of awareness, geographical differences; people
are less access to health education information regarding mental health and
mental health services. Inadequate knowledge and inadequate mental health
professional, inadequate coverage of health services and In other sense, due to
the, changing life style and competitive life patterns and some other problems
like conflict due to political situation in nation may also be contributing
factors for occurrence of depression. Limited resources are responsible for
increasing mental health problems. Working experience for last twelve years
in the mental health area inside and outside the Katmandu (health centers of
eastern region, Western region, central region) the investigator has observed
many cases of depression, so that it has inspired to do the research in this area.
It has been proved that depression is one of the emerging concerns and a great
interest for global health study. Suicidal and mental depression are correlated
to economic situation, family and working environment, ages and physical
conditions of the people, it is therefore, interested to assess and identify the
attitudes of family members towards depressive patients.
It is said that the mental health related data in Nepal have not been well
disclosed; some few research also not included the attitudes regarding family

members towards depressive's patients. Therefore, it is essential to give


priority for doing research in this aspect.

Chapter 2
Review of literature
The group of symptoms which doctors and therapist use to diagnosis
depression (depressive symptoms''), which includes the important proviso that
the symptoms have manifested for more than a few week and that they are
interfering with normal life, normal variation in brain chemistry. This alteration
is similar to temporary, normal variations in brain chemistry which can be
triggered by illness, stress, frustration, or grief, but it differs in that it is self
sustaining and does not resolve itself upon removal of such triggering events 9
if any such trigger can be found at all, which is not always the case.)
Instead, the alteration continues, producing depressive symptoms and through
those symptoms, enormous new stresses on the person:
Unhappiness, sleep disorders, lack of concentration, difficulty in doing one's
job, inability to care for one's physical and emotional needs, strain on existing
relationships with friends and family. These new stresses may be sufficient to
act as triggers for continuing brain chemistry alteration, or they may simply
prevent the resolution of the difficulties, which may have triggered the initial
alteration, or both.
The depressive brain chemistry alteration seems to be self-limiting in most
cases: after one to three years, a more normal chemistry reappears, even
without medical treatment. However, if the alteration is profound enough to
cause suicidal impulses, am majority of untreated depressed people will, in
fact, attempt suicide, and as many as 17% will eventually succeed. Therefore,
depression must be thought of as a potentially fatal illness.
"Mental neurological and psychosocial disorders constitute an enormous public
health burden for both developing and developed nations. A review of the
evidence demonstrates that the implementation of a comprehensive program of
prevention, based on currently available methods, could produce a significant

reduction of suffering, destruction of human potential and of the consequent


economic loss produce.
How you can improve the mental well-being of people close to you Just listen
Tragedies such as suicide can be avoided. Much heartache can be averted. To
do so require your commitment as practitioner that is a healer who actively
practices his or her life's work. And the most important part of ministering as a
doctor, nurse or health worker may well is LISTENING.
Whether people are a part of your family good friends, colleagues, neighbors,
acquaintances, clients or patients, the moment you agree to be there with when they
need to talk, you have entered into a special union. And the responsibility of that bond
is to hear what they have to say.Neurotic depression is thought to be related to some
significant loss in the person's life, either past or present. The onset of the illness is
influenced

by

environmental

factors.

http://www.drmarkhillman.com/depressionfactors.html
Chapagai G S (1997) Study of risk factors and precipitating factors for depression.
In this study supported the belief that depressive illness was more common in
female(90% of total cases) than males and the commonest age is 30-45 age
group(44%). More than 55% of the cases had a joint family with the number of family
members more than 8.
Depression illness was found to be more prevalent in case who got married in their
childhood. In this study 55.5% of cases got married before the age of 14 years
WhereasThe cases who got married after 22 years of age were only 11%. In this study
people with depressive illnesses are tended to be highest case. It might be because
depression was more purulent in people of higher cast or people of social spiritual and
household beliefs. According to distribution of cases by cast. Brahmin and newar

were 33.3% each Tamang being 16.6% Chhetri 11.1, and 5.5 untouchables ( Kami,
Damai)
Most of the study cases had good relationship with their family members except
22.2% of cases who had bad relationship. So far as relationship of the patients with
their neighbors was concerned, 39% of them had bad relations. 28% did not care their
relationship and the rest of them had good relationships with their neighbors.
Study shows that around 22% of cases correlated their illness with pre- existing
physical illness. 11.1% become ill after some particular incidents. One of the cases
explained the cause of his illness as somebody rushed into his room, without noticing,
making him wake up and he got bad mood. Since he was frightened at the time. Since
then his mood worsened, and he become severely depressed, people who blamed evil
spirit magic 0r their illness were 5.5% each. Most of cases had been to the
Dhami/Jhankri (55.5) before seeking any medical help and 64% of them did not get
any benefit from the non medical help. 21.4% cases got even worsen of their
illness.16.6% of cases sought health-post service from the beginning of their illness
and 5.5% of cases contacted directly mental hospital in Lagankhel.
Dhami/Jhankri (55.5) before seeking any medical help and 64% of them did not get
any benefit from the non medical help. 21.4% cases got even worsen of their
illness.16.6% of cases sought health-post service from the beginning of their illness
and 5.5% of cases contacted directly mental hospital in Lagankhel.

C. Wright, M.K. NepalW.D.A. And Breuce Jones 'Mental Health Patients in

P.H.C. Services in Nepal' Study revealed that Patient attending two primary
care settings in Nepal (a village health post & districts hospital outpatient
department) were screened for psychiatric morbidity using the self-reporting
questionnaires. Approximately one quarter of all patients screened were found
to have psychiatric morbidity. Women presenting were found to have higher

frequency of "psychiatric cadences", than men.Health worker recognition of


these cases was 29 % in health post & 0% in the hospital. (1975- study done)
In a WHO collaborative study (Harding, et al, 1980) (1) figures for this
frequency various from 10.6% in Sudan, 10.8% in Colombia, 16.3 in
Philippines and 17.7% in India.
In Kenya Dhadphale et al (1983) (2) found 29% prevalence of psychiatric
morbidity amongst general out patients in rural & semiurban areas.
Although this group of patient is so significant, there has been notable lack of
teaching, & most medical textbooks pay scant attention to them. It is a long
time since professor Michael shepherd (`1966) stated:
"The cardinal requirement for improvement of mental health services is not
large expansion and proliferation of psychiatric agencies, but rather a
strengthening of the family doctor in his therapeutic role" and yet this remains
an urgent need.In study Chapagaun Health Post workers made 10 diagnoses of
psychiatric disorder, 9 of which were of depression a 1 was alcohol
dependences.
Rose and Linda (1996) Research on the stress experienced by those
responsible for family care of mentally ill patients or their coping strategies, the
study emphasizes three areas, emotional climate of the family and stress, it
experience intervention studies, family members development personal coping
style to maintain a balance in family life or develop a sense of self enrichment,
usually family members who effectively cope with illness illnesses are females
who articulates their needs, actively engage in seeking the help and
information, have resources that enable them to make efforts to take care of
themselves.

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Mahat (2004) Impact study on mental health services in Western region, In his
study also claimed similar reason for having depression and epilepsy were over
all the commonest diagnosis given to mental health patients attending the
health post accounting for (78.3%) of all health diagnosis. The diagnosis
pattern varies considerably from health post to health post. As we know that
approximately 25% of patients presenting to PHC has identifiable
psychological disorder and that majority of these will be suffering from
depression and epilepsy.
Nakarmi. B( 2004) Study reveals ( Qualitative study in Chapagaun)

in

depression health staff were rightly able to identify the common clinical
features of depression. And they can manage to provide treatment in their local
level.
Psychiatric morbidity under community mental health programs in ( 9 health
centers)Bhaktapur district, ( 14 health centers) Makwanpur district,

Chapagaun) lalitpur district ( 14 health centers) Westeran region and Mugu


district report shows that 898 mentally ill patients were identified among them
28% cases were depressive patients, 25% were Severe type of mental illness
and 16% were epileptic patients.

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CONCEPTUAL FRAMWORK OF THE STUDY

Individual

Age

Sex

Education

Occupation

Ethnicity

Religion

Attitudes of family members towards family


members

Behavior &
Environment

Care of
Patient

Treatment
Modality

Prognosis
of illness

Family
perception
of marriage
& support

Regularity
of treatment

Work
performance

Independent
Independent variables which is already fixed and (Age, Sex, Education,
Occupation, Ethnicity and Religions) are affected the attitude of family
member's have a direct relationship. Which affects behavior, attitude, early
detection, treatment modality, prognosis of illness, family prognosis of
marriage work performance and regularity services.

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Hypothesis of the Study


a.

Proper attitudes will lead to healthy practices there by free from


mental illness or there will be well being of an individual.

b.

Female depressive patient usually more rejected by the family


members than male.

c.

The acceptance of depressive patient is higher among literate


families then illiterate families.

Variables in relation to the hypothesis


a.

b.

Independent -

Dependent

Sex

Illiterate

Literate

Socidemographic characters

Attitudes of family members towards depression.

Operational Definition and Measurement of Key Concepts/Variables

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CHAPTER -3
Research Methods
3.1.

Research Design
This is a exploratory cross- sectional study. This study will try to focus
on the socio demographic aspect and attitude of the family members
towards depressive patient.

The method will be use for data collection includes an interview schedule
questionnaire based on structured both open and closed ended.
The interview (questionnaires) measurement
a) The socio demographic data of the patient.
b) The socio demographic data of the family.
c) The attitude of the family towards depressive patients.
d) Information related to the reaction of the society towards the depressive
patient
3.2.

Study area and rational for selection.


The investigator will take three areas to conduct this study after
obtaining permission from the following areas.
Mental hospital Lagankhel-in patient department out patient
department
Chapagaun Teaching Healthpost
Bhaktapur district five HMG health post

3.3

Selection of the respondents


The family or relatives of depressive patients.

Depressive patient diagnosed by psychiatrist and treated by trained


health person in mental health (PHC or Health Post) in Lalitpur.

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Inclusion Criteria
To reduced the bias in the study
Those who were above 16 years of age and able to express feelings
and ideas were included in this study.
Family member or relatives of depressive patients- male and female.
Lagankhel Mental Hospital Chapagaun Health Post and five health
post of Bhaktapur district.
Psychiatric patient who is diagnosed and supervised by psychiatric
will be included in this study.
Exclusion Criteria
To reduce bias in the study
Those who are under 16 years of age are excluded as responded.
Patients who are not seen or diagnose by psychiatrists..
Patient who have not received treatment in mental hospital or health
post are excluded in this study.
Interview schedule:
Interview schedule will be based on structured and unstructured
questionnaires. Structrulal questionnaire will be used to collect the
primary data, which will be filled up by the investigator.
Interview
Investigator will be visited in respective areas to filled up the form with
structured questionnaire.
Informants:
Family member or relatives of depressive patients from the Lagankhel
mental hospital, Chapagaun health post and five health posts of the
Bhaktapur district.
3.4

Nature and Source of Data


Qualitative and quantitative data will be collected through interview
with family members or relatives of depressive patient.

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3.5.

Techniques of Data Collection


Family member or relatives of depressive patients selected who is good
informants having relationship only of husband-wife, parents-children
(above 16 years of age) with the patient and were willing to spend time
to answer the question.
The sample size will be 50, as far as possible both sexes dependent upon
the availability include in the sample.

3.5

Reliability and Validity of the data


The interview guide will be developed by the investigator, the tool will
corrected by the expert guide and necessary correction will made.
Procedure of the study:
The investigator will be visited in study areas. Permission for study will
be obtained from the relevant authority and respondents for ethical
respect. Individual interview with the family members or relatives
following self developing questionnaires to assess the level of socio
demographic aspect and the attitude of the family members towards
depressive patient. The information will be recorded in the form.

3.7

Data Analysis
All the collected information will be categorized in the relevant groups
and analyzed qualitatively and relevant category will form to relate the
information and present in table. A simple statistical analysis such as
mean and frequency distribution will be computed/ and the result in
graphical form.

3.8

Limitation of the Study


a. This study does not cover the total population of a particular country.
It is limited to 50 samples. So it cannot be generalize.

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b. The age of the respondents are limited in the study. Only above 16
years of age included.
c. The patient sample will be taken only diagnosed or seen by
psychiatrist.
3.9

Ethical Consideration of the study


Confidentiality, Verbal permission for this study from relevant authority
and from the respondents (family or relative) will be obtained for the
study. The optained information will be kept confidential.

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References
1. Adhikari, K. P., Huttunen, J. & Kiljunen, R (2000) A Mental Health in Nepal
2. Adhikari, K.P. (2000 b) Focus group study on Mental Health awareness
Myagdi District Nepal. Mental Health Program, United Mission to Nepal.
3. Adhikari, K.P. & Dennison. D.B. (1999) Mental Health in Nepal: A
Community Survey of a Village Lalitpur, Central Nepal. Mental Health
Program, United Mission to Nepal.
4. Bennett (1983) Dangerous wives and sacred sisters, social and symbolic roles of high
cast women in Nepal. Central Bureau of statistic, Nepal.
5. Chapagai G.S (1997) Study of risk factors and precipitating factors for depression
6. C. Wright, M.K. NepalW.D.A. And Breuce Jones 'Mental Health Patients in P.H.C.
Services in Nepal'
7. H.M.G., Ministry of Health/W.H.O( 1987- 1989), Community Mental Health
Services in Bhaktapur District
8. http://www.drmarkhillman.com/depressionfactors.html
9. Mahat P. (1997) A comparative study in the treatment pattern of mental illness
in trained and untrained jhankris in south Lalitpur.
10. Mahat P (2004). A Impact study of community health program in Western
Region, Nepal.
11. M Haralambos (2000) Sociological Theme and Perspectives: The isolated
nuclear family
12. Nakarmi B.(2004)A study of quality of mental health services provided by the
CDHP supported Health Post.
13. R.Sharma 1889. Principal of sociology: social research and social survey.
14. SOREC.2003 Analysis of society and culture in Nepal: compilation of books
& article review.
15. Wright, M.K. Nepal and W.D.A. Breuce Jones (1990 Jan-Feb-Mar). Mental

Health Patients in P.H.C. Services in Nepal Journal of the Institute of


Medicine, Vol 12, and No: 1, issue (31) C.
16. World Mental Health Day 2005.

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