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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 24
| Issue : 1 | Page : 27-35 |
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Disability among patients with mental illness in Jimma Town, Southwest Ethiopia, 2017, community based crosssectional study
Liyew Agenagnew1, Almaz Mamaru1, Hailemariam Hailesilassie1, Birhanie Mekuriaw2, Badiru Dawud3, Eba Abdisa4, Daniel Tolosa5, Mubarak Abera1, Matiwos Soboka1, Habtamu Kerebih1, Eyerusalem Yeshigeta1, Elias Tesfaye1
1 Department of Psychiatry, Faculty of Medicine, Institute of Health, Jimma University, Jimma, Ethiopia
2 Department of Psychiatry, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
3 Department of Psychiatry, College of Medicine and Health Science, Haramaya University, Harer, Ethiopia
4 Department of Psychiatry, College of Medicine and Health Science, Wollega University, Nekemt, Ethiopia
5 Department of Psychiatry, Adama General Hospital and Medical College, Adama, Ethiopia
| Date of Web Publication | 4-Jun-2020 |
Correspondence Address:
Liyew Agenagnew
Department of Psychiatry, Faculty of Medicine, Institute of Health, Jimma University, Jimma
Ethiopia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmhhb.jmhhb_42_19
Background: Disability is a limitation in performing socially defined roles and tasks expected within a social, cultural and physical environment. Despite it is a focus of concern in mental health care, the score of disability among mentally ill patients and its determinant factors were not studied in Jimma town, Southwest, Ethiopia. Therefore, this study aimed to assess the disability of patients with mental illness in Jimma town, Southwest Ethiopia, 2017. Materials and Methods: A community-based cross-sectional study, with case tracing method, was conducted from April 20 to June 24/2017 among 304 patients in Jimma University Teaching Hospital. Data were collected through face-to-face interviews using the World Health Organization Disability Assessment Schedule 2.0 with 12 items. The collected data were analyzed by bivariate and multivariate linear regression analysis method using Statistical Package for the Social Sciences version 20. Results: Out of 300 respondents, a majority had the diagnosis of schizophrenia 96 (32%) followed by 73 (24.3%) major depressive disorder. The median score of disability of the respondents was 11.1 within the ranges from 0 to 100). Over one-third of the respondents (39.3%, n = 118) reported no difficulty in any activity and only 5% (n = 15) reported an extreme difficulty or not able to do any activity for the past 30 days. While having a job negatively associated with disability (unstandardized B − 0.075, P = 0.007) and not attending school (unstandardized B 0.113, P = 0.020), number of admission (unstandardized B 0. 022, P = 0.033), and stigma (unstandardized B 0.008,P < 0.001) positively associated with disability score. Conclusions: The median score of disability of the respondents was 11.1 (within the ranges from 0 to 100), and most of the patients had no disability. Occupational status, educational status, number of admissions, and stigma were independent predictors of disability among mentally ill patients.
Keywords: Disability, Ethiopia, Jimma town, mental illness, World Health Organization Disability Assessment Schedule 2.0
How to cite this article:
Agenagnew L, Mamaru A, Hailesilassie H, Mekuriaw B, Dawud B, Abdisa E, Tolosa D, Abera M, Soboka M, Kerebih H, Yeshigeta E, Tesfaye E. Disability among patients with mental illness in Jimma Town, Southwest Ethiopia, 2017, community based crosssectional study. J Mental Health Hum Behav 2019;24:27-35 |
How to cite this URL:
Agenagnew L, Mamaru A, Hailesilassie H, Mekuriaw B, Dawud B, Abdisa E, Tolosa D, Abera M, Soboka M, Kerebih H, Yeshigeta E, Tesfaye E. Disability among patients with mental illness in Jimma Town, Southwest Ethiopia, 2017, community based crosssectional study. J Mental Health Hum Behav [serial online] 2019 [cited 2023 Mar 29];24:27-35. Available from: https://www.jmhhb.org/text.asp?2019/24/1/27/285992 |
| Background | |  |
The International Classification of Impairments, Disabilities, and Handicaps define disability as a restriction or inability to perform an activity in the manner or within the range considered normal for a human being, mostly resulting from the impairment.[1] Similarly, disability refers to limitations in performing socially defined roles and tasks expected within a social, cultural, and physical environment such as family, work, recreation, and self-care.[2]
According to the World Health Organization (WHO), mental disorders are the leading cause of disability in the United States for individuals between the ages of 15 and 44 years.[3] Furthermore, approximately 20% of people in the United States experience mental disorders in a year to which mental disorders contribute to limitations in daily activities and functioning of 3%–7% of the population.[4]
A study conducted in six European countries on functional disability of mental disorders and comparison with physical disorders using a cross-sectional study design face-to-face household interview survey of the adult population showed that mental disorders were related to functional disability on all domains measured by the World Health Organization Disability Assessment Schedule 36 (WHODAS 36) item. Anxiety disorders related to most disabilities, followed by mood disorders and alcohol-related disorders related to the least functional disability.[5]
The WHO reported that mental illnesses accounted for more disability in developed countries than any other group of illnesses, including cancer and heart disease.[6]
Looking only at the disability component of the burden of disease calculation, mental disorders account for 25.3% and 33.5% of all years lived with a disability in low- and middle-income countries, respectively; unipolar depressive disorders, schizophrenia, bipolar disorder, and alcohol use disorders are among the top ten causes of disability for health-related conditions in all countries and in low- and middle-income countries where they represent 19.1% of all disabilities related to health conditions.[7],[8] In Ethiopia, major depressive disorder and anxiety disorders are the third and the fifth leading cause of years lived with disability.[9]
Disability caused by mental illness reduces individual ability to contribute to family and community life, negatively affecting economic and social development. The cost to society of excluding people with disabilities from taking an active part in community life is high, which often leads to diminishing productivity and losses in human potential.[8],[10]
The economic loss to Ethiopia because of excluding disabled people from the labor market was estimated at USD 667 million or 5% of the country's gross domestic product.[11]
A qualitative study conducted in rural Ethiopia showed stigma, poverty, and family burden mostly mentioned consequences of disability of peoples with severe mental illness.[12] Stigma and discrimination toward mentally ill patients believed to have impaired functioning and saying not able to engage in productive work were reasons for the above problems.[6],[13],[14],[15]
The most mentioned factors in the literature which have an association with disability were symptom severity, type of diagnosis, length (duration) of mental illness and age at mental illness onset, number of previous hospitalizations, nonadherence, low social support, and stigma.[16],[17],[18],[19],[20],[21],[22]
Many studies showed that the disability because of mental disorders had a significant effect on the individual, community, and the country at large. In Ethiopia depending on the 1994 census classification, of 991,916 disabled persons, 64,284 were mentally disabled persons, but in 2007 census, it decreased to 58851,[23] because of this, there is a sense from Ethiopian government to address the issues of disability by adopting international standards and reflecting those in the domestic policies and strategies like in the constitution and the mental health strategy.[24],[25],[26],[27]
However, there are little data known about disability among patients with mental illness in Ethiopia, specifically in Jimma town. Therefore, this study aimed to assess the disability and its associated factors among mentally ill patients in Southwest Ethiopia.
The results of the study could helpful for mental health professionals to know the status of mentally ill patients to different dimensions of functionality which are rapidly increasing global problems with a strong impact on morbidity and mortality.
Besides, policymakers could use findings of this study to expand their understanding of current mental health practice and then to develop a better future policy for mentally disabled peoples to improve their functional disabilities. The results could be useful for future researchers to better understand the disability of mentally ill patients and to conduct further studies.
| Materials and Methods | | |
Study area and period
This study was conducted in Jimma town which is located 352 km in the Southwest of Addis Ababa. The town has 3 districts (Woreda) and 17 subdistricts (Kebele). The number of households in the town was about 32,191. The total population of Jimma town from 2007 Ethiopian calendar (E. C) central statistical agency census reported to be 120,960, and with a projection rate 4.7, it is estimated that in 2011 E. C, the total population is around 144,369.
The town has two hospitals: one general hospital and one university hospital. Psychiatric outpatient and inpatient services are available only at the university hospital in the Psychiatry Unit of Jimma University Teaching Hospital, which is one of the oldest psychiatry clinics in Ethiopia following Amanuel Mental Specialized Hospital. The Psychiatry Clinic of Jimma University Teaching Hospital was established in 1988. From this town, there were more than 1200 individuals who have follow-up treatment at psychiatric clinics; out of those, 698 of them were adult patients (age ≥18 years). The study was conducted from April 20 to June 24, 2017.
Study design
A community-based cross-sectional survey was conducted.
Sample size assumptions and sampling procedure
The study used census method to get the study participants, and from this census, we got 304 patients which were the final sample size for this study.
All patients with mental illness in Jimma town were interviewed after the following procedures: first, from “card office,” the patients' diagnosis, name, age, sex, address, and date of the first visit for all mentally ill patients living in Jimma town were registered. We found 698 adult patients and then the address of patients distributed to the health extension workers by their Kebeles to know who are alive, died, and live according to the registered address using the case tracing method. Besides, we used staff members who knew the patients' address and the patients' phone numbers to get them according to their address and ready for interviewers.
Inclusion and exclusion criteria
Inclusion criteria
All age 18 and above residents of Jimma town and who treated for mental illness in Jimma hospital psychiatry clinic and available during data collection were included in the study.
Exclusion criteria
Those patients diagnosed with the case of mental illness within 6-month duration before data collection and age ≤18 years were excluded from the study.
Instruments
All questionnaires were translated into the Amharic language before the data collection. A back translation by another expert fluent both in English and in local languages checked the consistency. Finally, the Amharic version questionnaire was used for data collection.
Outcome variables
Disability
A structured, WHODAS 2.0, with 12 items interviewer administered was used to assess the disability of patients with mental illness, which explains 81% of the variance of the more detailed 36-item version. It has a 5 Likert scale which scored using terms none (1), mild (2), moderate (3), severe (4), and extreme or cannot do (5). Besides, it reports the number of days whom the individual got difficulties for the past 30 days.
In this study, we used after recoding each 12 items the Likert scale became 0–4 then all 12 items summed up and multiplied by 100, and then divide by 36 to give the range from (0%–100%), which meant 0% = no disability 100% = extreme disability[28],[29],[30] [Questionnaire 1].
WHODAS 2.0 with 36item fully structured interviewer administered disability assessment tool was validated in Butajira, Ethiopia on patients with severe mental illness in Amharic language.[31] In this study, the internal consistency of WHODAS 2 with 12 items was 0.97 Cronbach's alpha.
Potential explanatory variables of disability
Demographic and economic variables of patients
These variables include age, sex, educational status, occupational status, marital status, ethnicity, religion, with the home they are living (living with family or outside), monthly income, and number of individuals in the household.
Clinical variables of patients
Duration of mental illness, treatment latency, duration of treatment, number of relapses, number of previous hospitalizations, age at mental illness onset, follow-up status, duration of stopping treatment, use of traditional medicine, use of a substance, and type of diagnosis were among from clinical factors considered in this study.
The remaining mentioned clinical factors were collected by reviewing charts and reports of the patients.
Patients who were using any traditional treatment such as religious (holy water, Quran, and praying), divine wizard, herbal medicine, and others considered as traditional medicine users.
Patients who were using at least one from the three substances at the time of data collection (alcohol, khat [it is a flowering plant native to the Horn of Africa and the Arabian Peninsula which contains two mild stimulants: cathinone and cathine], and a cigarette [tobacco]) were considered as substance users.
Psychosocial variables of the patients
Social support, stigma, premorbid marital status, and premorbid occupational status were among from psychosocial factors considered in this study.
Social support was assessed by the Oslo-3 item social support scale. It ranged 3–14 by which a score of 3–8 was poor support, 9–11 was moderate support, and 12–14 was strong support with its reliability across different studies was 0.5–0.6.[32],[33] In this study, internal consistency was 0.70 Cronbach's alpha.
Stigma was assessed by the Internalized Stigma of Mental Illness (ISMI) Scale with 29-item. ISMI is a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree) measure containing five subscales: alienation (6 items), stereotype endorsement (7 items), discrimination experience (5 items), social withdrawal (6 items), and stigma resistance (5 items).[34]
The level of stigma is based on the mean score:
- <2 of total score showed minimal stigma
- 2–2.5 of total score indicated low stigma
- 2.5–3 of total score indicated moderate stigma
- 3 + of total score indicated high stigma.[35]
Its internal consistency in this study was 0.90 Cronbach's alpha.
Data collection procedures
Data were collected by face-to-face interviews using a study questionnaire comprising of WHODAS 2.0 with 12 items. Two BSc psychiatry nurses and four mental health masters students had taken part in the data collection process after pretest conducted among 20 patients at the psychiatry clinic on those who were from outside the study area. The pretest results were not included in the final research report. Data collectors and supervisors were trained for 2 days on the purpose of the study, details of the questionnaire, on interviewing techniques, the importance of privacy, and ensuring the confidentiality of the respondents. In each kebele, two instructors were assigned as a supervisor. Daily close supervision and questionnaire reviewing such as checking for its completeness, accuracy, and consistency done at the end of every data collection by supervisors and investigators and then timely corrective measures were taken.
Data processing and analysis
Data were entered into EpiData software package (The EpiData Association, Odense M, Denmark, Europe). After double data entry verification, data were exported from EpiData and analyzed using the Statistical Package for the Social Sciences version 20 (South Wacker Drive, Chicago, Illinois, USA). Descriptive statistics (frequencies and percentages) and cross-tabulation were calculated to see the distribution of the study variables among the study participants. Bivariate and multivariable linear regression analyses were done to see the association between dependent and independent variables. Variables with P < 0.25 and 75% confidence interval for B in the binary analysis were subjected for multivariable analysis. Then, the multivariate analysis was performed to determine the independent predictor of the outcome variable using a backward method. Statistical significance was considered at P < 0.05 and 95% confidence interval. Normality, linearity, and homogeneity of variance assumptions were checked. Finally, the results of the study were summarized by tables, graphs, and narrative descriptions.
Ethical consideration
Ethical clearance was obtained from the ethical review board of Jimma University. We obtained both permission letters from the Jimma town health office and informed written consent from each respondent. The respondents were informed that their inclusion in the study was the voluntary to the extent they were free to withdraw from the study at any stage if they were not willing to participate, and four participants were not volunteered. All the interviews were made individually to keep confidentiality. Patients who were severely ill at the time of data collection were linked to the Psychiatric Clinic of Jimma University Teaching Hospital.
| Results | | |
Sociodemographic characteristics of the study participants
From 304 study samples, 300 of them completed the study questionnaires with a response rate of 98.7%. Data about the four participants were incomplete on the reason that they did not volunteer to continue with the study. About 61.7% (n = 185) of the participants were male. The mean age of the respondents was 35 years, with a standard deviation (SD) ±12 years. Most of the respondents were single (60.7%; n = 182) followed by married (26.7%; n = 80). By ethnicity, 48% (n = 145) were Oromo followed by Amhara (25%; n = 75). Nearly 43% (n = 129) the participants were Muslim, followed by Orthodox Christianity (40%; n = 121).
While most of the study participants were living with parents and siblings (64.7%; n = 194), 19.3% (n = 58) of the participants were living with kids and wife. On the other hand, 34.3% (n = 103) of the study participants attended primary school. In terms of occupational status, 46.3% (n = 139) of the participants were jobless. The mean estimated monthly household income was 503.4 ± SD 986 Ethiopian Birr (ETB) and the mean of individuals living in the household found to be 5, with SD ±2 family members [Table 1]. | Table 1: Sociodemographic characteristics of patients with mental illness in Jimma town, Southwest Ethiopia, 2017 (n=300)
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Clinical and psychosocial characteristics of the study respondents
A majority of the respondents were diagnosed as schizophrenia (32%, n = 96) followed by major depressive disorder (24.3%, n = 73). The median duration of the illness was 8 years with a range of 0–27 years, and the median value of the time duration of the respondents staying without treatment was 5 months with a range of 0–16 years. The respondents received treatment with an average time duration of 4 years, with a range of 0–24 years. The median value of relapse of the illness was two times (range: 0–14 times). The respondents admitted to the hospital with a median value of 0 times and range 0–7. Besides, the median age value at the onsets of the illness was 33 years old (range 18–67). A majority of the respondents (74.75%, n = 224) were on their job before the illness started. Moreover, two-third of the respondents (65.7%, n = 197) before the illness started were single. On the other hand, nearly two-third of the respondents discontinued their treatment without professionals' advice (63.3%, n = 190), and the median value of discontinuation time was 1 year.
During the time of the data collection, 69.3% (n = 208) of the respondents were on their follow-up, whereas nearly two-third of the respondents (64.3%, n = 193) were using traditional medicine as an option of treatment.
On the other hand, 50.3% (n = 151) of the respondents had ever use of at least one substance (alcohol, cigarette, and chat).
Most of the respondents (68.7%, n = 206) had moderate social support followed by (18.3%, n = 55) poor social support and (13%, n = 39) strong social support. The mean score of the overall (ISMI) stigma of the respondents was 2.14 ± SD 0.70. Using 2.5 mean scores as a cutoff point, 72% (n = 216) of the respondents had <2.5 mean scores and the remaining respondents (28%, n = 84) had higher than 2.5 mean scores.
World Health Organization Disability Assessment Schedule 2.0 Score of the respondents
The median WHODAS 2.0 score of the respondents was 11.1 within the range of 0–100. Over one-third of the respondents (39.3%, n = 118) reported no difficulty in any activity and only 5% (n = 15) of the respondents reported an extreme difficulty or not able to do any activity for the past 30 days.
There is no agree on cut point for identifying persons with significant disabilities, but based on the International Classification of functioning and disability, WHODAS-2.0 score was classified into the following five disability levels: no disability problem (0%–4%), mild disability (5%–24%), moderate disability (25%–49%), severe disability (50%–95%), and extreme disability (96%–100%). When it was reclassified into three groups extreme-to-moderate disability, mild disability, and no disability, 106 (35.3%) of the participants had extreme-to-moderate disability, 68 (22.7%) had mild disability, and 126 (42%) had no disability [Table 2]. From mental disorders, schizophrenic patients were the most disabled one, followed by major depressive disorder and bipolar disorder patients [Figure 1]. Other psychotic disorders decrease the disability score by 0.060 as compared to schizophrenia (unstandardized B = −0.060, P = 0.189). In addition to the bivariate result regarding the diagnosis and level of disability from the five categories of mental disorders, schizophrenia was most disabled with a high mean score (0.27, SD = 0.33), followed by major depressive disorder (0.23, SD = 0.30), bipolar disorder (0.20, SD = 0.27), other psychotic disorder (0.18, SD = 0.22), and anxiety disorder (0.12, SD = 0.20). | Table 2: Percentage of disability levels versus type of psychiatric diagnosis in the study respondents
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 | Figure 1: Type of psychiatric diagnosis and level of disability of the study participants in Jimma town
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Factors associated with the disability of the study respondents
In the bivariate analysis, factors such as being male, being married, living with parents, having a job, income, number of family members, being on follow-up treatment, using traditional medicine, not using substance, diagnosis as the case of other psychotic disorder, being married before the onset of the illness, and good social support negatively associated with the disability of patients with mental illness.
However, poor social support, not attending school, number of relapses, number of admissions, and stigma positively associated with the disability of patients with mental illness [Table 3]. | Table 3: Factors associated with the disability of patients with mental illness in Jimma town, Southwest Ethiopia, (n=300) in the bivariate linear regression analysis
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Factors predicting disability of the study respondents
Having a job decreases the disability score by 0.075 as compared to not having a job (unstandardized B = −0.075, P = 0.007). Besides, not attending school increases the disability score by 0.113 as compared to primary and secondary school (unstandardized B = 0.113, P = 0.020). On the other hand, a unit increase in the number of admissions results in a 0.022 increase in disability score (unstandardized B = 0. 022, P = 0.033). Furthermore, a unit increase in stigma score results in 0.008 increase in disability score (unstandardized B = 0.008, P < 0.001) [Table 4]. | Table 4: Independent predictors of disability of patients with mental illness in Jimma town, Southwest Ethiopia, (n=300) in the multivariate linear regression analysis
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The final linear regression model explains 42.8% of the variance on WHODAS 2.0 score with P < 0.001. Besides, this multicollinearity was checked with the minimum and maximum tolerance values (0.757 and 0.928) which were >0.1. This showed that there are no high correlations among independent variables.
| Discussion | | |
World Health Organization Disability Assessment Schedule 2.0 disability score
This study found that the median score of disability, in the WHODAS 2.0 scale, was 11.1 within the ranges of 0–100. To the best of our knowledge, this is the first study that measured disabilities and associated factors for mentally ill patients in the community. Besides this, since there is no clear-cut point in the median score of WHODAS 2.0 of 12 items, it is difficult to say that this finding is high or low. However, the results will be helpful for future researchers to use as a base.
Severity of disability among psychiatric diagnosis
In this study, from the five categories of mental disorders, schizophrenia was most disabled with a high mean score (0.27, SD = 0.33), followed by major depressive disorder (0.23, SD = 0.30), bipolar disorder (0.20, SD = 0.27), other psychotic disorder (0.18, SD = 0.22), and anxiety disorder (0.12, SD = 0.20). Schizophrenia is a severe and disabling disorder that affects multiple functional domains; adversely, there are major deficits in employability and independent living.[36]
This is similar to the study conducted in India among seven psychiatric disorders indicated that schizophrenia is by far the most disabling of the mental disorders, followed by depression, obsessive–compulsive disorder, bipolar affective disorders, and alcohol use disorders. Anxiety disorders cause the least amount of disability. Take into account the Sociodemographic characteristics difference of study participants and the previous study were including patients with obsessive–compulsive disorder and alcohol use disorder.[37] However, the finding from six European countries showed that anxiety disorders mostly related to disability.[5] This difference might be a result of being in low-income countries and sociodemographic difference between the participants.
Factors predicting disability score
The study found that respondents with jobs decreased their disability score by 0.075 as compared to those without a job (unstandardized B = −0.075, P = 0.007). This finding is similar to a study conducted in Taiwan among individuals with schizophrenia; quality of life was positively correlated with employment status.[18] Another national survey on the occupational status of people with mental illness reported that employment rates decreased with increasing mental illness severity. In contrast to this finding from Sudan among bipolar patients, WHODAS 2.0 mean score was high for patients with work.[38]
In this study, those mentally ill patients who did not attend school increased their disability scores by 0.113 as compared with those with primary and secondary school (unstandardized B = 0.113, P = 0.020). This result is in line with the study done in China indicating that disability due to mood disorders was higher among the illiterate population.[39] However, the study was conducted only among patients with mood disorders.
On the other hand, the study indicated that a psychiatric patient with a unit increase in the number of admissions results in 0.022 increase in disability score (unstandardized B = 0. 022, P = 0.033), which is in line with the study done in Barcelona among Bipolar patients' functioning.[19] Consideration of study design difference between the studies and the pervious study conducted only among patients with bipolar disorder. Similarly, a finding from Sudan indicates that chronicity positively associated with disability,[38] which is also similar to a finding from Ethiopia continuous course of illness associated with functional impairment among severe mental disorders.[40] It might be because of the severity symptoms hinder the functioning of patients.
In this study, a unit increase in stigma score results in a 0.008 increase in disability score (unstandardized B = 0.008, P < 0.001). This result is supported by a study done in the United States (2015) among 44 schizophrenia patients indicating a direct association between stigma and disability (r = 0.59, P = 0.01).[20] Besides, similar studies done in Latin America among bipolar disorder patients reported that higher scores of self-perceived stigma were correlated with lower scores of functioning.[41] Taking into consideration of difference in sample size and tools used to assess disability between the studies and the pervious study conducted only among patients with bipolar disorder. It is also similar with the finding from previous Ethiopian study which conducted among severe mental disorders.[40]
Limitation of the study
Since 45.5% of eligible participants completed the census, representativeness and generalizability of the results is under question.
As the study used a cross-sectional study design, no conclusions can be drawn regarding causality and alternative explanations of the findings and cannot be ruled out.
Another limitation of the study could be that as the information obtained through interviewer-administered questioner so that response might be prone to social desirability bias, interviewer bias, and recall bias or possible underreporting of difficulties which meant that some individuals might have difficulties in identifying the difficulties they face, with a proportion reporting “no problems.”
| Conclusions | | |
The median score of disability of the respondents was 11.1 ranged from 0 from 100), and most of the patients had no disability. Occupational status, educational status, number of admissions, and stigma were independent predictors of disability of patients with mental illness. Therefore, while giving treatment, it is good to screen the level of stigma and give psychoeducation about stigma. Thus, if psychiatric patients become adherent to medication, the number of relapses as well as the number of hospital admissions will be decreased and which, in turn, might be helpful to decrease the disability of patients with mental illness. Finally, the authors suggest for future researchers to do an objective assessment of the disability of patients with mental illness to avoid underreporting of problems in the subjective report.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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