Functional disability and associated factors among patients with severe mental illness attending psychiatry outpatient unit at Ayder comprehensive specialized hospital, Mekelle, Ethiopia: a cross-sectional study. CURRENT STATUS: POSTED

Background According to the World Health Organization (WHO), functional disability associated with severe mental illnesses was pervasive, affecting everyday life, and has a significant contribution to the global functional disability. The severe mental illnesses (schizophrenia, major depressive disorder, and bipolar disorder) were among the top ten leading causes of functional disability as indicated by years lived with a functional disability. These illnesses hurt the academic, occupational, social and family functioning of the patients. Despite this fact, functional disabilities and its contributing factors among severe mental illness were not clear. Therefore this study will assess the prevalence and associated factors of functional disabilities among patients with severe mental illnesses. Methods Institutional based cross-sectional study was conducted from Feb 03 to March 10, 2020, with a total of 423 participants in Mekelle, Ethiopia. A stratified random sampling method was included in the study. Functional disabilities were measured by WHO functional disability assessment schedule version two (WHODAS 2.0). Bivariate and multiple logistic regression analyses were performed to determine the association between independent and dependent variables.

Introduction 2nd highest global burden of disease and will account for 5.7%, and by 2030 in the first disease burden (DALYs) by contributing 6.2% (17,18). Bipolar disorder is a common, chronic, episodic and severe mood disorder that is one of the leading causes of functional disability worldwide (19). Importantly, schizophrenia, depression, and bipolar disorder remained in the top 10 causes of lost DALYs across important subgroups, including men, women, developed countries, and developing regions of the world (7,15).
Despite this significant functional disability resulted from severe mental illness, the study done in this area is very rare. Therefore, this study aims to assess the prevalence of functional disability among severe mental illness patients in Ayder comprehensive specialized hospital, psychiatry outpatient, Mekelle, Ethiopia.
A community-based cross-sectional study conducted in Canada shows schizophrenia has a more direct effect on neuro-cognitive impairment than that of bipolar disorder, but in both cases, the magnitude of functional disability found to be high (8).
A cross-sectional study in Barcelona indicates, 60% of bipolar patients show overall functional impairment using a functioning assessment short test (FAST), and another study conducted in Spain using the same tool revealed that BPD patients experienced a sustained impairment in different areas of psychosocial functioning (20) (21). A study conducted in Finland on schizophrenia showed that impairment in social functioning was present in more than 80% of the patients (22).
A community-based cross-sectional study from Australia in various mental disorders revealed that severe form of depression is among the disorders which cause severe &independent functional disability with 4% mild, 30% moderate, and 62% severe functional disability (23).
The study among Chinese people found that the prevalence of functional disability living with SMIs was as high as 69.6%. Older age and longer duration of hospitalization were risk factors related to functional disability (24).
A cross-sectional study from china among schizophrenics, which assess the prevalence of functional disability using WHODAS II, shows that 74 (73.3%) were disabled; among them, 71(70.3%) had a mild functional disability, 2(1.9%) had moderate functional disability, and one had an extreme functional disability (25).
Another hospital-based cross-sectional study from China on schizophrenic patients, shows female have higher level of functional disability than their male counterpart in all domains of WHO DAS − 2 (26).
A study done in India shows, (64%) of schizophrenic patients, (25%) of the BPD, and (57%) MDD patients with 2 to 5 years illness showed mild functional disability, followed by moderate functional disability (27%) of schizophrenia, (50%) of the BPD, and (43%) of MDD, while severe functional disability (9%) of schizophrenia patients, and (25%) of the BPD. The functional disability is stable with an increase in the duration of illness (28).
Patients even in mild depressive symptoms appear to function significantly worse than do in patients with several other chronic medical illnesses, and increased service utilization and social morbidity (29).
A study done in Nigeria shows that, schizophrenia with moderate to severe functional disability scored in the majority of participants in social activities and occupational domain of functionality (30).
Assessment of functioning of people with major depressive disorder, in Uganda, showed higher functional impairment, which is significantly associated with severity of symptoms (33).
In Ethiopia, 11% of the total burden of diseases was schizophrenia and depression (34). A study done in Butajira, Ethiopia, by using the SF-36 scale, revealed that 52-86% with recent-onset and 35-47% with enduring onset of the bipolar patients found having social and physical functional impairments, respectively (38).
Another study in Butajira and Ziway area showed longstanding illness (2 years and above) had higher functional impairment predominantly social and physical functioning (39).
According to the two studies in Spain, functional impairment in bipolar patients was significantly associated with age, depressive symptoms, number of previous manic episodes, number of previous mixed episodes, and number of previous hospitalizations (20).
A study from China in people living with severe mental illnesses revealed that: older age was a significant risk factor for functional disability, and shorter duration of current hospitalization was a significant protecting factor for functional disability (24).
Studies from China revealed that high levels of functional disability are positively correlated with an early age of onset, a longer duration of illness, poor social support frequency of admission, being female were significant association functional disability (25) (26).
According to the studies in India, there was no increase in the functional disability with longer duration of illness (18), Studies from Africa regarding schizophrenics, factors such as being female, poor response to initial treatment and longer duration of illness, symptom severity and non-compliance on maintenance treatment found to be significantly associated with functional disability (30)(31) Among people with depression; duration of illness, the presence of co-morbid somatic or mental disorders, the severity of symptoms leads to functional disability (28) (29) (33).
In Ethiopia, a study from Butajira on SMIs, lack of social support and substance use, which are all lead to deterioration of functioning (35). The study in Butajira and Ziway on bipolar cases found that the severity of depressive and manic symptoms was associated with functional impairment, while male sex, rural residence and being married were associated with better functional outcomes (38,39).
Although functional disability resulting from severe mental illness is enormous, it is grossly underrepresented, which tends to focus on mortality rather than morbidity or dysfunction, especially in low and middle-income countries.
Assessing the prevalence and associated factors of functional disability among SMIS patients should be considered as an inevitable component of management.

Study area and period
This study was conducted at Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia. Mekelle is located in Tigray regional state 783 km away from Addis Ababa, the capital city of Ethiopia. Psychiatry services of the hospital were provided by a psychiatrist, general practitioner, integrated clinical and community mental health professionals, psychiatry professionals, and clinical psychologists. The current flow of psychiatric patients on average was 946 patients per month. This hospital had 24 beds for inpatient and 4 OPDs for outpatients. The study was conducted from Feb 03 to March 10, 2020.

Study Design
An institutional-based cross-sectional study was conducted.

Source population
All patients with severe mental illness, who diagnosed as schizophrenia, major depressive disorder, and bipolar disorder according to DSM-V at Ayder comprehensive specialized hospital

Study population
Patients with severe mental illness, who have a regular follow-up at Ayder comprehensive specialized hospital during the study period, were included.

Inclusion criteria
All patients with severe mental illness with age 18 years and above, who have a regular follow-up at Ayder comprehensive specialized hospital receiving treatment for at least a year were included.

Exclusion criteria
Those who were unable to communicate had decision incapacity, and in acute condition were excluded from the study.

Sample size
The minimum number of samples required for this study was estimated by a single population proportion formula. Since there is no study done, taking 50% prevalence, with a 5% margin of error, and 95% confidence interval the final sample size was 423, by adding a 10% non-response rate.

Sampling technique and procedures
A stratified random sampling technique was employed. Patients who were on follow up from outpatient at ACSH during the study period were divided into three groups based on their diagnosis like schizophrenia, MDD & bipolar disorder. The systematic random sampling technique was used to select samples. The samples were drawn proportionally from each stratum using the following formula. The sample was selected every 18 patients (Fig. 1). WHODAS-2.0 was used to collect data regarding functional disability among SMIs.
It consists of 36 items, with six major life domains of functioning:-cognition (understanding and communication), mobility (ability to move and get around), Self-care (ability to attend to personal hygiene, dressing, and eating, and to live alone), getting along (ability to interact with other people), life activities (ability to carry out responsibilities at home, work and school) and participation with society (ability to engage in the community, civil and recreational activities) (41). WHODAS 2.0 is a cross-culturally valid and standard tool that was developed by the WHO to measure the impact of health situations on functional disability.
Each item of the WHODAS 2.0 will score from 0 (no functional disability) to 4 (extreme functional disability). Social support was measured by using OSS-3 scale with scores from 3-14 , 3-8 = poor support; 9-11 = moderate support, and 12-14 = strong support (42). Medication non-adherence was measured by 8-item Morisky medication adherence screening tool those who score: 0-good adherence, 1-2-moderate adherence and three or more-poor adherence (43). The data were collected by two psychiatry nurses. The questioner was translated from Tigrigna language to English by experts Medication non-adherence: those who score 0 = good adherence, 1-2= moderate adherence and 3 or more= poor adherence according to 8 items Morisky medication adherence screening tool.
Drug adverse effects: simply by asking whether they experience any drug side effects and by physical observation.

Data Quality Assurance
A pre-test was done among 5% (21participants) of the total participants which comprised MDD, Schizophrenia & BPD patients a week before the actual data collection time to check for the understandability and reliability of the questionnaires. Two days of training on the questionnaire and ethical issues were given for the supervisor and data collectors. Daily, each collected data were checked for completeness and inconsistence. Collected data with possible errors were returned to data collectors for correction.

Data analysis procedures
The coded data were entered, checked, and cleaned with Epi data 3.1 and analyzed using Statistical Package for the Social Sciences (SPSS) version 20. Descriptive summary using frequencies, percentage and graphs were used to present study results. Bivariate analysis was done for COR and multivariable analysis was employed to calculate AOR. The strength of the association was presented by the odds ratio with a 95% confidence interval (CI). P-value < 0.05 was considered statistically significant in our study.   reported that they experienced under-estimation by others including by their family members (Table   3).

Prevalence of Functional disability
According to WHODAS 2.0, the overall prevalence of functional disabilities in this study revealed that 88.1% with 95%CI [84.9-91.0] (Figure 2). Of the study participant, 51.3%, 27.5%, 9.3% had mild, moderate, and severe functional disability respectively. While the remaining, 11.9% of the study participants had no functional disability (Figure 3).   (Table 5).  variables with a p-value of <0.2 were entered into a multivariable logistic regression to control the effect of confounders.

Multivariable Analysis
On the multivariable logistic regression analysis, being jobless, illness for eleven or more years, medication non-adherent, having drug side effects, and having poor or moderate social support were found to be significantly associated with functional disability.   9.20)].
This finding is in line with a study done in China (26), in Ethiopia, Butajira (35). This similarity could be because social support is a protecting factor for any mental illness.

Conclusion
The prevalence of functional disability was found to be high. Being jobless, duration of illness ≥11 years, medication non-adherent, having drug side effects and having poor or moderate social support were significantly associated with functional disabilities. Therefore, when treating patients with severe mental illness giving especial attention to the bio-psycho-social aspect of treatment is essential.
Families of a patient with SMIs have to give support to patients. Mental health professionals have to give more attention to medication side effects while prescribing drugs, strengthening drug adherence by discussing barriers to compliance.

Limitation Of The Study
Since this study was cross-sectional it does not show the temporal relationship between the outcome variable and the independent variables. Social desirability bias (the participants may not tell their real functional status either to not be considered as impaired or expect something good if they have an exaggerated problem).

Declarations
Sciences. Written informed consent was obtained from every participant. The confidentiality of respondents was maintained. The participants have the full right to withdraw at any time during the interview process. The collected data didn't contain identifying information, and the collected data were used for this study only.

Competing of interest
The author declares that there was no conflict of interest. Magnitude of functional disability by a specific diagnosis of a patient with SMIs at psychiatric outpatient, ACSH, Mekelle, Ethiopia, 2020, (N=411)