Characteristics and Satisfaction with Services of Patients Attending a Geriatric Psychiatry Clinic in Southern India

Abstract

Background:

Specialist services, such as geriatric psychiatric clinics, aim to provide a multi-disciplinary and person-centred approach. There is not enough information available about the number and type of such clinics in India. In this descriptive article, we aim to detail the services provided and the socio-demographic and clinical characteristics of patients who have attended a geriatric psychiatry outpatient clinic in southern India.

Methods:

A specific data sheet was used to record the socio-demographic and clinical details of patients attending the weekly geriatric psychiatry outpatient clinic at the Institute of Mental Health and Neurosciences, Kozhikode. The clinic uses comprehensive proformas and assessment tools as appropriate. The Short Assessment of Patient Satisfaction scale was used to assess satisfaction with the services.

Result:

Between August 2023 and March 2024, 80 patients attended the geriatric psychiatry outpatient clinic. Men and women were equal in numbers (40, 50%). The mean age of the attendees was 68.91 (SD = 6.87). Sixty-four (80%) patients had co-morbid medical disorders. The most common psychiatric diagnosis was dementia and adjustment disorder (14; 17.5%). Eight (10%) patients each had depression and anxiety disorders. Regarding treatment, 48 (60%) were prescribed psychotropic medications: 21 (26.3%) were on antipsychotics, 37 (46.3%) were on antidepressants, and 14 (17.5%) were on benzodiazepines. Most patients were ‘very satisfied’ with the service, 47 (58.8%) scoring 27 or 28 on SAPS, where the maximum score is 28.

Conclusions:

A multi-disciplinary team ensures effective, holistic geriatric psychiatric care. High patient satisfaction highlights the importance of structured, person-centred approaches in mental health services for older adults.

Keywords

Geriatric old age outpatients dementia depression satisfaction

Key Messages:

This study describes the structure and details of care provided in a weekly geriatric psychiatry clinic. It also examines the level of satisfaction of the attendees with the services provided.

Findings indicate that such an approach effectively provides comprehensive treatment, care, and rehabilitation to older adults with mental health concerns.

High patient satisfaction highlights the importance of specialised person-centred service in geriatric mental health care.

A phenomenal increase in the global older adult population is predicted to reach 1.4 billion by 2030 and 2.1 billion over the next three decades.¹ One in six people is aged 60 years or over, and countries such as India will be home to two-thirds of them. Around 14% of adults aged 60 and over live with a mental disorder.² Psychological and physical disorders frequently coexist among older adults, which increases the disability.³ According to the National Mental Health Survey of India, older adults had a higher weighted lifetime (15.1%) and current (10.9%) prevalence of any psychiatric morbidity, as compared to the younger population (13.4% and 10.5%, respectively).⁴ With the gradual breakdown of joint families, changing value systems, and urbanisation, there is an emerging need to pay greater attention to older adults’ care and mental health issues.⁵ There is a huge treatment gap due to several reasons, including poor recognition of the seriousness of the disability it produces. Many countries have addressed this issue by providing specialised services to the elderly population with mental disorders using a multi-disciplinary approach.

Mental disorders of old age reflect genetic, environmental, social, and developmental vulnerabilities and resilience, emphasising the need for implementing personalised and effective treatment approaches.³ A bottom-up approach to geriatric mental health care has been proposed, which includes multi-disciplinary care for older adults with dedicated outpatient services to provide integrated care as needed.⁶ Geriatric psychiatry services offer comprehensive evaluations and diagnoses, medication management, psychotherapy, enhanced quality of life, and caregiver support.⁷ Cognitive decline related to age-associated brain shrinkage, increased risk of medication side effects, cultural factors impacting the mental health of older adults, social isolation, loss of independence, and changes in family dynamics are some of the factors that make the speciality unique.⁸

In India, specialist services for older adults with mental health issues are few.⁹ Patient satisfaction with services is an important parameter to evaluate treatment outcomes, and healthcare services are moving towards a client-service provider model in India, as well as from practices around the world, and as mandated by the WHO under its quality rights initiative for mental health.¹⁰ Measurement of patient ratings of satisfaction with hospital services as a marker of quality in healthcare and as a tool for improving the quality of medical care has been well established.¹¹

Aims and Objectives

We aimed to examine the socio-demographic characteristics and clinical profile of the geriatric population accessing the multi-disciplinary-led geriatric service in Kerala, explore patient and caregiver satisfaction with the multi-disciplinary geriatric service, and identify areas for improvement. The study evaluated the prevalence of comorbidities among the geriatric population accessing the service. The services provided by a multi-disciplinary team, the challenges faced in service delivery, and their final impact on patient satisfaction was examined. Feedback on patient and caregiver experiences with the multi-disciplinary approach, focusing on the quality of clinician care, was explored, with an emphasis on communication and joint decision-making. Based on the study findings, identify potential areas for improvement and challenges in delivering multi-disciplinary geriatric mental health services.

Methods

This research followed the ethical guidelines of the Declaration of Helsinki. The institutional ethics committee reviewed and granted ethics approval for this study. Informed consent was obtained from all participants. A specific data sheet was used to collect socio-demographic and clinical details from patients attending the weekly geriatric psychiatry outpatient clinic in the Institute of Mental Health and Neurosciences, Kozhikode from August 2023 to March 2024. All patients who attended the clinic during the study period were consecutively included. The multi-disciplinary team consists of a geriatric psychiatrist, senior resident, psychiatric social worker, neuropsychologist, clinical psychologist, psychiatric nurse, physiotherapist, speech and language therapist, and special educator. A geriatric physician is not a part of the core clinic team; we refer patients with complex medical issues to the Department of Geriatrics at the nearby Government Medical College. Our team maintains close liaison with them to ensure continuity and coordination of care. Patients can attend the clinic directly or via referrals from other clinicians or centres. The clinic utilises a comprehensive pro forma for assessment, encompassing socio-demographic details, clinical information, and assessment tools. After registration, patients are initially screened by the psychiatric nursing team using a brief assessment, which includes a general examination. The geriatric psychiatrist does a comprehensive evaluation to make a diagnosis and formulate a care plan. The care plan is based on a needs assessment, and referrals to respective multi-disciplinary team members are facilitated. Multi-disciplinary team meetings are conducted monthly to discuss new referrals and challenging scenarios. The inputs from the psychologist include psychological and neuropsychological assessments, psychoeducation, cognitive behavioural therapy, cognitive retraining, interpersonal therapy, family therapy, stress management, and caregiver support, among others. The psychiatric social worker focuses on assessments and interventions for psychosocial issues, as well as providing financial support, family therapy, caregiver support, and legal assistance. Patients are reviewed every four weeks or earlier as appropriate. All services are provided at no cost.

The Short Assessment of Patient Satisfaction (SAPS) scale is commonly used as an instrument to evaluate patients’ contentment with the services they receive.¹² This concise, reliable, and valid seven-item tool effectively measures patient satisfaction regarding their treatment.¹³ The scale was carefully designed by selecting items that demonstrate the best measurement properties and provide the most comprehensive coverage of patient satisfaction domains. The SAPS evaluates key areas of satisfaction, including treatment satisfaction, explanation of treatment results, clinician care, participation in medical decision-making, respect from the clinician, time spent with the clinician, and overall satisfaction with hospital or clinic care. The scale employs a 5-point response system and has been validated in clinical settings, demonstrating validity and reliability as a measure of patient satisfaction.^{13, 14} This scale can be applied in any service setting across various treatment groups. The interpretation of the scores is as follows: A score between 0 and 10 reflects significant dissatisfaction, suggesting that the patient feels their healthcare has failed them and they require urgent assistance. A score from 11 to 18 indicates general dissatisfaction, where patients are experiencing shortcomings in multiple aspects of their healthcare and need support in those areas. A score range of 19–26 suggests a level of satisfaction, but these patients should be further asked about specific areas of dissatisfaction to guide improvement efforts. Finally, a score of 27–28 indicates a very high level of satisfaction, suggesting that all aspects of care have either met or exceeded the patient’s expectations.

Microsoft Excel was used for data structuring, and statistical analysis was performed using IBM SPSS version 27. Descriptive statistics of frequency counts and percentages were used for categorical variables. Mean and standard deviation were calculated for continuous variables. Chi-square tests were used to test the difference between two proportions, and paired t-tests were used for continuous data. The difference was considered statistically significant when the p value was less than .05. This manuscript follows the STROBE cross-sectional reporting guidelines, available as supplementary online material.¹⁵

Results

Between August 2023 and March 2024, 80 patients attended the geriatric psychiatry outpatient clinic. Men and women were equal in numbers (40, 50%). The mean age of the attendees was 68.91 (SD = 6.87), with a range of 55–86 years and a median of 67 years. The majority (34; 42.5%) of the patients were in the 65–74 age group, followed by 29 (36.3%) who were under 65 years old.

Forty-one (51.2%) patients were from a rural background, and 72 (90%) belonged to the middle socio-economic category (72, 90%). Forty-seven (58.75%) attendees lived with their family members, while 27 (33.75%) lived with just their spouse. The mean education level, in terms of years, of the attendees was 9.21 years (SD = 5.84). 73 (91.3%) were new patients. Most (74; 92.5%) patients attended with a family member. The socio-demographic characteristics of the clinic attendees are summarised in Table 1.

Table 1.

Socio-demographic Characteristics of Clinic Attendees.

Variables	Mean (SD)/n (%)
▒Age in years	68.91 (6.87)
▒Median age in years	67 (range 55–86 years)
Age group (years)
▒Less than 65	29 (36.3)
▒65–74	34 (42.5)
▒75–84	15 (18.8)
▒Above 85	2 (2.5)
Gender
▒Male	40 (50)
▒Female	40 (50)
Locality
▒Rural	41 (51.2)
▒Urban	39 (48.8)
Living situation
▒Alone	4 (5.0)
▒Lives with spouse only	27 (33.75)
▒Lives with family	47 (58.75)
▒Others	2 (2.5)
Socio-economic status
▒Low	8 (10)
▒Middle	72 (90)
Education in years
▒Up to 7 years	44 (55.0)
▒8–14 years	22 (27.6)
▒15–21 years	13 (16.3)
▒Above 21 years	1 (1.3)
Mean education in the number of years	9.21 (5.84)

Original data from the Geriatric Psychiatry Outpatient Clinic, Institute of Mental Health and Neurosciences (Aug 2023–Mar 2024).

Fifty-four (67.5%) patients had co-morbid medical disorders; 25 (31.3%) had multiple diseases. Thirty (37.8%) had hypertension, followed by diabetes (22; 27.5%). Twenty-four (60%) females and 30 (75%) males had physical disorders. There was no statistically significant difference between genders in the presence of a medical diagnosis (p = .152). Medical and psychiatric diagnoses are detailed in Table 2.

Table 2.

Medical and Psychiatric Diagnoses of Clinic Attendees.

Type		N (%)
Medical diagnosis	Hypertension	30 (37.5)
	Diabetes	22 (27.5)
	Hypothyroidism	4 (5.0)
	DLP	8 (1.0)
	CAD	7 (8.75)
	CVA	3 (3.75)
	Parkinson’s disease	2 (2.5)
	Others	10 (12.5)

Psychiatric diagnosis	Dementia	14 (17.5)
	Mild cognitive disorder	3 (3.75)
	Organic affective disorder	7 (8.75)
	Psychosis	6 (7.50)
	Bipolar disorder	2 (2.5)
	Depression	8 (10)
	Anxiety disorder	8 (10)
	Obsessive compulsive disorder	3 (3.75)
	Adjustment disorder	14 (17.5)
	Somatoform disorder	6 (7.5)
	Others	9 (11.25)

Original data from the Geriatric Psychiatry Outpatient Clinic, Institute of Mental Health and Neurosciences (Aug 2023–Mar 2024).

CAD, Coronary Artery Disease; CVA, Cerebrovascular Accident; DLP, Dyslipidemia.

The most common psychiatric diagnosis was dementia and adjustment disorder (14; 17.5%). Eight (10%) patients each had depression and anxiety disorders. Four (28.6%) patients with dementia were less than 65 years old, while 5 (35.7%) belonged to the age group 65–74 years. Four (28.6%) of them were in the age category 75–84 years, and one (7.1%) patient was above the age of 85. Adjustment disorder (7; 50%) was most common in the age group 65–74 years. Depression (4;50%) and anxiety disorders (3; 37.5%) had an equal distribution between those who were less than 65 years old and those in the 65–74 years age category.

Regarding treatment, 48 (60%) were prescribed psychotropic medications: 21 (26.3%) on antipsychotics, 37 (46.3%) on antidepressants, and 14 (17.5%) on benzodiazepines. The most common antipsychotics prescribed were risperidone and olanzapine (8; 38.1%), followed by quetiapine (6; 28.6%). Escitalopram and mirtazapine (13; 35.1%) were the most frequently used antidepressants, followed by fluoxetine and sertraline (4; 10.8%). Clonazepam (13; 92.9%) was the most frequent choice as a sedative-hypnotic. Details of medications prescribed are presented in Table 3. As mood stabilisers, lithium was prescribed for two patients and sodium valproate for one patient.

Table 3.

Details of Medications Prescribed to the Clinic Attendees.

Prescriptions		N (%)
Antipsychotics ( n = 21)	Amisulpride	1 (4.8)
	Aripiprazole	1 (4.8)
	Clozapine	1 (4.8)
	Olanzapine	8 (38.1)
	Quetiapine	6 (28.6)
	Risperidone	8 (38.1)
Antidepressants ( n = 37)	Desvenlafaxine	1 (2.7)
	Escitalopram	13 (35.1)
	Fluoxetine	4 (10.8)
	Mirtazapine	13 (35.1)
	Sertraline	4 (10.8)
	Trazodone	3 (8.1)
	Venlafaxine	1 (2.7)
Dementia medications ( n = 11)	Donepezil only	5 (45.5)
	Memantine only	3 (27.3)
	Donepezil and memantine	3 (27.3)
Benzodiazepines ( n = 14)	Clonazepam	13 (92.9)
Benzodiazepines ( n = 14)	Diazepam	1 (7.1)

Original data from the Geriatric Psychiatry Outpatient Clinic, Institute of Mental Health and Neurosciences (Aug 2023–Mar 2024).

Among 14 patients who had dementia, 11 (78.6%) were on medications for dementia. The severity of cognitive impairment was based on clinical assessment. Among medications for dementia, donepezil was prescribed for five (45.5%) patients, memantine for three, and a combination of them also for three (27.3%) patients. 4 (28.6%) were on antipsychotics for behavioural and psychological symptoms, which were severe and non-responsive to psychosocial interventions.

Thirty-eight (47.5%) patients were referred for input by psychiatric social workers who were trained for various therapeutic interventions, which included supportive therapy, family therapy, and geriatric well-being groups. Twenty-two (27.5%) patients were referred for clinical psychology inputs, including assessments, cognitive behaviour therapy, etc. Three (3.8%) declined psychosocial interventions. Two (2.5%) patients received interventions from other professionals, such as physiotherapy. Follow-ups are arranged between one week and 8 weeks. Most are scheduled for a visit after 4 weeks (26, 32.5%), followed by 6 weeks for 17 (21.3%) patients.

Most patients were ‘very satisfied’ with the service, 47 (58.8%) scoring 27 or 28 on SAPS, where the maximum score is 28. Twenty-eight patients (35.0%) were ‘satisfied’ with the service, scoring between 19 and 26. One patient was dissatisfied with the service. The mean score was 26.01 (SD = 2.77). There was no statistically significant difference (p = .390; df = 74) in the total satisfaction score between men (26.32, SD = 2.73) and women (25.72, SD = 2.81). There was no statistically significant relationship between years of education and total satisfaction score (p = .558). SAPS mean score are presented in Table 4.

Table 4.

Scores of the Short Assessment of Patient Satisfaction Scale Items.

SAPS Items	Mean Score	SD
How satisfied are you with the effect of your {treatment/care}	3.39	0.83
How satisfied are you with the explanations the {doctor/other health professional} has given you about the results of your {treatment/care}?	3.88	0.36
The {doctor/other health professional} was very careful to check everything when examining you	3.77	0.48
How satisfied were you with the choices you had in decisions affecting your health care?	3.84	0.4
How much of the time did you feel respected by the {doctor/other health professional}?	3.95	0.22
The time you had with the {doctor/other health professional} was too short	3.58	0.69
Are you satisfied with the care you received in the {hospital/clinic}?	3.53	0.75
Total score	26.01	2.77

Original data from the Geriatric Psychiatry Outpatient Clinic, Institute of Mental Health and Neurosciences (Aug 2023–Mar 2024).

Discussion

After the Second World War, a rapidly ageing society led to the increased prevalence of dementia. This led to geriatric psychiatry as a distinct professional entity in the latter part of the 20th century across North America and Europe.¹⁶ Minimum attention has been paid to geriatric psychiatry as a sub-speciality during training, and there is a lack of geriatric mental health services.⁹ The importance of geriatric psychiatric clinics was recognised early, as the presentation of psychiatric illnesses in the old patients differs from that of adult patients.¹⁷ Additionally, physical illness often presents with psychological symptoms and vice versa. Along with the natural ageing of the brain, various factors contribute to psychological issues among older adults. These include physical health problems, cerebral pathology, and socio-economic challenges such as the disintegration of family support systems, social isolation, and reduced financial independence. These socio-cultural factors have been recognised as significant contributors to the burden of mental disorder morbidities faced by older adults in India.¹⁸ In addition to the unique needs of geriatric populations, a wide range of challenges are encountered at different levels of care and treatment, including acceptance, help-seeking, and treatment adherence.¹⁹ There is no adequate information about the nature of geriatric psychiatric services in India.

This is one of the first studies in southern India to describe the functioning of a multi-disciplinary geriatric psychiatry clinic, detailing both clinical profiles and satisfaction outcomes. Findings highlight the feasibility of establishing a multi-disciplinary geriatric clinic in a low-resource setting within a government-run outpatient clinic.

In this clinic, a patient-centred approach is utilised with a collaborative decision-making process among team members, where treatment plans are tailored to the individual’s preferences as appropriate. The prevalence of mental disorders among older adults varies depending on the setting and tools used, and the prevalence among this clinic sample is comparable to the reported rates.^20–22 The medication prescriptions adhere to the national guidelines.^23–25 The clinic adheres to the policy of following well-recognised guidelines in prescribing medications, ensuring they are only necessary at appropriate doses, closely monitoring side effects, and conducting periodic reviews.

Clinicians working in geriatric psychiatry clinics benefit from having a substantial interest and skills in understanding coexisting physical disorders. Older adults experience a higher prevalence of multiple conditions, such as diabetes, lung disease, and cardiovascular disease, as well as mental health disorders and other comorbidities, which are linked to early mortality, disability, and impaired functioning.^{26, 27} Those with chronic and severe mental health issues are at risk, as a situation is often exacerbated by ageism in health care, which is manifested by a lack of enthusiasm for diagnosis and treatment, as well as therapeutic nihilism.²⁸

A wide variety of psychosocial interventions are provided in this clinic. Evidence-based psychosocial interventions,²⁹ such as skills training programmes, assist individuals in acquiring behavioural strategies to manage their condition better, develop independent living skills, and enhance social interactions. Additionally, interventions designed for families or caregivers focus on addressing their specific mental health needs and concerns, providing support to those who care for individuals with mental health conditions. However, the particular reasons for declining psychosocial interventions were not documented in the clinical records. A small number of people refused psychological services; therefore, it is essential to explore the reasons for this decision in order to inform future benefits. Geriatric clinics should have access to the recommended services.²⁰ Psychosocial interventions encompass psychoeducation, psychological treatments, and strategies to reduce stress, enhance social support, and promote daily functioning. In addition to providing recommended psychosocial interventions in this clinic, geriatric well-being groups are conducted weekly, open to all, and last approximately two hours. These groups include psychoeducation, supportive interventions, and cognitive stimulation activities. Patients attend three to four sessions and are welcome to return for additional sessions if desired.

The majority (n = 74; 92.5%) of patients attended the clinic with their family members, who are also informal caregivers, and the clinic focuses on their needs as well. The caregiver burden can be reduced by information and support. Caregivers of older individuals with mental disorders often experience significant burdens and require both information and support. Involving them as informal members of the caregiving team offers mutual benefits for both the patient and the caregivers while also enabling more accurate clinical assessments and targeted interventions to promote well-being and prevent serious adverse outcomes. This highlights the importance of providing care that is not solely focused on the patient but also incorporates a family-centred approach.³ The concept of obligation and respect towards elders forms the cornerstone of informal care. This natural resource is in decline due to factors including the nuclearisation of families, which necessitates the facilitation of formal systems of care for the older adult population.²¹ Multi-disciplinary geriatric psychiatry clinics are in a position to support families in optimising the mental health of older adults and working towards a recovery goal.

The overall level of satisfaction among attendees here was higher than that reported by other outpatient services.²² This is one of the very few studies that used an instrument to evaluate satisfaction among the geriatric population. When evaluating satisfaction was not possible due to cognitive impairment, SAPS scores were reported by patients with mild dementia and with caregiver input in cases of moderate to severe dementia. Satisfaction is linked to whether patients perceive the services provided as adequate and in line with their expectations. However, the exact process by which patients form satisfaction or dissatisfaction remains unclear, as satisfaction is generally thought to reflect how well their expectations of treatment have been met or surpassed. The interpersonal aspects of care primarily shape these expectations.²³ The clinic attendees suggested improving the existing infrastructure to facilitate easy access and providing additional facilities for pharmacology and investigation.

Multiple forms of discrimination and stigma, including ageism (discrimination based on age) and mentalism (discrimination against individuals with mental disorders),^{24, 25} as well as structural ageism—age-based discrimination embedded in institutional policies, practices, behaviours, and procedures can be partially addressed through services like geriatric psychiatric clinics. Addressing the social determinants of health within an integrated healthcare framework is essential for enhancing health outcomes and reducing existing disparities in the health of older adults.²⁶ The lack of emphasis on the healthcare needs of older adults appears to contribute to the low level of public awareness regarding mental health issues in later life.²⁷ With a growing understanding that older adults are distinct psychologically, biologically, and socially, there has been a gradual shift in how they are approached.²⁷

The challenges of limited awareness, inadequate training opportunities, unequal distribution of healthcare resources, and the near absence of chronic care models in geriatric psychiatry in India have led to increased efforts to raise awareness, build capacity, and strengthen training and research activities. Recommendations for future-proofing geriatric mental health services in India include urgently strengthening healthcare delivery systems through a comprehensive, multipronged approach, focusing on developing a well-trained workforce and improving infrastructure. It is also crucial to implement review mechanisms to ensure updates on best practices and evidence-based medicine, with periodic evaluations to ensure ongoing effectiveness.⁶ In this context, specialised old-age mental health services are well-positioned to drive these efforts forward, offering both care and necessary training and clinical exposure for undergraduates and postgraduates. Collaborative care models between geriatric medicine specialists and psychiatrists can help deliver this model without placing additional strain on existing resources.⁶

Limitations

Certain limitations in the study include a small sample size and a limited period of clinic attendance. The findings from this clinic in an urban locality in a government setting may not be generalisable. However, the findings would be helpful in the current scenario, where we have limited published information on such services in this geographical context. We did not use a structured pro forma to gather socio-demographic and clinical information, as the data reflect the day-to-day clinical practice in an outpatient clinic. Although we have utilised one of the most widely used instruments to measure satisfaction, there may still be relevant socio-cultural domains that remain unaccounted for.

The study does not aim to draw generalisable conclusions but rather to describe patterns and highlight practical learnings from real-world settings. This descriptive study lays the groundwork for future research with larger cohorts. This sample size also represents the real-world clinical volume in the setting, comprising all consecutive new patients who attended the weekly psychiatric clinic over an eight-month period.

As this is a cross-sectional, descriptive study that focused primarily on service delivery and satisfaction, detailed follow-up data and treatment outcomes were not the study’s primary focus. It is also essential to undertake a comparative analysis of service user satisfaction between those who attend specialist geriatric psychiatric clinics and general psychiatry outpatient services.

It is essential to understand the reasons for refusing psychosocial interventions so that service providers can better understand the barriers to engagement. Future studies should investigate patient- or caregiver-reported reasons for treatment refusal.

Conclusions

A holistic, interdisciplinary approach is crucial to effectively address mental disorders in older adults, especially when multiple morbidities coexist. Geriatric psychiatry clinics can serve as a structured model to implement such care. We observed a high level of user satisfaction in the geriatric psychiatry outpatient clinic, suggesting clear support for its clinical utility. This positive feedback highlights the value of a multi-disciplinary, patient-centred approach tailored to the needs of older adults. This approach effectively addresses complex needs often overlooked in general adult clinics.

There is a need to have quality indicators to evaluate the systems and processes involved in such specialist clinics, ensuring the satisfaction of service users. They should be culturally sensitive and capable of offering appropriate, comprehensive care and support.

Comparative studies examining outcomes in patients attending general versus. Specialised geriatric psychiatry clinics would be valuable in evaluating the efficacy of services.

Supplemental Material

Supplemental material for this article is available online.

Footnotes

Acknowledgements

The authors acknowledge the participants for their active involvement in the study.

Consent to Participate

Informed consent was secured from all participants involved in the study.

Data Availability

The datasets used and analysed during the current study are available from the corresponding author and study investigators upon reasonable request.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Declaration Regarding the Use of Generative AI

None used.

Ethical Considerations

The study followed the ethical guidelines of the Declaration of Helsinki. The institutional ethics committee of the Institute of Mental Health and Neurosciences (IMHANS), Kozhikode, Kerala, approved the research. The ethical approval reference number was (IMHANS/IEC/S/2024/026), dated 21-08-2024.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Prior Presentation

The article has not been presented elsewhere prior to submission.

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