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INDIAN COUNCIL OF MEDICAL RESEARCH
Mental Health Research in India
(Technical Monograph on ICMR Mental Health Studies)
Division of Noncommunicable Diseases
Dr. Bela Shah#
Dr. Rashmi Parhee©
Dr. Narender Kumar*
Dr. Tripti Khanna##
Dr. Ravinder Singh**
Collated by
Dr. Narender Kumar*
# Senior Deputy Director General and Chief
*Deputy Director General (SG)
##Asstt. Director General
** Senior Research Officer
@ Ex. Senior Research Officer
Division of Noncommunicable Diseases
Indian Council of Medical Reasearch
V. Ramalingaswami Bhawan
Ansari Nagar, New Delhi
2005
CONTENTS
Page
Foreword
v •
Preface
vii
1
INTRODUCTION
I
II
III
COMMUNITY MENTAL HEALTH CARE
Collaborative Study on Severe Mental Disorders
5
Training Programme of Non-Psychiatrist Primary Care Doctors
8
CAR on Community Mental Health
10
Mental Health Care of Rural Aged
13
Urban Mental Health
16
PHENOMENOLOGY, NATURAL HISTORY AND OUTCOME
Collaborative Study on the Phenomenology and Natural history
of Acute Psychosis
18
Factors Associated with Course and Outcome of Schizophrenia
22
Psychopathology of Depression
27
A Clinical Study of HIV Infected Patients
28
Illness Behavior in Patients presenting with pain and its relationship
with Psychosocial and Clinical Variables.
31
MENTAL HEALTH INDICATORS
1CMR-WHO Project on Mental Health Indicators
38
Quality of Community Life
56
Development of a Tool for Psycho-Social Stress
64
Health Modernity Education Project
76
iii
IV
V
VI
VII
VIII
CHILD AND ADOLESCENT MENTAL HEALTH
Multicentric Study of Patterns of Child and Adolescent Psychiatric Disorders
82
Epidemiological Study of Child and Adolescent Psychiatric
Disorders in Rural and urban Areas
85
Study of Psycho-Social Determinants of Developmental Psycho
Pathology in School Children
92 ’
DRUG/SUBSTANCE DEPENDENCE
A Study on the Effects of Intervention Programme on non-Medical
Use of Drug/ Substance in the Community
101
Collaborative Study on Narcotic Drugs and Psychotropic Substances
106
A Survey of Drug Dependants in the Community in Urban Megapolis Delhi
109
SUICIDE BEHAVIOUR
Hospital Based Study on Suicide Behaviour
114
A Study of Domestic Burns in Young Women
120
Task Force Project on Suicide Behaviour
123
MENTAL HEALTH CONSEQUENCES OF DISASTERS
Mental Health Studies in MIC Exposed Population of Bhopal
126
Health Consequences of Earthquake Disaster (Marathwada)
with special Reference to Mental Health
130
Mental Health Aspects of Earthquake Disaster in Gujarat
136
CONTRIBUTIONS OF ICMR RESEARCH TO MENTAL HEALTH CARE
APPENDICES
I.
List of members of Advisory Committee on Mental Health.
146
IL
List of Consultants of Task Force Projects & C.A.R.
147 ‘
III
List of Task Force Projects (& C.A.R.) and Principal Investigators
149
IV
List of Ad hoc Projects and Principal Investigators.
157
V
List of Fellowship Projects
167
iv
FOREWORD
Mental and behavioural problems are increasing part of the health problems the world over. The burden of
illness resulting from psychiatric and behavioural disorders is enormous. Although it remains grossly under represented
by conventional public health statistics, which focus on mortality rather than the morbidity or dysfunction. The
psychiatric disorders account for 5 of 10 leading causes of disability as measured by years lived with a disability.
The overall DALYs burden for neuropsychiatric disorders is projected to increase to 15% by the year 2020. At the
international level, mental health is receiving increasing importance as reflected by the WHO focus on mental
health as the theme for the World Health Day (4th October 2001), World Health Assembly (15th May 2001) and th£
World Health Report 2001 with Mental Health as the focus. At the national level, mental health policy has been the
focus of Indian public health initiatives during last two decades. Currently India is implementing a national level
programme of integrating mental health with primary health care, the largest such effort in a developing world.
However, a lot of work remains to be done. For example, the treatment for epilepsy exists so that up to 70% of
newly diagnosed cases can be successfully treated with anti epileptic medication taken without interruption. Yet the
health care system of the country has not been able to provide the right treatment to those in need of it. It is important
to note that medications available for epilepsy are both effective and cost efficient. Given their low price they are an
affordable remedy in developing countries also. Alcohol dependence is another major public health problem
contributing to road accidents, accidents at work place and violet behavior. Suicide rates are increased in substance
dependence. Suicide risk among those whose abuse alcohol is 50 to 100 times greater than for general population.
The mental health care programme has to address these problems of enormous magnitude.
Research has advanced the understanding of psychiatric disorders and made major contributions to their treatment.
The helplessness of the past has been replaced by considerable hope since conditions like schizophrenia that once
where treated in closed institutions are being treated in general hospitals, in primary care services and through
interventions at home. Early treatment is essential for better recovery. Effective treatment for depressive disorders
are available, yet there are millions of people affected by depression where suffering and disability is prolonged
because their condition goes undetected, or is often not adequately treated. There is a need to strengthen mental
health care.
This Monograph presents the findings of major ICMR research projects in the area of mental health during last
two decades. It is hoped that this Monograph would be useful for researchers and planners in their endeavor to work
towards strengthening mental health care in the country.
DR. N.K.GANGULY
Director-General
V
PREFACE
Resources and services for mental and behavioural disorders are disproportionately low compared to burden
caused by these disorders the world over. In most developing countries, care programmes for the individuals with
mental and behavioural problems have a low priority. Provision of care is limited to a small number of institutionsusually over crowded and under staffed. Over past several decades, the model of mental health care has changed
from the institutionalization of individuals suffering from mental disorders to a community care approach. The
mental health research programmes of the council have played important role in this shifting paradigm. The Council
had brought out a document “Strategies for research in mental health” in 1982 that listed the mental health projects
carried out during 1960-1982 and described the mental health research strategies formulated in early 1980s. The
present Monograph gives a brief description of ICMR mental health research projects carried out during 1982-2004.
Mental health research programme of the Council at present has focus on development of modules of mental
health care in urban areas, psychiatric morbidity in disaster situations, and suicide behavior. Compared with the
routine peace time psychiatric epidemiology, the disaster situation (such as earthquake) has a strong temporal
component, that is the changing nature of pattern and prevalence as the time passes following disaster. A gradient
effect is observed particularly in case of disaster like earthquake which means that the impact of disaster is not
distributed uniformly, and dose response relationship exists between severity of exposure and subsequent
psychopathology.
Suicide has emerged as a leading cause of death the world over. Research studies of the council have developed
a simple tool for use by general physicians to identify persons with suicidal risk as it was found that a large proportion
of persons attempting suicide were in contact with treatment facility for some time before suicide attempt. A
community based task force project on suicide behaviour has now been undertaken for the first time. It is expected
that the ongoing research on suicide behaviour will help in evolving strategies for suicide prevention. A multicentric
project on urban mental health has been initiated to develop strategies for early identification of mental health
problems and appropriate services for early intervention.
The present Monograph on Mental Health Research covers a wide range of research areas in mental health. The
strength of ICMR mental health research programme is that over hundred experts from different parts of the country
have participated in this research programme as may be seen from the Appendices in the Monograph. The research
programme has covered nearly all parts of the country and generated data on various aspects of mental problems in
the country. I hope it will be useful to researchers as well as mental health planners to advance the cause of better
mental health care in the country.
,
DR. BELA SHAH
Senior Deputy Director General
Division of Noncommunicable Disease
vii
INTRODUCTION
There was hardly any research data available on mental health in India at the time of independence. Sir Joseph
Bhore in 1946 and Dr. A.L. Mudaliar in 1959 have made observations in their reports about non availability of data
on psychiatric morbidity in India. ICMR has initiated projects on mental health research at a significant level from
1960. The first major mental health survey was undertaken under the aegis of ICMR in Agra, U.P. in a study sample
of 29,468 in 1961. A series of epidemiological studies on psychiatric disorders were subsequently undertaken during
1960’s and 1970’s in south, north, eastern, and western parts of the country but, on relatively smaller study samples.
For the first time in the country, ICMR organized a multicentric collaborative study on Severe Mental Morbidity at
4 centres - Bangalore, Baroda, Calcutta and Patiala from 1976-83. This was the beginning of ICMR task force
projects on mental health research.
The recommendations of first ICMR Advisory Committee on Mental Health that met in July 1979 led to formation
of five task force groups and two working groups. The main objective of these groups was to initiate task oriented
operational research programmes on areas which are directly related to the mental health problems specific to our
country where additional knowledge would help in alleviation of morbidity from these disorders. The strength of
these research programmes was the active participation of mental health professionals from all parts of the country.
The process of mental health research planning and contribution of researchers from all over the country in this
endeavour have been described in ICMR. publication Strategies for Research on Mental Health (1982).
The role of Mental Health Advisory Committee was taken over by Scientific Advisory Group on Noncommunicable Diseases in 1990’s. The projects carried out by task force groups and Centres for Advanced Research
during last two decades (1982-2002) can be classified in 7 sections: (a) Community mental health, (b) Phenomenology,
natural history and outcome studies, (c) Mental health indicators, (d) Child and adolescent mental health, (e) Drug/
substance dependence, (f) Suicide behaviour, (g) Mental health consequences of disasters.
This monograph presents highlights of the mental health task force projects of the council. The areas covered
under community mental health include psychiatric morbidity surveys, intervention done by primary health care
personnel, development of training programme for non-psychiatrist primary care doctors, development of modules
for integration of mental health care with general health care. A PHC based module for total health care of the rural
elderly has been evolved with special reference to mental health. Most of these projects addressed the mental health
problems of the people in rural areas. Since rapid urbanization brings deleterious consequences for mental health
through the influence of increased stressors and factors such as overcrowded and polluted environment, dependence
on cash economy, high levels of violence, reduced social support, a new project on urban mental health has been
initiated to identify and develop strategies for early identification of mental health problems and to suggest necessary
intervention, including services.
.
The monograph presents a series of studies that were carried out, these include studies of phenomenology,
natural history and outcome of psychiatric disorders, Acute psychosis, Schizophrenia, Depression. Clinical descriptive
studies were also earned out on psychiatric, neurological, psychosocial and behavioural aspects of HIV infected
patients. Another descriptive clinical study explored the illness behaviour in patients presenting with chronic pain.
i
Mental Health Research in India
In the area of mental health indicators, task force projects were undertaken to develop tools of measurement for
quality of life at individual level, family level, and community level. A short instrument was developed to measure
psychosocial stress. The Health Modernity Education Project developed the concept of health modernity and developed
and evaluated health educational intervention to enhance health modernity of tribal population in Jharkhand.
The important projects in area of child and adolescent mental health include hospital based studies on psychiatric
problems of children, community based projects on mental health of child and adolescent population, studies on
school children and intervention strategy fortheir mental health care.
The task force projects in area of drug/substance dependence were carried out for community based surveys,
educational intervention modules, development of drug abuse monitoring system, and treatment evaluation.
The studies on suicide behaviour were carried out on suicide attempters, who were brought for management to
various departments of the hospital. A more comprehensive project with community based and hospital based
components has been initiated to study the entire range of suicide behaviour from suicidal ideation to suicide attempts.
Another important area taken up by the Council is the study of mental health consequences of disasters. The studies
carried out in the aftermath of MIC gas exposure at Bhopal and the earthquake disasters in Marathwada have been
presented. A multicentric project on mental health aspects of earthquake in Gujarat has now been initiated.
The task force projects are centrally originated projects on priority areas identified by the advisory committees
of ICMR. The council also supports open ended research at medical colleges and institutes of the country through ad
hoc research projects. The ICMR ad hoc research projects on mental health have been carried out in areas of biological
psychiatry, clinical studies, family studies, therapies, meditation and yoga, child psychiatry, mental retardation,
alcohol and drug dependence, psychiatric epidemiology, delivery of mental health services, psychometery, and
other social and psychology studies. A list of all mental health projects (task force, ad hoc projects, and fellowship
projects) carried out between 1982-2002 is given in the appendix. The list of mental health projects carried out
during 1960-1982 is given in 'Strategies for Research in Mental Health (1982)’. The addresses of the principal
Investigators given in appendices pertain to the period when these projects were undertaken. This monograph presents
main findings of projects in a wide range of areas of mental health research carried out under the task force mode
and centers of advanced research of the Council. It is hoped that this would be useful for researchers and planners as
it provides information in a concise form on mental health research programmes of ICMR.
2
COMMUNITY MENTAL
HEALTH CARE
COLLABORATIVE STUDY ON SEVERE MENTAL
MORBIDITY
Collaborative study on severe mental morbidity was
among the first few multicentric projects initiated by
ICMR under expanded programme of mental health
research. The study was undertaken at 4 centres in the
country viz. Bangalore, Baroda, Calcutta and Patiala.
The specific objectives of the study were as follows:
vernacular and in 11 sessions of two hours each in the
form of lectures, discussions, examples of cases and
actual demonstration of cases. The pre and post training
assessments had shown that the knowledge gain of the
doctors and health workers at all the four centers was
satisfactory.
a) To determine the prevalence of severe mental illness
in the community with focus on psychosis and
epilepsy at 4 different centres in the country.
Study instruments
The main instruments used in this study were i)
Indian Psychiatric Survey Schedule (IPSS) for measuring
psychiatric morbidity, ii) Katz's Social Adjustment Scale
(KAS Behaviour Inventories) to measure social
dysfunctioning of those assessed in detail with the IPSS.
This instrument was suitably modified for use in the
Indian setting. A short 15-item questionnaire was
developed to assess attitudes towards mental illness and
epilepsy. A short screening proforma was also developed.
b) To study the feasibility and effectiveness of
involving the multipurpose workers (MPWs) and
primary health centre (PHC) doctors for (i) detection
and management of all psychotics and epileptics in
rural areas, (ii) for bringing changes in attitudes
towards mental health in the rural community, and
(iii) to estimate the cost of training and management
of the programme in rural areas.
Prevalence survey
Study design
At the end of intervention phase, a field survey was
carried out by the research team at all the 4 centres to
estimate the prevalence of severe mental morbidity. It
was a two-stage survey. During the initial stage, trained
research investigators administered a simple 15 questions
screening proforma to one adult member of every
household in the study after collecting certain basic
socio-demographic information about the household.
This 'symptom in others' questionnaire asked them if
they knew anybody who suffered from one or more of
the 15 symptoms either in their families or in their
villages. During the second stage, all such nominated
probable cases were assessed in detail using the IPSS.
Based on the symptoms recorded by the IPSS, the
patients were diagnosed. The 'symptoms in others
questionnaire' is essentially an instrument which detects
severe mental morbidity, particularly different forms of
psychoses and epilepsy. Table 1 gives prevalence of
severe mental morbidity at the 4 centres.
The essential core of the study was the training of
and intervention by the primary health care personnel
for identification and management of severe mental
illness and epilepsy, and the evaluation of the
intervention by a final field survey. The study areas were
identified at all the four centers around primary health
center, covering roughly a population of 40,000 at each
centre. Following the selection of study areas and
population to be covered, the health workers and primary
health care doctors were given in-service training in basic
mental health care, without disturbing their routine tasks
and activities. Training programmes and separate
manuals of instruction in mental health care for PHC
doctors and multipurpose workers were developed. The
training for the PHC doctors consisted of 15 sessions of
2 hours each, in the form of lectures, discussions,
examples of cases and actual demonstration of cases.
Flexibility was permitted to suit the local situation. The
training for the health worker was carried out in the
5
Mental Health Research in India
Table 1. Prevalence of Severe Mental Morbidity
Bangalore
Patiala
Calcutta
Baroda
Diagnosis
No. of
cases
Rate/
1000
No. of
cases
Rate/
1000
No. of
cases
Rate/
1000
No. of
cases
Rate
100
Epilepsy
278
7.82
51
1.28
59
1.71
11
3.17
Organic brain syndrome
4
0.11
24
0.61
22
0.64
88
2.40
Schizophrenia
65
1.83
70
1.77
71
2.05
113
3.09
Mania
20
0.56
14
0.35
8
0.23
50
1.37
Depressive Psychosis
28
0.79
22
0.55
127
3.67
150
4.10
Total no. of cases &
Prevalence rate/1000
395
11.1
181
4.6
287
8.3
517
14.1
Population studied
35,548
34,582
39,665
36,5954
survey. Thus their improvement could be evaluated by
comparing the two 1PSS. While the changes in the social
discrepancy scores indicated improvement in patients
managed by the PHC team, these changes were not very
marked. It was noted that a majority of patients were
chronically disabled for several years. It was observed
that chronic psychosis and epilepsy patients need long
term and regular medication to show satisfactory
improvement in symptomatology and social functioning.
Management of cases by PHC staff
The primary health care staff identified and managed
severely mentally ill persons and epileptics in their
respective catchment areas and maintained simple case
records. All the patients detected and managed by the
PHC team were also assessed by the research staff using
the 1PSS during the intervention phase. The same patients
were reassessed by the research staff during the field
Table 2. Mental Health Care by PHC personnel
Population studied
Bangalore
Baroda
Calcutta
Patiala
35,548
39,655
38,582
36,595
Tota
146,380
♦
Total No. of patients severe
mental morbidity)
395
181
287
517
1,380
Rate per 1000 population
11.1
4.6
8.3
14.1
9.4
No. of patients identified and
managed by PHC team during
the intervention phase
72
36
58
6
232
Percentage of patients managed
by the PHC team
18.2
19.9
20.2
12.8
16.8
The percentage of cases managed by the PHC team is shown in table -2
6
COLLABORATIVE STUDY ON SEVERE MENTAL MORBIDITY
cost of training and intervention including case finding
and case holding by PHC personnel, cost of monitoring
and cost of the final survey, the cost of records, drugs,
training material and other incidental expenses. The
expenditure on research staff and cost of travel were
the main costs taken in to consideration. The usages of
the PHC personnel were not considered as they were
already in employment for carrying out various health
care activities. The total cost of the programme for
training and intervention, monitoring and final survey
amounted to about one lakh rupees at each centre in
early 1980’s.
Attitude survey
The results of the attitude survey, before and after
the intervention phase showed that at all the 4 centres
there were overall changes in the attitudes in positive
direction. While the overall changes were satisfactory,
item-wise analysis showed that certain crucial items like
suitability of the local health centre for treatment of most
of the mental illnesses has not changed considerably.
There was little change in belief regarding the causation
attributed to black magic, evil spirits, masturbation,
excessive sex and bad deeds of past and present. These
items elicited very few correct answers not only in the
initial survey but during the repeat survey also.
As the study was carried out as a research project, a
major portion of the total costs was constituted by the
salaries for the research staff. For large-scale replication
of the intervention programme, the costs are likely to be
less.
Cost evaluation
Simple costing exercise was carried out to estimate
7
TRAINING PROGRAMME FOR NON-PSYCHIATRIST
PRIMARY CARE DOCTORS
In its endeavour to investigate models of extension
of psychiatric services to the community, the ICMR
appointed a working group on delivery of mental health
services. The working group proposed a task force project
at Bangalore, Hyderabad and Vellore with following
objectives:
(a) A questionnaire was administered to local doctors
at each centre. Besides basic demographic data like
age, sex etc. the questionnaire sought information
on the number of psychiatric and epileptic patients
seen and referred by them in the previous 3 months.
(b) From the above information, a list of about 100
eligible doctors was prepared at each centre using
the two criteria, namely, MBBS qualification and
30 to 50 years age. These doctors were put on the
random numbers. Moving along the list, the doctors
falling on the random numbers were offered training.
This process was continued till about 35 doctors were
enrolled for training at each centre.
The objectives of the training programme were to
enable the primary care doctor to:
i.
Have diagnostic skills to identify common
psychiatric problems in his practice.
ii. Manage the above problems independently.
iii. Educate his patients and family members to remove
misconceptions regarding mental illness.
(c) The training programme consisted of 13, weekly
once afternoon sessions of two hours each with a 15
minutes break in the middle. The session topics
followed the same order as in the manual. The topics
covered were: Introduction, history taking and
interviewing principles, major psychiatric? signs and
symptoms, mental retardation, epilepsy, psychosis,
neurosis, psychogenic somatic conditions,
psychosexual problems of human reproduction and
family planning, psychopharmacology, psychiatric
emergencies, and principles of counseling. Mental
retardation was combined with epilepsy in one
session, and similarly psychiatric emergencies with
principles of counseling. However, the 1st session
included pre-training assessment, the ll,h and 12lh
sessions were case demonstration sessions, and the
last session was meant entirely for post-training
assessment and the feed-back information from the
trainee doctors.
iv. Develop skill in selectively referring cases for
psychiatric consultation.
v.
Inculcate psychological orientation towards medical
conditions.
Since a separate ICMR project on ‘severe mental
morbidity’ was already evaluating the training of primary
health centre doctors, the inclusion for this training
programme was restricted to MBBS doctors working full
time in primary health care practice, mostly general
practitioners.
Psychiatric conditions
Psychosis, neurosis, psychogenic somatic conditions
(neuroses presenting with somatic symptoms), mental
retardation, epilepsy, and psychosexual problems of
human reproduction and family planning were included
as common psychiatric problems.
(d) Each session of the training programme consisted
of: (i) Brief lectures on respective topics with the
help of slides using the manual as the guide, (ii)
Demonstration of ‘live’ cases for each clinical
diagnosis covered above, (iii) Discussion on trainee
doctors’ own experience with their patients having
similar symptomatology (iv) Session on psychiatric
emergency included suicide, stuporous states,
Training Programme
MBBS doctors between the age ranges of 30-50
years were selected for the training programme by the
following procedure:
8
TRAINING PROGRAMME FOR NON-PSY CHIATR1ST PRIMARY CARE DOCTORS
number of choices than the number of vignettes
used, (ii) rephrase or change the question on referral
(disposal).
excitements, and extra pyramidal symptoms. At the
end of each session, the trainee doctors were given
cyclostyled copies of the respective chapters of the
manual. A session wise record of the trainee doctors
attendance was maintained at each centre.
f. Nil-psychiatry and epilepsy vignettes can be made
redundant from the tools of assessment.
(e) The tools of assessment i.e. the assessment protocols,
developed at NIMHANS, Bangalore consisted of
two series (‘A’ and ‘B’) of six clinical vignettes each.
The vignettes of both the series were similar and
parallel. This ensured that the same doctor did not
get exactly the same vignettes for both pre and post
training assessments. The six vignettes represented:
g. It is necessary to try other measures of attitudes, as
the ones used do not reflect adequate change by
training.
2.
The Manual
The manual is adequate, easy to follow arid useful.
More practical details with more clinical case examples
of wider variety need to be included on neuroses. A
greater emphasis on practical aspects of management is
needed.
Nil-psychiatric (or normal), hysteria, schizophrenia,
depression, epilepsy and psychogenic somatic condition.
3.
Same set of questions accompanied each vignette
enquiring about: Diagnosis (multiple choice question
with choice of 6 diagnosis), drugs, dosage and their side
effects, management of the side effects, advising, and
disposal (i.e., when would the doctor refer the patient to
the psychiatrist?). There were also six attitude questions.
The training curriculum and programme
The training curriculum and programme are flexible
and adoptable. More adequate coverage on neuroses and
counseling is needed by: (i) more sessions, (ii) more
repeated presentation of important items of information
(iii) more number of demonstrations. The results of th^
training at all the three training centres were similar.
Observations and Discussion
I.
4.
The performance of the doctors on diagnosing
common psychiatric problems was high. It was good
before training also, and the training contributed to
increase in this ability. However, the question on
diagnosis needs suitable change in its own right in
future training programmes.
c. ‘A’ and ‘B’ series of vignettes are similar but need
random mixing for future use.
5.
d. They discriminate different levels of knowledge.
They measure a performance range of 30%
(Doctors before training) and 68% (psychiatry
residents) of maximum scorable. There is scope to
increase their sensitivity further by adding more
vignettes especially on neuroses and adding some
difficult vignettes.
The doctors have gained modest skill in selective
referral though the answers of most of them were
not relevant to what was asked of them. Flowever a
suitable change in the question on disposal (referral)
is needed in future programmes.
6.
Three psychiatrists in three different centres were
able to train a total of 97 General practitioners in 11
teaching sessions of 2 hours each, to the extent that
the performance of the GPs on the clinical question^
reached to 83% of the performance of the psychiatry
residents.
The tools of assessment
a. Found easy to administer and score
b. They have good inter-rater agreement
e. It is necessary to (i) change the question on
diagnosis to open ended question, or offer more
9
ICMR CENTRE FOR ADVANCED RESSEARCH ON
COMMUNITY MENTAL HEALTH
At the National level, the NMHP (1982) has provided
the policy framework for the development of mental
health services. The NMHP has received support from
the larger movement of primary health care in th?
country. NMHP was included in the 7lh five year plan
with budget allocation of rupees one crore. The major
steps that have been taken up for the NMHP
implementation are:
The establishment of the ICMR centre in 1984
occurred against the background of the NATIONAL
MENTAL HEALTH PROGRAMME formulated in
August 1982 and the NATIONAL HEALTH POLICY
adopted by the Parliament in 1983. Both of these major
policy documents emphasized the need to provide basic
services to the total population. The approach identified
was decentralization, deprofessionalization and active
community participation. Against these policy
backgrounds one of the major considerations of the centre
was to develop appropriate technology for
implementation of the NMHP.
i)
Sensitization of the planners and administration of
all States and UTs
ii) Involvement of mental health professionals in
NMHP implementation.
The decade of 1980’s was also a period of intense
research effort from ICMR in the area of mental health.
This period was marked by major research studies in the
area of epidemiology, phenomenology, studies of course
and outcome of mental disorders, integrating mental
health with primary health care, training of general
practitioners and related areas.
iii) Development of training materials (manuals etc.),
records, health education materials to support the
NMHP.
iv) Experimental district mental health programme in
Bellary district.
There have been major breakthroughs in the
understanding of mental health problems. The study of
acute psychosis has demonstrated the importance of early
treatment in terms of better outcome, as well as the
overall rapid recovery within weeks without relapse at
the end of one year of follow-up. The other ICMR study
on ‘course and outcome of schizophrenia’ has
reconfirmed the relative good prognosis of schizophrenia
in India. In this study the shorter duration of illness, drug
compliance was found to contribute to better prognosis.
In the study on Severe Mental Morbidity, the feasibility
of integrating mental health with primary health care
was studied. This 4-centre study provided an
understanding of the necessary steps for such integration
(training, supplies, records, monitoring etc.) and the
impact of such integration.
v) Importance given in some states like Karnataka*
Kerala and Maharashtra to develop state level plans
and programmes.
vi) Training of trainers from all the states and UTs.
vii) Initiation of first phase community mental health
projects in most of the states.
viii) Development of projects to integrate mental health
as part of school health, ICDS, Voluntary agencies
and volunteers.
There have been developments of institutional
framework for NMHP in the form of National Mental
Health Advisory Group, State Mental Health Advisory
Groups and identification of state level programme
officers.
These research efforts of the decade have highlighted
the importance of understanding mental disorders as they
occur in India as well as the necessity for developing
models of care keeping in mind the socio-economic
realities of the country.
As a result of all these efforts currently the stage is
set for the development of modest and viable programme
in each state rather than ambitious plan for a wider
coverage which may not be feasible with our limited
resources (Srinivasan 1989).
10
ICMR CENTRE FOR ADVANCED RESSEARCH ON COMMUNITY MENTAL HEALTH
The ICMR centre, through its various activities has
contributed to the implementation of NMHP.
3.
DEVELOPMENT OF MANUALS
Two manuals have been developed in the last 6 years.
The first of this the Manual of Mental Health for Multi
purpose workers was first published in 1983. The second
revised edition with visual material and incorporating the
experiences of the use of the manuals at different centres
was published in 1989. The Hindi translation of the 1989
manual was also brought out.
The specific activities in the 7 areas identified at the
time of grant of the centre arc as follows:
1. ESTABLISHMENT OF A FIELD PRACTICE
AREA AROUND SAKALAVARA MENTAL
HEALTH CENTRE.
The goal of this activity was to have an area and a
population unit for mental health monitoring; specifically
this was considered important for incidence studies,
prevalence studies, course and outcome of mental
disorders, study of aetiological factors, effects of social
change on mental health, study of effectiveness of
different interventions (both therapeutic and social). In
short this was envisaged as a long-term ‘public mental
health laboratory'.
The Doctors manual was brought out from
N1MHNAS in 1985, which has gone through further
revisions. In addition, a manual for Bhopal doctors on
mental health care was prepared in 1987
Another manual prepared in collaboration with WHO is
the Manual on ‘Recognition and management of patients
with functional complaints. (WHO/SEA/Ment.99.1989).
The manual of MPW’s has been adopted.with local
translations by professionals in Nepal. Bangladesh and
Afghanistan.
During the first 3 years of the centre the focus to
study the total morbidity of about 5000 population. In
19<39, this focus was shifted to include larger population
with broader goals of prevalence and incidence studies.
A total of 1,00,000 population of the Anekal PHC was
identified for the epidemiological study.
4. TRAINING PROGRAMMES FOR MENTAL
HEALTH PROFESSIONALS
The Council initiated this in 1981. Since the initiation
of the centre, every year one 4-week training was
organized for medical and non-medical mental health
professionals. In addition to the ICMR centre supported
trainers, over 100 professionals have taken part in these
trainers programmes with other funding. These
professionals are from different part of India and
neighboring countries.
2. DEVELOPMENT OF MODELS FOR BASIC
MENTAL HEALTH CARE
This part of the activity of the Advanced Centre was
taken up from 1985-1988. The project was completed
along with the analysis of the data.
A notable development was the recognition of this
training as important for initiating community mental
health programmes. The state of Mahrashtra regularly
deputed its professionals with state resources.
The Solur project report provides detailed
information covering one primary health centre about
the scope, process and impact of the integration of mental
health in primary care. As a result of this project, number
of tools were developed for study of health personnel,
the record system for mental health care and manuals
for training. An important outcome has been the
identification of the level of care and quality of care, the
need for support and supervision by mental health
professionals and the required administrative support.
5.
EPIDEMIOLOGICAL TOOLS
The epidemiology project has provided experience
of the utility of a number of ‘tools' use in India. In
addition the following specific tools were developed: I)
Kannada version of present state examination, ii) WHO
disability Assessment Schedule (Indian Adaptation) and
iii) Attitude Questionnaire.
This project has contributed to the development of
other projects in different parts of India. In addition the
experience of this project and the materials developed
has been the basis for development of similar projects
in Nepal, Pakistan and South Yemen.
6.
DISSEMINATION OF INFORMATION
This has been an important activity of the centre.
Publication of the community Mental Health News and
II
Mental Health Research in India
areas. A good example is the specific inputs made in the
event of the Bhopal Disaster.
other publications were carried out. It is well recognized
that the publications have been an important contribution
to the NMHP implementation in the country.
7.
Two workshops namely, Community Mental Health in
India and Research Issues in Psychiatric Epidemiology
were conducted by the centre.
.
PUBLIC MENTAL HEALTH EDUCATION
Systematic efforts to develop visual public health
education materials on the priority mental disorders have
been made; the flip chart and poster on FEATURES OF
MENTAL DISORDER were widely distributed. The flip
charts on M.R. and epilepsy were printed.
The reports and publications have been utilized in the
various training programmes and meetings of NMHP.
In conclusion, the ICMR centre was established at a time
of initiating the NMHP. In the 6 years of work the
activities have provided technical inputs for the NMHP
and supported its implementation.
In addition to those specific activities, the centre
worked actively with the Council in number of other
12
A STUDY ON MENTAL HEALTH CARE OF THE RURAL
AGED
the country’s population ages the number of these cases
will increase.
It is estimated that around the year 2025, the
proportion of the elderly in the developing countries will
escalate to 12 per cent of the population. Realizing the
importance of research on the health status and health
needs of the aged and psychosocial problems affecting
them, the ICMR constituted a task force in this area. A
task force project was carried out in two phases at the
Institute of Psychiatry, Govt. Rajaji Hospital, and
Madurai. While phase one was a hospital based study,
the phase -11 was a feasibility study for integrating health
care (physical as well as mental) of the rural aged with
general health care at PHC level.
An important finding of this study pertdins to the
family and social integration of the elderly. There was
no appreciable difference in the physical composition
of the families between the study group and the control
group. However, what mattered was the degree of their
integration into the family and social network; a lack of
family and social integration distinguished the study
group from the control group. The study has highlighted
that the family integration may suffer even among those
living within its fold. Similarly such of those elders, who
are living alone, need not suffer isolation. A large number
of these were found to be well integrated into the rural
society. These findings are of relevance for planning
psychosocial support. That psychiatric care cannot be
approached in isolation has been an important
conclusion. A comprehensive care is called for in the
management of geriatric subjects. The study (lsl phase)
being hospital based does not offer data that could be
generalized to the community. Nevertheless the data on
controls do have some limited utility in this direction.
Phase one of the study on “Problems of the Aged
Seeking Psychiatric Help” was hospital based and
conducted over a 3 year period on 150 consecutive
patients (101 males and 49 females) aged 60 and above
attending the Institute of Psychiatry, Madurai and an
identical number of controls matched for age and sex.
These aged patients formed 3 per cent of the total
attendance of the Institute of Psychiatry. Among the
psychiatric illnesses detected, affective disorders,
especially depression out numbered the others. Acute
organic brain syndrome and dementia formed one third
of the diagnoses. While depression equally involved both
sexes, mania was five times commoner in males. The
study revealed that the aged were handicapped by visual,
musculoskeletal and auditory impairment and many
others suffered from physical illness. These handicaps
and physical illnesses were significantly more in the
study subjects. The observation that 40 per cent of the
study group suffered from affective disorders should
prompt the institution of appropriate pharmacological
measure in such patients. Additional measures to
overcome their physical illness and handicaps are also
necessary. The study has also indicated that dementia is
prevalent in this part of the world and that the multi
infarct type is commoner than senile dementia Alzheimer
type (SDAT), thus dispelling the Western notion that
dementing illness is rare in the developing countries. This
pattern of vascular dementia outnumbering SDAT is
similar to that reported from Japan. It is natural that as
COMMUNITY BASED PROJECT
The community based project on health care of the
rural aged was carried out utilizing a Primary Health
Centre (PHC) near Madurai, that is at PHC Kallandiri
near Madurai with an estimated number of 4656
individuals aged 60 and above in its catchment area. The
PHC staff including the multipurpose health workers
(MHWs) participating in the project were suitably trained
by specialists from Madurai Medical College (and
training manuals evolved). The study covered 1910
subjects (664 males and 1246 females) registered either
at the ICMR Geriatric Clinic in the PHC or by field visits
by the project staff with MPHWs. Nearly 80 per cent of
the subjects were between 60-70 years of age. The
females outnumbered the males in the ratio of 2:1. Nearly
80 per cent of the subjects were illiterate; 91 per cent of
the subjects belonged to the SES IV and V. The tools
13
Mental Health Research in India
Ninety-two subjects were diagnosed as
hypertensives. 214 subjects were anaemic. Eight subjects
had myocardial infarction with 6 others complaining of
angina. There were 9 subjects with congesting cardiac
failure. Four had aortic stenosis and 2 aortic
incompetence. Irregular beats (Extra systole) were made
out in 4 subjects. Twenty-one subjects had postural
hypotension.
employed for the study were a Screening Schedule, Socio
Economic Status (SES) scale, Khatri’s Family Jointness
scale and Family and Social Integration schedules
(specially evolved for the study).
Each individual reported at the Geriatric Clinic with
an average of five or six symptoms. The visual complaint
accounted for 88 per cent and locomotor for 40 per cent.
The other complaints in the descending order were
related to the central nervous system (18.7%),
cardiovascular system (17.4%), respiratory system
(16.1%), skin (13.3%), abdomen/gastrointestinal tract
(9.9%), hearing impairment (8.2%), and urinary
problems (3.5%). The psychiatric problems accounted
for 8.5 per cent and took the eighth place in the rank
order. There were 11 patients with cancer (0.6%).
Diabetes mellitus was encountered in 21 subjects (1.1 %).
Nearly 76.5 per cent had two or three diagnosis and 13.2
per cent had four clinical diagnoses. Seventy three
percent of the subjects were managed at the PHC itself,
while 18.5 per cent were referred to specialists in the
Government Rajaji Hospital, Madurai.
Respiratory (N = 308, 16.1%)
Acute bronchitis (100), Upper Respiratory Infection
(82), Pulmonary tuberculosis (57), Bronchi#! asthma
(40), Chronic bronchitis (30) were common conditions.
Five subjects had Bronchiectasis.
Dermatology (N = 254, 13.3%).
Pruritus (51, Hansen's Disease (39), Eczema (28),
Scabies (24), Fungal infection (20), Urticaria (17),
Vitiligo (10) and Keloid (5) were the common skin
conditions.
Gastro Intestinal (N = 190, 9.9%)
PHYSICAL AND PSYCHIATRIC MORBIDITY:
The predominant findings in different systems arc
as follows:
Visual (N
Gastritis (64), Worm infestation (41), Peptic ulcer
(20), Ankylostomiasis (12) and Gastro enteritis (16) were
predominant ones.
1681, 88%)
Psychiatry (N
Immature cataracts (1378), aphakia (236), matured
cataracts (163); corneal opacity (68), dacryocystitis (34),
pterygium (38), leucoma (16), blindness (11) and
glaucoma (2) were the predominant ones.
160, 8.1%)
Among the psychiatric diagnosis. Depression
accounted for 133 cases (Endogenous, Reactive, Masked
etc.). There were 3 cases of Dementia. Two had
Delusional parasitosis and a solitary case of hypomania
was come across.
Locomotor (N:=764, 40%)
Degenerative joint disease (DJD) was diagnosed in
615 subjects and myalgia in 55; cervical spondylosis and
lumbago in 15 and 11 respectively. Fractures (malunited,
coIles’, tibia, rib, calcaneal etc.) accounted for 25.
Hearing (N
Neurological (N=358, 18.7%)
Genito Urinary (N
Peripheral neuritis (288), hemiplegia (15), senile
tremors (13), titubation (12), Parkinsonism (6), facial
palsy (5), epilepsy (2) were the predominant diagnoses.
Benign prostatic hypertrophy and haemorrhoids
were encountered in 24 cases each, and Urinary tract
infection was noted in 10 subjects.
Cardiovascular (N=333, 17.4%):
Oncological
156, 8.2%)
Otosclerosis and Presbyacusis accounted for 59 and
52 cases respectively. There were 19 with nerve deafness.
14
66, 3.5%)
A STUDY ON MENTAL HEALTH CARE Or THE RURAL AGED
The intervention, besides medical, consisted of
rehabilitation measures in the economic, nutritional and
recreational spheres and health education. Following
intervention measures, outcome data were collected to
assess their impact on clinical condition and the
psychosocial variables. The final evaluation after 30
months was achieved in 91.4 per cent of the cohort
(N=1745). A mortality rate of 5.7 per cent was observed
among the cohort (N=109). Clinical outcome was rated
as ‘cured’, ‘cured and relapsed’, ‘Improving’, Static’ and
‘Worsening’ for each illness. Following cataract surgery
38.4 per cent benefited. Hypertension was controlled in
77.5 per cent. Six of the 1 1 cancer patients died.
Depression had cleared in 70.2 per cent. Family and
social integration improved following psychosocial
intervention.
The following tumours were encountered; Lipoma
13; Papilloma 1; Benign nodular goiter 10; Multinodular
goiter 2; Dermoid cyst 2; Leukoplakia vulval;
Leukoplakia cheek 1; Leukoplakia oral cavity 2;
Haemangioma 2; Carcinoma Penis 1; Carcinoma cheek
2; Carcinoma breast 1; Carcinoma endometrium 1;
Carcinoma cervix 3 ‘ carcinoma larynx 1; carconoma
thyroid 1; 1 Bladder carcinoma; Melanoma face 1; Cystic
hygroma 1.
Diabetes Mellitus
Twenty-one cases were diagnosed as Diabetes
Mellitus.
MULTIPLE DIAGNOSIS:
Multiple diagnoses is a common clinical experience
in geriatric medicine. In terms of clinical diagnoses,
76.5% (N = 1460) had 2-3 clinical diagnoses while 16.5%
(N = 316) had 4 or more diagnoses. Single diagnosis
was encountered in 6.8% (N = 131). While physical
illness alone was observable in 91.4% (N = 1747),
Psychiatric illness alone was observable in 0.3% (N=5).
A combination of psychiatric and physical illness was
arrived at in 8.1% (N=155). It is thus evident that
psychiatric illness in the elderly cannot be considered
apart from physical illness. Sixty four per cent were
living in “Not at all joint’ families and only 7.3 per cent
were living in ‘Completely joint’ families; 25.5 percent
lived alone. Fifty five per cent were ‘Well integrated’
into the family 22 per cent were found to be ‘Isolated’,
53.9 per cent were ‘Socially well integrated’ and only
4.6 per cent were ‘Not integrated’ socially.
During the study two sub-sample surveys were
carried out. While the first one covered 603 subjects aged
60 and above in the catchment area, the second covered
843 subjects. The first survey collected data on the pattern
of utilization of health service by the aged and the second
survey assessed the impact of the intervention measures.
The study also revealed that 19 per cent of the aged in
the rural area were contented, happy and healthy.
This phase of the project has demonstrated that a
Geriatric Clinic in the PHC premises offering
comprehensive care could cater to the needs of the rural
aged. This model of total health care could be
incorporated into the existing PHC services with
augmentation of available resources.
15
URBAN MENTAL HEALTH
A WHO funded project on urban mental health problems
and service needs has been initiated with following
objectives:
It is expected that about 50% population will be
living in urban areas in the country in next two decades.
The urbanization brings deleterious consequences for
mental health through the influence of increased stressors
and factors such as overcrowded and polluted
environment, dependence on a cash economy, high levels
of violence, and reduced social support. There is
considerable stigma attached with mental disorders and
ignorance regarding information about mental illness and
available help and treatment. The mental health care in
urban areas is at present limited to psychiatric hospitals
and departments of psychiatry in medical colleges.
Mental health problems at early stage remain
unrecognized and untreated. There is tendency to conceal
even severe psychiatric problems due to stigma. It is
proposed to develop models for mental health care in
urban areas with focus on extension of mental health
care to community level.
i. To study the utilization pattern of existing mental
health care facilities in geographically defined urban
area, and assess strengths and weaknesses.
2. To study the pattern of mental health problems
through (a) Data available from mental health care
facilities, (b) Qualitative descriptive studies on
mental health problems in the community.
3. To identify and develop strategies for early
identification of mental health problems and to
suggest necessary intervenlion, including
appropriate services.
The project has been initiated at 3 centre’s - Delhi,
Lucknow and Chennai.
16
PHENOMENOLOGY, NATURAL
HISTORY AND OUTCOME
COLLABORATIVE STUDY ON THE PHENOMENOLOGY
AND NATURAL HISTORY OF ACUTE PSYCHOSIS
whether it is possible to clearly define a separate acute
psychosis as distinct from schizophrenia or affective
illness.
Clinical experience has shown that some patients
with acute onset of psychosis have a better outcome.
These cases often present with florid symptoms and
grossly disturbed behaviour and they do not precisely
fall in the diagnostic categories of schizophrenia or manic
depressive psychosis. The International Pilot Study of
Schizophrenia reported that this acute illness with full
remissions was more frequently seen in Africa and India
as compared to western countries. This suggested that
perhaps the acute psychosis cases seen in India were not
typical of the western concept of schizophrenia but could
be a variant of schizophrenia or manic depressive
psychosis, or perhaps a benign acute psychotic illness
with good outcome and not hitherto recognized as
separate entity.
Inclusion - Exclusion Criterion
(1) Age of the patient between 1 5-(S0 years,
(2) Sudden onset of symptoms, development of full
blown psychosis within days, upto a maximum of two
weeks, (3) Contact with the clinic within four weeks,
and (4) Presence of any of the marked eight features.
The presence of delusion or hallucination alone would
also qualify for inclusion as a case. Gross organic brain
disorder, Epilepsy, MR, History of previous episodes of
psychotic illness, residence beyond a defined catchment
area etc., were the exclusion criteria of the study.
The Indian Council of Medical research initiated a
collaborative project at four centres (Bikaner, Goa,
Patiala and Vellore) to examine these issues and to study
the outcome of such cases.
Inspite of the rather strict inclusion and exclusion
criteria employed in the study, including (a) that the
patient must have reported to the centre within four weeks
of onset of illness, (b) must be a resident within the
defined catchment area, (c) no history of any previous
mental illness, overall prevalence rate was 8.7% of all
cases of psychosis seen at the four centres. The figures
would probably be much higher if we remove the
stringent inclusion and exclusion criteria.
Aims of the study
The aims of the study were to study the
phenomenology, natural history, sociodemographic
correlates, family history, response to treatment, long
term outcome and prognostic indicators of cases of Acute
Psychosis. It also aimed to study whether acute psychosis
is a unitary, hitherto unrecognized disease entity or made
up of a heterogeneous group of disorders, and if so
The male-female ratio of acute psychosis cases was the
same as that for the total sample of psychotics. It was
seen that acute psychosis did not differ from the total
Table 1: Acuity of onset (percentage)
Bikaner
N=68
Goa
N=85
Patiala
N=102
Vellore
N=68
All centres
Acute less than 48 hours
47
84
31
57
54
Acute 48 hours -1 week
34
16
46
31
33
Subacute 1 - 2 weeks
19
0
23
12
14
X2= 56.02
d.f.
6
p value<0.05
19
N=323
Mental Health Research in India
Family history of mental illness
sample of psychosis in any other socio-demographic
variable.
A positive family history was found in only 28%
cases, and among these, the ICD categories of manic
depressive psychosis, schizophrenia and non-organic
psychosis were equally represented.
Onset of illness
The onset of psychotic illness in these cases was
found to be very rapid. In 54% cases, the interval between
the onset of first symptom to the full blown psychosis
was less than 48 hours and in other 33%, this period was
between 48 hours and one week, and in only 1% this
period was between 1 and 2weeks. The present study
does not support the hypothesis of purely reactive or
psychogenic psychosis since 19% were found to be
definitely reactive while 28% were rated as possibly
reactive. Physiological stress was more common (30%)
than psychological stress (26%) whereas in some cases
both were present.
ICD Diagnosis
At the time of initial contact, 35% were diagnosed
as Schizophrenia (ICD-295), 25% as MDP (ICD-296)
and the remaining 40% as under (1CD-298) other nonorganic psychosis (unspecified category). At the end of
one year, the percentage of cases categorized as
schizophrenia remained the same (35%). There was a
slight increase in the number of cases diagnosed as MDP
(from 25 to 29%) with a corresponding decrease in other
non-organic psychosis (from 40 to 36%).
Premorbid personality
ICMR categories
A majority of these patients (74%) were rated as
having a normal premorbid personality and the remaining
26% included patients of hysterical personality or
schizoid personality and only 4% were reported to have
deviant or anti-social personality.
Descriptive categories were evolved in this ICMR
project based on clinical presentation for classification of
these cases as shown in table 2. Almost 50% cases got
classified in two diagnostic categories i.e., predominantly
Table: 2 Distributions by ICMR - Descriptive Categories.
S.No.
ICMR descriptive
Categories
1.
Bikaner
N=68
%
Goa
N=85
%
Patiala
N=102
%
Vellore
N=6<S
%
All centres
N=323
%
Predominantly Depressed type
5.9
11.8
17.7
1 1.8
11.8
2.
Prcdmominantly Elated type
14.4
8.2
0.0
4.4
.4.2
3.
Predominantly Withdrawn type
14.7
14.1
6.9
16.2
12.9
4.
Predominantly Excited type
42.7
28.2
24.5
20.6
29.0
5.
Predominantly Paranoid type
22.1
27.1
22.5
11.8
20.8
6.
Predominantly Confessional type
1.5
1.2
1.8
1.5
2.0
7.
Predominantly Satirical type
5.9
3.5
2.0
20.6
8.0
8.
Possession type
0.0
1.2
3.9
1.5
2.0
9.
Fixed type
1.5
2.4
9.8
11.8
6.3
10.
Others
1.5
2.4
1.0
1.5
1.6
20
COLLABORATIVE STUDY ON THE PHENOMENOLOGY AND NATURAL HISTORY OF ACUTE PSYCHOSIS
Table 3. Outcome at 1 year
S. No.
Outcome
No.
%
1.
Full remission and no psychotic relapse (FOC-1)
245
75.9
2.
Full remission and one psychotic relapse (FOC-2)
28
8.7
Full remission and more than one psychotic relapse (FOC-3)
3
0.9
4.
Full remission and no psychotic relapse (FOC-4)
28
8.7
5.
Still in index episode (FOC-5)
19
5.9
course and poor outcome. Outcome was not found to be
related to age or sex.
excited and predominantly paranoid type while the
remaining 50% were distributed over their remaining 8
categories. It was noted that the clinical presenting picture
of predominantly withdrawn or predominantly paranoid
type were significantly more likely to be labeled as
schizophrenia whereas the predominantly excited, elated
and depressed categories were significantly more often
labeled as MDP. Almost all the cases of non-organic
psychosis (other and unspecified) belong to the remaining
descriptive categories and also paranoid type category.
Acuteness of onset was related to the outcome.
Patients with very acute onset i.e., full blown picture
developing within 48 hours had the best outcome - 82
percent had full remission no relapse, 9 percent achieved
remission with relapse and only 9 percent did not achieve
full remission at the end of one year. Patients with onset
between 48 hours and one week also showed good
recovery but it was less dramatic than the previous
category.
Treatment
Analysis using CATEGO program me
Treatment compliance was very good. 86 percent
received the full treatment and follow up. 11 percent
received partial treatment and only 3 percent were
untreated. Neuroleptics were the most commonly used.
ECT was used in only those cases that failed to respond
to drug treatment.
According to classification using CATEGO
programme the largest number (22%) fell into the
uncertain psychotic class, and further 13 percent were
assigned more than the one CATEGO class and therefore,
35 percent of all cases of acute psychosis could not be
classified into any clear cut diagnostic category. There
is considerable agreement between the clinical and
CATEGO diagnosis in cases of schizophrenia (ICD-295)
where 48 cases are classified the same by both, and for
manic depressive psychosis (ICD-296) 43 cases being
correctly identified by both methods, but the greatest
discrepancies arose in cases clinically labeled as other
non-organic psychosis (298.0-298.8) and the NOP
‘other’ group (298.9) .Of the 64 cases clinically
diagnosed as 298 (0 to 8) none was so classified by
CATEGO. Similarly in the group of 30 cases of other
NOP (298.9) no case was diagnosed as such by the
CATEGO programme. According to CATEGO analysis,
20 percent of all patients of acute psychosis were
diagnosed as schizophrenia, another 19 percent as cases
Clinical outcome at one year
The outcome was rated into 5 categories (FOC-1 to
FOC-5). 75 percent of all cases were in the category of
FOC-1 at one year follow up i.e., fully recovered with
no relapse of psychotic episode. Another 10 percent fell
into categories FOC-2 (9%) or FOC-3 (1%) i.e. full
remission with one or more relapse, while remaining 14%
had a poor outcome falling in to categories of FOC-4 or
FOC-5.
It is interesting to note that all the cases that achieved
full recovery at one year, had recovered completely within
the first 3 months, whereas those who were still in the
Index episode at 3 months tended to have a prolonged
21
Mental Health Research in India
clearly defined diagnostic category clinically 40 percent
and on CATEGO 50 percent.
of manic-depressive psychosis and 11 percent as
depressive psychosis or Reactive depression. Thus a full
50 percent were either not assigned to any clear-cut
diagnostic category (35%) or were assigned more than
one diagnostic category (13%) or into ‘other’ category
(2%).
The clinical presentation of an acute illness thus
includes three main categories of patients: a)
approximately 25 percent both at initial contact and at
one year follow up and confirmed by CATEGO program
to be cases of schizophrenia, (b) 25 percent are found to
be cases of MDP, (c) remaining 50 percent cases in which
there are no clear cut symptoms of schizophrenia or
primary affective disorder and in addition do not show
the symptoms of anxiety or perplexity etc., constitute
third group of Acute Psychosis not hitherto recognized
as a separate group. However, these patients differ from
the two former groups not only on the basis of their
clinical picture but also on the basis of their normal
premorbid personality, absence of family history of
mental illness and an excellent recovery rate over 85%
and at one year follow up were continuing to remain
well without maintenance treatment. These cases were
identified as cases of Acute Psychosis, a unitary distinct
entity, different from schizophrenia and manic depressive
psychosis.
On the basis of the initial ICD diagnosis as well as
the ICD diagnosis at one year follow up it is seen that
out of a total number of 323 cases of Acute psychosis as
per inclusion criteria for the study, 35 percent were
categorized as suffering from schizophrenia while
another 25 percent as cases of MDP. Thus the remaining
40 percent (161 out of 323) were cases, which were
unclassified and can be designated as cases of'Acute
psychosis not otherwise specified.
Thus it is evident that acute psychosis cases as defined
for purpose of this study comprise of 3 distinct groups:
(a) those categorized as schizophrenic clinically (35%)
(on CATEGO classification 20 percent) (b) Manic
depressive psychosis clinically 25 percent, (on CATEGO
19 percent) and (c) Those cases who do not fit into any
22
FACTORS ASSOCIATED WITH THE COURSE AND
OUTCOME OF SCHIZOPHRENIA
continuous without return to premorbidJevel and
should not be more than 2 years.
A multicentric investigation to examine the factors
associated with the course and outcome of schizophrenia
(SOFACOS) was carried out under the auspices of the
Indian Council of Medical Research at three centers K. G. Medical College, Lucknow; Madras Medical
College, Madras, and Christian Medical College,
Vellore. The project addressed the following research
questions:
1.
(D) Any one or more of the following:
Is it possible to identify sociocultural and clinical
variables, which are associated with and might be
etiologically related to the course and outcome of
schizophrenia.
i.
poor social adjustment.
ii.
Schizoid premorbid personality.
in.
Family history of schizophrenia
iv. Hallucinations.
v.
Emotional blunting.
vi. Catatonic episodes.
2.
Is the course and outcome of schizophrenia better in
a developing country such as India as is suggested
by the WHO multi country project - International
Pilot Study of Schizophrenia?
All the above criteria A, B. C, and D must be
fulfilled. Only patients in the age group 15-45 years were
included. 386 patients were studied; 207 in Lucknow,
96 in Madras, and 83 in Vellore.
3.
Do the three centers in India with different
sociocultural backgrounds differ in the course and
outcome of schizophrenia?
Initial psychiatric evaluation
The following tools were used for this purpose:
These tools were adapted after making small
modifications from those used in the WHO Collaborative
study on Determinants of outcome of severe mental
disorders.
Selection of patients
All consecutive patients who attended the psychiatry
clinics of the participating centers from 15th October 1981
to 15th October 1982 and satisfied the inclusion criteria
were included in the study. These criteria were adapted
from Feighner’s criteria of diagnosis (Feighner etal.,
1972). The duration was taken as 3 months since it was
felt that we might otherwise lose some acute
schizophrenic patients for the study.
i.
A screening schedule to select the patients who
satisfied the criteria of inclusion and exclusion as
elaborated above.
ii. A detailed psychiatric history was taken from all
available sources using the WHO Psychiatric and
Personal History Schedule.
The following were the criteria of diagnosis used in
this study:
iii. A detailed mental status examination was conducted
using Present State Examination 9lh Ed. (PSE) (Wing
and Cooper, 1974).
(A) Presence of delusions or disorganized thoughts and
communication or passivity feelings.
iv. A Diagnostic and Prognostic Schedule (DPS) was
also used as part of initial psychiatric evaluation.
(B) Absence of primary affective illness, manifest
organic cerebral disorders, regular abuse of alcohol,
epilepsy, or severe or moderate mental retardation.
Before beginning the Study, a workshop was
organized in Vellore to get experience with the tools and
to conduct reliability exercises. The investigators.
(C) The duration of illness should be at least 3 months
23
Mental Health Research in India
consultants and research staff participated. All the above
tools were discussed in the group. When one member of
the group interviewed a relative of the patient (using PPHS
1) or the patient (using PSE) the others scored. Several
such exercises were conducted. The inter rater reliability
in most of the items was about 90% in the use of the above
tools. It was found that some items showed consistent
disagreement. These items were discussed to get
uniformity in assessment. The above exercises were
repeated at future meetings of investigators, consultants
and research staff.
experience and reports from various studies. These are
grouped
under
the
following
headings:
Sociodemographic variables (14 items); past history
variables (8 items); variables related to episode of
inclusion (4 items) and variables related to follow up
period (8 items).
Since the above variables had to be correlated to
course and outcome, it was important to evolve a method
of quantifying course and outcome. For this purpose a
method similar to that used in IPSS (WHO 1979) was
used. The outcome was assessed on following
dimensions:
Follow-up
After the initial assessment the patients were
regularly followed up at least once in 3 months during
the first year and at least once in six months for the next
four years. The interim Follow-up Schedule (IFS) used
for this provided information regarding symptomatology,
details of treatment, and drug compliance. This tool was
also adapted from a WHO Schedule used in the
Collaborative Study on determinants of outcome of
severe mental disorder.
a) Percentage of follow up period spent in psychotic
state: 0-15%; I6%-45%;46-75 %; 76-100 %
b) Pattern of course (clinical outcome): (This was taken
from PPHS 111 Item 2.6). The operational definition
of remission used in this study was the same as thai
used in the WHO study. It is a state following a
psychotic episode in which none of the symptoms
characteristics of a psychotic episode would be
present for a minimum period of 30 days.
A detailed reassessment was done after 1 year of
initial assessment using a 1-year follow up Psychiatric
and Personal History Schedule (PPHS) and P.S.E. If any
patient did not come for follow up, even after sending 3
letters, home visits were made to complete follow up.
This was a trial follow up to find out whether the study
was going in the right direction and also to evaluate the
possible follow up rate. This showed that in all the 3
centres the one-year follow up was more than 90%.
Interim follow up was continued as referred to earlier.
A detailed assessment was made as before at the end of
two years using a 2-ycar follow up Psychiatric Personal
History Schedule (PPHS 111) and PSE. Similarly the
patients were assessed at the end of third, fourth and
fifth years. Throughout the course of the study, every
10"’ patient in each centre was assessed by a second
person also to assure intra-centre reliability.
c) Occupational outcome: For the assessment of
occupational outcome, 3 items on PPHS III were
used, viz: 6.10; 6.13; and 7.3 along with 11.4 of
PPHS I. Different items of PPHS 111 were used for
housewives and students.
d) Social outcome: For the assessment of Social
outcome, PSE items 106 and 107 and PPHS III 9.1.1
to 9.1.4 items were used.
An overall assessment of outcome was done using
the above 4 dimensions to give the best, worst and
intermediate outcomes. This has been referred to as
'overall outcome’. An outcome grouping similar to that
used in IPSS (WHO 1979) was also used. This was
referred to as IPSS outcome.
Assessment of course and outcome
Offshoot studies
The main objective of the study was to identify the
factors which influence course and outcome of
schizophrenia. A large group of hypotheses variables
were therefore selected mainly based on clinical
Each of the centre carried out offshoot study to
explore relationship of other dimensions with course and
outcome of schizophrenia. Lucknow centre studied the
Attitudes of key relatives and the outcome of
24
FACTORS ASSOCIATED WITH THE COURSE AND OUTCOME OF SCHIZOPHRENIA
schizophrenia. Madras and Vellore centers carried out
studies on (a) Life events and the course and outcome of
schizophrenia, (b) Disability in schizophrenia.
(f) Younger age of onset
Results and conclusions:
(h) Absence of delusions of persecution
The following are the main observations of this study:
(i) Presence of agitation.
(1) The clinical manifestations of schizophrenia are very
similar in all the 3 centres. The following were the
commonest clinical manifestations: lack of insight,
social impairment, blunted affect, auditory
hallucinations, delusions of persecution, delayed
sleep, self neglect, social withdrawal, and incoherent
speech.
(g) Absence of economic difficulties
Besides the above, another nine factors also were
significantly related to good outcome at 2 year follow
up, namely, presence of religious activities at the time
of intake; absence of self neglect as a presenting
symptom; items such as schizoid traits in personality,
catatonic symptoms. Avoidance of relatives and
neighbours was also associated, but a I ittle less than being
statistically significant.
(2) Most of the symptoms subsided at 2 year follow up
and the same tendency continued at the end of 5
years.
(7)
A combination of factors such as absence of
dangerous behaviour, good drug compliance, rise
in socioeconomic level, low age of onset of illness,
low level of education, rural background, regular
occupational history and acute onset can correctly
classify about 80% of patients into good and bad
outcome groups.
(8)
Of the 386 patients studied, 12 patients committed
suicide, thus giving a suicide risk of 3.1,%.
(9)
The offshoot study on Disability showed that the
mean disability score were between mild to
moderate. There was high correlation between the
disability score and all the course and outcome
parameters. Good outcome groups had low
disability score.
(3) The follow up rate was about 84% at the end of 2
years and 75% at the end of 5 years.
(4) About 67% of patients showed good outcome at the
end of 2 years and 5 years using IPSS method (tables
1 & 2 ). This is very similar to the outcome in Agra
center in the I.P.S.S.
(5) The 3 centres did not differ in the course and
outcome.
(6) The following factors are significantly related to the
course and outcome at 5 year follow up:
(a) Drug compliance
(10) The offshoot study on life events showed that
neither the total number of life events nor the
objective stress score were significantly related tQ
relapses.
(b) Absence of dangerous behaviour
(c) Rise in socioeconomic level
(d) Low level of education
(11) The offshoot study on Attitudes of key relatives
showed that number of critical comments, hostility,
dissatisfaction, and lack of warmth are significantly
related to poor course and outcome and*relapses.
(e) Short duration of illness
25
Mental Health Research in India
Table 1: Course and outcome of schizophrenia cases at Second Year Follow up.
Madras
(N=84)
I.
II.
Vellore
(N=66)
Lucknow
(N=l 76)
Total
(N=326)
No.
%
No.
%
No.
%
No.
%
1. 0-15%
40
48.2
44
68.8
118
67.0
202
62.5
2. 16-45%
28
33.7
11
17.2
39
22.2
78
24.1
3. 46-75%
9
10.8
6
9.4
17
9.7
32
9.9
4. 76-100%
6
7.3
3
4.6
2
1.1
bl
3.5
1. Best remission
42
50.6
34
53.1
70
39.8
146
45.2
2. Worst remission
15
18.1
6
7.8
14
8.0
34
10.5
3. Intermediate
26
31.3
25
39.1
92
52.3
143
44.3
1. No impairment
33
39.8
28
43.7
69
39.2
130 40.2
2. Severe imp
17
20.5
7
10.9
33
18.7
57
3. Some imp.
33
39.8
29
45.3
74
42.0
136 42.2
1. No impairment
22
26.5
16
25.0
71
40.3
109
33.7
2. Severe impairme
7
8.4
12
18.7
22
12.5
41
12.7
3. Intermediate
54
65.1
36
56.2
83
47.2
173
53.6
1. Best
23
27.7
24
37.5
58
33.0
105
32.5
2. Intermediate
47
56.6
35
54.7
104
59.0
186
57.6
3. Worst
13
15.7
5
7.8
14
8.0
32
9.9
1. Very favourable
32
38.5
33
51.6
62
35.2
127
39.4*
2. Favourable
10
19.3
11
17.2
60
34.1
87
26.9
3. Intermediate
29
35.0
16
25.0
51
29 0
96
29.7
4. Unfavourable
6
7.2
3
4.7
1
0.6
10
3.1
5. Very unfavour
0
0.0
1
1.5
2
1.1
3
0.9
Psychotic state
Pattern of course
III. Occupational adjustment
17.6.
IV. Social interaction
V.
Overall outcome
VI. Outcome group-IPSS classification
26
FACTORS ASSOCIATED WITH THE COURSE AND OUTCOME OF SCHIZOPHRENIA
Table 2: Fifth year follow-up: Course and Outcome
Madras
(N=68)
1.
II.
Vellore
(N=60)
Lucknow
(N=159)
Total
(N=287)
No.
%
No.
%
No.
%
No.
%
1. 0-15%
46
67.6
33
55.0
114
71.7
193
67.2
2. 16-45%
14
20.6
16
26.7
38
23.9
68
23.7-
3. 46-75%
6
8.8
9
15.0
7
4.4
22
7.7
4. 76-100%
2
2.9
2
3.3
0
0.0
4
1.4
1. Best remission
16
23.5
19
31.7
46
28.9
81
28.2
2. Worst remission
4
5.9
4
6.7
5
3.1
13
4.5
3. Intermediate
48
70.6
37
61.7
108
67.9
193
67.2
1. No impairment
25
36.8
24
40.0
63
39.6
I 12
39.0
2. Severe impairment
11
16.2
10
16.7
30
18.9
51
17.8
3. Some impairment
32
47.1
26
43.3
66
41.5
124 43.2
1. No impairment
14
20.6
17
28.3
43
27.0
74
25.8
2. Severe impairment
9
13.2
21
35.0
32
20.1
62
21.6
3. Some impairment
45
66.2
22
36.7
84
52.8
151
52.6
1. Best
11
16.2
17
28.3
40
25.2
68
23.7
2. Intermediate
53
77.9
39
65.0
1 14
71.7
206
71.8
3. Worst
4
5.9
4
6.7
5
3.1
13
4.5
1. Very favourable
14
20.6
18
30.0
45
28.3
77
26.8
2. Favourable
31
45.6
15
25.0
70
44.0
116 40.4
3. Intermediate
21
30.9
24
40.0
44
27.7
89
3 1.0
4. Unfavourable
2
2.9
2
3.3
0
0.0
4
1.4
5. Very unfavourable
0
0.0
1
1.7
0
0.0
1
0.3
Psychotic state
Pattern of course
III Occupational adjustment
IV Social interaction
V.
Overall outcome
VI. IPSS outcome
27
PSYCHOPATHOLOGY OF DEPRESSION
The main findings of the study are as follows:
The project was undertaken by the ICMR Centre for
Advanced Research on Health & Behaviour at Madurai
Medical College, Madurai with following general aims:
1.
45 cases out of 50 could be followed up to 36 months:
Cases that remained unchanged
a) To examine the cognitive triad in cases of major
depression.
Cases that pursued recurring course
= 6.7%
1.1%
Cases in remission after index intervention
without any recurrence
= 2.2%
b) To correlate the cognitive triad with depressive
mood, pineal gland function and cortisol profile in
depressed patients.
c) To examine whether recurrences of depressive
disorders are characterized by the re-appearance of
pattern of original disorder of thinking and associated
pineal gland and cortisol abnormality.
The consecutive cases of major depression attending
the OPD of Institute of Psychiatry, Govt. Rajaji Hospital,
Madurai were examined from Is' November 1986 to 3011’
April 1987. 50 cases satisfied the inclusion criterion diagnosis of major depression as per DMS-III and
consensus on diagnosis between two psychiatrists who
independently examined the case. The methods of
assessment included: Schedule for Standardized
Assessment of Depressive Disorder (WHO, 1984),
Beck’s Depressive Inventory, Beck’s Hopelessness
Scale, Presumptive Life Events Scale, and Crandell’s
Cognitions Inventory.
The study required observation on remissions,
recurrences, complications like suicide behaviour and
most importantly to study the cognitive abnormality
(based on clinical, BDI, BHS and CCI ratings), its
persistence in phases of remission and recurrence and
estimation of melatonin levels (in blood and urine). The
occurrence of chronicity and refractoriness to treatment
were also noted.
During the phases of remission and recurrence,
standard psychiatric examination was carried out as well
as the re-administration of the schedules (BDI, BHS, CCI
etc.) as at index evaluation. Estimation of melatonin (in
blood and urine) was carried out during these phases.
28
2.
The mean age of onset was lower (3 1.47 years) for
those pursuing a recurring course than those who
are in continuous remission (46.16 years)
3.
The sample of 50 subjects comprised 21 suicide
attempters prior to index evaluation. During follow
up five instances of suicide attempts (one of which
was a completer) were encountered. These happened
in their recurrent state of illness.
4.
Two thirds of remitted patients were free from
cognitive abnormality during first remission.
5.
Those with cognitive abnormality in remission are
more prone for recurrence than those who do not
have cognitive abnormality during remission.
6.
A significantly higher risk for early recurrence was
found among those who had cognitive abnormality
persisting notwithstanding clinical remission.
7.
Those who pursued a recurring course had more
stressful life events than those who are in continuous
remission without recurrences in remitted state.
8.
The melatonin study on depression concluded that a
dip in nocturnal melatonin levels appears to be a
feature of depression and its reversal towards normal
the index of recovery. Failure to register a nocturnal
rise in melatonin seems characteristic of patients with
persistent negative cognitions even while they had
recovered from depression.
A CLINICAL STUDY OF THE HIV INFECTED PATIENTS
The study was undertaken by the ICMR Centre for
Advanced Research on Health and Behaviour at the STD
OP Department of Govt. Rajaji Hospital, Madurai with
following objectives: (i) to study psychiatric and
neurological features and neuropsychiatric syndrome in
HIV infected subjects, (ii) to allocate clinical syndrome
according to DSM III R category of diagnosis, (iii) to assess
the premorbid personality of the subjects with an emphasis
on sexual behaviour prior to the index evaluation, and (iv)
to offer psychiatric, psychological and other management
measures to the subjects and the family members.
The research team consisting of medical officers,
social workers and clinical psychologists screened
consecutive registrants. The demographic details, the
Table 1: Source of Intake
S.No.
Source of in take
Male
(N=90)
34
Female
(N=45)
Total
(N=45)
%
17
11
7
10
51
21
7
11
57
23
8
12
1,
STD-OPD________________________
2.
Referred by AIDS surveillance Centre
Vigilance Home___________________
10
Prisons
1
3.
4.
Table 2: Distribution of HIV cases by marital status
S.No.
Marital Status
1.
2.
Male
________________________ (N=45)
Unmarried________________
21__
Married__________________
19
3.
Widowed/separated/divorced
Female
(N=45)
8
Total
(N=90)
23
14
42
5
29
19
Table 3: Distribution of HIV cases by occupation
5. No.
_L__
2. __
3. __
4.
5.
Occupation
Coolie/worker
No.
26
16
23
8
17
House wife______
Prostitute
Transport workers
Others
%
29
18
25
9
19
Table 4 - Mode of HIV Infection
1.
2
3.
T
5.
6.
Promiscuity of the subject
Heterosexual
Bisexual_______________
Promiscuity in spouse
Blood Transfusion______
Could not be ascertained
Total:
68
73
5
4
3
10
90
29
32
47
21
Mental Health Research in India
mood, an attitude of resignation, a fear of deaths
disfigurement and apathy. However, there were others
who appeared to remain unperturbed and also those who
expressed a “denial”. No reaction was observed in 10
and an attitude of “unconcern” was noticed in 8. In all,
thirty-two subjects showed negative responses:
(overlapping in some) Depressed mood with suicide
tendency (20), Suicide attempts (5), a panic reaction with
fear of death (6), anxiety (15), fear of disfigurement (1),
Two of the subjects who reacted with depression
proceeded to a full major depression. The schedules were
administered in these cases to assess the degree of
anxiety, depression and state of hopelessness.
correct address of the subjects and clinical features of
STDs were collected at the initial screening, and the blood
was collected for sero testing for syphilis and HIV. After
the receipt of HIV result, the sero-positive subjects were
contacted by home visits or at the STD OP itself. 90 HIV
positive cases could be registered after screening 5483
cases. The source of intake is shown below in table 1.
Further data on clinical and behavioural aspects were
collected and the following rating scales were
administered: BDI, BFIS, CPRS and Bender Gestalt and
memory scales. STD findings were obtained from Dept.
Of STD, and Professor of Neurology furnished the
neurological findings. The psychiatric and psychological
status was ascertained by the Principal Investigator and
the project medical officers. In thirty-eight subjects brain
CT scan could be done.
STD diagnosis
An assessment was possible in 79 subjects. Sixty-five
(82%) had one or more STD diagnosis. These are as
follows: Syphilis (34), Trichomonas vaginolis (12), genital
warts (8), genital herpes (5), Gonorrhoea (6), Chancroid
(5), L.G.V. and P.I.D. (3), Kaposi's sarcoma (I ) etc.
The seropositivity status was disclosed to the patients
and consequent psychological responses noted.
The psychological responses in general, especially
the negative ones following the disclosure of HIV
seropositivity were elicited in 50 subjects. The method
of eliciting the response was more or less on the lines of
clinical psychiatric examination. It must be stated that a
number of subjects who were the inmates of Vigilance
Home. Prison at the time of intake have already had a
‘hunch’ that they were infected with HIV. In these
subjects, a clear-cut response following the disclosure
or confirming their fear of having contracted the infection
could not be made out. The negative psychological
responses to disclosure were in the nature of depressed
Other physical diagnosis
An assessment was possible in 71 subjects. Thirty
subjects (42%) were diagnosed to have one or more of
other physical illnesses. These are as follows: P.T. (4),
Bronchitis and L.R.I. (4), Peptic ulcer and chronic
diarrhea (3), Hansen’s disease (2), Viral fever (2),
Chronic Myeloid Leukemia (1), Cirrhosis lever (1),
Urinary tract infection (I) etc.
Psychiatric illness
Thirty-four (49%) of the 70 subjects assessed had
Table 5 - Diagnostic classification of psychiatric disorders
5. No. Diagnosis
No.
%
1
Depression
24
34.3
2
Mental Retardation
7
10.0
3
Substance abuse
5
7.1
4
Alcohol abuse
2
2.8
5
Paranoid schizophrenia
1
1.4
6
Grief reaction
1
1.4
7
Chronic anxiety
1
1.4
30
A CLINICAL STUDY OF THE HIV INFECTED PATIENTS
Table 6 - Psychometry Findings
N
%
Average
37
55.2
Below average
30
44.8
Normal
21
31.3
Abnormal
46
68.1
INTELLIGENCE (N=67)
Superior
VISUO-MOTOR FUNCTION (N=67)
MEMORY (N=67)
Verbal impairment only
4
Non-Verbal impairment only
6
Both impairment
26
Both intact
31
46.3
Extrovert with neuroticism
23
34.3
Neuroticism with extroversion
43
64.2
Ambivalent
1
1.5
53.7
PERSONALITY (N=67)
one or more diagnosable psychiatric disorders. The
diagnostic break up of psychiatric disorders is given
below in Table 5.
Cerebral oedema
10
Possibility of post-encephalitic sequelae 2
Possibility of pituitary adenoma
1
Cortical atrophy
1
Bil. Calcaneum ; Baral Bronchiectasis
1
vi) Suggestive of old tuberculoma
1
vii) Old treated granuloma
1
viii) Normal
21
Intervention measures consisted of psychiatric
treatment with drugs and counseling; treatment of STDs
and other physical diseases. Health education was
imparted with a view to prevention of spread of infection
from the subjects. The impact of health education and
the degree of compliance and behaviour change were
noted. The change in behaviour among the promiscuous
did not correlate with age, sex, literacy or marital status.
The only factor that appeared to influence favourable in
effecting a behaviour change was the shorter duration
of the currently diagnosed STDs or absence ol earlier
STD history.
i)
ii)
iii)
iv)
v)
Psychometric Findings
The psychometric findings have been presented in
table 6. There was evidence of extroversion and
neuroticism in almost all cases (98%). As many as 45%
were rated as below average on intelligence and 55%
were in the ‘average’ category. None was rated as
‘superior’.
Abnormality in visuo-motor function was detected
in 68% of subjects. On the memory scale 54% were found
to have verbal impairment, or non-verbal impairment or
both.
Scan Findings
Brain CT Scan was done in 38 subjects. These
findings are as follows:
31
ILLNESS BEHAVIOUR IN PATIENTS PRESENTING WITH
PAIN AND ITS RELATIONSHIP WITH PSYCHOSOCIaL
AND CLINICAL VARIABLES
Procedure of data collection: Co-operation of
colleagues was solicited for referral of patients from the
concerned clinics. The patients thus referred were
screened using the inclusion/exclusion cri i ria. Subjects
thus included were examined and interviewed clinically
to collect the following data:
Chronic and intractable pain is a common medical
problem responsible for large amount of health service
utilization, economic loss and suffering to the afflicted
persons. This project was undertaken with the objective
to (i) study the illness behaviour in patients primarily
presenting with chronic pain, (ii) study the role of
psychological and socio-demographic variables in illness
behaviour of such patients, (iii) study the efficacy of
selected therapeutic measures on illness behaviour in
patients with chronic intractable pain, and its relationship
with psychosocial variables.
a) Sociodemographic variables: Age sex, marital
status, religion, education, occupation and ruralurban background were elicited from i ie patient and/
or one of his close relatives.
b) Clinical variables: The data pert ming to the
following clinical variables was stud.ed:
A pilot study was first undertaken on fifty-one
consecutive new patients reporting to the following
clinics of Postgraduate Institute of Medical Education
and Research, Chandigarh:
Organ/system wise classification ul'pain
Qualitative description of pain
Severity of pain measured in tern s of disability
caused
Mental status examination using a structured
schedule
Pain clinic, General medicine, Neurology/
Neurosurgery clinic, Orthopaedic clinic, Gynaecology
clinic, Psychiatry clinic, Rheumatology clinic,
Radiotherapy/Cancer clinics.
Clinical diagnosis (physical and psychiatric)
using ICD-9
Main Study
The main study included two hundred consecutive
patients reporting to the various clinics as described
above. Only those patients were included who had
“continual” pain. Pain has been operationally considered
to be continued if the pain-free period did not exceed
four days at a time. The other inclusion/exclusion criteria
were as follows:
c) Psychological variables: The psychological variables
studied were:
Life events - using the Social Readjustment
Rating Scale (Holmes and Rahe. 1967).
Psychoticism, Extraversion, Neuroticism
Inventary (PEN) (Eysenck and Eysenck. 1968)
as translated and adapted at Chancigarh 1 Verma
and Wig, 1972).
Inclusion criteria: Patients with the first or second
volunteered complaint of ‘pain’ of duration of three
months or more. For the purpose of the study, pain was
operationally defined as the complaint of‘pain’ referred
to the body or any part of it.
Illness Behaviour: was assessed using
Pilowsky’s Illness behaviour questionnaire
(IBQ). (Pilowsky and Spence 1975). The
questionnaire was translated and adapted for use
in this part of the country.
Exclusion criteria: The following patients were not
selected for the study:
d) Pilot study of selected treatment modalities in
patients was attempted. The patients were subjected to
psychotherapy, acupuncture and conventional treatment.
These subjects were followed up after 3 months to assess
the efficacy of the treatment methods.
a) Children below 15 years of age, and people above
65 years of age.
b) Patients with gross organic lesion ordinarily
sufficient in the estimate of the treating clinician to
explain existence, and substantially the severity of
pain.
e) A general information manual was prepared giving
relevant details of the study .
32
ILLNESS BEHAVIOUR IN PATENTS PRESENTING WITH PAIN AND ITS RELATIONSHIP WITH PSY( HOSOC1AL
AND CLINICAL. VARIABLES
Follow-up
psychiatric disorders found among patients presenting with
pain were: Depressive neurosis, Anxiety srates, hysteria
& Hypochondriasis, Psychalgia and others (’fable 1).
Intensity of pain was moderate to severe in 81 (40.55%)
cases and mild in remaining about 60% cases (Table 2).
Attempts were made to contact all patients for
follow-up. One hundred and thirty patients could be
followed up at three months from intake or within two
weeks of termination of therapy and the following data
were collected:
Comparison of pain with and without organicity
Treatment given
To see the relationship between the pain and its
organic basis, the sample was divided into two groups
as follows:
Change in intensity of pain
Duration of attack of pain
Frequency of pain
(i) Patients with absolutely no identifiable physical
disease or illness, or where the physical illness or
organic lesion was not considered by the physician
to be adequate to explain the nature and Severity of
pain. They were labeled as patients ol non-organic,
chronic, intractable (NOCI) pain.
Change in psychological problems encountered.
Mental State Examination was repeated using
screening version of PSE. Illness Behaviour Questionnaire
was re-administered to look for any changes.
Observations
(ii) Patients suffering from chronic, intractable pain
having a diagnosed physical illness or definite
organic pathology sufficient to explain the pain.
It was found that 100 cases (50%) had a physical
diagnosis while the remaining 50% had no physical
diagnosis. The physical disorders included Arthralgia,
Rheumatoid Arthiritis, Trigeminal Neuralgia & CNS
conditions, Gastro-intestinal (IBS, Peptic ulcer),
Neoplasms, Genitourinary and others. 144 cases (72%)
had diagnosable psychiatric problem. The more frequent
The two groups were comparable with each other in the
socio-demographic attributes, pain variables,
psychosocial problems and psychiatric diagnosis.
Table 1: Physical and Psychiatric Diagnosis of Pain Patients.
Physical
Diagnosis
N
Anxiety
States
Neoplasms
10
3
6
Trigeminal Neuralgia
& CNS conditions
21
4
Gastro-Intestinal
Disturbances (IBS,
Peptic ulcer)
14
Genitourinary
Depressive Hyst.&
Neurosis Hypoch
ondriasis
Psychalgia
Others
Psvchos is
6
0
0
0
A
5
1
0
0
0
11
5
5
2
0
1
0
I
7
2
1
0
0
0
3
Arthralgia
Rheumatoid Arthritis
42
2
12
1
2
T
1
Others
6
0
0
0
0
2
Nil Organic
100
22
32
19
5
6
33
No
Psy.
Dis.
22^
0
4
i .4
Mental Health Research in India
Table 2 - Intensity of Pain.
Site of Pa in
(Organ system- wise)
Intensity
Mild
(19=200)
Moderate
(N=119)
Severe
(N=69)
Total
(N=12)
Head, face & neck
56
24
28
4
Chest-Abdomen
47
30
15
2
Back and Lower back
30
21
8
1
Extremities
41
26
12
Whole body and others
26
18
6
Table 3 presents the pain variables like site,
qualitative description, intensity, frequency, and duration
of pain vis-a-vis organicity. The NOCI pain was
uniformly represented over various parts of the body head, face and neck (29 per cent), chest and abdomen
(22 per cent), extremities (20 per cent). Fourteen per
cent patients had pain all over the body. There is a
significant difference (P< 0.05) as regards qualitative
description. ‘Dull’ aching pain was the predominant type,
though the other variates of pain were also reported.
There was no difference in the two groups of chronic
pain patients as regards frequency and duration of pain.
2
Conclusions
Two hundred consecutive patients between (he age
range of 15-65 years with first or second volunteered
complaint of pain of more than three months duration
with the pain free period not exceeding 4 days at a time,
with no gross organic pathology, were studied. Some
inferences that can be drawn from this study are as
follows:
There is a good sample representatioi. in all clinics
of patients with pain as the chief symptom of
presentation.
ii) Pain is uniformly present in all age groups and both
sexes. Marital status and occupation also made no
significant differences in the presentation of pain.
iii) Pain has been reported to be ‘severe’ in intensity by
those educated up to matric, ‘mild’ | a in has been
reported more by those educated above matric. Pain
of ‘severe’ intensity is reported more* often by
patients from rural background.
i)
Psychosocial problems
Non-organic chronic pain has caused marked
psychosocial disability. Eighty one percent had personal
dissatisfaction. Fifty five percent reported disinterest in
work and lack of work motivation. Absenteeism from
work was associated with 41% cases. Forty one percent
had social problems and 26% domestic problems. Similar
conditions were found in patients with identifiable
organicity. There was no significant difference between
NOCI patients and those with some organicity with
regard to social problems, except school/college
disruption, which was significantly, more in NOCI pain
patients (Table 4).
iv) Certain physical illnesses, namely neoplasm,
nervous system disorders are more often associated
with ‘severe’ pain.
v) “Continuous” pain was reported by a great majority
(75 per cent) of patients.
vi) Common psychosocial problems arc associated with
patients presenting with chronic, continual pain.
Lack of interest and motivation in work, personal
dissatisfaction and social problems were more often
reported.
Other important parameters of illness behaviour in
patients presenting with pain included depressive
symptoms, and biological disturbances of depressive
nature, which have been presented in tables 5 and 6. The
tables are self-explanatory.
vii) Seventy-two per cent of patients had identifiable
psychiatric problems. Neurotic disturbances
34
ILLNESS BEHAVIOUR IN PATENTS PRESENTING WITH PAIN AND ITS RELATIONSHIP WITH PSYCHOSOCIAL
AND CLINICAL VARIABLES
Table 3: Clinical description of pain
Total Cases
NOCT
N=200
N=10()
Chronic
Pain with
some
organicity
N=l0()
56
47
30
41
26
29
22
27
25
75
7?
20
14
2?
42
p salite
Site of pain
Head and face
Chest/abdomen
Pelvis and back
Extremities
Whole body
Qualitative description
Dull
Pricking/burning
Squeezing, pulling, boring
Throbbing
Intensity of pain
Mild
Moderate
Severe
Frequency of pain
Once a week or more
Once or several times a day
Continuous
Duration of pain
Less than 1 day
One day to 1 week
16
4?
79
35
22
31
22
1 19
69
12
66
29
5
53
40
7
32
21
147
19
7
74
7
74
41
23
3
18
6
0
74
73
One week to 1 month
Continuous
12
77
48
34
13
L47
predominate. Depressive neurosis and anxiety
neurosis were diagnosed in almost 50 per cent of
the sample.
N.S.
0.05
N.S.
N.S.
73
N.S.
inclusion in the study.
*
ix) Almost 80 per cent had reported improvement after
various treatments given of which 43 per cent
reported ’good relief. An overall improvement was
also noticed in the psychosocial problems and the
psychiatric symptoms.
Fifty per cent of the cases had no identifiable organic
pathology in any form or severity. The other 50 per
cent of the cases had some physical problems
associated, but it was not sufficient to explain the
severity and nature of pain.
X)
viii)Though the majority of patients reported
psychological symptoms as anxiety, worrying,
depression, lack of confidence, only 17 per cent had
sought any form of psychiatric treatment prior to
35
Ten of the subjects treated with Acupuncture could
be followed up. ‘Partial’ to ‘good’ relief was reported
by 80 percent though the pain remained ‘continuous’
in duration in nine of the ten subjects. A general
improvement was noticeable in the psychosocial
problems.
Mental Health Research in India
Table 4: Psycho-social problems encountered
Total Cases
N=200
NOCI
N=10()
Absenteeism
71
41
Marital discord
16
10
6
N.S.
Lack of work motivation
116
55
61
N.S.
Personal dissatisfaction
165
81
84
N.S.
School-College disruption
15
12
3
0.02
Disinterest in work
110
54
56
Social problems
87
41
46
N.S.
Domestic problem
44
26
18
N.S.
Chronic Pain
with some
organicity
(N=100)
30
Table 5: Depressive Symptoms
PSE Item
N
Subjectively inefficient thinking
1 1
5.5
Poor concentration
33
16.50
Neglect due to brooding
27
13.50
Irritability
83
41.50
Loss of interest
63
31.50
Depressed mood
80
40.00
Hopelessness
33
16.50
Suicidal plans
16
8.00
Social withdrawals
19
9.50
Self-depreciation
12
9.00
Table 6- Biological disturbances of depressive nature
PSE Item
N
%
Loss of weight
36
/s.oo
Delayed sleep
27
13.50
Subjective anergia and retardation
23
1 1.50
Early morning waking
4
2.00
Loss of libido
34
1 7.00
Morning depression
12
o.OO
36
o value
N.S.
MENTAL HEALTH
INDICATORS
MENTAL HEALTH INDICATORS
ICMR - WHO PROJECT ON MENTAL HEALTH INDICATORS
combined, (d) for all persons aged less than 18 years,
and (e) for all persons aged over fifty years. This provided
an opportunity to study the stability of factor structure
across centres, for males as well as females, and
separately for adolescents and for elderly (to examine
whether the factor structure breaks down towards the
tail of age range included in the study or it remains
stable). The factor structure was found to remain stable
across all strata of study population. The concurrent
validity of Subjective Well Being Inventory was assessed
by finding correlations between scores oi subjective
well-being and Home Risk Card (HRC).
An ICMR-WHO project on mental health indicators
was initiated to develop Indicators of well-being and to
develop psychosocial interventions to improve well
being of young mothers. The project was carried out at
three centres: Bangalore, Delhi, Lucknow. Following
indicators of mental health were developed during first
phase of the project:
Subjective Well Being Inventory to assess well being
at individual level
Home Risk Card (well being at family level)
Home Risk Card (HRC):
Subjective well being inventory
Home Risk Card (HRC) is another instrument
developed in the first phase of the project. The
requirement was to prepare a short instrument - a service
tool, which can be used by field workers. The use of
tool should not mean additional burden and its usage
should require only a few minutes during home visit of
families by the anganwadi worker/field worker, and she
should be able to interpret and make use of data in her
day to day work.
Although human health has been explored in depth,
yet the positive subjective well being has been largely
ignored. Some theoretical and empirical work on well
being has been undertaken over last two decades,
subjective well being has been of central importance to
those interested in measuring the quality of life.
The subjective Well Being inventory developed in
1CMR-WHO project consists of 40 items. Nineteen of
these elicit positive affect, that is, whether one feels
happy or good or satisfied about particular life concerns.
Twenty-one items elicit negative affect i.e., unhappiness
or worry or regret about particular life concerns. A brief
description of dimensions of subjective Well Being
Inventory (as identified by factor analysis) and number
of questions in each dimension are given in Table 1.
The first version of the instrument developed was a
comprehensive schedule consisting ol 71 items. A step
up multiple regression analysis of HRC items was
undertaken with (a) nutritional status of children as
dependent variable, and also with (b) cognitive
development of children as dependent variable. This led
to identification of 21 items that made significant
contribution to cognitive development or nutritional
status of children. This helped in reducing the interview
schedule for identifying children at risk from 71 items
to 21 items.
The inter-rater reliability exercises were carried out
during initial phase of the project. The inter-rater
reliability was found to be high ; intra centre as well as
inter-centre. The factor validity was established through
factor analysis. The factor analysis was carried out
separately for the following strata of study sample: (a)
each of three centres separately, (b) for males of all
centres combined, (c) for females of all centres
The 21 items belonged to seven areas t factors) Inter
rater agreement exercises were undertaken to find out if
these seven factors could be directly rated as present or
absent by health workers in a reliable manner. The inter
rater agreement between research worker and each
39
Mental Health Research in India
Tabic 1: Description of factorial dimensions of Subjective Well Being Inventory
5. No.
Factor
(No. Of items)
Description
1.
Subjective Well-being
Positive affect
Feeling of well-being arising out of an overall
perception of life as functioning smoothly and joyfully.
2.
Expectation-achievement
Congruence
Feelings of well being generated by achieving
success and the standard of living as per one’s expectation, or
what may be called satisfaction.
3.
Confidence in coping
Perceived personality strength, the ability to
master critical or unexpected situations. It reflects positive menial
health in an “ecological sense” i.e. the ability to adapt to change
and to face adversities without breakdown.
4.
Transcendence
Feelings of subjective well being derived are beyond the ordinary
day-to-day material and rational existence. These have a touch of
spiritual values.
5.
Family group support
Positive feelings derived from the perception of the wider family as
supportive, cohesive and emotionally attached.
6.
Social support
Feelings of security derived from supportive attitude in tm es of crisis.
7.
Primary group support
Feelings of happiness/worry about one’s relationship with primary
family, viz. spouse and children.
8.
Inadequate mental mastery
Feelings of having a sense of insufficient control over, or inability
to deal efficiently with certain aspects of life that arc ca ■>; blc
of disturbing the mental equilibrium. This inadequate mastery
is perceived as disturbing or reducing subjective well-being.
9.
Perceived ill health
Perceived physiological dysfunctioning complaints
10.
Deficiency in social contacts
Feelings of missing friends or lack of close relationship
11.
General Well-being
negative affect
Feelings of ill being in an overall perspective,
reflecting a generally depressed outlook on life.
40
ICMR - WHO PROJECT ON MENTAL HEALTH INDiCA TORS
anganwadi worker was found to be over 80 per cent for
each factor separately. The use of HRC in phase 11 of
project established sensitivity of HRC in assessing
change brought about by family intervention programme.
Factors of HRC are described in table 2.
Phase -II
Psychosocial interventions to improve well-being of
young mothers were developed and these were carried
out through home visits by Anganwadi Workers during
second phase of the project. The strategy adopted for
family (psychosocial) interventions is shown in the
schematic diagram.
Table 2: Factors of HRC Schedule
Description
Child health was chosen as the entry point in th$
homes as visit of health worker/Anganwadi worker to
the home for child health activities is accepted and
welcomed by the families. The Anganwadi workers were
given orientation training and on the job training lor the
intervention. During initial visits, the Anganwadi
workers evaluated the family in terms of problem areas
in the family such as abject poverty, adverse
neighbourhood environment, poor house keeping,
emotional/psychological problems of young inolher such
as irritability or remaining sad without reason, neurotic
traits in children, child neglect severe marital discord
and the family resources such as knowledge about health
care needs, willingness to cooperate in the intervention
adequate coping ability, economic stabilit adequate
family routine, presence of family cohesiveness,
presence of a leader or person from whom counsel is
sought. The intervention workers helped he uomei?
enhance their coping abilities for tasks related to their
day to day life in which child care also formed an
important part.
The results of intervention showed that tliciv was
significant improvement that was maintained at I'nllowup also in various health parameters. The ii iprovcment
in subjective well being of young mothers is.shown below.
A significant difference (marked improvement in
experimental groups as compared to control group) was
found in the following factors of S.W.B.I.
Neighborhood Environment
Inadequate play space
Neighbors who dislike/discriminate against the child
No peer group
Witnessing aggression and violence would
constitute adverse neighborhood environment
Abject poverty
Difficulty for food, clothes etc.
Cannot arrange play material for child
Kuccha house
Poor house keeping
Unclean house
Evidence of poor house keeping
Children unclean
Personality characteristics of mother
Sad or depressed for long period without reason
Gets upset easily
Severe marital discord
Often serious problems with husband
Often solid reason for conflict
Conflict over money matter
Conflict over children
Not happy with married life
Neurotic traits
Bed-wetting
Stammering
Child neglect/abuse
Not showing affection to child
No regular routine for child
Frequent beating
Blaming, scapegoating or humiliating the child
Lack of playmates for the child
41
Mental Health Research in India
SCHEMATIC DIAGRAM OF FAMILY INTERVENTION
Indentification of Risk factors / resources
Indentification of Family capabilities
Selection of entry point
As a part of tasks already being done by the worker, e.g. health education, MCH care etc
Tasks should be perceived as needed by the family
Tasks should be acceptable to the family
Plan of interventions
List series of tasks to be jointly performed by the family member and the worker
Tasks should be feasible and simple
Tasks should be flexible
Feeling of concern
High degree of involvement of the worker
Empathy and understanding
praise and appreciation of the family’s efforts
Family feels helped
Health worker’s satisfaction
Increases family’s participation overtime
Sense of imporvement and gain in confidence
Measurable improvement on health parameters
42
Mental Health Research in India
Table 5. Percentage distribution of families by presence of H.R.C. factors at Lucknow
HRC factor
Percentage of families having home risk factors
Experimental area
Conti >1 area
Initial
6 months
1 year
Initial
6 m mtlis
Adverse neighborhood environment.
35.00
31.25
29,49*
54.67
49.: *
46.75*
Abject poverty.
30.00
13.75*
13.92*
34.67
29.? 3
26 92
Poor house keeping.
78.75
30
24.05*
58.67
46.( 7*
C) 00*
Characteristics of mother.
33.75
16.25*
15.19*
44.00
37.: 3
37.17
Severe marital discord.
22.5
12.5*
11.39*
26.67
21.. 3
20.51
Neurotic traits.
27.5
3.75*
2.53*
22.67
12.( 0*
I 1.54*
Child neglect
82.5
56.25*
45.00*
72.00
6S.( 0
1.79
\ car
* Indicates significant improvement as compared to initial evaluation
# Indicates significant deterioration
NUTRITIONAL STATUS OF CHILDREN: The
improvement observed in nutritional status of children
is shown in bar diagram 1.
COGNITIVE
OF
DEVELOl'MEM
CHILDREN:
The improvement observed in cognitive development
of children is shown in bar diagram 2.
Diagram 1:
Nutritional status of children as percentage of
Harvard Standard
Diagram 2:
Mean score for development quotie n of hilore i
Bangalore
Bangalore
I
r
i
i
'i
Delhi
Delhi
J
i
..J
3
Lucknow
4-
Lucknow
_________
0
20
-I-
I
—I—
40
60
80
1)0
I20
Mean percentage sco i
65
70
El 1 year
75
80
□ 6 months
85
90
□ Initial
|
□ 1 year
□ 6 months
D nitial
44
|kvr
1CMR - WHO PROJECT ON MENTAL HEALTH INDICATORS
and the world around them. From a practical view point,
it is important to know how different persons fee! with
regard to their day-to-day concerns like their health or
family. Such knowledge is necessary if an improv -ment
in the quality of life of people is to be brought.
The instruments of psychosocial measurement are
usually long and serve the purpose of only research
instruments. This project has attempted to develop tools
of psychosocial measurement following scientific rigors,
but making them so simple to use and interpret that these
may be of practical use in day-to-day work of field level
workers. A very significant aspect of the methodology
used in their development was that the validity with
relevant independent criteria was kept in the forefront
from the beginning.
This is a questionnaire on how y< u feel .' bout some
aspects of your life. Each question may be answered by
any one of the given categories by putting a cii ?lc O
around the number which seems to represent) oui I ■cling
best. For example, in the first question, if yoti fed that
your life is very interesting. Please put a circle around
the response 'Very much' (1) At times you may find that
your feeling is nor represented perfectly by an .■ >f the
given response categories. In such cases, just choose the
one closest to what you think.
The project has demonstrated that it is simple to carry
out psychosocial interventions at family level through
home visits by field level workers with impressive
positive health outcomes.
SUBJECTIVE WELL-BEING INVENTORY
All information given by you will be treaied as
confidential and will be used only for research purposes.
People are different. They live in a variety of
situations and they do not feel the same way about life
Subjective Well-being Inventory
Job No. 2 0 3
Card No.
□F
Centre
Type of Area
Address
Family Serial No.
Name of the respondent
SI. No. of the respondent
10-11 *
Age
12-13
Sex
;4
Education
15
Occupation
16-17
45
-{I
Mental Health Research in India
Subjective Well-being Inventory
I.
□ 18
Do you feel your life is interesting?
Very much
To some extent
Not so much
2.
3.
4.
5.
6.
7.
8.
9.
1
2
3
Do you think you have achieved the standard of living
and the social status that you had expected?
□ ■9
Very much
To some extent
Not so much
1
2
3
Very good
Quite good
Not so good
1
2
3
Most of the time
Sometimes
Hardly ever
1
2
3
Very happy
Quite happy
Not so happy
2
3
Very happy
Quite happy
Not so happy
I
2
3
How do you feel about the extent to which you have
Achieved success and are getting ahead?
Do you normally accomplish what you want to
Compared with the past, do you feel your present life is:
On the whole, how happy are you with the things
you have been doing in recent years?
Do you feel you can manage situations even when
they do not turn out as expected?
Most of the time
Sometimes
Hardly ever
1
2
3
Very much
To some extent
Not so much
1
2
□ 24
Do you feel confident that in case of a crisis (anything
which substantially upsets your life situation) you will be
able to cope with it/face it boldly?
•
□ 26
The way things are going now do you feel confident
to coping with the future?
Very much
To some extent
Not so much
46
1
2
3
ICMR - WHO PROJECT ON MENTAL HEALTH INDICATORS
10.
□ 27
Do you sometimes feel that all of us are part of a
common force? (God or any such force)
Very much
To some extent
Not so much
11.
12.
13.
14.
□ 28
Do you sometimes experience moments of intense
happiness which are difficult to describe?
Quite often
Sometimes
Hardly ever
1
2
3
Quite often
Sometimes
Hardly ever
1
2
3
Very much
To some extent
Not so much
1
2
Does it give you happiness to think that you are
part of mankind?
16.
17.
□ 31
How do you feel about the relationship you and
your children have?
1
2
o
4
□ 32
Do you feel confident that relatives and/or friends
will look after you if you are severely ill or meet
with an accident?
Very much
To some extent
Not so much
1
2
3
Very much
To some extent
Not so much
1
2
□ 33
Do you get easily upset if things don’t turn out as expected?
n
□ 34
Do you sometimes feel sad without reason?
Very much
To some extent
Not so much
18.
□ 29
Do you feel confident that relatives and/or friends
will help you out if there is an emergency, e.g. if
you lose what you have by fire or theft?
Very good
Quite good
Not so good
Not applicable
15.
1
2
3
1
2
3
□ 35
Do you feel too easily irritated, too sensitive?
Very much
To some extent
Not so much
47
1
2
3
Mental Health Research in India
19.
Do you feel disturbed by feelings of anxiety and tension?
Very much
To some extent
Not so much
20.
21.
22.
24.
25.
26.
27.
28.
□ 36
o
37
Do you consider it a problem for you that you sometimes lose
your tempor over minor things?
Very much
To some extent
Not so much
1
2
3
Very much
To some extent
Not so much
1
2
Do you consider your family a source of help to you in finding
solutions to most of the problems you have?
□ 38
2
39
Do you think that most of the members of your
family feel closely attached to each other?
Very much
To some extent
Not so much
23.
1
2
1
2
3
Do you think you would be looked after well by your family in
case you were seriously ill?
40
Very much
To some extent
Not so much
1
2
3
Very much
To some extent
Not so much
1
2
Do you feel your life is boring/uninteresting?
Do you worry about your future?
□41
42
Very much
To some extent
Not so much
1
2
Very much
To some extent
Not so much
1
2
3
Very much
To some extent
Not so much
Not applicable
1
2
3
4
■>
□ 43
Do you feel you life is useless?
Do you sometimes worry about the relationship you and your
wife/husband have?
45‘
Do you feel your friends/relatives would help you out
if you were in need?
Very much
To some extent
Not so much
48
□ 44
1
2
3
ICMR - WHO PROJECT ON MENTAL HEALTH INDICATORS
29.
46
Do you sometimes worry about the relationship you
and your children have?
Very much
To some extent
Not so much
Not applicable
30.
31.
32.
□ 47
Do you feel that minor things upset you more than
necessary?
Very much
To some extent
Not so much
1
2
3
Most of the time
Sometimes
Hardly ever
1
2
3
Do you get easily upset if you are criticized?
34.
35.
36.
37.
38.
□48.
49
Would you wish to have more friends than you
actually have?
Very much
To some extent
Not so much
33.
1
2
3
4
1
2
3
Do you sometimes feel that you do not have a real
close friend?
50
Very much
To some extent
Not so much
1
2
3
Very much
To some extent
Not so much
1
2
3
Most of the time
Sometimes
Hardly ever
1
2
3
Most of the time
Sometimes
Hardly ever
1
2
3
Most of the time
Sometimes
Hardly ever
1
2
3
Most of the time
Sometimes
Hardly ever
1
2
3
Do you sometimes worry about your health?
Do you suffer from pains in various parts of your body?
Are you disturbed by palpitations/a thumping heart?
□52
53
□ 54
Are you disturbed by a feeling of giddiness?
Do you feel you get tired too easily?
55
49
Mental Health Research in India
39.
56
Are you troubled by disturbed sleep?
Most of the time
Sometimes
Hardly ever
40.
1
2
3
57
Do you sometimes worry that you do not have
close personal relationship with other people?
Very much
To some extent
Not so much
Thank you.
1
2
envisaged to be an instrument requiring qualified social
scientists for data collection and interpretation. No
complex scoring system was desired.
HOME RISK CARD
Home Risk Card (H.R.C) is one of the instruments
developed in the first phase of W.H.O. ICMR project on
Indicators of Mental Health. The earl ier work in this area
in Sri Lanka had indicated that nutrition of the child
showed significant association with lack of curiosity,
opportunities for play, items reflecting the Caretaker’s
knowledge of child care, household organization and
interest in and knowledge of child’s needs. Further the
Sri Lanka experience had shown that health workers
could obtain reliable data on such parameters. The inter
rater reliability of 90 per cent or more was found for
factual items and 75 per cent or more for subjective
judgments. It was decided in the present project to
undertake work in this area in a holistic manner drawing
from experience of Sri Lanka and other countries as well
as the vast experience available in our country in the
area of child mental health. The validation of the
instrument with relevant and independent criterion
variables was planned from the initial stage of the project.
The idea was to develop a set of indicators which can be
rated by health worker through observations and informal
talk with the housewife during home visits. The tool
should help the health worker in identifying families in
need of special care (with regard to psychosocial
development of child and well being of mother).
Development of an interview schedule
A comprehensive schedule was first developed collect
data on family, home and social environment that could
be risk for healthy psychosocial development of children.
This involved development of a schedule based on
available literature and experience in this area. The first
draft of the schedule included items on factors that were
identified during similar efforts in Sri Lanka and
Indonesia. This schedule was revised three times by
making significant contributions based on experience of
the investigators. The three revisions of the schedule were
necessitated to incorporate the additional items that were
suggested as a result o experience during field trials and
the interaction among the experts. The following
reliability exercises were undertaken during the process
of evolving the Interview schedule for Identifying
Children at Risk:
Definition of problem
The requirement was to prepare a short instrument
- a service tool, which can be used by field workers.
The use of tool should not mean additional burden and
its usage should require only a few minutes in known
families. The field worker should be able to interpret
and make use of the data in her day to day work.
First revision : Field trial in 60 families at Bangalore
and 40 families at Lucknow Centre
ii) Second revision : Field trial and inter-rater reliability
exercises in 40 families at each centre.
iii) Third revision : Inter-rater, and inter-centre
reliability exercises in 40 families.
i)
This should be differentiated from a psychosocial
measurement schedule which require elaborate
conceptualization of theoretical constructs, and then
some kind of scoring procedure to provide a measure of
the psychological/social attribute under study. It was not
50
ICMR - WHO PROJECT ON MENTAL HEALTH INDICATORS
The inter-rater reliability showed over 80 per cent
agreement for each item of the schedule separately.
workers in identifying risk families (as regards
psychosocial development of child and well being of
mother) through some general observations and informal
talk. The development of such a tool from the
questionnaire was undertaken as follow:
Condensation of Interview Schedule and Validity
Exercises
The 21 items belonged to seven areas (factors). It
was decided to undertake an exercise to find out if these
seven factors could be directly rated as present or absent
by health workers in a reliable manner. Inter rater
reliability exercises were undertaken in 50 families at
each study centre as follows:
The interview schedule for identifying children at risk
(of poor psychosocial development) was reduced in size
from 71 items to 21 items using step up multiple
regression analysis. It also helped in validating the
instrument against independent criterion variables. In
order to reduce the size of H.R,.C., and to validate it
against independent criterion, step up multiple regression
analysis of H.R.C. items was undertaken with (a)
nutritional status of children as criterion variable for
Bangalore Centre (n+411) and for Lucknow Centre
(n+401), (b) cognitive development of children as
criterion variable for Bangalore Centres and for Lucknow
Centre. The items thus selected are given in table 1. The
multiple correlation R between H.R.C. items and
cognitive development was found to be 0.74 and 0.65
for the two study centres respectively. The value of R
between HRC items and nutritional status was 0.55 and
0.43 for the two study centres respectively.
a) 21 - item HRC rating by research worker
b) HRC-7 factor version direct rating by research
worker
c)
HRC-7 factor version direct rating by Anganwadi
worker-1
d) HRC-7 factor version direct rating by Anganwadi
worker-11
The inter rater agreement was examined between
research worker and Anganwadi worker-1, research
worker and Anganwadi research worker-II, Anganwadi
worker-I and Anganwadi worker-II. It was found to be
over 80 per cent for each factor separately.
Further evidence of validity was provided by
studying the multiple correlation of these 21 items of
HRC with subjective well being of mother. Multiple R
was found to be 0.80 for Bangalore Centre and 0.74 for
Lucknow Centre.
Ratings
The factors of HRC arc rated as present or absent by
the health worker/AWW. Presence of two or more risk
factors in a family indicates that the family is at risk (for
poor psychosocial development of children). The use of
H.R.C. in phase-II of the project established sensitivity
of HRC in assessing change brought about by family
intervention programme.
The interview schedule for identifying children at
risk was reduced in size from 71 items to 21 items as
described above. But it was still an interview schedule.
The health workers are not expected to administer a
questionnaire during routine home visits. The tool can
be of use in routine home visits if it can help the health
51
M H'' F0
Table 1. Items of the condensed form of H.R.C. schedule
Description
Neighbourhood environment conductive for child?
Abject poverty
Difficulty for'food, clothes etc.
Cannot arrange play material for child
Kuccha house
Poor house keeping
Unclean house
Evidence of poor house keeping
Children unclean
Personality characteristics of mother
Sad or depressed for long period without reason
Gets upset easily
Severe marital discord
Often serious problems with husband
Often solid reason for conflict
Conflict over money matter
Conflict over children
Not happy with married life
Neurotic traits
Bed wetting
Stammering
Child neglect/abuse
Not showing affection to child
No regular routine for child
Frequent beating
Blaming, scapegoating or humiliating the child
Lack of play mates for the child
GLOSSARY
I.
gets upset easily).
Adverse neighborhood environment: (Not at all
conducive for child’s proper growth).
A chronic physical or mental illness (depression or
anxiety or any other illness) of mother is likely to
adversely affect the child especially if there are no
other caretakers. Similarly if the mother lacks self
confidence, this may also adversely affect the
psychological development of the child. The mother
will never be sure what she is doing is right or wrong
and may be inconsistent in her behaviour with the
child, especially discipline (constant nagging or
frequent irritability of the mother may inhibit the
child’s expression of feelings and thinking.
It is thought that if the neighborhood environment
is unsanitary, very noisy, has inadequate play space,
neighbors who dislike the child, or no peer group,
then the neighborhood is not conducive to the child’s
growth and development. If the neighborhood is
delinquent and rowdy, it may adversely affect the
harmony and peace of the family and thereby
adversely affect the family members that take care
of the child. Witnessing aggression or violence may
adversely affect the child’s psychosocial growth.
2.
3.
5.
Deprivation means less nutrition and also less
psychological stimulation or perhaps negative over
stimulation due to overcrowding. Extreme poverty
is also indicative of other social mental/physical
problems in the family and inability of the later to
meet the psychological needs of the child.
Severe marital discord: (often serious problems
among the couple, conflict over money matters,
drinking habits, or general dissatisfaction with
married life) Severe marital discord is well known
to be associated with children’s psychological
problems. It may also have adverse effect on child
rearing and on psychosocial development of child.
6.
Neurotic traits: (bed wetting or stammering if any
child in the house is in age group 3-6 years).
Poor house keeping: (Unclean house, poor house
routine, unclean children).
7.
Child neglect: (lack of interest/affection and lack of
routine, child gets frequent beating or is blamed
often, child lacks play mates).
Abject Poverty: (the family has difficulty even for food/
cloths, or can not affort any play material for child).
It is known that disorganization of the house is
associated with lack of, or inadequate child care.
Points of observation such as unclean house and
children are important. Poor house routine indicate
poor organizing capacity of the family and therefore
less care to the child.
4.
Characteristics of mother: (Remains sad or
depressed for long periods without reason or often
Child neglect is reflected through criticism of the
child, constant nagging, lack of appropriate affection,
psychological stimulation and happy interaction, and
whether the child has a routine for activities of daily
living. Presence of either physical or psychological
abuse will have adverse implications for child
development.
Mental Health Research in India
(HOME RISK CARD)
Job No.Cols.
:Card No.
Centre
Type of area
Address
Family serial no.
Name of the mother
S. No. of mother
Age :
Education
Occupation
Number of children
Number of children between 3 and 6 years
1-3
4
5
6
7-9...
10-11..
12.13..
14
15-16 •
17
i.
Adverse Neighbourhood Environment
(not at all conducive for child’s proper
growth and development)
18
II.
Abject poverty
(the family has difficulty even for food/clothes,
or cannot afford any play material for child)
19
111.
Poor house keeping
(Unclean house, poor house routine,
(unclean children)
20
IV.
Characteristics of mother
(She remains sad or depressed for long periods
(without reason or often gets upset easily)
21
22
Severe marital discord
(There is often serious problem with
husband, conflict over money matter,
drinking habits or she does not feel happy
with married life in general)
23
Neurotic traits
(In any child in house in age goup 3-6 years)
(bed wetting or stammering)
24
Child neglect (for any child in age group 3-6 years)
(lack of interest/affection and lack of routine
for child or child gets frequent beating or is
blamed, child lacks playmates)
a. Yes e. No. 3. Not certain
25
54
MEASURES OF QUALITY OF COMMUNITY LIFE
The concept of quality of community life has
assumed special significance in the medical field in the
wake of progressive move towards rehumanising hightech medicine. Comprehensive health assessment should
not be restricted to physical and psychopathological
problems but should also include the quality of life.
Assessment of health should be conceptualized
holistically with due emphasis on positive aspects of
health and subjective perspectives of the individual.
There has been a growing awareness about the need of
in-depth enquiry about the quality of life and its role in
the epidemiology of various illnesses, their prevention
and treatment procedures.
i.
To carry out stepwise Ethnographic Exploration to
evolve items for in-depth study on Quality of
Community Life (QOCL).
2.
To study the factor structure of QOCL. To carry out
item reduction and to arrive at a short tool to measure
QOCL.
3.
To study the validity of the measures of QOCL
against independent criterion variables including
health related variables.
The study thus aimed to develop an instrument using
the process of stepwise ethnographic exploration td
measure the quality of community life and develop
insights into the support systems available and operating
in the community. It was conducted in villages, urban
slums and other urban colonies.
Health Sector in India from the time of independence
has appreciated the need of community involvement in
improvement of health care and several ambitious health
programmes have been started with community
participation as an important component. Mass media have
been extensively used to educate and sensitize the people.
Development of the Questionnaire
WHO/SEARO has been concerned with the
development of indicators of quality of life; WHO/
UNICEF inter-country workshops during 1980’s
emphasized the need of studying communities, which
was re-emphasized by Regional Coordinating Group for
Mental health Programme in September 1986. It was
observed that little work had been done on indicators of
quality of community life. The meeting also observed
that it would be futile to scientifically study the
community intervention programmes without developing
indicators of quality of community life. ICMR and WHO
have already developed Subjective Well-being Inventory
for studying the quality of individual’s life. ICMR has
also developed Home Risk Card to study the quality of
family life. As a logical sequence ICMR undertook this
research project to develop an instrument to study Quality
of Community Life (OOCL).
The concepts relevant to community life were
identified by conducting a comprehensive ethnographic
study in Chennai, South India, and Lucknow, North
India. The sample of ethnographic study included widely
divergent socio economic groups comprising of a
representative segment of rural community, urban
colonies, and urban slums (authorized and unauthorized).
The concepts identified during this study were
subsequently transformed into questionnaires by both
the centres independently. The respective questionnaires
were administered to 500 respondents each drawn from
above-mentioned residential areas at the two centres. The
data so-collected was factor-analyzed to study
meaningful clustering of items. Items found to be less
sensitive or less relevant to community life were dropped.
The analysis based on consideration of factor loadings
resulted into a reduction of number of items and to a
questionnaire of 80 items. This questionnaire was again
field-tested by administering it on 600 respondents each
at the two centres. The data so obtained was factoranalyzed using combined data of the two centres to
identify the factors relating to community life.
Aims of the study
The Task Force study on Measures of Quality of
Community Life (QOCL) was undertaken at Chennai
and Lucknow with the following objectives:
55
Mental Health Research in India
Analysis provided identification of 11 factors as
given below:
measure the same characteristics (Quality of Community
Life) and the instrument is internally consistent.
1. Relationship with colleagues.
Validity:
2. Community efforts for sanitation.
Two types of validity have been established: factor
validity and concurrent validity.
3. Support of relatives.
The separate factor analysis for the two centre yield
similar factors supporting the robustness of factorial
structures.
4. Support of family.
5. Support of neighbors.
Although there is no absolute standard of QOCL and
therefore we cannot demonstrate validity of our
instrument by studying its degree of correlation with such
a standard instrument. Concurrent validity can be shown
by correlating score on QOCL with score on related
measure such as infrastructure facilities (which can be
seen as objective parameters of quality of community
life) and Home Risk Card. Correlation analysis shows
that score on QOCL has significant correlation with thesd
parameters.
6. Relationship with friends.
7. Medical & other facilities.
8. Social discrimination.
9. Social contacts & Community information.
10. Law & order problems.
The significant differences in mean QOCL scores
between different types of residential areas point to a
good sensitivity of the instrument to differences in
neighborhood and thereby to changes over time in socio
economic development of the area.
11. Caste and religion.
To make the instrument appreciably precise so that
it could be easily administered to different groups or
communities, attempt was made to select only three
questions for each factor having the highest factor
loadings. The final questionnaire therefore consists of
only thirty-three items (questions) found to be most
relevant to the quality of community life.
This instrument has been able to differentiate
between the quality of community life in different
geographical areas as well as amongst rural and urban
population. The scores on the questionnaire reflect the
state of the area as is evident by similar responses in a
given residential area. This questionnaire can
differentially estimate the problem areas in a given
community e.g. problem of discrimination in rural and
urban slum of Lucknow Centre, which is different from
Chennai.
In addition to the above, a checklist was also
developed to assess infrastructure facilities. Since these
facilities relate to a varied nature of community variables
they were broadly categorized into the following six areas
for purpose of assessment:
Internal Consistency:
This instrument can be used in all situations where
community participation is central to the programme e.g.
all national programmes (Family planning, Literacy etc.).
In psychiatry it can be used to assess wherever
community resources are utilized in rehabilitation or in
district mental health programme. Proper intervention
may play a significant role in the acceptance of any
co mm unity-based programme.
To establish internal consistency of the
questionnaire, squared multiple correlation of each item
with all other items was computed. It was fond that each
item has a significant correlation with all the remaining
items of the questionnaire. As all items are significantly
correlated among themselves it implies that all items
56
MEASURES OF QUALITY OF COMMUNITY LIFE
QUALITY OF COMMUNITY LIFE QUESTIONNAIRE
Instructions for administration:
All people perceive life differently. This perception of life is intricately related to one's health and well-being.
The knowledge about individual’s perception of life around him can be utilized to improve health and productivity.
This questionnaire contains some questions regarding perceptions of people and support facilities available to them’.
Read these questions carefully and circle the response which appears close to your feelings.
QUALITY OF COMMUNITY LIFE QUESTIONNAIRE
I. Are you satisfied with the amount of contact you have with people in your community?
1. Not really
2. To some extent
3. Very much
2. Are you satisfied with opportunities to obtain information about your own locality?
1. Not really
2. To some extent
3. Very much
3. Are you satisfied with the help you get from your neighbours?
1. Not really
2. To some extent
3. Very much
4. Are you satisfied with the opportunities in your area to obtain general information?
1. Not really
2. To some extent
3. Very much
5. Do you feel content about the relationship you have with your relatives?
1. Not really
2. To some extent
3. Very much
6. Do your relatives share your happiness?
1. Not really
2. To some extent
3. Very much
7. Do you think that you will get enough help from your neighbours in your family functions?
1. Not really
2. To some extent
3. Very much
8. Are you satisfied with the relationship you have with colleagues at your working place?
1. Not really
2. To some extent
3. Very much.
9. Do you think that criminals are making daily life of people difficult in your community?
1. Very much
2. To some extent
3. Not really
4.N.A. (unemployed, house wife, student, retired)
10. Do you feel that you can easily get good medical care?
1. Very much
2. To some extent
3. Not really
11. Do you feel that you can easily get good medical care?
1. Not really
2. To some extent
3. Very much
57
Mental Health Research in India
12. Do you some times feel disappointed that you cannot avail of the services/benefits which you feel are due to
you?
1. Very much
2. To some extent
3. Not really
13. Are you satisfied with the transport facilities in your area?
1. Not really
2. To some extent
3. Very much
14. Are you satisfied with the help you get from your family members?
1. Not really
2. To some extent
3. Very much
15. Do you think that your family members will sympathize with you in times of sorrow?
1. Not really
2. To some extent
3. Very much
16. If people are in difficulties, do you think that it is your duty only to help persons of your own religion?
1. 1 would only help people
2. Sometimes it may be of my religion right to help people of other religions
3. No.l should help anybody
4. N.A. (homogenous community)
17. Do you sometimes feel disappointed for not getting what is due to you because of caste or religious considerations?
1. Very much
2. To some extent
3. Not really
18. Are you often unhappy-because of your family?
1. Very much
2. To some extent
3. Not really
19. Are you sometimes disappointed that friends are unwilling to help when you are in need?
1. Very much
2. To some extent
3. Not really
20. Do you feel that your neighbours will share your grief?
1. Not really
2. To some extent
3. Very much
21. Do you think that your colleagues at work will help you financially in times of need?
1. Not really
2. To some extent
3. Very much
4.N.A. (unemployed, self-employed, housewife)
22. Do your relatives share your grief?
I. Not really
2. To some extent
3. Very much
23. Do you think your friends will help you out in times of need?
1. Not really
2. To some extent
3. Very much
24. Could getting help from your colleagues at work cause problems in the future?
1. Not really
2. To some extent
3. Very much
25. Do you feel that you should share your happiness only with people of your own caste?
1. Very much
2. To some extent
3. Not really
58
MEASURES OF QUALITY OF COMMUNITY LIFE
26. If people are in difficulties, do you think that it is your duty only to help persons of your own caste?
1. 1 would only help people
2. Sometimes it may be of my own caste right to also help people of other castes
3. No.l should help anybody
27. Are you satisfied with the ease of access of medical facilities in ;your community?
1. Not really
2. To some extent
3. Very much
28. Do you think that sufficient efforts are being made by people in your community to maintain sanitation (disposal
of sewage and waste)?
3. Very much
I. Not really
2. To some extent
29. Do you think that sufficient efforts are being made by people in your community to manage toilet facilities? .
1. Not really
2. To some extent
3. Very much
30. Do you think that sufficient efforts are being made by people in your community to maintain the drainage
facilities?
3. Very much
2. To some extent
1. Not really
31. Do you sometimes feel disappointed for not getting what is due to you because of corruption?
1. Very much
2. To some extent
3. Not really
32. Do you feel that criminals in your areas are too strong and powerful?
1. Very much
2. To some extent
3. Not really
33. Are you satisfied with the relationship you have with your friends?
1. Not really
2. To some extent
3. Very much
SCORING OF THE QUESTIONNAIRE
Factors
Item Numbers
Scoring
1.
Colleagues
8
21
*24
1,2,3
1,2,3
3,2,1
IL
Community efforts
28
29
30
1,2,3
1,2,3
1,2,3
111.
Relatives
5
1,2,3
1,2,3
1,2,3
6
22
IV.
Family
1,2,3
1,2,3
3,2,1
14
15
*18
59
Mental Health Research in India
V.
VI.
Neighbours
Friends
VII. Medical & other facilities
3
1,2,3
7
20
1,2,3
19
*23
33
1,2,3
3,2,1
1,2,3
11
1,2,3
1,2,3
1,2,3
1,2,3
13
27
VIII. Social Discrimination
IX.
Social Contact
*12
*17
*31
3,2,1
3,2,1
3,2,1
3
1,2,3
1,2,3
1,2,3
1
2
X.
Law & Order
*09
*10
*32
3,2,1
3,2,1
3,2,1
XI.
Caste and Religion
*16
*25
3,2,1
3,2,1
3,2,1
*26
*Negatively structured items.
Note : Range of score for each factor : 3-9
Range of score for all the factors : 33-99
HIGHER THE SCORE, GREATER THE QUALITY OF LIFE
60
MEASURES OF QUALITY OF COMMUNITY LIFE
INFRASTRUCTURE FACILITY SCHEDULE
Available
(1)
I.
BASIC AMENITIES:
1. Water supply
Electricity
sewage facility
Garbage disposal
Roads
Public transport
Markets
IL EDUCATIONAL FACILITIES
8. Primary school
9. Junior High School
10. High School
11. Intermediate
12. College/University
13. Technical education
III. HEALTH FACILITIES
14. Dispensary
15. P.H.C.
16. Indoor hospital
17. District hospital
18. Private health facilities
19. Medical College
61
Not available
(2)
Mental Health Research in India
IV. OTHER FACILITIES:
20. Fair price shop
21. Post Office
22. Telephone
23. Bank
24. Cooperative Society
25. Balwadi/Anganwadi
26. Local newspaper
27. Sports facilities
28. Entertainment facilities
V. ORGANIZATIONS/ASSOCIATIONS:
29. Youth club
30. Mahila Mandals
31. Resident associations/NGOs
VI. (a) Religious bodies
(b) Caste specific associations
The infrastructure checklist can be very useful in obtaining supplementary objective information about
infrastructure facilities available in the community.
The instrument consisting of 33-item questionnaire and Infrastructure Checklist could be widely used to assess
the quality of community life and should be especially helpful in the studies of mental health and public health.
62
DEVELOPMENT OF A TOOL FOR PSYCHOSOCIAL STRESS
The research on psychosocial stress in India has so far
remained confined to some specific life domains and
for particular groups of people. There are several studies
on organization structure, executive stress, but the nature
and experience of stress in rest of the population has
remained unexplored. In fact no simple measurement
instrument was available for Indian population for
assessment of emotional stress experienced by persons
of all age groups and from different strata of society in
their day-to-day life as well as due to stressful life events.
There was a felt need among medical researchers for a
short psychometric instrument for assessment of
psychosocial stress which could be used in research on
risk factors for non-communicable diseases. An ICMR
project to develop such an instrument was carried out at
two centres - Ahmedabad and Varanasi.
The above dimensions of operational social stressors
were confirmed by factor analysis. These may be
considered as dimensions or subscales of stress
questionnaire. The stress factor of‘personal inadequacy’
or ‘low self esteem’ has been covered in this structure
under the factors of ‘interpersonal relations’ and
‘responsibility’.
The questionnaire of psychosocial stress was
prepared in the form of a ‘semi-structured interview’.
The self-report measure of stress purports to assess the
extent of basic components/constructs of felt stress
arising from excessive environmental forces in various
domains of social life. In order to widen the applicability
of the instrument, the items were so framed as to be
suitable to assess the extent of stress of the people
irrespective of their age, sex, religion, culture,
educational level and socio-economic status.
The stress questionnaire provides for collection of
information about above operational social stressors in
following spheres of social interaction: person-self,
family, relatives, neighborhood, peer group, work place,
community or society. In addition to the questionnaire^
a short measure of stress arising from infrequent but
crucial life events that occurred in respondents’ personal/
social life in recent past was also prepared in order to
cover broader area of operation of psychosocial stress
and also to make the tool more comprehensive.
The questionnaire assesses the social stressors in the
area of:
Reliability:
(e) Health related problems (of own or/and family
members)
(f) Adverse social situation, legal and property related
problem etc.
(g) Perceived/or imagined threat to social position,
economic status etc.
The reliability of the scale was estimated through
different methods, such as Cronbach’s -Alpha
Coefficient, split-half (odd-even), retest and inter-rater
consistency for the whole as well as for seven sub-scales
of the Stress Questionnaire on the data collected in pilot
study at two centres. The analysis revealed that the score
on the Stress Questionnaire as a whole as well as on its
seven sub scales were stable over time. The table 1 given
below shows the reliability index of the Questionnaire
estimated through different methods.
(a) Tense or strained interpersonal relationships
(b) Economic constraints
(c) Excessive
responsibility, over and under
expectations
(d) Marriage related problems (of own or/and family
members)
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Mental Health Research in India
Table 1: Reliability Indices of Stress Questionnaire and its Seven Sub-Scales
Sub-Scales
Methods of Reliability Estimation
Split-half
(odd-even)
Cronbach’s
alpha
Retest(at
interval)
10 days
Inter
Rater
Sample-I
N=156
Sample I
N=59
Sample
N=53
Sample 11
N=60
Sample I
N-156
Strained Interpersonal Relations
.47**
.46**
.63**
.53**
.59**
Threat to social status
.65**
.51**
.53**
.86**
Economic constraints
and social Liabilities.
81**
.79**
.73**
.75**
.48**
yg**
Marriage Related Problems
.36**
.39**
^7**
.38**
Health Related Problems
.36**
.43**
29**
.37**
.30**
.34**
Bureaucracy
.73**
.69**
.33**
.42**
.70**
.41**
49**
.33**
46**
.88**
.72**
.64**
.65**
Others
Total_____
**p<0 .01, * p<0 .05
.88**
Validity:
After having established factor validity, the Questionnaire was further validated against concurrent criteria. The
correlation of the respondents felt stress with certain psychological, behavioural and health outcomes were examined.
The obtained coefficients of correlation given in Table 2 below make it obvious that psychosocial stress as a whole
as experienced in various spheres of social life correlates with symptoms of neuroticism (measured through P.G.l.
Health Questionnaire), use of emotional coping patterns, and various types of behavioural and somatic pathologies.
Table 2: Coefficients of Correlation between psychosocial stress and its behavioural and health
outcomes (Sample I, N = 158)
Psychosocial Stressors
Strained Interpersonal
Relations_______________
Responsibilities/Liabilities
Economic Constraints
Marriage Related Problems
Health Related Problems
Neuroticism
Emotional
Coping
Somatic
Diseases
Behavioural
Pathologies
28**
28**
28**
37**
.32**
49* *
,35**
.44**
50**
36**
31**
28**
38**
29**
,36**
.31**
.41**
.46**
7y**
.54**
.50**
.39**
.40**
.34**
Threat to Prestige/Status
51**
52**
7y**
.13
Overall Social Stress
38**
.32**
Adverse Social Situations
**p .01
64
.45**
.41 **
DEVELOPMENT OF A TOOL FOR PSYCHOSOCIAL STRESS
Pattern of psychosocial stress and coping:
such as events leading to events; and strains and events
providing meaningful contexts for each other. Events
and chronic strains often flow together in people’s lives.
These can be experienced either as liberating or
depriving. It is not an event or strains only that merits
attention, but how the organization of people’s lives may
be disrupted in the stress process.
Pattern of psychosocial stress and coping in the
community was studied using above instrument in
representative samples at the two centres. The study
shows that interpersonal relationships are the most
important source of psychosocial stress. Another
important factor is perceived/imagined fear to social
position, respect, prestige, position in profession/
vocation. These perceived/imagined threat and worries/
apprehensions reflect on negative expectations from
interpersonal relationships.
The present study has also collected data on how
people cope with psychosocial stress. Coping refers to
the strategy adopted by individual persons to combat
stress and strains. Theoretical models of Lazarus and
Folkman emphasized that the selection of coping
strategies is determined by stable characteristics of the
individuals as well as appraisal of situation
characteristics. The data of present study shows that d
large number of respondents (significantly higher
percentage of females than males) adopted coping style
of not taking decision in stressful situation, or leave it
for others to decide, or demand decision from others, or
become irritable and upset. This implies that a large
number of stressful situation arc expected to remain
unresolved without outside professional help. There is
need to enhance knowledge base in the area, to assess
the needs for professional help, and to develop effective
interventions.
Research on relationship between life stress and
illness has focused largely on stress caused by presumed
stressful life events. The present study shows that chronic
stressors are the main contributors to psychosocial stress.
The event is more likely an episodic segment of
continuing problems. Inventory of life events allows us
to see only the segment and not its history; we ignore
the more extended life circumstances of which the event
may be a part. Thus in interpreting events-hcalth
relationships, we are susceptible to exaggerating the
importance of eventful change and to minimizing or
overlooking altogether the problematic continuities of
people’s lives. There are various ways in which events
and chronic strains come together in stressful experience,
65
Mental Health Research in India
ICMR STRESS QUESTIONNAIRE
Job No.
Centre
44
□5
Types of areas
Card No.
6
Address
SI. No. of Family
Namae of respodent
□ 10
SI. No. of respodent
Age
Sex
13
Marital Status
14
□ 15
Educational level
□ u16-17
Occupation
Income of respodent
18
Family income
20
Type of family
□ 21
Family members (in 13-16 years age range)
Caste & religion
66
DEVELOPMENT OF A TOOL FOR PSYCHOSOCIAL STRESS
Part-A
PSYCHOSOCIAL STRESS FACTORS
(Key for qusetions in Part A:
Not at all = 0, A little/mild/some times=l
Moderate/many times=2, Severe/often=3
I. Do you feel under stress/tension due to interpersonal relationships ? To what extent ?
23
1. within family
24
2. other relatives
□ 25
3. neighbourhood
□ 26
4. working place
5. school/college/peer group
27
6. others (specify)
28
II.Do you feel under stress because of responsibilities/liabilities/over
expectations/under expectation ? To what extent ?
29
1. within family
2. other relatives
□ 31
3. neighborhood
32
4. work place
5. school/ college/ peer group
□ 33
6. others (specify)
□34 .
III.Do you feel under stress due to economic difficulties ? To what extent ?
1. difficulty in arranging food, clothing and housing
2, expenses on education-self or family members
36
3. expenses on treatment - self or family members
37
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Mental Health Research in India
4. expenses on marriage
38
5. expenses on other social obligations
39
6. unemployment (for those seeking employment)
□ 40
7. repayment of loan
□ 41
8. competition for buying things just because others also have it
□ 42
43
9. other (specify)
IV.Do you feel under stress due to matters related to marriage ? To what extent ?
1. worry (or undesirable apprehensions) about marriage
44
2. worry (or undesirable apprehensions) about own marriage
45
□ 46
3. serious problems in marriage of a close relative
47
4. serious problem in own marriage
□ 48
5. other (specify)
V.Do you feel under stress due to health reasons? To what extent?
□49
1. health problems of self
50
2. sex related stress
□ 51
3. chronic illness of a family member
□ 52
4. others (specify)
VI.Do you feel under stress due to adverse/difficult situations as described below ? To what extent ?
1. feeling of insecurity due to general law and order situation
53
2. feeling of insecurity due to enmity or special reasons
54
3. harassment by bureaucracy
55
4. harassment by police
56
5. stress due to court cases
57
6. property disputes
58
68
.
DEVELOPMENT OF A TOOL FOR PSYCHOSOCIAL STRESS
7. physical discomfort/fatigue
59
8. physical/mental handicap of own self
60
9. physical/ mental handicap of family members
61
10. conflicts among different roles (family, job, social)
62
□ 63
11. others (specify)
VII.Do you feel under stress due to perceived/imagined threat for the following ?
To what extent ?
1. social position
64
2. respect/ prestige
65
3. position in profession/ vocation
66
4. economic position
□67
5. fear of sexual abuse/ assault
□ 68
6. others (specify)
□ 69
Vlll.Stressful Life Events
Have the following events taken place during last one year ? If yes, to what
extent it was stressful to you ?
(Put a cross mark if the event has not taken place during last one year)
1. Death of a close relative
70
2. Service illness / accident of own self
71
3. Severe illness / accident of family member
□73
4. Separation / divorce of own self
74
5. Separation / divorce of close relative
6. Violent encounter (robbery / physical attack / sexual abuse)
□75
7. Theft / fire
76
8. Other serious financial los
77
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Mental Health Research in India
9. Decline in income
78
□ 79
10. Problem with law / police
11. Loss of job
80
12. Examination failure
81
13. Conflicts in love affair
82
14. Other (specify)
83
IX.Special (additional) section for teenagers (13-19 years)- Students
(Put a cross mark if not applicable otherwise rate 0, 1, 2 or 3 according to the key)
a) Have you joined a new school / college during last one year ? If
yes, has It been a cause of stress to you ? To what extent ?
84
b) Was there a change of medium of instruction for you in school/
College ? If yes, was it stressful for you ? To what extent ?
85
c) Do you feel under stress due to pressure from peer group (for
Smoking, breaking school / college regulations or other deviant
behaviour) ? To what extent ?
d) Do you feel under stress because of rejection / isolation by
peer group ? To what extent?
87
e) Do you feel under stress due to fear of punishment /rejection
from teacher ? To what extent ?
88
f) Do you feel under stress due to examination ? To what extent ?
89
g) Do you feel that your family has been unfair to you and not
provided necessary opportunities to you ? If yes, to what
extent do you feel unhappy/under stress for it ?
90
X. Special (additional) section for teenagers (13-19 years)- Non-Students
a) do you feel under stress because of problems related to basic needs
like food, clothing etc. ? To what extent ?
91
b) Do you feel under stress because of problems related to housing ?
To what extent?
□ 92
c) Do you feel under stress because of problems related to occupational
70
93
DEVELOPMENT OF A TOOL FOR PSYCHOSOCIAL STRESS
(non-payment of wages, excessive work, beating / abuse or other
types of exploitation by employer )? To what extent ?
d) Do you feel under stress due to fear from administration / police ?
To what extent ?
94
e) Do you feel under stress because of antisocial elements / pressure
for joining antisocial groups ? To what extent?
95
f) Do you feel under stress due to absence of social / emotional support?
To what extent ?
□ 96
g) Do you think that your family has been unfair to you and not
provided necessary opportunities to you ? If yes, to what extent do
You feel unhappy / under stress for it ?
□ 97
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Mental Health Research in India
Part-B
Coping Style
Probes
Are you generally successful in controlling stress with your own resources?
Yes / No
How often ?
How do you achieve success - (if yes)
What do you do when not successful?
(Record verbatim. Wait for sometime as some respondents are slow to begin giving details).
If response not spontaneously given -ask - People use different methods to gain
control over the situation such as given below. Are these true in your case ? How often ?
(Key : Not at all = 0. Some times = 1, Often = 2, Always -3)
a) Some people
- make extra effort to gain control over stressful situation
- seek help from friends / relatives /teachers / parents / neighbours
regarding information about what to do or how to do things, etc.
- make new plans-modify it
- weigh alternatives, then take rational decisions
- make special efforts to overcome and then accept the results whatever
they might be.
98
□
□
99
100
101
102
b) Some people
- do not take decision / postpone decision making
103
- take impulsive decision
104
- leave it for others to take decision
105
- demand helf / decisions from others
106
- start worrying too much without doing much about it
, 107
- blame others / self. Feels hopelessness, helplessness
108
- becomes irritate, angry, easily upset, quarrelsome
72
DEVELOPMENT OF A TOOL FOR PSYCHOSOCIAL STRESS
- depressed, even suicidal thoughts
110
- withdraws, gives up, accepts defeat
111
b) Stress situations sometimes lead to physical and / or mental problems.
Physical
- poor appetite
I 12
- disturbed sleep
□ 113
- palpitation
□ 114
- breathlessness
115
- headache
116
- indigestion / vomiting / constipation
□ 117
-change in blood pressure (High/Low)
□
118
- vague aches and pain
119
- excessive smoking / tobacco use
120
- excessive drinking / drug abuse
□
121
- general feeling of weakness
□
122
Mental
123
- suicidal thoughts
□ '24
- fears
- anxiety
125
- depression
126
Overall assessment of interviewer about coping style of this person
127
(Key : a = Healthy coping style, Problem solving =1
b = Self preoccupation, Emotional, Unhealthy = 2
c = Conversion symptoms, Somatic response =3)
Note: In case the subject asks for or, appears to be in need of help, refer him to the nearest psychiatrist dr, clinical
psychologist for help and guidance.
73
Mental Health Research in India
Part C
Outcome parameters
a) Overall how do you feel your life is
(Key : Going on smoothly = 0,
Somewhat stressful
Moderate stress many times, or severe stress sometimes = 2
Severe often =3)
128
1
b) How do you feel about your health ?
(Key : Better than average for your age =0, Average for persons of your age =1
Not so good = 2
Not at all well = 3)
129
c) Have you been diagnosed as suffering from
(Key : No =0, Yes =1)
Diabetes
□
13°
□ 131
Cardiac problem / Heart disease (specify)
□ 132
Hypertension....
□ l33
□ l34
□ 135
□ l36
Ulcer
Cancer
Other chronic disease (specify)
At least one of the above
d) Have you been diagnosed as having a psychiatric problem?
(Key : No = 0, Yes = 1)
e)
Do you smoke / use tobacco ?....
(Key : No = 0, Only sometimes)
Regular or chain smoker = 3 )
137
138
1, Often (but not a regular user) = 2,
Do you use alcohol / intoxicant drugs ?
(Key : No = 0, Only sometimes =1, Many times = 2, Regular = 3)
139
g) Are you able to get required time and attention to your job / studies ?
( Key : Yes, always = 0, Yes, often = 1,
Just managing the work = 2, No, the work is suffering = 3)
140
f)
h) Class room behaviour (For teenager-students)
(Key : Regular attendance = 0,
Sometimes missing classes = 1,
Many times missing classes = 2,
□ 141
Often missing classes / punished or
Warned for missing classes = 3)
□ U142-143
Time taken for this schedule in minutes
74
HEALTH MODERNITY EDUCATION PROJECT
Concept of Modernity
and political development. Health Modernity is the pre
requisite for human development, which undoubtedly is
the sum mum of all development. The individual must
be alive and cognitively, competent to be economically
productive, socially liberal, and politically democratic.
Admittedly, Health Modernity does not ensure and
guarantee social, economic and political modernity, but
nonetheless, it is the fundamental precondition of all
development.
In social science literature the concept of Modernity
has been defined as an aggregate of certain personalitycum-attitudinal traits which facilitate individual growth
and development with social responsibility and make
the individual and effective agent of socio-economic and
political development . Attitudinal Modernity has been
considered as a pre-requisite for socio-political and
economic development.
Health Modernity Scale (HMS)
ICMR Development of Modernity Scale Project
(DMSP)
A Health Modernity Scale was constructed with
seven dimensions, namely: (i) Physical Health (PH), (ii)
Mental Health (MH), (iii) Diet and Nutrition (DN), (iv)
Family Planning (FP), (v) Child Care (CC), (vi) BreastFeeding (BF), and (vii) Health Habits (HH).
The project constructed a Modernity Scale with four
sub-scales namely, Personality, Socio-Cultural, Political
and Health. The sub-scale of Health Modernity was
added to other acknowledged dimensions of Modernity
on the rationale that health is the first input in the
developmental process of the individual, influencing
cognitive growth, which, in -turn, influenced personal,
socio-cultural and political attitudes. In view of the
importance of health, the project recommended that a
more comprehensive Health Modernity Scale (HMS) be
prepared to cover the important aspect of health and
health-related issues.
Using the Health Modernity scale a survey was
conducted in two rural blocks of Ranchi District which
exposed “The Myth of the Healthy Tribal”, reporting
that the Health Modernity in the tribals in the seven
dimensions of Health Modernity Scale varied from 0.2%
to 3.5%.
From Modernity to Health Modernity to Cleanliness
Modernity
1CMR Health Modernity Education Project (HMEP)
The focus of the project was on Modernity. It
changed to health Modernity in the first phase of HMEP.
In the second phase it narrowed down to Cleanliness
Modernity.
The Concept of Health Modernity
The HMEP defined Health Modernity as:
Scientifically correct information, attitudes and
behaviour in relation to physical and mental health,
family-planning and child-care, personal-hygiene and
environmental-sanitation and such other issues which
are essential pre-requisites for healthy living, and
therefore, for human and social development.
The Concept of Cleanliness Modernity
The concept of Cleanliness was considered as an
appropriate integrating theme for the various health
messages in relation to Personal Hygiene and
Environmental Sanitation. Another factors that
influenced the decision to use the concept of Cleanliness
as the focus of the intervention study was the fact that in
popular image also Cleanliness was positively associated
with health and uncleanliness with disease.
EIMEP considered Health Modernity as an important
component of total Modernity arguing that:
If modernity is a pre-requisite for social, economic
75
Mental Health Research in India
Definition of Cleanliness Modernity
demonstrated that the posters with photographs could
be more meaningfully used than the slides with
synchronized commentary. Most of the villages covered
did not have electricity. The posters were used as an aid
to the health educator. The health educator did not read
the messages written on the posters. She/he used the
blow-up photographs to initiate discussion. Without
giving any direct hint, the health educator tried to elicit
from the respondents the health messages that were to
be communicated and were written in the posters. After
the group arrived at the messages on its own, the taped
cassette was played which repeated these messages in a
more systematic way. The contents of the taped
commentary were discussed to ensure understanding.
The taped commentary was repeated which ended with
the dance song, which was replayed. The group was
encouraged to join in singing. The dance song used tribal
tunes and was sung by male and female voices.
Cleanliness Modernity has been operationally
defined for the present study as “scientifically correct
knowledge, Attitudes and Practice (KAP) in relation to
Cleanliness of Body, Food-Water, Home and Village”.
Admittedly, this definition needs modification and
refinement. The present definition was decided by the
realities of the present study, as it developed.
Cleanliness Modernity Scale (CMS)
A Cleanliness Modernity Scale was prepared with
four dimensions, namely, Cleanliness of Body, FoodWater, Home and Village. Each Dimensional Scale
consisted of 12 items; each item having 3 scores (0,1,and
2), thus, yielding a range of 0-24. The four Dimensional
Scales have positive statistically significant correlations
(Table 3.3). The Total Cleanliness Modernity Scale is a
combination of the four dimensional sub-scales. It has a
range of 0-96 scores. The reliability of the Cleanliness
Modernity Scale was
The three main aims of the present study were:
established using split-half technique. Its validity has
been examined by computing its correlation with
Cleanliness Habits Scale.
(i) To prepare tribal-appropriate educational materials
on the themes of Cleanliness of Body, Food-Water,
Home and Village.
Aims of the Present Research
(ii) To measure the extent of Cleanliness Modernity in
the tribal population of two rural blocks in Ranchi
District and,
Cleanliness Education Materials (CEM): Preparation
Cleanliness Educational Materials on Cleanliness of
Body, Food-Water, Home and Village were prepared
incorporating 50 messages. The CEM was prepared in
two forms: (i) Nineteen posters with photographs and
(ii) 109 slides with synchronized commentary. The script
of the nineteen posters and that of the synchronized
commentary of the slides were identical. Each of the
nineteen posters was prepared in the form of questions
and answers. It gave scientific explanations of the health
messages. It ended with a couplet summarizing the
messages. The couplet was sung in the manner of a tribal
dance song. The posters as well as synchronized
commentary used Nagpur language spoken by the tribals
of the present study.
(iii) To conduct a Cleanliness Intervention Programme
to measure its impact.
The Sample
The sample location of the present study has been
taken from two rural blocks of Ranchi District namely
Ranke and Namkum. The former served as the Control
Group and the latter as Experimental Group. The
sample stratification was based on sex and age (15-24),
25-34, 35-44 and 45-54 years). Each age category had
approximately the same percentage, sex-wise, of the total
sample size, as was its representation in the village. The
sample consisted of 700 cases. The Control Group had
250 and Experimental Group had 450 cases. The entire
sample consisted of the tribal persons. The most
important demographic characteristics of the sample
Cleanliness Educational/materials (CEM): Field
Administration
Initial field experiences and a pilot study
76
HEALTH MODERNITY EDUCATION PROJECT
were that most of them (82%) were illiterate and poor,
59% having a monthly income of Rs. 200 or less.
Impact Evaluation of Cleanliness Education
Intervention
Main Findings
The impact of Cleanliness Education Intervention
was evaluated in three ways: (i) Comparison of Before
and After Intervention Data of Experimental Group
(Item-wise), (ii) Comparison of Before and After
Intervention Data of Experimental Group (Mean Scores.
The main findings of the present research relate to:
(i) The extent of Cleanliness Modernity, and
(ii) The Impact Evaluation of Cleanliness Education
Intervention.
Comparison of Before and After Intervention Data
of Experimental Group (item- wise)
Extent of Cleanliness Modernity in the Sample
Scores on each item of Cleanliness Modernity Seale
Extent of Cleanliness Modernity was measured by
obtained by Experimental Group during before and After
Cleanliness Modernity Scale having four dimensions,
Intervention surveys were compared by using Chi-Square
namely, Cleanliness of Body, Food-Water, Home and
test. The scores of After Intervention, in most cases were
Village. Each Dimensional Scale had a range of 0 to 24
significantly higher than those obtained in the Before
scores and the Total Cleanliness Modernity Scale had a
Intervention Survey indicating the fact that intervention
range of 0 to 96. The extent of Cleanliness Modernity
had a positive impact on improving Cleanliness
was measured on the basis of three sets of data, (i) Bench
Modernity. The intervention failed to have impact on
Mark Data of Control Group, (ii) Bench Mark Data of
items which involved complex procedures as in preparing
Experimental Group and (iii) Resurvey Data of Control
a ditch for storing excreta of animals. It also related to
Group. Four statistical techniques were used, namely, (i)
items removed from their living conditions, e.g.
mean scores of the sample groups, (ii) percentages of
advantages of entrance of kitchen water in the vegetable
'Modern Scorers’ i.e., those who had scientific KAP on
garden. In most tribal homes, the vegetable garden (Bari)
Cleanliness Modernity Scale, (iii) percentages of Non
is usually located a little away from the residential
Modern Scorers, i.e., those who did not have scientific
houses. Another factor which worked against the
KAP, and (iv) main areas of ignorance and misconceptions
intervention was the entrenched popular habits such as
i.e., items on which 50% of the sample or more had
the message on cleaning of mouth before sleeping at
scientifically incorrect KAP. The main conclusion that
night. In many instances the economic factors were the
emerged from the analysis was that the extent of
main reasons for the non-impact of intervention. These
Cleanliness Modernity was very low in the sample group.
included washing of garments and bedclothes and
About half of the sample was ignorant about cleanliness
washing
of hand with soap after defecation.
and 20% had only partially correct knowledge.
Table 1. Inter-Correlations Between subscales of Cleanliness Modernity scale (N=700)
CBS
CFWS
CHS
CVS
CMS
.47
.38
.42
.59
.43
.46
.3
.39
.52
CFWS
CHS
.61
CVS
CBS
CFWS
CHS
Cleanliness of Body Scale
Cleanliness of Food-Water Scale
Cleanliness of Home Scale
77
Mental Health Research in India
CVS
CMS
Cleanliness of Village Scale
Cleanliness Modernity Scale
All correlations are significant at .01 levels.
Table 2. Cleanliness Modernity before and after intervention
Cleanliness Cleanliness Cleanliness
Of Body
ofFood
of Home
Cleanliness
of village
Cleanliness
Modernity’
Behavior
Cleanliness
Habits
0-24
0-24
0-24
0-24
0-96
0M5
10.49
6.04
8. 48
5.88
7.05
5.32
10.39
5.94
36.41
21.97
5.97
3.63
2. Experimental Group- Base
line (n=450)
M
10.93
D
3.72
8.99
4.23
7.33
5.32
5.49
10.76
38.01
20.85
6.14
3.74
48.82
22.20
7.07
39.10
21.29
6.06
3.63
Range of Scale
1. Control Group- base
line (n=250)
M
SD
3. Experimental Group-after
intervention (n=450)
M
SD
14.13
11.54
9.49
4.89
4.23
5.59
13.66
4.86
M
SD
11.14
6.35
9.23
6.07
7.78
6.01
10.96
6.25
3,71
4. Control Groupresurvey (n=250)
Cleanliness Modernity Scale. In all four dimensions of
Cleanliness Modernity the mean scores of After
Intervention was significantly higher than Before
Intervention mean scores. This trend was also true for
the Health Habits Scale.
The mean scores on TOTAL Cleanliness Modernity
and its four dimensions show significant increase after
the intervention in Experimental Group Table 2). There
was a gain of 11 points in the After Intervention Data as
compared with Before Intervention Data in the Total
78
MULTI-CENTRE STUDY OF THE PATTERNS OF CHILD AND
ADOLESCENT PSYCHIATRIC DISORDERS
This multi-centre project was initiated with the
general aim to systematically study the psychiatric
disorders in children and adolescents seen in psychiatric/
child guidance clinic set up. The information on children
and adolescents included in the study was collected
uniformly in standardized manner and diagnosis made
on 1CD-9 (WHO, 1978) multi-axial system of
classification (Rutter, 1978). The specific objectives of
the project were as follows:
1.
2.
excluded from the study.
A semi-structured interview schedule was developed
to collect the data pertaining to the sample and the multi
axial scheme of classification for child and adolescent
psychiatric disorders evolved by Rutter et al., and I.C.D.9 were adopted for diagnosis. Thus each case wa§
diagnosed on five axes viz: Axis I - Clinical psychiatric
syndrome, Axis Il-Specific delays in development, Axis
HI - Intellectual level, Axis IV - Medical conditions
and Axis V - Abnormal psychosocial situations.
To study the relative prevalence of various
psychiatric disorders in children and adolescents,
within and between various centres.
The distribution of cases according to psychiatric
diagnosis is given in table 1.
To compare the relative prevalence of different
associated abnormal psychosocial factors observed
within and between various centres.
To compare the information collected to diagnose
the clinical syndromes (Axis I and II of MAS), to
make a checklist of symptoms along with a glossary.
The symptoms to be arranged in order of their
frequency and this check list could help in evolving
interview schedules or questionnaires in regional
languages for field studies.
In the age group 0-5 years, maximum number of
children (33%) had diagnosis of hyperkinetic syndrome.
The common diagnoses in age group 6-11 years were:
hysterical neurosis, hyperkinetic syndrome, and conduct
disorders. The common disorders in age group 12-16
years were: psychosis, hysterical neurosis, and conduct
disorders. Psychoses and conduct disorder cases were
significantly more among males while hysterical neurosis
cases were more common among female children.
The sample consisted of all children below 16 years
attending the child psychiatry outpatient clinics at the
four collaborating centres during the study period.
Children with moderate, severe or profound retardation,
as well as those with only medical diagnosis were
Mild mental retardation was present in 22% children
in 0-5 years age group, 19% children in 6-1 I years age,
and among 6% in children of 12-16 years age group
among those attending the psychiatric clinics/child
guidance clinics.
3.
81
Mental Health Research in India
Table 1: Pattern of Axis I diagnosis in three age groups
£ No
Diagnosis
0-5 years
(N=188)
No.
%
6-11 years
(N=632)
No^
<
%
12-16 vears
(N=1015)
No.
%
I.
Psychoses
4
2.1
45
7.1
412
40.6
2.
Hysterical neurosis
3
1.6
142
22.5
274
27.0
3.
Conduct disorders
12
6.4
83
13.1
72
7.1
4.
Emotional disorders of childhood
and other neurosis
8
4.3
39
6.2
50
4.9
5.
Hyperkinetic syndrome of childhood
62
33.0
92
14.6
9
0.9
6.
Enuresis
3
1.6
39
6.2
19
1.9
7.
Stammering and stuttering
5
2.7
33
5.2
25
2.5
8.
Specific disorders of sleep
2
1.1
8
1.3
14
1.4
9.
Psychalgia (Tension headache)
0
0
12
1.9
10
1.0
10.
Academic problem (Scholastic
backwardness)
1
0.5
46
7.3
20
• 2.0
11.
Adjustment reaction
3
1.6
5
0.8
10
1.0
12.
Others
10
5.32
30
4.7
50
4.9
13.
No psychiatric diagnosis in Axis I
75
39.9
58
9.2
50
4.9
Table 2: Abnormal Psychosocial Factors
Abnormal
psychosocial factors
Bangalore
(N=702 )
%
Delhi
(N=262)
%
Lucknow
(N=285)
%
Waitair
(N=586)
%
Total
(N=1835)
%
1.
Mental disturbance
in other family members
22
13
10
4
13
2.
Discordant
intrafamilial relationship
20
11
3
0
10
3.
Familial over
involvement
38
16
5
7
‘20
4.
Inadequate/inconsistent
parent control
18
5
4
0.3
8
5.
Animalous family
situation
13
8
5
3
8
6.
Stress or
disturbances in school
19
11
2
4
11
82
HEALTH MODERNITY EDUCATION PROJECT
The other important observations from the project
pertain to abnormal psychosocial situations in family and
other social environment of children. The psychosocial
factors were: familial over involvement, mental
disturbance in other family members, discordant
intrafamilial relationship, inadequate/inconsistent
parental control, stress in school environment. It was
found that abnormal psychosocial factors were more
associated with conduct disorders, emotional disorders,
psychalgia (headache, tension) and academic problems.
Symptom checklists were prepared for clinical
syndromes.
This was the first large scale study conducted on
childhood mental health problems conducted in different
parts of the country using standardized instruments for
assessment.
83
Mental Health Research in India
EPIDEMIOLOGICAL STUDY OF CHILD AND
ADOLESCENT PSYCHIATRIC DISORDERS IN RURAL
AND URBAN AREAS
The area of child and adolescent psychiatric
epidemiology has been little investigated in India. A few
studies carried out so far, have reported wide variations
in prevalence rates due to small non-representative
sample, and unstandardized assessments. The methods
for child psychiatric epidemiological studies have made
considerable progress. The method of screening
populations, tools of assessments and diagnostic
classification have gone through lot of developments and
improvement. Since the methods of evaluations of
preschool and school children and adolescents differ, an
epidemiological study should make suitable provisions
in this regard. Therefore there was a need for a
methodologically sound epidemiological study on
representative sample of adequate size in urban and rural
areas .A task force project on child and adolescent
psychiatric disorders in rural and urban areas was
undertaken at Bangalore and Lucknow with following
objectives:
100 families from each selected colonies/ village were
selected by random sampling. In case, the selected family
did not have a child in 0-16 years age group, the next
house was included in the study. The number of children
finally selected was 2064 at Bangalore centre and 2309
at Lucknow centre.
STUDY INSTRUMENTS: The study instruments
used at various stages of investigation are shown in
Flow Chart
KEY:
1. SDP: socio demographic proforma
2.
SLC: screening checklist.
3.
VSMS: Vineland social maturity scale.
4. CBCL: child behavior checklist.
5. AM: additional module
(i) To find out the prevalence rates of child and
adolescent psychiatric disorders in rural and urban
areas.
(ii) To study the psychosocial correlates of the child and
adolescent psychiatric disorders.
(iii) To assess perceived needs of the family for help /
treatment regarding psychological /psychiatric
problems of children and adolescent.
6.
FTN: felt treatment needs.
7. PE: physical examination.
8. SIS: structured interview schedule.
9.
PIS: parent interview schedule.
10. C-GAS: children global assessment scale.
SAMPLE: It was decided to select 2000 children at
each center so that psychiatric disorders with a
prevalence of 5% may be estimated within range of 4%
- 6% with probability of type I error equal to 0.05. It
would detect disorders with true prevalence of 1% within
range of 0.5% - 1.5%. The sample was selected in two
stages. Colonies from slum and non-slum urban areas
and villages from rural areas were selected at the first
stage by simple random sampling. Thus 3 colonies from
urban slum, 3 colonies from non-slum areas and 4
villages from rural areas were selected at each center.
11. D1SC-P diagnostic interview schedule for children
(parent version).
12. DISC-C: diagnostic interview schedule for
children (child version).
13. BKT: Binet Kamat test.
14. SLD: specific learning disability.
15. (+/-) As & when needed.
84
EPIDEMIOLOGICAL STUDY OF CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS IN RURAL AND URBAN
AREAS
FLOW CHART SHOWING THE VARIOUS INSTRUMENTS USED FOR DIFFERENT AGE GROUPS
STEP: 1
Socio demographic proforma (SDP)
STEP: 2
SCREENING
0-3 years
SCL
VSMS
6-12 years
CBCL
AM
Rutter’s Form
4-5 years
CBCL
AM
12-16 years
CBCL
AM
Rutter’s Form
STEP: 3
Diagnostic assessment and confirmation for those screened positive and 10% of those screened negative.
FTN
PE
Clinical
Examination
SIS
PIS
FTN
PE
C-GAS
BKT (+/-)
DISC-P
PIS
FTN
PE
C-GAS
BKT (+/-)
SLD (+/-)
DISC-P
PIS
FTN
PE
C-GAS
DISC-C (+/)
BKT (+/-)
SLD (+/-)
scholastic problems. Some children who had poor
scholastic problems, epilepsy, mental retardation,
enuresis and phobias etc. were not picked up as positive
by CBCL as their score remains too low. Therefore it
was decided to have an additional module to tap these
areas. Hence 12 questions were added as an additional
module. The sensitivity of CBCL with additional module
ranged from 0.74 to 0.81 at the two study centers.
The children with psychiatric problems were
identified through a two stage methodology (a) screening,
(b) diagnostic assessment and confirmation for those
screened positive. 10% of those screened negative were
also examined in detail by psychiatrists to obtain an
estimate of sensitivity of screening instrument.
Screening checklist (SCL) was used for screening
for children 0-3 years age group. SCL was developed
combining the child behavior checklist (CBCL) for 2-3
years age group and the behavior checklist developed at
AIIMS, New Delhi. The sensitivity of SCL ranged from
0.95to 0.98. . Children in 4-16 years age range were
screened using CBCL, an additional module for CBCL
and Rutter’s teachers questionnaire it was found that
CBCL did not screen for developmental disorders and
Diagnosis according to ICD-10 was assigned for
children in 0-3 years age group through clinical
examination. Structured interview schedule and parent
interview schedule were used for children in 4-5 years
age, and DISC-P and parent interview schedule for
children in 6-16 years age group to obtain information
for diagnostic assessment.
85
2
E.
3"
FLOWCHART ON METHODOLOGY
re
C/3
a
£0
Children &
Adolescent
1
0-3 years
4-16 vears CBCL+AM±Rutter’s
VSMS+SC
—r
£
£
OS
D+VE
SCL
D + VE
SCL-VE
+ VE
+VF. FTN
-VF
+VF.CFTN)
oc
I
I
D-VE
SCL+VE
1
D+VF HKT
'n' rase clinical exam
—r
6-16 vrs DISC-
4-5 yrs.PIS+SIS
D-VF.C-
£
<17 Yrs
>17 vrs
“V
£
£
IQ normal
IQ Low
f
D-VE C-GAS
‘.’DISC - C
r
SneriFic rlelavs C-GAS
Global
D+V
♦
D+VE
C-GAS
DISC-C
?CIS
C-GAS
hkt
IQ normal
IO normal
▼
SLD
▼
+ve
▼
C Gas
EPIDEMIOLOGICAL STUDY OF CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS IN RURAL AND URBAN
AREAS
Multi axial system of classification was used to
record diagnostic information on five axes: (1) psy
chiatric diagnosis (2) specific developmental delays,
(3) intellectual level, (4) significant non-psychiatric medical diagnosis (5) abnormal psychological
condition.
Table 2. Distribution by psychiatric disorder at Lucknow centre
DISORDER
TOTAL N
2325
No of cases
rate per 100
2
0.09
Mild depressive episode
Social phobia
0.19
Separation anxiety disorder
0.09
Gen. Anxiety disorder
3
0.14
Simple phobia
TT
1.98
Agro phobia
i
0.05
0.05
Enuresis
i
"os’
4.70
Stammering
22
1.06
Pica
0.48
Behavior disorder NOS
To"
IT
Sleep disorder
2
0.09
Non organic encopresis
2
0.09
Panic
Obsessive compulsive disorder
0.60
0.09
Conduct disorder (C.D.)
2
0.09
C D (NOS)
"T
0.05
Oppositional defiant disorder
13
0.60
Trans tic
0.09
Chro tic
2
Feeding disorder
0.09
0.14
~22
1.06
Hyperkin. CD
1
0.05
Other psych. Disorder
7
0.33
Mild M.R.
TT
0.78
Moderate M.R.
5
0.24
Severe M.R.
1
0.05
278
13.47
ADHD
Total
S7
Mental Health Research in India
Table 2. Distribution by psychiatric disorder at Lucknow centre
DISORDER
TOTAL N = 2325
No of cases
rate per 100
Conversion disorders
4
0.17
Conduct disorders
34
1.46
Mixed conduct- emotional disorder
2
0.09
Emotional disorder
9
0.39
Non organic enuresis
65
2.79
Pica of infancy
51
2.19
Stuttering
10
0.43
Other psychiatric disorder
6
0.26
Developmental delay
17
0.73
Specific learning disability
10
0.43
Mental illness NOS
52
2.24
Mild M.R.
17
0.73
Moderate M.R.
3
0.13
Severe M.R.
2
0.09
Total
282
12.13
Results :
Rural 14.36% slum 11.5% urban 15.2%
For 4-16 years it is 12%
Rural 1 1.9% slum 10.6% urban 13.5%
When a C-GAS score below 70 was taken to mean
disability, the prevalence in the 4-16 years fell to
5.3%. All this is done excluding the ‘SLD only’
groups.
Bangalore centre:
1) 278 children were identified as having psychiatric
disorder in study sample of 2064 children in age range (0-16) years giving prevalence rate of 13.4%.
It was found that 41 (2.0%) children had diagnosis
only on axis II (developmental delay), 14(0.7%) had
diagnosis on axis III (intellectual level), 142 (6.9%)
had one diagnosis on axis I (psychiatric disorder),
44(2.1%) had more than one diagnosis on axis I,
and 37 children (1.8%) had diagnosis on more than
one axes of the multi axial diagnostic classification.
3) Of the cases taken up for 2nd stage evaluation, 33%
were categorized in the scale41-70 on the C-GAS,
placing them as moderately disabled. There was only
one case, which was placed in the severe disability
category (0-40).
4) Enuresis, simple phobia, stammering ADHD, ODD
in descending order of frequently constituted the most
often diagnosed condition on axis-I in the 4-16 years
age group. Of the 22 cases diagnosed ADHD, 15 were
from the urban (non slum), 5 from the slums and just
2) Prevalence rate excluding ‘only’ SLD for 0-16 years
= 12.5%
Rural 12.4% slum 10.8% urban 13.9%
For 0-3 years it is 13.7%
88
EPIDEMIOLOGICAL STUDY OF CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS IN RURAL AND URBAN
AREAS
two were from the rural area. This urban
preponderance was noticed for ODD, where 8 were
from urban, 4 from the slum and just one was from
the rural area. In the 0-3 years age group breath holding
spells, pica, behavior disorder NOS, speech delay and
epilepsy constitute the most common diagnosis in all
axes put together.
(psychiatric disorder), 53 (2.3%) had more than one
diagnosis on axis-I, and 1 1(0.5%) children had
diagnosis on more than one axes of multiaxial
diagnostic classification. The boys significantly
(p<0.05) had more psychiatric disorders (13.72%)
than the girls (10.69%) and the difference waS
constituted mainly by axis I psychiatric. This
difference was maximum in adolescents
(boysll.79%, girls 3.55%, p <0.01).
5) Only in 37.5% of the cases did the parents feel that
their child had a behavior /emotional /developmental
problems. In 15.4% of cases who had symptoms but
no diagnoses the family members felt that they had a
problem. When asked directly, 63.5% felt a doctor
would help them.
6)
2) Prevalence of psychiatric disorder in the children and
the type of residential area were not significantly
related. Also there was no relationship between sex
and prevalence of a single or multiple disorders. More
children in slum areas were likely to have multiple
psychiatric disorders than in rural or urban non-slum
areas but this was just short of statistical significance.
When diagnosis in subject by age and sex is tabulated,
the overall prevalence is 13.4%. The prevalence here
did not include epilepsy & BHS. In the age group 46 years, prevalence is significantly higher (p<0.05)
in girls than in boys. In other age groups, prevalence
is higher (but not significant) in boys than among girls.
3) 52 (2.25%) children had only one diagnosis of
unspecified mental disorder. In this category the
disorders were behavioral problems, a developmental
disorder, enuresis, pica, pain syndromes, over activity,
inattention, nail biting, insomnia and separation
anxiety.
7) When diagnosis in subjects by type of area and sex
are taken, prevalence rate among urban male children
was significantly higher (p<0.05) as compared with
males in other areas.
4) Nocturnal enuresis was the commonest diagnosis (96,
4.16%) followed by pica (55,2.38%)conduct disorder
(41, 1.78%) specific developmental disorders
(29,1.26%), mental retardation (26, 1.13%) and
stuttering (19, 0.62%) dissociative disorder was the
next in order (4,0.17%) 28 (1.2%) children received
a diagnosis unspecified mental disorder as a second
or third diagnosis.
8) Abnormal Psychosocial Situations: Physical abuse
and mental disorder /deviance in the family were the
only 2 abnormal psychosocial situations, which were
significant when cases and non-cases were compared.
Only in 37.5% of the cases did the family members
feel that their child had a problem. Scholastic
problems are often-repeated complaints of parents and
teachers, which needs separate attention. There is a
need to follow- up the cohort to understand the
outcome and plan intervention.
Lucknow centre:
5) Specific reading disorder was found in 12(0.52%)
children. Expressive and receptive language disorder
were each present in 8(0.35%) children. Mild mental
retardation with or without behavioral problems was
found in 19(0.82%) children.
1) 282 children were identified as having psychiatric
disorder in study sample of2325 children in age range
of 0 - 16 years giving prevalence rate of 12.1 %. It
was found that 17 (o.7%) children had diagnosis only
on axis-II (Developmental delay), also 17 (o.7%)
children had diagnosis only on axis-III (Intellectual
level). 184 (7.9%) had one diagnosis on axis-1
6) Mental retardation was often comorbid with enuresis
and oppositional defiant disorder. Specific
developmental disorders were found comorbid with
elimination disorder, stammering and pica. Conduct
disorders were comorbid with disorders like enuresis,
stammering, unspecified disorders, emotional and
depressive disorder. Enuresis was comorbid with
89
Mental Health Research in India
disordered children revealed that:
conduct disorder, mental retardation and unspecified
disorder. Pica was comorbid unspecified behavioral
problem.
1) 61.70% parents have no awareness regarding their
child’s psychiatric disorder.
7) Oppositional defiant disorder was significantly more
(p<0.05) among boys in rural and urban slum areas.
There was no difference in any other diagnostic
category.
2) 93.26% think that the child will not out grow his
problem without additional help
3) 97.87% say that they will not need additional help
to care for the child at home.
Physical Disorders:
4) However 63.83% think that the child will not be
cured with the doctor’s help.
13 (2.49%) boys, 11(2.11%) girls or total of 24
(4,60%) out of total 522 (293 screen positive and 229
screen negative) children had a physical disorder. These
physical disorder were seizure disorders 9( 1.72%), breath
holding spell 7(1.34%), febrile fits 2(0.38%),
microcephaly 2(0.38%), poliomyelitis lower limbs
1(0.19%), visual impairment 1(0.19%) and hearing
impairment 2(0.38%). These conditions were not
mutually exclusive.
5) But 99.29% (nearly everyone) think that
hospitalization is not needed.
6) 98.80% disagree with the statement that alternative
medicine will not be of any help.
7) 62.06% parents do not think that their child will
become independent if given proper Training.
Global functioning!
In general, parents of children with specific
developmental disorders have lesser awareness or hope
that the doctor can cure the child or that the child will
become independent with the treatment.
CGAS (applicable in children 4-16 years) rating
showed very good functioning to only some difficulty
in a single area in 98 (78%) children having no
psychiatric disorder. In comparison, this was so in
84.86%of children with one or more psychiatric disorder,
and definite impairment (CGAS rating <70) was found
only in 15.14% psychiatric disordered children. Among
children with multiple psychiatric disorders, 25% showed
a definite impairment.
Abnormal psychosocial situations:
In the study of families with one or more children
with psychiatric disorder per family, the psychiatric
illness was not found to be associated with abnormal
psychosocial situations. Presence of one or more
abnormal psychosocial situations and the number of
children with no. one or more psychiatric disorder were
not found associated with each other.
Treatment needs:
The responses to 7 questions on the need of the
family regarding management of their psychiatrically
90
STUDY OF PSYCHOSOCIAL DETERMINANTS OF
DEVELOPMENTAL PSYCHOPATHOLOGY IN
SCHOOL CHILDREN
The project was carried out at PG IM ER, Chandigarh
with following main objectives: to study the extent and
nature of psychiatric symptoms in school children and
understand the course of these symptoms during
development, (ii) to study psychosocial determinants of
developmental psychopathology in children with special
reference to temperament of children, life stress, patterns
of parental handing of children.
2. Rutter-B scale for completion by teachers (Rutter
1967).
3. Pre-school Behaviour Checklist (McGuire &
Richman, 1985).
4. Childhood Psychopathology Measurement Schedule
(Malhotra et al 1988).
5. Temperament Measurement Schedule (Malhotra &
Malhotra 1988).
Sample Selection:
Stratified random sampling technique was used to
select schools out of the total list of 175 in Union
Territory Chandigarh and then for children from each
selected school. Out of the 18 schools selected at the
first stage, 15 schools gave permission to study children
from their schools. Children in the age range of 4-12
years were included for study, which covered classes
from Nursery to Class VI. They were categorized in to 4
age brackets of 4-6 years, 6-8 years, 8-10 years and 1012 years. Total number of children in each age category
in each school was taken from the respective attendance
registers of the classes. All the sections of the class were
included, wherever there was more than one section. Out
of the total pool of eligible children in each class 20%
(one in five) were selected by random numbers.
6.
Parental Handling Questionnaire (Malhotra 1984).
7.
Life Events Scale for Indian Children (Malhotra
1989).
8. Case History Sheet
9.
Socioeconomic Status Scale (Gupta & Sethi, 1978).
10. Malin’s Intelligence Scale for Indian Children
(Malin, 1968).
11. Vineland Social Maturity Scale (Malin, 1972).
Observations
Out of 15 schools included in the study, there were
7 government schools and all co-educational, out of
which 362 children were selected. Government aided
schools were also all co-educational and 248 children
were selected from these schools. Among the two private
schools included in the study, one was an all girls’ school
and the other was an all boys’ schools. 157 children were
selected from girls’ school and 106 from boys’ school.
Thus a total of 873 children were finally included in the
study.
(i) In a randomly selected representative sample of 963
school children in 4-12 years age range in the city
of Chandigarh and Union Territory the prevalence
of overall psychiatric disorders was 9.34%.
(ii) Disorders were more in boys, and in children from
lower SES categories. Rates of disorders were
significantly higher in the government schools than
the government aided private schools or private
schools. Within the SES category, schools did have
different rates of disorders.
Tools Used:
(iii) Teachers reported psychiatric disorder in 11.23%
of all children by use of the standard cut-off pointy
which gave an overestimate of actual rate of disorder.
1. Sociodemographic data sheet
91
Mental Health Research in India
Because out of these only one third were confirmed
to have psychiatric disorder. Parents reported
psychiatric disorder in 10.88% of children on CPMS
out of which two thirds were finally confirmed to
have psychiatric disorder.
(ix) Prevalence rates of various psychiatric diagnoses
indicates enuresis 2.28%, Conduct disorder in
1.66%, ADHD in 1.35% Specific developmental
disorder in 0.93%.
Disorder of emotions in 0.62%, mild mental
retardation in 0.41%, somatoform & conversion
disorder in 0.20%, adjustment disorder in 0.20%.
Overlap between teachers’ assessment and parents’
assessment of psychiatric disorder was very low
(only in about one quarter of cases).
(x) Thirteen children had dual diagnosis and 2 had three
diagnoses. Dual diagnosis was more in males and
the commonest condition was enuresis.
Out of the cases who were found positive on both
teacher’s assessment as well as parent’s assessment
92% were concordant with final clinical assessment.
While the study documents the rates of psychiatric
disorder in India, it is interesting to note that the
prevalence rates are much lower than what are
reported from Western countries. The reasons for thi§
could be related to socio-cultural and family factors.
(iv) Rates of psychiatric disorders are highest in middle
childhood with a peak at 6-8 yrs age. Problems of
anxiety, depression and low intelligence with
behavior problems increased with age whereas
special symptoms decreased with age.
Follow-up study
Rates of conduct disorder, somatization and physical
illness with emotional problems remains relatively
constant across age different age groups in children.
11.11% of children had associated physical illness,
which was significantly more in males.
A follow up study of the positive identified cases as
well as a sub sample of negative cases was carried out to
study the natural history of psychiatric problems and
disorders in children. Models of intervention for parents
and teachers for the childhood psychiatric problems were
developed in this longitudinal study.
(v) Rates of physical illness did not differ in relation to
age or SES.
(vi) Psychiatrically disordered children had overall lower
IQ than normal children.
All positive cases identified at school or at home in
the ongoing epidemiological study were contacted again
at their homes after five years of their initial assessment.
A small proportion of negative subjects (10%) were also
followed up. All cases found to have clinical disorder
were registered in the Child and adolescent Psychiatry
Clinic at the department of Psychiatry and managed as
per need.
Significantly higher proportion of low I.Q. children
was from low SES in the sick group. Distribution of
l.Q. among normal children followed a normal
distribution.
(vii) Temperamentally children showed an increase in
sociability and rhythmicity and a decrease in
distractibility with age. Emotionality and energy
showed no change. Negative emotionality, high
energy, low rhythmicity and low distractibility were
correlated with psychopathology.
Course and outcome:
Some important observations on c'ourse of
psychiatric problems during follow-up are presented in
tables 1-5.
(viii) Disordered children were found to have a greater
parental control. High parental control was
associated with negative temperament traits. Patterns
of care did not differ in disordered and normal
children. Disordered children encountered
significantly more number of life events and greater
stress score.
The most frequently present problems in children
were ’enuresis’ followed by behavioural and conduct
problems, emotional problems and scholastic problems.
Most of these problems had considerably improved on
the first follow-up.
92
STUDY OF PSYCHOSOCIAL DETERMINANTS OF DEVELOPMENTAL PSYCHOPATHOLOGY IN SCHOOL
CHILDREN
Table 1. Main problems on first assessment and their course.
Problems
Present in
1992-1995
Problems
present
Course on Follow-up
Worsened
Persisted
Improved
Slightly
Considerably
improved
Disapea red
No.
%
No.
No.
No.
No.
No.
Emotional
Problems
11
16.67
1
1
0
5
4
Behavioral
Conduct
Problems
21
31.82
5
3
1
7
5
Habit Disorders
7
10.61
0
0
0
3
4
Scholastic
Problems
10
15.15
1
1
4
1
Psychosomatic
Problems
1
1.52
0
1
0
0
0
Developmental
Problems
1
1.52
0
0
0
1
Organic
Problems
3
4.55
1
0
0
1
1
Attention Deficit
0
0
0
0
0
0
0
Hyperactive
4
6.06
1
0
0
3
0
Speech
Problems
4
6.06
0
2
0
1
1
Compulsive
Habits
0
0
0
0
0
0
0
Social Phobia
0
0
0
0
0
0
0
School Refusal
1
1.52
0
0
0
1
0
Enuresis
23
34.85
2
2
1
8
10
Others
4
6.06
1
0
0
1
2
93
Mental Health Research in India
Table 2: Duration of persistence of problems (n=66)
Duration in months
Positive Cases
No.
%
0-24
8“
izn
24-48
7
10.61
48-72
5
7.58
72-96
3
4.55
96-120
2
3.03
120-144
6
9.09
144-168
3
4.55
168-192
2
3.03
Table 3: Frequency and Percentage of parents reporting the following new problems
that has occurred (n=66)
No.
%
12
18.18
Physical Ailments
3
4.55
Scholastic problem
3
4.55
Others
7
10.61
Whether new problems have occurred in the child
Names of the new problems:
Most of the problems persisted for a duration of 1 -4 years.
Minor physical ailments and the scholastic problems
were mainly the new problems that occurred in the child.
first follow-up visit were ‘behavioural and conduct
problems’ followed by emotional problems. Most of the
problems had considerably improved or disappeared after
the interventions given during 6 months-1 year.
Course of problems on follow-up after intervention:
The respondents gave multiple responses
Follow-up was carried out during 1999-2000 after active
intervention for cases found positive on second
assessment. The description of intervention is given in
the appendix. Evaluation results of intervention regarding
psychiatric problems of children are given in tables 4-5.
Minor physical ailments and scholastic problems
were the new problems that occurred in the children.
The School Mental Health Program that has been
initiated in the purview of this study has also evoked a
good response from other schools in the city. One of the
future directions definitely indicates the need for the same
program at other schools in the area in order to enhance
The Respondents gave multiple responses
The most frequently present problems in children on the
94
STUDY OF PSYCHOSOCIAL DETERMINANTS OF DEVELOPMENTAL PSYCHOPATHOLOGY IN, SCHOOL
CHILDREN
Table 4: Previous problems and their present status (N=44)
Problems
present in
second
follow-up
visit after
intervention
Worse
ned
Persisted
Slightly
improved
Considerably
improved
Dis
appeared
No.
No.
No.
No.
No.
No.
Emotional
Problems
13
1
1
2
7
7
Behavioral
And conduct
Problems
14
0
3
2
7
2
Habit disorders
7
0
1
1
2
3
Scholastic
Problems
15
0
6
3
4
2
Psychosomatic
Problems
4
0
1
1
2
0
Developmental
Problems
1
0
0
0
0
1
Organic
Problems
0
0
0
0
0
0
Attention
deficit
4
0
2
0
0
7
Hyperactive
2
0
1
1
0
0
Speech problems
1
0
0
0
1
Q
Compulsive
Habits
1
0
0
0
1
0
Social phobia
1
0
0
0
1
0
School refusal
1
0
0
0
1
0
Enuresis
6
0
1
0
0
5
Others
4
0
0
0
4
0
Problems
Present in
Previous
Assessment
(1998-on first
F/U visit)
95
Mental Health Research in India
Table 5: Frequency and percentage of parents reporting that their children
developed new problems (n=44)
F
%
New problems developed in the child
8
18.18
Names of the new problems
Physical ailments
4
9.09
Scholastic problems
4
9.09
Others
0
0
and maintain sound mental health in school children. This
program has also helped to establish a positive cooperative
relationship between teachers and parents.
The treatment plan devised was highly
individualized so that each specific need and problem
of the child’s mental, physical and social life was
addressed and intervened into.
An important need that emerged in the study is for
the training of the parents in handling their children and
their problems. Practical Training Manuals and
Workshops should be organized to take care of parental
training.
The Treatment plan was prepared under the
supervision of a Consultant. Treatment plan was based
on the experience gained from intervention given to those
cases that had psychiatric disorder or problem.
Short and focused therapies have been of great help
to parents in dealing with the problem behaviour of the
child.
Assessment of the treatment needs involved the
assessment of:
i)
Another suggestion emanating from this study
indicates the need to have coverage in the school
curriculum of the understanding of mental health and
ways to enhance the same.
Nature of.the problem
ii) Severity/persistence of the problem
iii) Frequency or intensity of the problem
iv) Duration or type of the problems
This project was carried out as an adhoc project of
1CMR at PG1MER, Chandigarh. It was not a task for a
project, but its summary has been included in this
monograph as it is also a major project of the Council
adding to the data base necessary for evidence based
development of child and adolescent mental health
services.
v) Attitude of children and parents to the problems
vi) Possible causes of problems i.c. emotional state,
physical state of the child, and development of child,
character and personality of the child.
To set the goal of the therapy: Focus was clearly on
INTERVENTIONAL PLAN
i)
Intervention plan took care that the treatment
could mainly be directed at the person who was
directly looking after the child - parents, teachers, or
both. The children were also counseled as to what they
should do about their problems.
The existing symptoms and current life situation
ii) The enhancement of social - adaptive functions.
To decide on intervention strategy: Treatment
strategy was chosen according to the nature of the
problem, whether a single mode of treatment was needed
or a package of treatment was required.
96
STUDY OF PSYCHOSOCIAL DETERMINANTS OF DEVELOPMENTAL PSYCHOPATHOLOGY IN SCHOOL
CHILDREN
Specific therapies:
i)
a.
Drugs - as required
Education
i)
Increasing awareness about normal development
of the children
ii) Psychotherapy (supportive) was given with the aim of:
ii) Psychological needs of the child
(a) Correction of situational problem,
iii) Individual differences with respect to
intelligence, temperament, etc.
(b) Restoring or strengthening defenses.
iv) Factors effecting psychopathology
(c) Prevention of emotional breakdown.
Constitutional factors
The effects of physical disease/injury
iii) Behavior therapy or modification aimed:
Temperamental factors
a) To alter the child’s behavior and modify or remove
the symptoms
Environmental factors
b.
b) To stop inappropriate behavior,
c) To develop new behavior
i)
d) To maintain new behavior
Changing attitudes and maximizing resources,
ii) Resolving conflicts and inconsistencies in the
management of problem
iv) Guidance and counseling was done with special
focus on:
a)
Attitude and perception of parents towards the
problems:
iii) Appropriate method of handling of emotional
and behavioral problems through
Parental expectations/handling
Reward
b) Children’s cxpectations/behavior
Making play contingent with studies
v) Cognitive therapy aimed at:
A daily schedule
a)
Less criticism, more appreciation
Exploring cognitive themes and distortions
Ways of prevention
b) Providing alternatives
c)
Practical and easily understandable suggestions
about management
Cognitive restructuring
Healthy parental handling
vi) Life Skills Training: Intervention modules were
framed on the basis of the problem areas reported
by the children in their day to day life: anger
management, positive thinking, methods for
effective study, memory and concentration, handling
adolescence and effective communication.
Acceptance
Affection
c.
Enhancement of the mental health
Advice on training in:
i)
Parental/Family counseling: Counseling of parents
was done on certain issues like:
Healthy life style
ii) Positive outlook
iii) Life Skills Training
97
,
DRUG / SUBSTANCE
DEPENDENCE
A STUDY ON THE EFFECTS OF INTERVENTION
PROGRAMME ON NON-MEDICAL USE OF DRUGS IN
THE COMMUNITY
The effectiveness of health education programme
depends on many explicit and implicit factors. The
explicit factors amongst them are (a) a realistic target
group, (b) clearly stated rigorous methodology, both in
planning and execution, (c) selection of appropriate
material and planned execution of the programme, (d)
built in evaluation mechanisms (e) objective criterion
of evaluation, (f) possibilities of midcourse corrections
(g) combination of education with treatment and (h)
community mobilization.
characters in the audio-visuals.
(iii) The message should be objective, factual, conveying
problems related to alcohol and tobacco use. They
should not be value judgemental.
(iv) The material prepared should be open to mid-course
corrections, based on the audience feed back.
Why focus on alcohol and tobacco :
Alcohol and tobacco, were selected for the following
reasons:
The present project combined some of the above
stated elements, and others emerged as lessons. The aims
and objectives of the study flowed from the Government
of India official report, 'Drug Abuse in India' (1977)
which emphasised that educational prevention models
should be developed for the country on priority basis.
The salient aspects of the study are given below:
(a)These were the most commonly used substances in
the community, (b) They were most commonly
interwoven with individual's life styles and social and
ceremonial use situations, (c) The health hazards of these
drugs were clearly identified, (d) It would not be possible
to develop intervention materials for all drugs at one
time, (e) Theoretically in a society like ours where
abstinence is still a cherished norm, the messages should
find easier community acceptance.
The aims and objectives of the study were:
(i) To obtain base line data on (a) prevalence and
incidence of non-medical use of drugs (b) existing
knowledge and attitudes towards such drug use, (c)
Perceived drug related problems in rural, urban,
industrial communities and (d) to study the socio
demographic characteristics of users, and
The study has another important conceptual
dimension that if the use of licit drugs i.e. alcohol and
tobacco can be reduced or minimized, it would have a
snow-balling effect on use of illicit drugs. Therefore, if
a feasible strategy for alcohol and tobacco use prevention
could be designed, developed and evaluated, it would
provide a vehicle for bringing in other illicit drugs in the
intervention programme network. It would also help in
providing a rationale for prevention/educational
programmes, related to these drugs.
(ii) To develop appropriate pre-tested health education
materials and intervention strategies, with a view to
study their impact on the base line non-medical use
data in the community.
Development of educational material:
Research Design: The study adopted before and after
design along with control group, i.e. both the
experimental and control groups were to be assessed on
drug use patterns and knowledge etc. as enumerated in
the aims and objectives. Both the groups were again to
be evaluated on the same parameters at the end of the
study. The experimental group was to be assessed more
often following each intervention and a sleeping period.
The intervention programme was developed keeping
in view the following basic guide lines:
(i) Development of materials: The message should be
target audience specific, keeping in view the
composition of the group.
(ii) The target group should be able to identify with
101
■
U8L/5
Mental Health Research in India
The study initially was conceived as a multi-centric,
to be conducted in different geographical regions of the
country, i.e. Delhi (North), Bangalore (South), Dibrugarh
(East) and Goa (West). These centres were selected on
the basis of their geographical locations and availability
of research expertise and infrastructure at the respective
institutions. The institutions involved in the study were
All India Institute of Medical Sciences (New Delhi),
Agriculture University and National Institute of Mental
Health and Neuro Sciences (Bangalore), Assam Medical
College (Dibrugarh) and Goa Medical College (Panaji,
Goa) which was later shifted to Central Institute of
Psychiatry, Ranchi on the request of the Principal
Investigator of the centre.
Specific groups of the population, viz. Urban, rural,
industrial, tea plantation and tribal groups were selected.
The basis of selection of these groups was their
vulnerability and their peculiar drug problems.
The distribution of these groups according to each
centre is given below :
1.
Bangalore :
Heavy Industry and Rural Population
2.
Delhi
Medium Industry and
resettlement population
3.
Dibrugarh :
4.
Ranchi
:
:
Urban
Tea Plantation and Rural Population
prevalence rates to half of the existing rates and taking
in to consideration design effect for cluster sampling,
the minimum sample required was approximately 1000
adults above 15 years. An equal sample size was selected
for the respective control groups.
Since it was a longitudinal study involving health
education intervention which is a group activity, a cluster
of samples was preferred instead of randomly selected
scattered population. In the urban areas a cluster of two
blocks providing a population of about 1500 persons,
yielding a population of 1000, above the age of 15 years
was selected as an experimental area for intervention
programme. Another cluster of two blocks in the urban
area of approximately the same size, situated at a distance
of 15 to 20 kilometers. From the experimental area and
approximately matched on socio-economic status was
included as control sample. In the rural population, the
basis of selection of the sample was village with a general
population of 1500 or 1000 persons above the age of 15
years, while another village of the same size having similar
socio-economic background, situated at a distance of 1520 kilometers was selected as a control area. As regards
the samples of industrial workers, an industry having
approximately 1000 workers was included an
experimental area for longitudinal assessment.
The intervention phase could be carried out only at
Delhi centre.
Urban and rural tribal population
Experimental and control groups: The study design
avoided the common error of earlier health intervention
programmes by including a comparable control group.
The effects of the intervention hence could be measured
by comparing the changes in both experimental and
control groups in the study, as also repeat monitoring of
the experimental group after intervention. The control
groups were not selected in the industrial populations at
Bangalore and Delhi centres primarily due to difficulty
in obtaining matching controls that were sufficiently
separated and due to distance and financial managerial
constraints. The industrial groups hence served as their
own controls longitudinally.
The experimental and control groups al Delhi center
were selected from the following areas:
Delhi (a) Urban
Experimental : J.J. Colony Khanpur
Control : J.J. Colony, Inderpuri
(b) Industry
M/s.Kelvinator of India Ltd. '
Faridabad (Haryana)
The intervention programme aimed at :
Increasing awareness about drug problems
Attempting change in attitudes
Sample size : The sample size required for the
intervention programme focusing on alcohol and tobacco
was estimated utilizing the available data from the studies
conducted on the prevalence and pattern of drug abuse
in the county at that time. In order to reduce the
Altering drug use behavior (specially alcohol
and tobacco)
Motivating abstinent or reduce use of tobacco
and alcohol.
102
ASTUDY ON THE EFFECTS OF INTERVENTION PROGREMME ON NON-MED1CAL USE OF DRUGS IN THE
COMMUNITY
(b) Preventing fresh induction to substance use through
-
Information dissemination
- Assimilation of information
-
Increase in the level of knowledge
-
Increased motivation of users towards non use.
- Change in the existing attitude towards drug use
- Reduction in drug use.
An important outcome of any health education
programme is reflected by the extent to which the freshly
acquired knowledge is utilized by the target group
(community) in future decision making or problem
solving situations. In this respect the present study have
been presented in two cohorts. Firstly, individuals who
had been assessed at the Base line (B) and Resurvey I
(RSI) (short term impact evaluation) immediately after
the first exposure of the intervention material and a gap
Impact Evaluation:
The following is the outline of the programme and evaluation strategy adopted in the study:
Baseline survey
Jnuary to August
1982
1st exposure of intervention
material - December
1983 to April 1984
Immediate Impact evaluation
December 1983 to
April 1984
2st exposure of intervention
meterial - October
1984 to January 1985
Short term assessment
(Resurvey - 1)
December 1984 to
March
Long term assessment
October 1985 to March
1986
of 8 to 10 months after the first health education
intervention. Secondly, those who had participated in
both the baseline and Resurvey II (RS II long term impact
evaluation), i.e. after a gap of 12 months of the second
exposure of the intervention programme. A separate
assessment was also carried out along with the first
exposure of the material i.e. 'immediate impact
evaluation'.
Evaluation:
sample also included an industrial area that wds exposed
to health education intervention. It was found that about
one third of respondents cither stopped or reduced
alcohol use after exposure to educational intervention.
However no control area could be included from
industrial area as stated earlier.
The impact of health education intervention for
tobacco use showed that 10% of tobacco users stopped
and 40% cut down use of tobacco from base line to
resurvey - I. These results were significantly better as
compared to urban control area (table 3). It was found at
resurvey - II that 9% of smokers had stopped and 27%
cut down tobacco use. The results in urban experimental
area were significantly better as compared to urban
control area (table 4). In the industrial area exposed to
health education intervention, over 40% of respondents
either stopped or reduced tobacco use.
It was found that 16% of alcohol users stopped
alcohol use and 27% cut down alcohol use in urban area
exposed to health education intervention from base line
to resurvey - I.
These results were significantly better as compared
to urban control area (table 1). This improvement was
sustained up to second resurvey also (table 2).The study
103
Mental Health Research in India
Table 1. Number and percentage of male alcohol users according to status of drinking (frequency)
from Base line to Resurvey - I.
Status of drinking
(frequency)
Urban
Expt.
Urban
Control
Industrial
Stopped
21
(16.4)
7
(4.0)
89
(18.8)
Cut down
35
(27.3)
26
(14.9)
62
(13.1)
Status quo
51
(39.8)
94
(54.0)
283
(59.7)
Increased/Started
during This period
21
(16.4)
46
(26.4)
40
(8.4)
Not specified
TOTAL
1
(0-6)
174
(100.0)
128
(100.0)
474
(100.0)
Table 2. Number and percentage of male alcohol users according to status of
drinking (frequency) from Base line to Resurvey - IL
Status of drinking
(frequency)
UE
UC
MI
Stopped
20
(16.4)
11
(7.2)
91
(21.4)
Cut down
26
(21.3)
7
(4.6)
63
(14.8)
Status quo
58
(47.5)
94
(61-4)
231
(54.2)
Increased/started during
this period
18
(14.8)
40
(26.1)
41
(9.6)
Not specified
Total:
1
(0.6)
122
(100.0)
153
(100.0)
104
426
(100.0)
ASTUDY ON THE EFFECTS OF INTERVENTION PROGREMME ON NON-MEDICAL USE OF DRUGS IN THE
COMMUNITY
Table 3. Distribution of male tobacco users according to pattern of change in smoking ' From
Base line to Resurvey -I.
Urban Expt.
Urban control
Industrial
Stopped during this period
20
(10.5)
79
(14.8)
Cut down
76
(40.0)
7
(3-5)
32
(15.9)
181
(33.8)
Status quo
73
(38.4)
85
(42.3)
218
(40-7)
Increased/Started during
this period
21
(11.1)
77
(38.3)
190
(100.0)
201
(100.0)
55
(10.3)
2
(0-4)
535
(100.0)
Status of smoking
NR
TOTAL
Table 4. Distribution of male tobacco users according to pattern of change in smoking from
Base line to Resurvey - II.
Status of smoking
Stopped during this period
Cut down
Status quo
Increased/started during
this period
NR
Total
Urban Expt,
16
(8.7)
50
(27.3)
89
(48.6)
27
(14.8)
1
(0.5)
183
(100.0)
Urban Control
Industrial
6
(3-4)
29
(16.7)
101
(58.0)
37
(21.3)
1
(0-6)
174
(100.0)
63
(12.8)
141
(28.5)
223
(45.1)
63
(12.8)
4
(0-8)
494
(100.0)
care workers not only in rural but also urban
conglomerates and industry.
With the modest achievement through health education
modality, the study has paved way for such programmes.
There is need to supplement this programme with other
health components, i.e., treatment and management of
drug dependent individuals. There is a need to develop
adequate training programmes and modules for primary
The country is too wide and diverse to permit the
development of a single module. Similar experience at
other centers would certainly enrich this educational
intervention.
105
kVR
COLLABORATIVE STUDY ON NARCOTIC DRUGS AND
PSYCHOTROPIC SUBSTANCES
coordinated activities of one component that is
monitoring component- Delhi Center, community
survey- Lucknow center and treatment evaluationJodhpur center.
Reports on rapidly spreading problem of heroin and
other opium derivates in the press and other mass media
focused attention and were cause of considerable concern
for the government and people of our country since early
1980’s. The Narcotic drugs and Psychotropic substances
act was passed in 1985. There was a felt need for
monitoring use of these drugs in the community. The
Council convened a task force group to initiate work in
the area. The members of the group felt that all drugs
and substances of abuse should be studied, and not only
heroin and opiates. As regards health hazards of
substance abuse, tobacco use is important risk factor.
Then problem of alcohol dependence is also quite
serious. Therefore consensus was to study all narcotic
drugs, psychotropic substances, alcohol and tobacco. The
feasibility of developing a drug abuse monitoring system
was discussed. A drug abuse reporting system will be
useful only if there is a network of institutions/centres
that are in contact with drug users, and they must be
willing to participate in the reporting system. This
required a feasibility study in a few cities where several
treatment/counseling centres exist. It was obvious that
only a small percentage of drug users contact any
treatment agency in our country, and the reporting system
alone will not be able to provide estimates of magnitude
of the drug use problem in the community. Therefore, it
was decided to undertake community survey also. The
members of the task force group felt that study on
evaluation of existing treatment modalities for drug
dependence was also very important. Thus, the T.F.
group initiated a multifaceted project to carry out the
following studies:
1.
Feasibility study for Drug Abuse Monitoring System
(D.A.M.S)
2.
Drug abuse survey in selected areas.
3.
Treatment evaluation of drug dependence (alcohol
and opiates)
DRUG ABUSE MONITORING SYSTEM: The
basic purpose of monitoring component was to develop
methodology and test feasibility for implementing
monitoring of drug abuse in the existing working system
of treatment centres/agencies. Drug abuse monitoring
systems help in identification and description of drug
users, the emerging risk groups, mode of drug intake
etc. The data is also an indirect indicator of magnitude
of the problem and treatment load on health care delivery
system. This project has tested the feasibility'of using a
simple proforma for monitoring drug abuse. This
proforma contains 33 items divided into 3 sections. It
has undergone field-testing and implementation over 3
years in three cities of North India. Of the 33 items, 15
can be filled up by a record clerk and the rest by a trained
volunteer or any clinical staff of an agency. Opinion of
a medical doctor is required to fill two items only. The
treatment centres /agencies that participated in drug
abuse monitoring, did so without any additional staff
strength. The important thing was motivation. Cost of
such an exercise is minimal, and can be absorbed by the
cost of implementation of drug abuse control
programmes. A training manual has also been developed
to help in the implementation of D.A.M.S,. It is hoped
that it would be possible for drug abuse control
programme of the government to initiate D.A.M.S. in
metropolitan cities, where a number of treatment centres/
agencies already exist, using the methodology developed
in this project. As the intravenous drug abuse is already
serious problem in North-Eastern provinces, and this
mode of drug use might spread to other parts of the
country, it is suggested that the government initiates
D.A.M.S. in metropolitan cities and other selected areas
soon. The severity of problem in cases of alcohol use
and opiate use reporting at treatment centres is shown in
table 1 below. The opiate users at Delhi center were
mostly heroin users while in Jodhpur and Lucknow
people used raw opium.
The project was carried out at three centres: Delhi,
Jodhpur, Lucknow. Each of the three centres also
106
KVR
IM
KVR
COLLABORATIVE STUDY ON NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES
TABLE 1: Severity of mental / physical dysfunction among drug users.
(CLINIC BASED STUDY)
ALCOHOL USED
Jodhpur
Delh
PROBLEMS
167
(31.39)
Severe Mental/ physical
dysfunction
136
Moderate mental/
physical dysfunction.
(25.56)
143
(26.88)
77
(19.47)
532
Mild mental / physical
dysfunction.
No mental / physical
dysfunction.
Total
2
(0.98)
2
(0.98)
89
(43.63)
111
(54.41)
204
_____ OPIATE USED
Lucknow
Jodhpur
Delhi
Lucknow
(0)
49
(65.33)
26
(34.67)
0
(0)
75
561
io
(32.09)
255
(14.59)
525
(30.03)
371
(21.22)
1748
(3.14)
4
(1-26)
141
(44.34)
163
(51.26)
318
0
(0)
73
(58.87)
44
(35.48)
7
(5-65)
124
(figures in parenthesis indicate percentage)
sample of about 10,000 persons (aged over 10 years)
was studied at each center. The percentage rates for use
of any drug/substances (including tobacco) varied from
34% to 42% among males at the three centres. These
rates are reduced to about half, that is 17% to 23%, if
only tobacco users are excluded.
Community survey:
Community survey on drug abuse in selected localities
in the three cities were carried out as supplementary
component to treatment facility based D.A.M.S. A
45 A
40
35 x
30 x
25 x
20
15 x
10 x
5x
0^
El Including tobacco
Excluding tobacco
DELHI
JODHPUR
LUCKNOW
Fig 1: Percentage rates of drug/substance use (within last one month) among males in community survey.
DELHI^
,94
JODHPUR
132
LUCKNOW
,42
0
10
20
30
40
□ Tobacco □ Alcohol □ Heroin □ Raw Opium Ei Cannabis I
Fig. 2: Percentage users of different kinds of drugs/substances among males (community survey)
107
IM
P<vr
IM
n<VR
Mental Health Research in India
Fig 3: Average no. of days of alcohol use in last 30 days
32
27 ” 27.1
22
i 17
E
12.5
< 12
7
2 40
[0.4
5.4
3
6
9
12
Months
15
18
21
24
Treatment evaluation
The breakup of data substance-wise shows that
percentage of alcohol users vary from 15% to 20% while
percentage of tobacco users vary from 29% to 39%
among males in the three cities. Further information on
alcohol use suggests that roughly one third of total
alcohol users (that is 5 % to 7% of males in the study
sample) were to some extent dependent on alcohol use
or they had formed a habit of alcohol use. Less than 1 %
males at each centre used other drugs/substances except
that raw opium was used by 1.19% at Jodhpur center.
0.5% males at Delhi, 0.04% at Lucknow and none at
Jodhpur used heroin. Cannabis was used by 0.27% to
0.50% in study area of three centres. Hallucinogens,
barbiturates, cocaine and amphetamine were not used
by any one in the study samples in three cities. Heroin
was used through chasing and smoking, and oral use
was the mode for raw opium. There was only one
individual in the entire study sample who used the drug
intra-muscular, 4% to 9% females used tobacco. Use of
other substances was negligible among females. Surveys
may be used in place of, or in addition to reporting
system, depending on the network of treatment agencies
in the area that are in contact with drug users. While
surveys are valuable for determining hat proportion of a
study population have used drugs, the reporting system
helps in studying patterns of heavy drug use, and for
assessment of treatment load on the health care
infrastructure.
Follow-up studies were carried out to evaluate
treatment in admitted cases fulfilling DSM lll-R criteria
of alcohol and opiate dependence. After detoxification,
group re-educative therapy was provided to all cases in
groups of 6-10 cases. This included sharing experience,
discussion on medical and psychological complications,
social and family problems, treatment process and
recovery, craving and relapse, structuring of free time
and future plans. Outcome was evaluated on frequency
of drug use at various follow up stages, change in life
function, change in problems, and employment related
problems. Most of the cases discontinued drug use
following treatment, but some of them relapsed at
subsequent follow up. The observations at follow up for
alcohol users and and opium users are shown in graphs
given below. The drug related problems also showed
considerable decline, but there was relapse in some cases.
There is need for more studies on treatment evaluation
of drug dependence.
It was observed during the study period that drug
dependent subjects had shown positive change towards
help seeking behaviour. There is need for further study
on factors that prevent relapse and those which contribute
towards relapse.
108
-li
[K^R
|KVR
A SURVEY OF DRUG DEPENDANTS IN THE COMMUNITY
IN URBAN MEGAPOLIS DELHI
independently interviewed a sub sample of the population
. The concordance was found to be high.
In our country, earlier epidemiological studies on
drug use focused only on defining a category of user /
non user in study population . No data was available
that could provide estimates either of dependent or non
dependent users of psychoactive drugs. A task force study
was initiated by ICMR at AllMS Delhi with following
objectives:
A survey and resurvey (with time interval of one
year) were carried out in representative sample in urban
mega polis Delhi. A stratified multistage sampling
scheme was adopted for the survey. The union territory
was stratified in to five strata; unauthorized colonies ,
resettlement colonies , regularized colonies , urban
villages, and other colonies . A total of 72 colonies were
randomly selected from the five strata at the first stage.
One hundred households were selected by simple random
sampling from each of the selected colony at the second
stage for the first survey. A resurvey was carried out
after an interval of one year. It was decided to select 50
old households already included in the study sample from
each of the selected colonies, and 40 new households
from the same 72 colonies for the resurvcy. An additional
study sample from 8 colonies in the walled city was also
selected for the rcsurvey as this area was not adequately
represented during the first survey.
a) to develop an instrument and methodology for
obtaining reliable data on dependent /non dependent
drug users in a general population.
b) To ascertain the magnitude of drug dependent and
non -dependent use in the general population of
Delhi.
c) To assess the change in trends of drug use over a
period of time.
A rapid population survey instrument based on DSM
III -R operationalised criteria and methodology was
developed to estimate the prevalence of substance abuse
(dependent and non- dependent use). The instrument and
methodology were pre-tested and non - medical interviewers
trained in collecting the data. In the pilot phase, the
information on drug use obtained by interviewing only head
of the house hold (about all family members) was compared
with the information obtained from individuals interviews
with individual family members. It was found that reliable
information on ding one can be obtained by interviewing
HOH(head of house hold) only.
The households were the basic unit of the sample
and the information was collected from the head of the
household regarding use of dependence producing drugs
by him and other members of the family over the past
30 days. All members of either sex above the age of 10
years were included in the study. Drug use was found to
be exclusively a male phenomenon in the present study.
The types and combinations of drug use found in survey
and resurvey are shown in the table 1 below;
The dependent - nondependent drug use as diagnosed
were further evaluated by a qualified clinician who
Table 1. Distribution by type of drug use among males.
Type of drug use
Only tobacco_____
Only alcohol______
Alcohol & tobacco
Tobacco & cannabis
Tobacco &opiates
Multiple drug use
Total study sample
I - SURVEY
Number
2129
385
1112
7
20
22
11995
II-SURVEY
%
17.7
3.2
9.3
0.1
0.2
0.2
109
Number
1999
258
873
___ 9
23
28
10,353
%
19.3
2.5
8.4
0.1
0.2
0.3
Mental Health Research in India
The observations from the survey bring out that non
user rates among males was around 60 - 80 % depending
upon the type of housing cluster. Secondly, the voluntary
abstention from all substance use by the women. The
use of drugs still appeared to be a man's prerogative.
Third, is the absence of use of cannabis except in urban
villages where it was a part of traditional lifestyle. The
opioid use did not appear to be a major problem. On the
face value these estimates appeared to be under estimates
for opioid dependents but they correspond closely to the
number of opioid dependents who sought help form all
treatment agencies in Delhi (ICMR, 1992). The
relationship of drug use and sociodemographic
characteristics showed that drug use was positively
related to age. It increased with increase in age. Education
showed a negative correlation suggesting that drug use
declined with rise in educational attainments. Being
married or single was not related with drug use. Drug
use increased with individual income.
The dependent and non- dependent use of drugs in
different types of residential colonies are shown in fig.
1. the drug use was high in urban villages, resettlement
colonies and unauthorized colonies.
10
resettlement
regulearised
unauthorised
urban villages
other colonies
Fig. 1 Dependent and non- dependent drug use (among males) by type of residential Colonies.
30 -i
25 20 15 -
5 -
il
0
—
10
resettlement
unauthorised
1
regularised
urban villages
other colonies
Fig.2 Change in dependent drug use (among males) from 1st survey to 2nd survey .
110
IO
KVR
[0
[KVR
A SURVEY OF DRUG DEPENDANTS IN THE COMMUNITY IN URBAN MEGAPOLIS DELHI
Just as a society is constantly changing, so do the
patterns of drug use and its distribution in various
population groups. Longitudinally it is expected that
changes in drug use in any country may occur quickly
and without any prior warning therefore it is important
to use epidemiological surveys at frequent intervals to
monitor the current rates of use and characteristics of
users to understand the distribution and diffusion of
tobacco, alcohol and illicit drug use in various population
groups. The method of survey evolved in the project is
cost effective and reliable.
Change in trends of drug use were assessed by
surveying same house holds in each type of colony after
a period of one year. The overall rates of abuse of
different drug categories remained unaltered. Changes
were observed within the colony type, mainly for alcohol
and tobacco use. Fig.2. shows the changes in dependent
drug use from 1 st survey to 2nd survey. It is seen that
dependent drug use increased significantly in one year
time duration from 1st survey to 2nd survey in
resettlement colonies.
111
SUICIDE BEHAVIOUR
HOSPITAL BASED STUDY ON SUICIDE BEHAVIOUR
1 l,female5) were recruited from the medical, surgical
wards and the intensive care unit of the govt. Rajaji
hospital, Madurai. The cases were also enlisted from
among those attending the OPD, Institute of Psychiatry,
Govt. Rajaji Hospital, Madurai. The ratio of completers
and the attempters is estimated at 1: 15. The project staff
including medical officers, social workers and the
psychologists were combing these words every day
(morning and evening) for collection of the sample. After
recruitment in the study, the cases were interviewed along
with available key persons from among the family
members. The specially prepared proformae were
completed in all the cases to obtain information on
demographic, social, psychological and clinical variables
in accordance with the objectives of the study. The DSM
111 criteria were adhered to for clinical diagnosis. The
concurrence of the two research psychiatrists was
required in arriving at a diagnosis.
A hospital-based study on suicide behaviour was
under taken by ICMR center for advanced research at
medical college, Madurai with following objectives:
•
•
To delineate the patterns of social, psychological,
psychiatric and pineal, cortisol profiles in suicide
attempters.
To assign the cohort to diagnostic categories as per
the DSM 111 criteria by a consensus of two
psychiatrists
•
Prevention of repetition of suicide attempt by
intervention (e.g. lithium prophylaxis in depression)
•
To study the contributory roles of psycho -social,
psychiatric and biological factors (pineal and
cortisol) towards the repetition of the attempts.
Two hundred and fifty consecutive cases comprising
suicide attempters (first attempt n=234;male 128,
femalel06) and suicide completers (n=16; male
The modes of suicidal attempts are given below in table 1:
Table 1. Mode of suicide attempt
MODE
NUMBER
%
160
68.4
18.4
Tablets (Diazepam/ Imipramine /phenobarbitone /others)
Hanging
43
16
8
Oleander seeds + tablets
1
0.4
Tablets* glass pieces
I
0.4
Jumping into the well
I
0.4
Others (cutting the throat/powdered glass)
4
1.8
Total
234
100.0
Organo phosphorus
(Bug killer/rat killer/mosquito killer/insecticide/pesticide/kerosene/
Caustic soda/copper sulphate)
Oleander seeds and other herbal poison.
6.8
3.4
Organophosphorous outnumbered all other types of poison (68.4%). Second came the oleander seed poison
(18.4%) followed by tablets poison (6.8%). There were 8 instance of hanging.
115
Mental Health Research in India
Diagnosis on multiple axis
The diagnosis on axis-1 (clinical syndrome), axis II (personality factor), axis 111 (physical illness), axis IV
(psychosocial stress), axis V (level of pre morbid adjustment) is given in table 2.
Table - 2
Diagnosis (DSM-III)
(n=234)
No
%
1
0.43
19
8.12
9
3.85
20
8.55
8.55
AXIS -I (CLINICAL SYNDROME)
Schizo -affected disorder
Adjustment disorder with depressive mood
Dysthymic disorder__________________
Family circumstances________________
Marital problem_____________________
20
Parent child problem_________________
Occupational problems_______________
Interpersonal problem
Academic problem
Life problems______________________
Major Depression Melancholia
Major Depression without Melancholia
Chronic Alcoholism
Atypical psychosis
Cannabis abuse
Homosexuality-ego syntonic___________
Mental retardation___________________
16
25
25
Schizophrenia (hebeprenia)
Grief reaction
None
Axis II (PERSONALTY FACTORS)
Immature
Inadequate
6.84
10.68
10.68
3.85
9
37
15.81
23
9.83
1
0.43
9
3.85
1.28
3
1.28
1
0.43
2
6
0.85
2.56
1
0.43
37
15.81
18
7,69
44
18.80
Atypical mixed_____________________
4
1.71
Mixed____________________________
Neurotic___________________________
Dependent
Impulsive
1
5
0.43
1.71
2.14
21
8.97
Passive aggressive
7
2.99
Histrionic
2
Cyclothymic
2
1.28
0.85
4
116
HOSPITAL BASED STUDY ON SUICIDE BEHAVIOUR
Antisocial
2
05
Sensitive
10
4.27
Hysterical
6
2.56
Delinquent
2
0.85
Anxiety
8
3.42
Introvert
23
9.83
Depressive
1
0.43
Obsessional
6
2.56
Avoidant
4
1.71
Schizoid
4
1.71
Borderline
0.43
None
68
29.06
Peptic ulcer
26
11.11
Premenstrual syndrome
15
6.41
Pain abdomen (unclassified)
33
14.10
Dysmenorrhoea
4
1.71
Dysfunctional uterine bleeding
5
2.14
Chest pain
3
1.28
Bronchial asthma
3
1.28
Chronic Headache
2
0.85
Old case of cranial stenosis
1
0.43
Grandmal epilepsy
1
0.43
Fibroid uterus
1
0.43
Skin infection
1
0.43
Sexual problems
1
0.43
Epilepsy
1
0.43
Acute Appendicitis
1
0.43
Gastritis
2
0.85
Allergic wheezing
1
0.43
Myalgia
1
0.43
Abdominal colic
2
0.85
Axis-Ill (PHYSICAL ILLNESS)
Liver damage
0.43
Chronic Diarrhoea
1
0.43
Alcohol withdrawal
Pelvic infection
_1
1
0.43
0.43
117
Mental Health Research in India
130
55. 55
Nil
3
1.28
Minimal
10
4.27
Mild
52
22.22
Moderate
58
24.78
Severe
100
42.73
Extreme___________________________________________
7
2.99
Catastrophic
2
0.85
Unspecified
2
0.85
Superior__________________________________________
0
0
Very good
0
0
Good
48
20.51
Fair
88
37.61
Poor
85
36. 32
Very poor
■4
1.71
Grossly impaired
9
3.85
None
AXIS - IV (PSYCHOSOCIAL STRESS)
AXIS -V (LEVEL OF PRE MORBID ADJUSTMENT)
Management of cases:
psychotherapy. In addition subjects with psychiatric
problems were managed with anti- depressants (15.4%)
Clinical management_of cases was carried out with
and other psychotropic drugs (12%) others with
67.5% of the cases being given counseling followed by
gynecological and other physical problems were referred
24.8%of the cases receiving brief supportive
to respective departments for investigations and treatment.
Table - 3. Management of cases
Number
%
Counseling
158
67.5
Psychotherapy (brief supportive)
58
24.8
anti depressants
36
15.4
Minor tranquilizers
17
7.3
Major tranquilizers
11
4.7
Others (referral)
43
18.7
TREATMENT
Suicide ideation
Outcome:
Suicide ideation was found persisting in 18 cases. The
nature of ideation was a wish to be dead in 10, a wish to
be killed in 5, and a wish to kill in 3. There were 3 re
attempt in the series up to one-year follow up.
The overall assessment of outcome of the 155,cases that
completed lyear follow up revealed that 70 had
completely recovered, 51 were found to be improving,
29remaining unchanged, 4 having worsened and one
mortality (from suicide)
118
HOSPITAL BASED STUDY ON SUICIDE BEHAVIOUR
The diagnosis -wise outcome is given in table below:
TABLE 4. OUTCOME ON FOLLOW-UP (N=155)
AXIS- I (Clinical Diagnosis - DSM - III)
Clinical
syndrome/
Diagnosis
Schizophrenia
Completely
Improving
Unchanged
Relapse Worsening
following
New
Changed.
recovery
11
I
Paranoid schizophrenia
Catatonic schizophrenia
1
Acute Psychosis
1
Schizo-affective disorder
1
Dysthymic disorder
1
3
Major depression
18
1
8
4
1
1
2
3
3
Adjustment disorder with
depressive mood
2
Anxiety
Ch. Alcoholism
2
13
3
3
2
Mental retardation
borderline
1
1
Homosexuality
Life circumstances
14
8
2
Family circumstances
8
4
2
2
Interpersonal problems
10
5
1
3
Marital problems
6
5
3
2
Parent child problem
10
4
Academic problem
3
Occupational problems
7
2
1
4
Inadequate information
I
5
119
Mental Health Research in India
h) Have there been any marital problems?
Pain especially chronic abdominal pain from
duodenal ulcer and gynecological disorders has figured
importantly as a “cause” for suicide attempts and
suicides. Many of the patients with physical illness are
in contact with non-psychiatric medical professionals
like internists, general practitioners, medical
professionals and gynecologists. They need to be
screened for suicide risk. An easy -to-administer
questionnaire has been developed that enables detection
of suicide potential for psychiatric referral. The
questionnaire is addressed to the patients with chronic
pain, including abdominal pain, during routine clinical
examination. The assessment of suicide risk in this group
will give a new direction to suicide prevention. The
questionnaire is given in the appendix. This does not
suggest, “medicalizing” suicide; rather it adds one more
factor to the list determining such behavior.
i) Do you feel that the above problems will not be
resolved in future?
3. Psychiatric illness
j) Do you have crying spells, sleep disturbance, or
feel lethargic?
k) Do you feel life to be “worthless” and feel
“hopeless” about the future?
a) Do you think that everything you do is a failure?
b) Do you feel that your life is full of confusion?
c) Do you feel that your life is a disappointment?
d) Do you feel discouraged about the future?
Screening questionnaire for general practitioners for
eliciting suicidal risk in chronic pain patients.
e) Do you feel you are very sad or unhappy about
your life?
I. Physical illness
0 Do you feel you are a totally unlucky person or
a) Is your pain chronic? If yes, duration?
useless?
b) Has the pain already been diagnosed?
g) Do you feel life is not worth living?
c) Does the pain persist/ recur despite adequate
medical therapy?
h) Does the future appear very bleak to you?
J) Has there been any earlier history of psychiatric
illness?
d) Do you feel hopeless about the improvement
from your present illness?
1) Has there been any history of psychiatric illness/
suicide attempt in the family?
e) Do you think that things cannot improve?
f) Do you feel all treatments have been tried and
nothing else can be done?
4. Suicide intent
m) Do you entertain suicidal ideas from time to
time?
2. Life problems
n) If yes indicate whether they are wish to die/ wish
to be killed /wish to kill.
g) Were there any (one or more) life events within
the past 6 months that caused you distress? If
yes, please specify.
m) Have you made any suicide attempts before?
120
A STUDY OF DOMESTIC BURNS IN YOUNG WOMEN
100 consecutive cases of female burns were recruited
from 16th march-16th October 1988 from the burns wards
of the department of plastic surgery, Govt. Rajaji
hospital, Madurai. All the cases were contacted soon after
their admission into the wards and detailed information,
as much as possible was collected considering the
sensitive nature of clinical setting, the procedure of
psychological autopsy was carried out in all cases of
mortality with a view to ascertain the circumstances
leading to the burn injuries. This involved eliciting
information from key members of the family and others
through visits to their homes as often as possible after
the fatal events. The magisterial authorities obtained
dying declarations. The treatment for those surviving
the burn injuries was instituted by plastic surgeons.
Weekly meetings were held and these were attended by
the project officer and the staff of the center and co
investigators from the departments of plastic surgery and
forensic medicine. Each case was discussed in detail and
the decision on the nature of burns (accidental, suicidal,
homicidal, not classifiable) was arrived at. The nature
of burns is shown in table below:
This study was an offshoot of the ICMR projects A study of suicide behavior, carried out on 250 cases of
attempted suicide. That study in its cohort of 250 cases
included just 2 cases of burns. It was felt that burn wards
had not been screened and cases of domestic burns
remained uninvestigated. Therefore a separate study on
domestic burns was undertaken with following
objectives:
a) To analyze female burn cases and to find
frequency of suicide, homicide and accidents
among them.
b) To ascertain the ‘cases’ of suicide with special
reference to dowry related problems.
c) To analyze and manage the problems of
survivors of suicide attempt and also their family
members regarding psychological and
psychiatric aspects.
d) To suggest broad outlines for prevention of
suicide.
Table-1. Nature of burns (N =100)
ALIVE
19
EXPIRED
6
TOTAL
25
3
67
70 ‘
Homicide
3
3
Not Classifiable
2
CLASSIFICATION
Accident
Suicide
TOTAL
22
78
121
100
Mental Health Research in India
Table -2.
Reasons / causes for burns
ACCIDENTS (N=25; 25%)____________________________________________
a) Carelessness:______________________________________________________
21
b) Inexperience in handling the cooking device____________________________
7
c) Epilepsy:__________________________________________________________
1
d) Rushing to save and put off the fire:
e) Depressive symptoms:_______________________________________________
1
2
HOMICIDE (N=3; 3%)_________________________________________ ______
1) Interpersonal adjustment problems with relatives
I
2) Interpersonal adjustment problems with husband:________________________
1
3) Mental illness in husband
1
SUICIDE (N=70; 70%)________________________________________________
MENTAL ILLNESS (N=16; 23%)______________________________________
a) Schizo - affective disorder___________________________________________
1
b) Adjustment problems with depressed mood____________________________
2
c) Paranoid schizophrenia______________________________________________
> I
d) Mental retardation__________________________________________________
1
e) MDP - depression__________________________________________________
1
f) Immature personality________________________________________________
6
g) Impulsive personality_______________________________________________
2
PHYSICAL ILLNESS (N=l(); 15%)_____________________________________
1) Chronic pain abdomen______________________________________________
3
2) Epilepsy__________________________________________________________
3) Dysmenorrhoea____________________________________________________
2
2
4) Premenstrual syndrome_____________________________________________
2
5) Hysterectomy (gynecological anomalies)______________________________
1
MARITAL PROBLEMS (N=36; 51%)___________________________________
1) Alcoholic husband and wife beating___________________________________
16
2) Extra-marital relationship (self or spouse)______________________________
15
3) Adjustment problems with husband___________________________________
’19
DOWARY RELATED PROBLEMS (N=5; 7%)___________________________
1) Interpersonal problems with in-laws in Connection with dowry related issues
5
OTHER STRESSFUL FAMILY AND LIFE CIRCUMSTANCES (N=26; 37%)
1) Interpersonal adjustment problems with Parents, sister, and in-laws________
22
2) Love affair and illicit relation________________________________________
7
3) Academic problems_________________________________________________
5
INADEQUATE INFORMATION (N=2; 3%)
Cause not known
2
122
Mental Health Research in India
TASK FORCE PROJECT ON SUICIDE BEHAVIOUR
study.
Suicide is a leading cause of death for young adults.
It is among the top three causes of death in the population
aged 15-34 years. The first scientific attempt to
understand the rationale behind suicide started in 1763
with the work of Merian who emphasized that suicide
was neither a sin nor a crime, but a disease. At the
beginning of 20lh century, Gaupp, R reported for the first
time that there were some peculiar and unique personality
traits among people committing suicide. Research over
last several decades indicates that it is the state of mind
along with all external influences, which result in suicide.
d) To prepare guidelines for intervention.
e) To prepare guidelines and manuals for training of
research staff.
The main study will be initiated on completion of
the pilot study to address the following objectives:
Overall Objective:
To study the descriptive epidemiology of suicidal
ideation and behaviour.
The ICMR centre at Madurai had carried out studies
on suicide behaviour by studying those who made suicide
attempts and were brought to hospital. It was felt that
there was need for a community-based project to study
the entire range of suicide behaviour from suicidal
ideation to suicide attempts.
Specific Objectives:
A pilot study on suicide behaviour has been
undertaken at two centres - Delhi and
Thiruvananthapuram with following objectives:
a) To adapt/develop and pre-tesi study instruments for
the task force project on suicide behaviour.
b) To work out fieldwork logistics and referral system
for the project.
c) To establish project work logistics for hospital based
124
1.
To study occurrence of suicidal ideation in the
community.
2.
To study the factors and processes contributing to
suicidal ideation.
3.
To study factors and processes contributing to
suicidal attempt.
4.
To identify what are the additional diagnoses among
suicide attempters (hospital cohort) as compared to
suicide ideators found in the community cohort.
5.
To study the course and outcome in individuals with
suicidal ideation.
MENTAL HEALTH
CONSEQUENCES OF DISASTERS
MENTAL HEALTH CONSEQUENCES OF DISASTERS
MENTAL HEALTH STUDIES IN MIC EXPOSED
POPULATION OF BHOPAL
The project was undertaken with following general
Objectives:
control area was surveyed for each rotational survey
independently. This random sample was generated by
the computer center of BGDRC, Bhopal from its cohort.
1. To study the prevalence of psychiatric disorders in
The head of the selected families was approached
by the team. The team comprised of psychiatrist,
psychologist, sociologist and a social worker. The mental
health item sheet of Verghese and Beig (1973) was
administered to the head of the family, also information
on the same schedule regarding other adult members of
the family (aged 16+) was gathered. If any member of
the family was rated positive on three or more items, the
case was examined further. Semi-structured proformae
on psychiatric history, personal history, pre-morbid
personality were also completed. Subjects identified as
having psychiatric problems were administered Present
State Examination, and they were referred to psychiatrist
(also co-investigator of Hamidia Hospital Bhopal for
management (treatment). The inter-rater reliability was
tested.
MIC exposed and non-exposed areas.
2. To study the factors associated with psychiatric
disorders.
3. To study the course and outcome of disease in
identified cases (at first survey).
4. To carry out annual (2nd, 3rd, 4lh and 5th year)
prevalence surveys on independently drawn sample.
METHODOLOGY:
The design of present study falls under the category
of ex-post facto inquiries.
The staff were provided training to administer mental
health item sheet of Verghese and Beig (1973). The
psychiatrists / psychologists were trained to administer
Present State Examination (PSE). The inter-rater
reliability between R.O. and S.R.O. ; R.O./SRO and co
investigator were carried out from time to time to
ascertain the reliability of data.
Locked houses were revisited twice. Migrated
families, locked houses (even after three visits) were
replaced by additional families. The list of additional
families was obtained from computer section of Bhopal
Gas Disaster Research Centre (BGDRC) on random
sampling basis.
Selection of cases :
During first year of data collection, all the 700
families of severely exposed area were surveyed and
thereafter 700 families of mildly exposed area and 700
families of control area approached.
A random sample of 700 families from each area,
i.e. severely exposed area, mildly exposed area and
127
Mental Health Research in India
Table I - Prevalence rates of psychiatric disorders in each rotational survey.
MILD
SEVERE
Year
CONTROL
Total
sample
Cases
detected
Prev
/1000
Total
sample
Cases
detected
Prev
/1000
Total
sample
Cases
detected
Prew
/1000
1985-86
2099
279
132.92
2460
148
60.16
1891
47
24.85
1986-87
2179
133
61.03
2440
100
40.98
1845
30
16.26
1987-88
2212
95
42.95
2329
90
38.64
1729
30
17.35
1988-89
2119
102
48.13
2261
108
47.77
1752
26
14.84
1989-90*
1478
41
45.02
1685
79
46.88
1 146
16
13.96
*(From Sept.l, 1989 to 31st March. 1990)
Table 2 - Year wise distribution of psychiatric disorders in exposed and non exposed areas.
Y car
Nonexposed
exposed
Anxiety
Prev/ Neurotic Prev Others
1000
/1000
Prev Anxiety Prev Neurotic Prev Others Prev
/1000
/1000
/1000
/1000
1985-86
143
31.4
86
54.8
34
7.5
14
7.4
22
11.6
11
5.8
1986-87
72
15.6
125
27.1
36
7.8
6
3.3
17
9.2
7
3.8
1987-88
62
13.7
116
25.5
7
1.5
9
5.2
15
8.7
6
3.5
1988-89
128
29.2
71
16.2
11
2.5
10
5.7
14
7.9
2
1.1
1989-90*
93
29.4
23
7.3
4
1.3
12
10.5
2
1.7
2
1.7
* Up to 31st March 1990
The members of Project Advisory Committee
recommended that the survey in the control area should
be undertaken simultaneously with the survey in the
severe and mild area i.e. 10 days for severe area, 10 days
in mild and 10 days in control area in a month. This
pattern was followed thereafter.
1000 to 13.96/1000 in the non-exposed area.
It is revealed from table 2 that Anxiety state and
Neurotic depression were the most common diagnosis
in the exposed area as well in the non-exposed area. The
overwhelming incidence of Anxiety state and Neurotic
depression in the exposed population is striking.
During the initial survey (1985-86) prevalence rate
in the M1C exposed area was 96.66 per thousand whereas
prevalence in non-exposed area was 24.85 / 1000. The
prevalence in the MIC exposed area was about four times
higher than the non exposed area.
ORGANIC BRAIN DAMAGE
A study to determine any evidence of organic brain
damage in toxic gas exposed persons was earned out on
a sub sample of the main study. A computer print out of
all adult family members with at least one death due to
MIC gas disaster was obtained from the Bhopal Gas
Disaster Research Centre. Thereafter a manual screening
The prevalence rate of psychiatric disorders
decreased gradually over a period of time. In the exposed
area it is from 93.66/1000 to 37.94/1000, similarly 24.85/
128
MENTAL HEALTH CONSEQUENCES OF DISASTERS MENTAL HEALTH STUDIES 1NM1C EXPOSED
POPULA TION OF BHOPAL
systemic examination with special emphasis on
neurological system and mental status examination.
was carried out to determine severity and persistence of
physical symptoms by personal interview of each subject
using an initial screening proforma. Thus 75 cases were
identified that met the following inclusion criteria: death
in the family, presence of severe and persistent physical
symptoms, age above 16 years and educational level VI’h
standard, and above.
(iv) Luria-Nebraska Neuropsychological Battery
(LNNB).
Observations and discussion:
1.
Twenty five cases were selected also from the study
population from exposed area, but with no persistent
physical symptoms and no death in the family due to
MIC exposure. This sub-sample was drawn to enable
comparison between severely exposed population with
and without physical symptoms.
'The distribution of identified organic brain damage
cases in the three study samples is presented in table 1.
It is seen that the percentage of organic brain damage
cases is significantly higher (p<0.05) in the severe
exposed area (having physical symptoms) as
compared to the control area. The percentage of brain
damage cases identified in the severely exposed area
is almost two times higher than the control area. It
indicates that MIC gas has caused organic brain
damage.
The control group of 100 subjects was a randomly
drawn sample from the non-exposed control area of
Bhopal. These persons were also above 16 years of age
with educational level Vllh standard, and above.
2.
Exclusion criteria was that the subjects should not
have pre-existing dementia. A dementia questionnaire
was devised and used for the purpose.
Study instruments:
A very high number of organic brain damage cases
(27%) in the control area could be because of the
following reasons:
(a) Cases identified as having equivocal or diffuse
damage could be taken as borderline cases of damage
and if these are dropped out from the actual count of
organic brain damage cases, then the percentage of
cases will drop down to 14% in control group and
21.3% in severe exposed group.
(i) Screening proforma.
(ii) Dementia Questionnaire.
(iii)Semi-structural Proforma for medical, general and
Table I : Number of organic brain damage cases identified in each area
Brain
damage
Severe Exposed
(with physical
symptoms)
Control
Exposed(without
physical symptoms)
No.
%
No.
%
No.
%
Present
39
52.0
9
36.0
27
27.0
Absent
36
48.0
16
64.0
73
73.0
Total
75
100.0
25
100.0
100
100.0
129
Mental Health Research in India
(b) When localization break up of organic brain damage
cases of the control area was studied, it was found
that there was a concentration of cases in the left
parieto-occipital area. Left parieto-occipital
localization scale has a very high correlation with
educational achievement. Items which best identify
injuries in this area of the brain are items that
measure reading, writing, arithmetic and
intelligence. As a result, the individual with a history
of school problems may show isolated elevation on
this scale, which confirms nothing by itself, except
that the person probably did have school problems
(Golden etal.,1983).
(c) L.N.N.B is capable of detecting very soft
neurological signs related to higher cortical
functions. Abnormal profiles or organic brain
damage by the exposure of MIC has generally caused
impairment of the cerebrum or higher cortical
functions.
3.
No significant association was found between
psychiatric illness (mainly Neurotic Depression and
Anxiety State) and organic brain damage*.
4.
Neurological examination performed on each of the
organic brain damage cases did not show any signs
of central nervous system deficit. This may be due
to the fact that LNNB identified cases of organic
brain damage especially of the higher cortical
functions. Functions, which are so subtle that they
may not be detected by clinical neurological
examination.
5.
No specific lateralization pattern has emanated from
the lateralization scales. It indicates that MIC has
not caused damage to any specific hemisphere.
6.
The above findings of inconsistent lateralization
pattern is further substantiated by the localization
scale findings. MIC has not affected any*particular
lobe in the brain damage cases.
130
HEALTH CONSEQUENCES OF EARTHQUAKE DISASTER WITH
SPECIAL REFERENCE TO MENTAL HEALTH
Marathwada earthquake disaster of 30 September
1993 was one of the worst human tragedies of modern
times that captured global attention because of the
massive impact it had in terms of loss of life and property.
The quake, that measured 6.5 on the Richter scale,
claimed 8000 lives and left 14,000 injured. Sixty seven
villages were razed to ground while large number of
houses were damaged in another 886 villages. Size of
the affected population was 1,70,000. Property in excess
of rupees three hundred crore was destroyed. Prompt
large-scale relief operations were undertaken involving
civilian and military personnel. There was ‘convergence’
of volunteers and NGOs from all over the world. Affected
community received a comprehensive long term
rehabilitation package of Rs. 1 100 crore which included
compensation for human loss and injuries, reconstruction
of 52 villages wherein 26,000 houses meeting safety
requirements were built, and infrastructure and
socioeconomic development.
exposed (control) subjects was selected after the
exposure occurred. Control group came from an area
located remotely (300 km.) from the disaster affected
region, f amily was the basic unit of study. The disaster
affected area from which the sample was selected was
defined by the State Administration as zone -A
comprising of villages in Latur and Osmanabad districts
where extensive destruction including human loss had
taken place. Proportional allocation strategy was adopted
in sampling for population living in large, medium and
small villages in A-zone. Selection of villages was
carried out at the first stage and then about 150 families
were selected from each of these villages at the second
stage. The sample finally consisted of 1661 family units;
910 from disaster affected area and 751 from the control
area generating a cohort of 8557 individuals.
Psychiatric assessment: Two stage assessments
comprising of screening stage and confirmation stage
were employed. Modified SRQ (Self Reporting
Questionnaire) and SCAN (Schedules for Clinical
Assessment in Neuropsychiatry) were the psychiatric
screening and confirmation tools in adults. First phase
of the study was carried out during one and half years to
two and half years post-disaster. Follow-up was
undertaken four and half to five years post-disaster.
Recognizing the dearth of systematic information
about psychosocial and health consequences of such major
disasters in India and from other developing nations, Indian
Council of Medical Research initiated a Centre for
Advanced Research on health consequences of earthquake
disaster with special reference to mental health at the
Maharashtra Institute of Mental Health, Pune.
OBSERVATIONS: Following were the important
observations of the first phase of the study:
There were two main objectives of this study. The
first one was concerned with determination of nature
and prevalence of psychiatric morbidity, physical health
complaints and vital statistics in the disaster affected
population through a longitudinal epidemiological study.
Assessment of various dimensions of disaster exposure
(human and material losses, injuries, experiences of
threat, etc.) and subsequent stresses as well as mediating
factors in the form of life events and social support and
their association with the mental health outcome
constituted another important objective.
(i) Exposure to the disaster: Villages with varying
disaster death ratios from very high (480.7) to low (1.5)
had found representation in the study. This gradient was
also reflected in the sample. One third of families
(32.09° o) in the affected sample had suffered human loss,
which was multiple in the case of majority (64.04%) of
them. There was a preponderance of female gender
(58.13%) and younger age group among the deceased.
31.75% subjects had sustained disaster injuries which
were minor in majority of the cases (61.23%). 15.61%
adults and 5.90% children in the sample were
hospitalized for treatment of their injuries. Gradient and
Study sample: The study employed a modified
cohort design in which the sample of exposed and non
131
Mental Health Research in India
clustering was also observed with regards to injuries.
Since the disaster struck at an early hour (3.53 A.M.),
most of the people were still asleep in their homes. 34.9%
adults and 27.0% children were trapped in the debris. A
large proportion of adults (35.9%) and few children were
also exposed to body handling, multiple ones in several
instances. All persons in study sample were rendered
homeless and in addition, majority reported loss of means
of livelihood in terms of loss of farming equipment,
damage to irrigation facilities, loss of livestock, loss of
merchandise, etc.
affected group recorded a significantly higher birth rate
of 35.7 compared to 21.77 of the control group. There
was no difference in age and gender controlled mortality
rates in two groups.
(v) Post-disaster increase in nuclear type of families
was observed (from 5.04% to 61.54%). Proportion of
single member families was also significantly higher in
the affected sample. A noticeable trend of addition to
the families through marriages and births was observed,
contributed by remarriages of widowers (60%) while
there was no widow remarriage.
(ii) Significant increase in psychiatric morbidity in
the disaster affected group (tables 1 and 2). Excess
morbidity was observed in both the genders in the disaster
affected group. Overall prevalence of 139 per thousand
in the affected sample was significantly higher than 68
per thousand in the control sample. 21.46% adult males
in the affected group received psychiatric diagnosis
compared to 13.14% in the control group. Corresponding
figures for adult females were 14.99% and 5.05%; for
male children 7.67% and 4.26%; and for female children
6.70% and 3.17% respectively. Differential distribution
of cases was noticed in the affected villages paralleling
the gradient of disaster losses. There was a clustering of
cases within families.
(vi) Disaster affected subjects reported less number
of desirable and more undesirable life events than their
controls. Significantly higher proportion of respondents
in the affected sample reported dissatisfaction with social
support while as those reporting ‘feeling very satisfied’
were also more in the same group.
Sample coverage at the first phase was 96.38% and
95.75% for the two study areas. 7.91% adult cases and
6.95% child cases in the affected sample were lost to
follow-up mainly due to death and migration. Age and
gender distribution as well as diagnostic break-up of
these was uniform. Corresponding attrition rates in the
control group were 10.0% and 2.0%.
(iii) Nature of psychiatric morbidity: Higher
prevalence rate in adult males as compared to females
in both types of areas was accounted for by the category
of Alcohol dependence. Bulk of cases in the disaster
affected group (11.89% in males and 9.40% in females)
belonged to the category ‘Other reactions to severe stress’
and had sub threshold depressive and anxiety features.
Post Traumatic Stress Disorder (PTSD) and Major
Depression were the other important categories found
in the disaster affected area. Major depression was more
prevalent in females (1.99% as compared with 1.44% in
males) while as PTSD was diagnosed in 1.60% males
and 0.95% females. Cases of sleep disturbance formed
an important group in children in addition to ‘Other
reactions to severe stress’.
Important findings of the follow-up:
(1) While as birth rate in the affected sample continued
to be high (42.80%), reversal towards the pre-disaster
values was noticed on other parameters like gender
ratio, family type, single member families, family
size etc.
(2) Remission of psychiatric morbidity: 68.5% adult male
cases and 70.76% female cases had remitted.
Remission rate was even higher in children (82.76%
in male children and 91.84% in female children).
Due to this, the number of cases in the (wo study
groups has become comparable. The diagnosis wise
outcome of psychiatric cases are shown in tables 3
and 4.
(iv) Physical health complaints and vital statistics:
More respondents reported their health to be ‘bad’ in
the affected sample. Musculoskeletal complaints were
the commonest physical symptoms reported. The
o
Case control study was carried out on “nested’
sample for determination of risk factors for psychiatric
132
HEALTH CONSEQUENCES OF EARTHQUAKE DISASTER WITH SPECIAL REFERENCE TO MENTAL HEALTH
morbidity at both the phases. Age and gender matched
controls were selected through simultaneous one-to-one
matching. Univariate and multivariate analyses were
undertaken. Stepwise logistic regression identified
following risk factors at the first phase: disaster injury,
occurrence of disaster death in the family, trapping
experience and dissatisfaction with social support in case
of adults and occurrence of disaster death in the family
in case of children. At the follow-up, satisfaction with
social support, occurrence of desirable life events and
absence or minimal severity of disaster injury emerged
as significant protective factors.
Outcome study: More number of desirable life events
and less number of undesirable life events reported at
the follow-up were found to be associated with recovery
in adult psychiatric cases detected at the first phase of
the study.
Table 1 Nature of Psychiatric morbidity in adults in disaster affected and control areas
1CD-100
Diagnostic categories
F 10
Mental and behavioural
disorder due to use of alcohol/
Dependence syndrome________
Mental and behavioural disorder
due to use of cannabinoids_____
Schizophrenia________________
Persistent Delusional disorders
F 12
F20
F22
F 31
F 32
F34.I
F 40.2
F41.0
F43.I
F43.2
F 43.8
F44.2
F 45.8
F51
F 51.3
F 52.452.8
F 54
F 70-79
F 98.5
Disaster affected
Males
Females
n-1254
_______ n=1244
54+10 (5.14 %)
00
Control
Males
Females
rr%004
n~l188
98+1 (9.86%)
00
00
02 (0.19%)
00
1 (0.07%)
07+1 (0.64%)
01 + 1 (0.16%)
3 (0.23%)
1 (0.07%)
01 (0.08%)
Bipolar affective disorder
25 (1.99%)
18-i 3 (16.88%)
Depressive episode___________
13 (1.03%)
4 (0.32%
Persistent mood disorder______
Specific (isolated) phobias_____ _________ 00 __________ 00
Panic disorder_______________ _________ 00 __________ 00
12 (0.95%)
Post traumatic stress disorder
20 (1.6%)
14 (1.11%)
09 (0.72%)
Adjustment disorders_________
Other reactions to severe stress 1384 IQ (H.89%) 115 >■ 3 (9.40%)
_______ 00
01 + 1 (0.19%)
01 (0.09%)
01 (0.09%)
02 (0.19%)
_______ 00
05 (0.49%)
_______ 00
14 (1.39%)
00
02 (0.16%)
2 (0.15%)
00
00
3 (0.25%
_____ 00
_____ 00
2 (0.16%)
10 (0.84%)
D(0.08%)
I (0.08%)
_____ 00
37 (3.11%)
1 (0.08%)
1 (0.08%)
00
02 (0.16%)
01 (0.08%)
1 (0.07%)
1 (0.07%)
00
00
1 (0.08%)
00
00+02 (0.16%)
00
00
03 (0.29%)
I
(0.08%)
02 (0.16° o)
00+1 (0.08%)
n=267
(21.46%)
______00
______ 00
n=88
(14.99%)
Dissociative disorders
Other somatoform disorders
Non organic sleep disorders
insomnia____________________
Sleepwalking (somnambulism)
Premature ejaculation & Other
sexual dysfunction____________
Psychological & behavioural 00
factors associated with disorder
or diseases classified elsewhere
Mental retardation____________
Stuttering
Total
08+4 (0.96%)
133
5 (0.49%)
______ 00
n=132
(13.14%)
370-25%)
______ 00
n=61
(5.05%)
Mental Health Research in India
Table 2 Nature of Psychiatric morbidity in children in disaster affected and control areas
Disaster affected
Control
ICD-100 Diagnostic categories
Males
N-808
Females
N=790
Males
N=704
F32
Depressive episode
1
(0.12%)
00
00
00 ’
F43.1
Post traumatic stress disorder
2
(0.24%)
00
00
(0.37 %)
Females
N=629
F43.8
Other reactions lo severe stress
24+2
(3.2%)
12+1
(1.64%)
00
00
F44.2
Dissociative disorder
1
(0.12%)
1
(0.12%)
00
00
F 51
Non organic sleep disorders insomnia
12+1
(1.64%)
00
00
(0.9%)
F 51.3-4
Sleepwalking (somnambulism)
5
(0.61%)
4
(0.50%)
6+1
(9.9%)
1+1
(0.31%)
F 70-79
Mental retardation
3
(0.37%)
2
(0.25%)
4
(0.49%)
3
(0.47%)
F80.0
Specific speech articulation disorder
2+1
(0.85%)
2
5 (0.79%)
6
(0.37%)
5
(0.25%)
F 81.0
Specific reading disorder
1
(0.12%)
00
00
00
F91.0
Conduct disorder
4
(0.49%)
00
00
00
F93.0
Separation anxiety disorder of childhood
1
(0.12%)
00
(0.95%)
00
00
F 98.0
Non-organic enuresis
6
(0.74%)
10+1
(1.3%)
9+1
(1.4%)
8
(1.27%)
F 98.3
Pica of infancy and childhood
3+3
(0.74%)
3
(0.37%)
00
00
F 98.5
Stuttering
00
00
2
(0.28%)
1
(0.15%)
n-62
(7.67%)
n~53
(6.7%)
n=30
(4.26%)
n=20 .
(3.17%)
Total
134
HEALTH CONSEQUENCES OF EARTHQUAKE DISASTER WITH SPECIAL REFERENCE TO MENTAL HEALTH
Table 3 Outcome of adult cases according to Psychiatric diagnosis
Males
ICO-100 Diagnostic categories
Females
Baseline
Follow-up
Baseline
Follow-up
F 10
Mental and behavioural disorder
due to use of alcohol / Dependence
syndrome
54
37 (68.5%)
0
0
F 12
Mental and behavioural disorder
due to use of cannabinoids /
Dependence syndrome
8
4 (50%)
0
0
F20
Schizophrenia
8
7 (87.5%)
1
’ 1
F22
Persistent Delusional disorders
I
3
2 (66.7%)
F31
Bipolar affective disorder
1
I
1
F32
Depressive episode
18
2 (11.11%)
25
4 (16.0%)
F34.1
Persistent mood disorder; Dysthymia
4
6 (150%)
13
18 (138%)
F43.1
Post traumatic stress disorder
20
0(0.00%)
12
0(0.00%)
F43.2
Adjustment disorders
9
4 (44.4%
14
5 (35.7%)
F 43.8
Other reactions to severe stress
138
1 (0.8%)
115
18 (15.7%
F44.2
Dissociative disorders
0
0
2
1 (50%)
F45.8
Other somatoform disorders
2
1 (50%)
0
0
F51
Non organic sleep disorders insomnia
1 (33.3%)
2
0
F 70-79
Mental retardation
2
2
0
0
F 98.5
Stuttering
1
1
Total
267
78 (29.2%)
108
50 (26.6%)
135
Mental Health Research in India
Table 4 Outcome of child cases according to Psychiatric diagnosis
Females
Males
Follow-up
ICD-100 Diagnostic categories________________ Baseline
Baseline
Follow-up
F32
Depressive episode__________________
1_______
0
F43.1
Post traumatic stress disorder__________
2_______
3
0
F 43.2
Adjustment disorders
1
F 43.8
Other reactions to severe stress
F44.2
Dissociative disorder_________________
£
£
1_______
24_______
£
£
1________
£
1________
£
7________
£
5
£
£
£
£
£
F45.8
Other somatoform disorder
F 51
Non organic sleep disorders insomnia
F 51.3-4
Sleepwalking (somnambulism)________
•>
12
1
2
12
4
2
0
F 70-79
Mental retardation___________________
F 80.0
Specific speech articulation disorder
2
2
2
. 1
F 81.0
Specific reading disorder_____________
1
£
0
0
F 91.0
Conduct disorder____________________
4
2
0
0
F 93.0
Separation anxiety disorder of childhood
£
0
0
F 98.0
Non-organie enuresis________________
£
£
10
0
F 98.3
Pica of infancy and childhood_________
0
3
1
F 98.5
Stuttering
10
(16.13%)
53
4
(7.54%)
Total
62
relative importance of primary exposure variables
in genesis of morbidity in early phase while the
secondary and mediating factors (life events and
social support) assume significance as time passes
by.
The study concluded that:
1.
Moderate increase in psychiatric morbidity was
observed in medium term in the disaster affected
group which for most part had subsided by the
follow-up stage five years post-disaster.
2.
Socio-demographic indicators provided valuable
information to complement psychiatric assessment
as measures of distress and recovery of the affected
community.
3.
Case-control and outcome studies highlighted the
Important strengths of the study are: It is a
community based cohort study with long observation
period, adequate sample size and ‘independent’ control
group that employed standard tools of assessment and
achieved high response rate of above 90%. Assignment
of physical disorder diagnosis was constrained due to
logistic difficulties.
136
MENTAL HEALTH ASPECTS OF THE EARTHQUAKE IN
GUJARAT
emotional support for the relief providers.
In response to the devastating earthquake on 26lh
January 2001, a pilot study on “Mental Health Aspects
of the Earthquake in Gujarat” was initiated by 1CMR
with 1HBAS, Delhi as the Coordinating Centre. The study
was carried out in collaboration with mental health
personnel from Ahmcdabad, Bhuj and Jamnagar.
Objectives of the pilot study were as follows:
1.
To assess the immediate mental health serviee needs
of the earthquake affected population.
2.
To study the strength and weaknesses of mental
health services, both governmental and non
governmental, and feasibility of establishing
linkages with different agencies in the community.
3.
To generate initial data experience on community
perceptions about menial health services, coping
mechanisms, response patterns and protective factors
in the affected population.
4.
To collect preliminary data/ experience on need for
development of models for psychological and
5.
To examine the feasibility of long term project on
mental health service needs in earthquake affected
areas at Gujarat. To formulate research questions,
and draw research plan for the long term project.
The pilot study involved a rapid assessment of A
broad range of psychological experiences, emotional
slates and behavioural patterns of different individuals
and groups in various parts of the earthquake affected
areas. Initially, for two weeks, intensive field work was
carried out collectively by teams of 1HBAS and Gujarat
during 4lh and 5,h week post disaster period. Field work
was further continued by Gujarat teams alone in different
areas and at limes with the investigators from 1HBAS
who joined them during their visits to Gujarat. Besides
cam) ing out assessment of various mental health aspects,
the field team also provided mental health services to
the people identified during the study.
The common emotional states, behavioural states
identified in a sample of 178 persons by method of free
listing are shown in Table 1.
Table 1: Common emotional states/behavioural states following earthquake disaster
Sl.No.
During First 24 hours
After one week______
After 20 days_______
_L___
Fear_________________
Fear
______
Fear__________
2.___
Crying_______________
Worry
Worry
1___
Running around
Hope
Relief measures
4. ___
Fear of entering building
Thinking of future
Normalcy______
5. ___
Worried______________
What will happen now
confused_______
6. ___
Palpitations
Weep______________
Thought of future
7.
8.
Leave the place
Loss of sleep________
Remembering God
Nature’s play
Collective efforts
Involved in rescue work
Brotherhood
After shocks
9.
10.
Terrorized due to
destruction of buildings
Unable to think
Sadness
Sadness
137
Mental Health Research in India
evaluation. The pattern of psychiatric morbidity profile
of these 99 cases in the earthquake affected area is shown
in Table 2.
A pilot survey was carried out using General Health
Questionnaire (GHQ) on 417 persons. 99 cases of
psychiatric disorders were confirmed after clinical
Table 2: Psychiatric moi bidiij profile (n=99)
FREQUENCY
DISORDER
1.
Moderate Depressive episode without somatic syndrome
29
2.
Acute stress reaction
26
3.
Mixed Anxiety and Depressive Disorder
14
4.
Generalised Anxiety Disorder
9
5.
Panic Disorder
8
6.
P.T.S.D.
4
7.
Non-organic insomnia
4
8.
Adjustment Disorders
2
9.
Other non-org. sleep disorders
1
10.
Undifferentiated Schizophrenia
2
11.
Dissociate disorder (convulsions)
I
The pilot study also used a number of other qualitative
research methods such as Focus group discussions, Semi
structured interviews, Key informant interviews and
participant observations.
Conclusions:
According to assessment of the pilot study, 70-90
% of population in the affected area had transient
psychological disturbances 4-5 weeks after the earth
quake. 30-50 % of population was expected to have
moderate to severe psychological/ psychiatric signs and
symptoms, subsyndromal problems and acute stress
related disorders 3-6 months after the earthquake. 5-15
% ol population was expected to have long term mental
health morbidity.
Existing Service Delivery Models:
Following service delivery models were found to be
existing in the earthquake affected areas:
(a) OPD services in psychiatric hospitals/departments
of medical colleges.
The research team reported that the communities and
populations could take care of their emotional and
psychological needs with their own resources to a
considerable extent. The mental health service needs of
large proportions of the affected population can be served
by relief and rescue workers and health care providers,
as well as by strengthening and supporting the socio
cultural coping mechanisms of the local communities.
Relief and rescue workers were as a general pattern,
sensitive to the emotional and psychological needs of
(b) Specific counseling centres - exclusively providing
mental health services.
(c) Counseling provided along with general relief
measures by (untrained) general relief providers.
(d) Camp approach to provide menial health services to
the people at the community level .
(e) Mental health relief occurring as a result of group
activities in the community such as prayers, spiritual
religious discussions, yoga etc.
138
MENTAL HEALTH ASPECTS OF THE EARTHQUAKE IN GUJARAT
Project are to study the mental health service needs of
and to study various service delivery models for the
earthquake affected people of Gujarat.
the population. They made spontaneous efforts to assist
the population in dealing with psychological
disturbances. These efforts can be enhanced by training.
Specialist mental health expertise can be useful and is
required for (a) services for a relatively smaller
proportion of the population which is severely affected,
(b) sensitization and training of the rescue/relief workers
and health care providers who can take care of the needs
of larger proportion of the affected population.
The specific objectives of the multi centric project
are as follows:
Physicians and other health care providers who
worked under constraints of the enormity of work load,
were moderately or less than moderately sensitive to the
emotional and psychological aspects. No noticeable
efforts were seen for mental health care on the part of
health care providers except for a few individuals or
teams. There is a need for sensitization and training here.
There is a long term need to continue to focus on the
mental health service needs of the disaster affected
population.
It should be possible to combine the service delivery
and research aspects within the long term plans of Gujarat
Government and other national and international
agencies. There are research opportunities available for
generating highly useful scientific information, which
need to be appropriately utilized with due consideration
to the ethical obligations to individuals and communities.
1.
To .study the prevalence of psychological symptoms
and psychiatric disorders in earthquake affected
population in Gujarat.
2.
To identify the different levels of mental health care
required to fulfill the mental health needs of
earthquake affected population in Gujarat.
3.
To assess the existing mental health service and
service delivery models for their relevance,
usefulness and acceptance in the earthquake affected
area of Gujarat.
4.
To study the psychological problems and needs of
relief providers.
5.
To develop service delivery modules to address the
psychological problems of earthquake affected
population.
().
To study the effect of various factors related to
earthquake, relief measures and early psychosocial
intervention on the mental health consequences of
the earthquake in Gujarat.
7.
To study the effect of socio-demographic factors
related to individual resilience, social support and
past experience on the mental health consequences
of earthquake in Gujarat.
Multi-centric Task Force Project:
After completion of the pilot study, a multi centric
Task Force Project has been initiated at Bhuj, Jamnagar,
Rajkot and Ahmedabad with a coordinating centre at
1HBAS, Delhi. The general objectives of the Task Force
139
CONTRIBUTION OF ICMR’s
RESEARCH TO MENTAL
HEALTH 2 ARE
CONTRIBUTIONS OF ICMR’s RESEARCH TO MENTAL
HEALTH CARE
one each in Andhra Pradesh, Assam, Rajasthan and Tamil
Nadu. The DMHP was extended to 22 districts in 20
states in the ninth five year plan, and it is proposed to
extend it to 100 more districts in the duration of tenth
five year plan. The approach adopted in the current
programme includes (a) training of mental health team
at identified nodal Institutes within the states, (b) increase
awareness about mental health problems, (c) provide
services lor early detection and treatment of mental
illness, and follow-up of cases discharged from hospitals
in the community, (d) to develop data system at
community level for future planning, improvement in
services and research.
The efforts to develop mental health programme for
the country began in 1960s. The Mental Health Advisory
Committee constituted in 1962 had meetings in 1963,
1965 and 1966 to consider the various aspects of mental
health needs in the country. Subsequently a national
level workshop was organized in 1981 to consider a draft
mental health plan to formulate National Mental Health
Programme. The National Mental Health Programme
was finally approved by the Central Council of Ministry
of Health & Family Welfare in August 1982. The 1CMR
research efforts facilitated these developments by
generating the necessary data base and demonstrating
the feasibility of integrating mental health care with
primary health care. Some of the important land mark
studies during this period were;
1.
The first large scale psychiatric epidemiological
study in Agra in 1960s ;
2.
1CMR-DST collaborative study on severe mental
morbidity focusing on integration of mental health
in primary health care during 1976-82,
3.
Study on child psychiatric disorders;
4.
Study on psychiatric problems for the elderly
A major lacunae in mental health care has been
inadequate exposure of general physicians to common
menial disorders. This need has been repeatedly
expressed in a number of expert committees and other
forums without a significant change in situation.
With reference to mental health care, the World
Health
Report-2001
has
made
following
recommendations for mental health care in primary care:
(a) Recognize mental health as a component of primary
health care (b) provide refresher training to primary care
physicians (c) develop locally relevant training material
(d) include the recognition and treatment of common
menial disorders in training curriculum of all health
personnel (e) Improve effectiveness of management of
menial disorders in primary health care (f) improve
referral patterns. The 1CMR research programmes have
addressed these issues at the level of demonstration
projects.
These studies provided major inputs for development
of National Mental Health Programme. An Advanced
Centre on Community Mental 1 lealth was then initiated
by the Council at N1MHANS, Bangalore to develop and
evaluate modules for integration of mental health care
with primary health care. The advanced centre also
carried out training programmes for mental health
programme managers, state level workshops for the
health directorate personnel, sensitization and
involvement of the state level programme officers, and
preparation of support materials in the form of manuals,
health records for different types of health personnel,
and health education materials.
CLINK Al. STUDIES:
The 1CMK study on phenomenology of acute
psychosis established acute psychosis as a unitary
hitherto unrecognized disease in entity separate from
schizophrenia and manic depressive psychosis^ It showed
that acute psychosis defers from the two established
categories of schizophrenia and manic depressive
During the last decade, the District Menial Health
Programme (DMHP) was launched at the national level.
The DMHP was launched in 1996-97 in four districts.
143
Mental Health Research in India
psychosis on the basis of their clinical picture, normal
pre morbid personality, and an excellent recovery rate
suggesting that this may be a benign type of acute
psychosis which tends to recover rapidly within weeks
or months without any residual symptoms. This research
has led to the inclusion of acute psychosis as a distinct
diagnostic category. In ICD-8 and ICD-9, acute psychosis
could be classified under the broad category of
schizophrenias indicating a conceptual position on the
nature of these disorders. Acute psychosis was classified
as acute schizophrenic episode (295.4). The ICD-10
removed acute psychosis from the broad category of
schizophrenias and it was covered as a specific diagnostic
entity - acute and transient psychotic disorders (F23).
ICD-10 also defines the time limit for the onset (within
two weeks) as well as for the duration of illness (up to
three months). Unlike ICD-9, the ICD-10 excludes cases
with acute onset and brief duration of schizophrenic
symptoms from the diagnostic category of schizophrenia.
If PHC doctors are trained in the identification and
management of patients of acute psychosis, this will help
in management of such cases in the community.
DEX El OPMENT
MODULES:
OF
INTERVENTION
Development of intervention modules was a part of
all major epidemiological studies in mental health. A
task force study on mental health care of rural aged
determined not only the physical and psychiatric
morbidity among the elderly but also developed a manual
for health care of the elderly, physical as well as mental*,
in the PHC set up. Study of developmental
psychopathology in school children has developed an
interventional plan that focused at the persons who were
directly looking after the child that is parents, teachers,
or both.
Alcohol causes substantial health as well as social
and economic problems. It is well known that alcohol
use causes a \ariety of physical and psychologicalproblems and.these are all seen in India. However a
number of additional problems have been identified in
Indian population using alcohol. These include
nutritional problems, infections and malignancies. One
problem that is somewhat peculiar to India is adulteration
of alcoholic drinks with poisonous substances including
methyl alcohol Every year, many people die from this
reason alone and many more suffer major disabilities
including blindness. ICMR task force project developed
and evaluated health educational interventions to help
users of alcohol and tobacco in the community to quit or
reduce substance use. A drug abuse monitoring system
was dc\ eloped for the purpose of on going evaluation of
alcohol and drug use using clinic based data.
The study on factors associated with course and
outcome of schizophrenia has shown that there are a
number of factors influencing in course and outcome of
schizophrenia which are amenable to intervention, such
as treatment at an early stage, good drug compliance,
positive and supportive attitude of family members and
provision of some kind of regular occupational schedule.
If these aspects are incorporated in the training of medical
and paramedical personnel, this will go a long way in
improving the prognosis of the disorder.
hidicators i f mental health were developed that can
be used for monitoring mental well being of the
communitv and lor evaluation of social intervention
programmes. Subjective Well Being Inventory was
developed to measure subjective well being at individual
leve . An assessment tool Home Risk Card was
developed to assess well being at family level. The
measures of cgiality of community life were also
developed to assess the quality of life at the community
level. Psychosocial interventions were developed to
enhance the subjective well being at the individual and
family level. These interventions also demonstrated a
positive effect of cognitive development and nutritional
statu el children in the family.
The study on psychopathology of depression has
found higher risk for recurrence of depression in patients
with persistence of cognitive abnormality,
notwithstanding clinical remission. A dip in nocturnal
melatonin levels was found to be a feature of depression
and its reversal towards normal the index of recovery.
Failure to register a nocturnal rise in melatonin level
seems characteristic of patients with persistent negative
cognitions even while they had recovered from
depression. This finding on association between
recurrence in depression and persistence of cognitive
abnormality provides a better insight for management
of cases of depression.
144
CONTRIBUTIONS OF ICMR RI-SEARCH TO MENTAL HEALTH CARE
A simple measurement instrument was developed for
assessment of emotional stress experienced by people.
It can be used for assessment of persons of all age groups
and found different strata of society. It assesses the stress
in day-to-day life as well as due to presumed stressful
life event, and can also be used for study of emotional
stress as risk factor for various non communicable
diseases.
The study on suicide behavior has developed a
simple questionnaire for use by general physicians to
identify person: with suicidal risk as it was found that a
large percentage of persons who attempted suicide were
in contact with treatment facility for some time before
suicide attempt It is expected that the further ongoing
research on suicide behavior will help in evolving
strategy for suic de prevention. Similarly, the other major
ongoing research programmes on urban mental health
and the mental health studies in earthquake affected areas
of Gujarat, are also aiming at evolving suitable mental
health care strategies that may be suitable in those areas.
145
APPENDICES
Appendix
Appendix - I
Members of First Advisory Committee on Mental Health
Dr. J.S. Neki
Dr. R.L. Kapur
Dr. D.N. Nandi
Dr. S.M. Lulla
Dr. B.B. Sethi
Dr. D. Mohan
Dr. G.G. Prabhu
(Chairman)
Members of Second Advisory Committee on Mental Health
Dr. J.S. Neki
Dr. N.N. Wig
Dr. R.L. Kapur
Dr. D.N. Nandi
Dr. V.N. Bagadia
Dr. R.S. Murthy
Dr. D. Mohan
Dr. G.G. Prabhu
(Chairman)
(Co-Chairman)
Special invitees:
Dr. D.B. Bisht
Dr. P.N. Chuttanni
Dr.P.N. Tandon
Shri J.C. Jetli
149
Mental Health Research in India
Appendix - II
LIST OF CONSULTANTS FOR TASK FORCE PROJECTS & C.A.R.
Dr. M Aghi
Dr. A.K.Agrawal
Dr. A. Avasthi
Dr. J.S. Bajaj
Dr. N.E. Bharucha
Dr. S.M. Channabasvanna
Dr. S. Parvathi Devi
Dr. K.C. Dube
Dr. E. Hoch
Dr. B.C. Goshal
Dr.Mohan K. Issac
Dr. J. Jairaman
Dr. Alok Kalla
Dr. R.L. Kapur
Dr. P. Kulhara
Dr. K. Kuruvilla
Dr. G. Lakshamipathy
Dr. Savita Malhotra
Dr. S.C. Malik
Dr. S. Roshan Master
Dr. Manju Mehta
Dr. M. Sarda Menon
Dr. A.K. Mukherjee
Dr. G.C. Munjal
Dr. R.S. Murthy
Dr. K.K. Mutatkar
Dr. R. Nagpal
Dr. D.N. Nandi
Mr. G. Narain
Dr. Usha Nayar
Dr. J.S. Neki
Dr. J.N. Pande
Dr. N. Prabhakaran
Dr. G.G. Prabhu
Dr. R. Raghurami
Dr. L. Ramachandran
Dr. V. Ramachandran
Dr. A. Venkoba Rao
Dr. G.N. Narayana Reddy
Dr. S.K. Sahu
Dr. K. Satyavathi
150
Appendix
Dr. Kusum Sehgal
Dr. H. Sell
Dr. B.B. Sethi
Dr. Anil V. Shah
Dr. S.D. Sharma
Dr. A. K. Singh
Dr. Baldev Singh
Dr. Gurmeet Singh
Dr. I.P. Singh
Dr. D.N. Sinha
Dr. Amresh Srivastava
Dr. R.K. Srivastava
Dr. P.N. Tandon
Dr. J.K. Trivedi
Dr. S.K.. Varma
Dr. V.K. Varma
Dr. R. Venkatrathnam
Dr. Abraham Verghese
Dr. N.N. Wig
151
( IM-
Mental Health Research in India
Appendix - III
List of CAR And Task Force Projects (1982-2002)
Title And Duration
1
2
Name Of The Principal Investigators
CENTRE FOR ADVANCED RESEARCH
Centre For Advanced
Research In Community
Mental Health
Duration: 1984-90
Dr. R.Srinivasa Murthy
Professor
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore-560029
Centre For Advanced Research
In Health And Behaviour
Duration: 1985-93
Studies Carried Out:
Dr. A.Venkoba Rao
Professor (Psychiatry)
Madurai Medical College And
Government Rajaji Hospital Madurai
625020
Psychopathology Of Depression
Study Of Suicide Behaviour
Study Of Domestic Burns In Young Women
A Clinical Study Of The HIV Infected Patients
3
Centre For Advanced Research on Health
Consequences Of Earthquake Disaster With
Special Reference To Mental Health
Duration: 1995-2000
Dr Mohan Agashe
Professor And Director ,
Ml MIL Sasoon General Hospital
Station Road
Pune 411001
Dr. Neha R.Pande
Professor
Department Of Psychiatry
B.J.Medical College And
Sasoon General Hospital
Station Road
Pune
411001
152
Appendix
TASK FORCE PROJECTS
4
Collaborative Study On Severe Mental
Morbidity
Duration: 1976-83
1. Dr. A.B.Khorana
Professor
Department Of Psychiatry
Medical College And
S.S.G.Hospital
Vadodara- 390001
2. Dr. Gurmeet Singh
Professor
Department Of Psychiatry
Government Medical College And
Rajendra Hospital
Patiala- 147001
3. Dr R.L Kapoor
Professor And Head
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
4. Dr. Mohan K.Isaac
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
5. Dr. D.N.Nandi
R.G.Kar Medical College
And Hospital
Belgachia Road
Kolkata-700004
2. Dr. C.Shamasundar
Additional Professor
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
153
Mental Health Research in India
3. Dr. Jacob K.John
Professor
Department Of Psychiatry And
Psychological Medicine
Christian Medical College
And Hospital
Vellore- 632004
6. Study On The Problems Of The
Aged Seeking Psychiatric Help
Duration: 1981-82
7
Health Care Of The Rural Aged
Duration: 1984-88
8
Collaborative Study On Phenomenology
And Natural History Of
Acute Psychosis
Duration: 1981-85
Dr. A.Venkoba Rao
Professor (Psychiatry)
Madurai Medical College And
Government Rajaji Hospital
Madurai- 625020
1. Dr. A.Venkoba Rao
Professor And Head (Psychiatry)
Madurai Medical College And
Government Rajaji Hospital
1. Dr. Gurmeet Singh
Professor
Department Of Psychiatry
Government Medical
College And
Rajendra Hospital
Patiala-147001
2. Dr. L.N.Gupta
S.P.Medical College And
Associated Group Of Hospitals
Bikaner- 334003
3. Dr. K.Kunivilla
Christian Medical College
And Hospital
Vellore- 632004
4. Dr. J.M.Fernandez
Assistant Professor
Institute Of Psychiatry
And Human Behaviour
Panaji- 403001
Madurai 0625020
9
Study Of Factors Associated
With Course And Outcome Of
Schizophrenia
Duration: 1981-88
1. Dr. Abraham Verghese
Professor And Head
Department Of Psychiatry
Christian Medical College
And Hospital
Vellore-632004
154
Appendix
2. Dr. B.B.Sethi
Former Director
Sanjay Gandhi Postgraduate
Institute Of Medical Sciences
Post Box. No.375
Rae Bareli Road
Uttrathia
Lucknow- 226014
3. Dr. S.Rajkumar
Former Additional Professor
Department Of Psychiatry
Chennai Medical College And
Government General Hospital
Deemed University
Chennai- 600003
10
Study On Illness Behaviour In
Patients Presenting With Pain
And Its Relationship With
Psychosocial And Clinical
Variables
Duration: 1981-83
Dr. V.K.Varma
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
11 Study On Development Of
Modernity Scale
Duration: 1981-83
Dr. A.K.Singh
Professor And Head
Department Of Psychology
University Of Ranchi
Ranchi- 834008
12 Health Modernity Education
Project
Duration: 1985-89
Dr. A.K.Singh
Professor And Head
Department Of Psychology
University Of Ranchi
Ranchi- 834008
13 Study On Indicators Of
Mental Health
Duration: 1987-92
l.Dr S.M. Channabasavanna
Director, National Institute Of Mental
Health And Neurosciences
Bangalore- 560029
2. Dr. Prabhat Sitholey
Department Of Psychiatry
K.G’s Medical College,
Lucknow
155
Mental Health Research in India
Dr. S.D.Sharma
Prof. & Medical Suptd.
Safdarjang Hospital
New Delhi- 110029
Dr B.B Sethi
S.G.P.G.I.
Lucknow 226003
14 Measures Of Quality Of
Community Life
Duration: 1994-97
1. Dr. Shuba Kumar
Social Scientist
Clinical Epidemiological Unit
Chennai Medical College And
Government General Hospital
Deemed University
Chennai- 600003
2. Dr. A.K.Agarwal
Professor
Department Of Psychiatry
K.G’s Medical College
Lucknow- 226003
15 Development Of An Instrument
For Psychosocial Stress
Duration: 1993-96
1. Dr. D.M.Pestonjee
Indian Institute Of Management
Vastrapur, Ahmedabad
2. Dr. A.K.Srivastava
Reader
Department Of Psychology
Banaras Hindu University
Varanasi- 221005
16 Study On The Pattern Of
Child And Adolescent
Psychiatric Disorders
Duration: 1981-83
1. Dr. Jaya Nagaraja
Professor
Department Of Psychiatry
Andhra Medical College
And King George Hospital
Visakhapatnam- 530002
2. Dr. Shiva Parkash
Assistant Professor
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900, Bangalore- 560029
156
Appendix
3. Dr. Prabhat Sitholey
Professor And Head
Department Of Psychiatry
K.G’s Medical College
Lucknow- 226003
17 Epidemiological Study Of Child
And Adolescent Psychiatric
Disorders In Urban And Rural
Areas
Duration: 1995-00
1. Dr. Shobha Srinath
Additional Professor
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
2. Dr. Prabhat Sitholey
Professor And Head
Department Of Psychiatry
K.G’s Medical College
Lucknow- 226003
18 Study On The Effects Of
Intervention Programme On
Non-Medical Use Of Drugs In
The Community
Duration: 1981-86
1. Dr. Davinder Mohan
Professor And Head
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 1 10029
2. Dr. B.R.Bhadra
Former Associate Professor
Department Of Psychology
College Of Basic Sciences
And Humanities
Bangalore- 560001
3. Dr. S.D.Sharma
Former Director,
Central Institute Of
Psychiatry
Kanke Road
Ranchi- 834006
4. Dr. I.Dutta
Former Professor
Department Of Psychiatry
Assam Medical College
Dibrugarh- 786002
157
Mental Health Research in India
19 Collaborative Study On Narcotic Drugs
And Psychotropic Substances
Duration : 1987-92
l.Dr. Prabhat Sitholey
K.G’s Medical College ,Lucknow
2. Dr. Davinder Mohan
Professor And Head
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar, New Delhi- 110029
3. Dr. D.R.Purohit
Professor
Department Of Psychiatry
Dr.S.N.Medical College And
Associated Hospitals
Shastri Nagar
Jodhpur- 342005
20 A Survey On Drug Dependence
Duration: 1989-93
Dr. Davinder Mohan
Professor And Head
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
21 Mental Health Studies In M.I.C. Exposed
Population At Bhopal 1.
Duration: 1985-92
Dr. B.B. Sethi
S.G.P.G.I., Lucknow
2. Dr. Ashok Bhiman
S.G.P.G.I., Bhopal
22 A Pilot Study Of Organic Brain
Damage In Toxic Gas Exposed
Population
Duration: 1988-90
l.Dr. Ashok Bhiman
Sanjay Gandhi Postgraduate
Institute Of Medical Sciences
Lucknow.
23 Psychosocial And Health
Correlates Of Self-Esteem
Among Young Women
Duration: 1989-93
1. Dr. S.D.Sharma
Prof. & Medical Suptd.,
Safdarjang Hospital
New Delhi
110029
24 Task Force Project On Suicide Behaviour
(Ongoing)
Dr N.G.Desai
Professor and Head (Psychiatry)
l.H.B.A.S. Delhi
Dr K.A.Kumar
Professor and Head (Psychiatry)
Medical College, Thiruvanathapuram
158
Appendix
25 ICMR-WHO Project On Urban Mental Health
Dr N.G.Desai
Professor And Head (Psychiatry)
I.H,B,A,S, Delhi
Dr S.C. Tewari
Professor of Psychiatry.
K.G.M.C. Lucknow
Dr Palaniappan
Medical Superintendent
Institute Of Psychiatry
Chennai
26 Task Force Project On Mental Health Service
Needs Of Earthquake Affected People In Gujarat
(Ongoing)
1. Dr N.G.Desai
Professor and Head (Psychiatry)
I.H.B.A.S., Delhi
2. Dr. Ajay Chauhan
Institute Of Mental Health
Ahmedadbad
3. Dr. Chitra Somasundram
M.P. Shah Medical College, Jamnagar
4. Sanjeev Gupta
Hospital for Mental Health, Bhuj.
5. Dr.M.J. Samani
Professor of Psychiatry,
Govt. Medical College, Rajkot.
159
Mental Health Research in India
Appendix - IV
LIST OF AD HOC PROJECTS
Principal Investigators
Title and Duration
CLINICAL STUDIES
1
Emotional Arousal And
Wakefulness In SchizophrenicsA Psychophysiological Study
Duration: 1982-84
Dr. C.R.Mukundan
Assistant Professor
Department Of Clinical
Psychology
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
2
Lithium And Aggression
Duration: 1983-85
Dr. B.B.Sethi
K.G’s Medical College
Lucknow- 226003
3
Clinical And Biochemical
Correlates Of Tardive
Dyskinesia
Duration: 1983-86
Dr. Sanjay Dube
Lecturer
Department Of Psychiatry
K.G’s Medical College
Lucknow- 226003
4
Correlation Of Clinical State
And Serum Prolactin Levels In
Patients Suffering From
Functional Psychosis
Duration: 1985-88
Dr. Alice Kuruvilla
Professor
Department Of Pharmacology
Christian Medical College
And Hospital
Vellore- 632004
5
Coping Behaviour In Relation
to Auditory Hallucinations In
Schizophrenics - A Study Of
Psychosocial And PhenomenoLogical Correlates
Duration: 1985-88
Dr. A. Ramanathan
Assistant Surgeon
Institute Of Mental Health
Kilpauk
Chennai- 600010
6
Psychophysiological Correlates
Of Recovery In Schizophrenia
Duration: 1985-88
Dr. C.R.Mukundan
Assistant Professor
Department Of Clinical Psychology
National Institute Of Mental
Health And Neurosciences
Hosur Road P.B.2900
Bangalore- 560029
160
♦ Appendix
7
A Prospective Study Of
Psychiatric Disorders In
Pregnancy And The First
Postnatal Year
Duration: 1988-91
Dr. Parmanand Kulhara
Additional Professor
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
8
Depression In Schizophrenia :
A Study On Phenomenology And
Predictive Variables
Duration: 1992-95
Dr. Parmanand Kulhara
Additional Professor
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
BIOLOGICAL PSYCHIATRY
Renal Functions And Lithium
Duration: 1981-83
Dr. B.B.Sethi
K.G’s Medical College
Lucknow- 226003
10 A Biochemical Study Of Human
And Animal Cannabis Users
Dr. B.B.Sethi
K.G’s Medical College
11 Platelet Monoamine Oxidase
Activity In Chronic
Schizophrenia
Duration: 1983-86
Dr. J.K.Trivedi
Professor
Department Of Psychiatry
K.G’s Medical College
Lucknow- 226003
12 Platelet Radioreceptors Assay
Of Biogenic Amines In Patients
Of Affective Disorders And
Schizophrenia
Duration: 1983-85
Dr. B.B.Sethi
K.G’s Medical College
Lucknow- 226003
9
FAMILY STUDIES
13 A Neuropsychiatric Study Of
Children Of Schizophrenics
Duration: 1985-86
Dr. M.Sarada Menon
Former Director
Schizophrenia Research
Foundation (India)
R/7a North Main Road
West Anna Nagar Extn.
Chennai- 600102
161
Mental Health Research in India
Dr. S.Sabhesan
Tutor (Infection Diseases)
Madurai Medical College And
Government Rajaji Hospital
Madurai- 625020
14 Families Of Head Injured
Patients-Their Attitudes,
Experienced Burden And
Psychopathology
Duration: 1987-88
THERAPIES
15 Determination Of Dosage
Schedule Of Lithium To Indian
Patients And Indicators Of
Response To Lithium Therapy In
Case Of Affective Disorders
Duration: 1979-83
Dr. S.M.Channabasavanna
Former Director
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
16 Propranolol In Neuroleptic
Resistant Schizophrenics
Duration: 1983-85
Dr. B.B.Sethi
K.G’s Medical College
Lucknow- 226003
17 A Study Of The Evaluation Of
The Effectiveness Of Brief
Inpatient Family Intervention
Versus Outpatient Intervention
For Mentally Retarded Children
Duration: 1991-94
Dr. S.C.R.Girimaji
Associate Professor
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
18 Survey On The Motor
Disturbances Induced By
Neuroleptic Drugs
Duration: 1992-94
Dr. Jacob K.John
Professor
Department Of Psychiatry And
Psychological Medicine
Christian Medical College
And Hospital
Vellore- 632004
19 Sleep Polysomnography As A
Predictor Of Response To
Electroconvulsive Therapy In
Depression
Duration: 1996-99
Dr. B. Gitanjali
Associate Professor
Department Of Pharmacology
Jawaharlal Institute Of
Postgraduate Medical Education
And Research
Dhanvantari Nagar
Pondicherry- 605006
162
Appendix
20 Influence Of Stimulus
Variables On EEG Seizure
Parameters During EOT :An
Intra-Individual Cross-Over
Study
Duration: 1997-00
Dr. B.N.Gangadhar
Additional Professor
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
21 Development Of A Simple Regime
Of Play Therapy And To Assess
The Impact Of This On Growth
And Development Of
Institutionalized Children In
An Orphanage Setting
Duration: 1/2001-31/2001
Dr. Jacob M.Puliyel
Head
Department Of Paediatrics And
Neonatology
St.Stephen’s Hospital
Tis Hazari
Delhi- 110054
MEDITATION AND YOGA
22 Physical,Physiological,BiocheMical & Psychological CorrelaTes Of Experience In Consci
ousness By Pranayama,TranscenDental Meditation & Kundalini
Duration: 1983-90
Dr. T.Desiraju
Late Professor
Department Of Neurophysiology
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
23 Study Of Patanjali Yoga
Through Personal Experience
Duration: 1983-88
Dr. R.L.Kapur
Indian Institute Of Science
Sir C.V.Raman Avenue
Bangalore- 560012
24 The Efficacy Of Yogic Therapy
In The Treatment Of PsychoGenic Headache
Duration: 1985-89
Dr. S.Prabhakar
Professor And Head
Department Of Neurology
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
25 Effects Of Yoga On The Health
Of Nurses
Duration: 1986-89
Dr. Inderjit Walia
Assistant Professor
College Of Nursing
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
163
Mental Health Research in India
26 Yoga Therapy With Anxiety
Neurotics
Duration: 1986-88
Smt. Gunninder Sahasi
Clinical Psychologist
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 110029
27 Comparative Study Of
Progressive Relaxation & Yogic
Relaxation Techniques In The
Management Of Anxiety Neurosis
Duration: 1989-92
Si nt. Gurminder Sahasi
Clinical Psychologist
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 110029
28 Role Of Yoga In The Treatment
Of Essential Hypertension
Duration: 1992-95
Dr. V.K.Varma
Former Professor
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
CHILD PSYCHIATRY
29 Childhood Mental Disorders In
Rural School Children
Duration: 1988-91
Dr. Manju Mehta
Additional Professor
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 110029
30 Study Of Psychosocial
Determinants Of Developmental
Psychopathology In Children In
The Community
Duration: 1992-95
Dr. Savita Malhotra
Professor And Head
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
31 Community-Based Follow Up
And Treatment Of Children
Identified To Have Psychiatric
Disorders
Duration: 1998-02
Dr. Savita Malhotra
Professor And Head
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
164
Appendix
Dr. Manju Mehta
Additional Professor
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 110029
32 Stress In Children
Duration: 1997-00
MENTAL RETARDATION
Dr. K.Krishnamurthy
Former Assistant Professor
Department Of Psychiatry
Osmania Medical College And
Associated Hospitals
33 Care Of Mentally Handicapped
Children Through Anganwadi
Workers
Duration: 1982-85
Koti
Hyderabad- 500001
34 Development Of A Home Care
Programme For Mentally
Retarded Children
Duration: 1985-87
Dr. V.K.Varma
Former Professor
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
35 Training Mothers Of Mentally
Retarded Children : Evaluation
Of Variables Determining
Success
Duration: 1985-87
Dr. Manju Mehta
Additional Professor
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 110029
36 A Study Of The Evaluation Of
The Effectiveness Of Brief
Inpatient Family Intervention
Versus Outpatient Intervention
For Mentally Retarded Children
Duration: 1991-94
Dr. S.C.R.Girimaji
Associate Professor
Department Of Psychiatry
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
165
Mental Health Research in India
ALCOHOL AND DRUG DEPENDENCE
37 Cannabis And Health
Duration: 1980-83
Dr. B.B.Sethi
K.G’s Medical College
Lucknow- 226003
38 Mental Health Problems Of
Cannabis Abusers
Duration: 1985-88
Dr. V.Ramachandran
Late Neuropsychiatrist
Department Of Psychiatry
Institute Of Mental Health
Kilpauk
Chennai- 600010
PSYCHIATRIC EPIDEMIOLOGY
39 An Epidemiological Study Of
Mental Illnesses Prevalent In
An Urban Community - Migrant
Sindhi Population
Duration: 1981-84
Dr. P.S.Gehlot
former Professor
Department Of Psychiatry
S.M.S.Medical College
And Hospital
Jaipur- 302004
40 Mental Health Survey In & aro
und Calcutta To Ascertain Mag
nitude Of Mental Health Probl
ems & Aetiological Significan
ce Of Environmental Factors*
Duration: 1983-84
Dr. Ajita Chakraborty
Institute Of Postgraduate
Medical Education And Research
And S.S.K.M. Hospital
244,Acharya J.C.Bose Road
Kolkata- 700020
41 Severe Mental Disorder: A
Prospective Five-Year Follow
Up Study
Duration: 1985-88
Dr. V.K.Varma
1 •‘'ormer Professor
Department Of Psychiatry
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
42 Longitudinal Study Of Funct
ional Psychosis In An Urban
Community
Duration: 1985-89
Dr. S.Rajkumar
Former Additional Professor
Department Of Psychiatry
Chennai Medical College And
Government General Hospital
Deemed University
Chennai- 600003
166
Appendix
43 Geropsychiatric Morbidity In
Rural Area
Duration: 1988-91
Dr. S.C.Tiwari
Professor
Department Of Psychiatry
K.G’s Medical College
Lucknow- 226003
DELIVERY OF MENTAL HEALTH SERVICES
44 Training Of Primary Health
Care Physicians In The
Delivery Of Mental Health
Services To The Community
Duration: 1982-84
Dr. N.N.Wig
Former Professor
Department Of Psychiatry
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 110029
45 Comparative Study Of Efficacy
Of Training Material And
Development Of Record System
For Primary Mental Health
Care
Duration: 1983-84
Dr. Shiv Gautam
Professor And Head
Department Of Psychiatry
S.M.S.Medical College
And Hospital
Jaipur- 302004
46 Community Mental Health:
Service-Cum-Research And
Training Programme
Duration: 1985-87
Dr. Mukul Sharma
Former Lecturer
Department Of Psychiatry
Sanjay Gandhi Postgraduate
Institute Of Medical Sciences
Post Box. No.375
Rae Bareli Road
Uttrathia
Lucknow- 226014
PSYCHOMETERY
47 Standardization Of Hindi
Adaptation Of Wais - R
Verbal Scale
Duration: 1981-83
Dr. T.R.Shukla
Associate Professor
Department Of Clinical
Psychology
Central Institute Of
Psychiatry
Kanke Road
Ranchi- 834006
48 Use Of Psychometric Assessment
In Brain Dysfunction Cases
Duration: 1981-84
Dr. Dwarka Pershad
Associate Professor
Department Of Psychiatry
P.G.I.M.E.R
Chandigarh- 160012
167
Mental Health Research in India
49 Translation Of Eysenck PersonAlity Questionnaire (Epq)
Into 3 South Indian Languages
(Tamil, Telugu And Malayalam)
And Their Standardisation
Duration: 1985-87
Dr. Annamma Abraham
Senior Lecturer
Department Of Psychiatry
Christian Medical College
And Hospital
Vellore- 632004
50 The Development Of A
Neuropsychological Battery
For Use Of Hindi Knowing
Patients
Duration: 1988-91
Sh. Surya Gupta
Additional Professor
Deptt. Of Clinical Psychology
All India Institute Of
Medical Sciences
Ansari Nagar New Delhi- 110029
51 Neuropsychological
Localization
Duration: 1993-96
Sh. Surya Gupta
Additional Professor
Deptt. Of Clinical Psychology
All India Institute Of
Medical Sciences
Ansari Nagar
New Delhi- 110029
SOCIO-CULTURAL AND CLINICAL PSYCHOLOGY
52 The Impact Of The Handicap In
Speech, Vision And Hearing On
School Achievement And
Emotions Of Children Between
The Age Groups 6-13
Duration: 1980-83
Dr. R.B.Vachhrajani
Late Honorary Director
Health Research Institute
Gujarat Research Society
Samshodhan Sadan
16th Road, Khar
Mumbai- 400052
53 Phenomenology Of A Culture
Bound Syndrome And Its SocialPsychological Significance: A
Study Of Mediumistic Trance
Behaviour In Rajasthan
Duration: 1985-87
Dr. Y.S.Vagrecha
Reader( Psychology)
B.S.Ccntre Of Neuro-Psychology
And Counselling
Dr.Hari Singh Gour
Vishwavidyalaya
Gour Nagar
Sagar- 470003
Sector 12
Chandigarh- 160012
54 A Study Of Impact Of Thalass
emia And Other Comparable NonGenetic Types Of Anaemia
Children On Cognitive
Information Processing
Duration: 1986-89
Dr. M.L.Sharma
Former Professor
Department Of Pathology
S.M.S.Medical College
And Hospital
Jaipur- 302004
168
Appendix
55 A Study Of Spirit Medium With
Reference To Their Role In
Health, Especially Mental
Health
Duration: 1/1988-12/88
Dr. D.N.Kakar
Associate Professor
Department Of Community
Medicine
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
56 Psychological Outcomes
Associated With Severe Iodine
Deficiency
Duration: 1988-91
Dr. B.D.Tiwari
University Of Gorakhpur
Gorakhpur- 273009
57 Psychological Aspects Of
Infertility Due To Various
Causes: A Prospective Study
Duration: 1989-92
Dr. G.I.Dhall
Postgraduate Institute Of
Medical Education And Research
Sector 12
Chandigarh- 160012
58 Investigation Of Cases Of The
Reincarnation Type With Birth
Marks/Birth Defects
Duration: 1996-99
Dr. Satwant Pasricha
Additional Professor
Department Of Clinical
Psychology
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
59 Recidivism : A Study To
Identify Risk Factors To
Formulate Preventive And
Rehabilitative Strategies
Duration: 1998-02
Dr. S.C.Tiwari
Professor
Department Of Psychiatry
K.G’s Medical College
Lucknow- 226003
169
Mental Health Research in India
Appendix - V
List of Fellowship Projects
Guides Of Research Fellows
Title And Duration
1
Psychological Profile Of
Male Civil Pensioners And The
Consequent Hazards For Their
Mental Health.
Duration: 1981-83
Dr. Ram Singh
Professor
Postgraduate Department Of
Medicine
S.N.Medical College And
Hospital
Agra- 282002
2
A Study Of Anxiety.
Duration: 1981-84
Dr. P.K.Chatterjee
Professor And Head
Department Of Psychology
University College Of Science
And Technology
University Of Calcutta
92, A.P.C.Road
Kolkata- 700009
3
An Experimental Study Of
Arousal Mechanisms In
Schizophrenics.
Duration: 1981-82
Dr. C.R.Mukundan
Assistant Professor
Department Of Clinical
Psychology
National Institute Of Mental
Health And Neurosciences
Hosur Road
P.B.2900
Bangalore- 560029
4
Biochemical Studies On Blood,
Brain And Spinal Fluid Of
Patients Suffering From
Schizophrenia And Affective
Disorders.
Duration: 1981-83
Dr. Diptis Sengupta
Professor
Department Of Biochemistry
University College Of Science
3 5,Bally gunge Circular Road
Kolkata- 700019
5
A Study On The Effect Of
Psychological Treatment
In Epileptics.
Duration: 1983-87
Dr. K.Jagannathan
Chennai Medical College And
Government General Hospital
Deemed University
Chennai- 600003
170
Appendix
6
Cancer : Is It A Psycho-Social
Problem ?
Duration: 1983-87
Dr. P.K.Chatterjee
Professor And Head
Department Of Psychology
University College Of Science
And Technology
University Of Calcutta
92, A.P.C.Road
Kolkata- 700009
7
Construction And
Standardization Of A Test For
Assessment Of Disability In
Urban And Rural Psychiatric
Patients
Duration: 1985-88
Dr. P.B.Behere
Institute Of Medical Sciences
Banaras Hindu University
Varanasi- 221005
8
Behavioural Analysis And
Therapy Of Coronary-HeartDisease-Prone Persons
Duration: 1986-89
Dr. Sandhya.S.Kaushik
Reader
Department Of Psychology
Mahila Maha Vidyalaya
Banaras Hindu University
Varanasi- 221005
9
Bio-Feedback: A Therapeutic
Aid To Cancer Patients
Duration: 1988-91
Dr. P.K.Chatterjee
Professor And Head
Department Of Psychology
University College Of Science
And Technology
University Of Calcutta
92, A.P.C.Road
Kolkata- 700009
10
A Study Of Drug Addiction In
Northern India (Its Genesis &
Consequences)
Duration: 1988-92
Dr. Jitendra Mohan
Professor
Department Of Psychology
Mohanjitendra® Hotmail. Com
Panjab University
Sector 14
Chandigarh- 160014
11
The Effect Of Marriage On
Existing Mental Disorder.
Duration: 1989-92
Dr. S.N.Sharma
Reader
Department Of Psychiatry
Institute Of Medical Sciences
Banaras Hindu University
Varanasi- 221005
171
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